High Fibrosis-4 Index Is Related with Worse Clinical Outcome in Patients with Coronavirus Disease 2019 and Diabetes Mellitus: A Multicenter Observational Study

Impact of liver fibrosis on COVID-19 in-hospital mortality in Southern Italy

BACKGROUND & AIMS

SARS-Cov-2 infection manifests as a wide spectrum of clinical presentation and even now, despite the global spread of the vaccine, contagiousness is still elevated. The aim of the study was the evaluation of the impact of liver fibrosis assessed by FIB-4 and liver impairment, assessed by cytolysis indices, on intrahospital mortality in COVID-19 subjects.

METHODS

This is a retrospective observational cohort study, which involved 23 COVID Hospital Units in Campania Region, Italy. Exposure variables were collected during hospital admission and at discharge. According to FIB-4 values, we subdivided the overall population in three groups (FIB-4<1.45; 1.453.25), respectively group 1,2,3.

RESULTS

At the end of the study, 938 individuals had complete discharged/dead data. At admission, 428 patients were in group 1 (45.6%), 387 in group 2 (41.3%) and 123 in group 3 (13.1%). Among them, 758 (81%) subjects were discharged, while the remaining 180 (19%) individuals died. Multivariable Cox's regression model showed a significant association between mortality risk and severity of FIB-4 stages (group 3 vs group 1, HR 2.12, 95%CI 1.38-3.28, p<0.001). Moreover, Kaplan-Meier analysis described a progressive and statistically significant difference (p<0.001 Log-rank test) in mortality according to FIB-4 groups. Among discharged subjects, 507 showed a FIB-4<1.45 (66.9%, group 1), 182 a value 1.453.25 (9.0%, group 3). Among dead subjects, 42 showed a FIB-4<1.45 (23.3%, group 1), 62 a value 1.453.25 (42.3%, group 3).

CONCLUSIONS

FIB-4 value is significantly associated with intrahospital mortality of COVID-19 patients. During hospitalization, particularly in patients with worse outcomes, COVID-19 seems to increase the risk of acute progression of liver damage.

Correlation Between Coronavirus Disease 2019 Severity and Noninvasive Assessment of Liver Fibrosis in Patients with Metabolic Dysfunction-Associated Fatty Liver Disease

BACKGROUND/AIMS

Metabolic dysfunction-associated fatty liver disease is a crucial global health concern. Studies have shown that metabolic dysfunction-associated fatty liver disease patients are at higher risk of severe coronavirus disease 2019. However, there are no precise measures of the correlation between the degree of metabolic dysfunction-associated fatty liver disease fibrosis and coronavirus disease 2019 severity. This study evaluated the association between metabolic dysfunction-associated fatty liver disease with varying degrees of fibrosis and coronavirus disease 2019 prognosis.

MATERIALS AND METHODS

All hospitalized coronavirus disease 2019 patients who had liver steatosis as determined by computed tomography scan were included. Metabolic dysfunction-associated fatty liver disease was diagnosed in accordance with international consensus criteria. Liver fibrosis was assessed using the nonalcoholic fatty liver disease fibrosis score, FIB-4 and FIB-8 indexes. Coronavirus disease 2019 severity was defined using World Health Organization criteria. Logistic regression was used to determine the associations between varying degrees of fibrosis and the severity of coronavirus disease 2019.

RESULTS

A total of 996 confirmed hospitalized coronavirus disease 2019 cases with complete data were reviewed; of these, 296 (29.7%) cases of metabolic dysfunction-associated fatty liver disease were diagnosed. Metabolic dysfunction-associated fatty liver disease patients with any fibrotic state had more severe coronavirus disease 2019 than nonmetabolic dysfunction-associated fatty liver disease patients (adjusted odds ratio 1.912, 95% CI 1.363-2.684; P < .05). Multiple logistic regression analysis showed that metabolic dysfunction-associated fatty liver disease patients with significant fibrosis according to the FIB-8 score were more likely to have severe coronavirus disease 2019 (adjusted odds ratio 5.458, 95% CI 1.481-20.110; P < .05).

CONCLUSION

The presence of metabolic dysfunction-associated fatty liver disease in hospitalized coronavirus disease 2019 patients strongly correlated with the severity of coronavirus disease 2019. The hepatic FIB-8 index appears to provide the best prognostic value among the fibrosis scores in metabolic dysfunction-associated fatty liver disease patients with coronavirus disease 2019.

COVID-19 and Fatty Liver Disorders

In late 2019, the world was shaken by the COVID-19 pandemic. Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection became one of the main causes of illness and hospitalization worldwide, especially in subjects with metabolic comorbidities such as obesity, diabetes, or liver disease. This scenario crosses with the metabolic liver disorders' "pandemic", caused by the exponential spreading of non-alcoholic fatty liver disease, which is now the most prevalent cause of chronic liver disease (CLD). The aim of this review is to analyze the key factors of the relationship between COVID-19 and the spectrum of fatty liver disorders (FLD), in terms of molecular mechanisms and clinical presentation which can predict a more severe course of the infection. In addition, this review will face the change in management of FLD during pandemics, with a central role of telemedicine, and the role of other interventions in preventing and treating severe infection in these subjects.

Association of non-alcoholic fatty liver and metabolic-associated fatty liver with COVID-19 outcomes: A systematic review and meta-analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) are on the rise like any other liver disease, and tend to affect 25% of the United States population. The impact of NAFLD and MAFLD on patients with coronavirus disease 2019 (COVID-19) remains unclear.

AIM

To identify the association of NAFLD and MAFLD with mortality, hospitalization, hospital length of stay, and supplemental oxygen utilization in COVID-19 patients.

METHODS

A systematic review of literature on Cochrane, Embase, PubMed, ScienceDirect, and Web of Science databases was conducted from January 2019 to July 2022. Studies that evaluated NAFLD/MAFLD using laboratory methods, noninvasive imaging, or liver biopsy were included. The study protocol was registered in PROSPERO (ID CRD42022313259) and PRISMA guidelines were followed. The National Institutes of Health quality assessment tool was used to assess the quality of the studies. Pooled analysis was conducted using software Rev Man version 5.3. The stability of the results was assessed using sensitivity analysis.

RESULTS

Thirty-two studies with 43388 patients were included in the meta-analysis of whom 8538 (20%) patients were observed to have NAFLD. There were 42254 patients from 28 studies included in the mortality analysis. A total of 2008 patients died from COVID-19; 837 (10.52%) in the NAFLD group and 1171 (3.41%) in the non-NAFLD group. The odds ratio (OR) was 1.38 for mortality with a 95% confidence interval (95%CI) = 0.97-1.95 and P = 0.07. A total of 5043 patients from eight studies were included in the hospital length of stay analysis. There were 1318 patients in the NAFLD group and 3725 patients in the non-NAFLD group. A qualitative synthesis showed that the mean difference in hospital length of stay was about 2 d between the NAFLD and non-NAFLD groups with a 95%CI = 0.71-3.27 and P = 0.002. For hospitalization rates, the OR was 3.25 with a 95%CI of 1.73-6.10 and P = 0.0002. For supplemental oxygen utilization, the OR was 2.04 with a 95%CI of 1.17-3.53 and P = 0.01.

CONCLUSION

Our meta-analysis suggests that there are increased odds of hospitalization, longer hospital length of stay, and increased use of supplemental oxygen in NAFLD/MAFLD patients.

The Role of APRI, FIB-4, and SAD-60 Scores as Predictors of Mortality in COVID-19 Patients

Objective

Predictors of mortality that indicate disease severity plays an important role in COVID-19 management and treatment decisions. This study aimed to investigate the association between fibrosis-4 (FIB-4) score, aspartate aminotransferase-to-platelet ratio index (APRI), and novel biomarker-based score (SAD-60) with mortality in COVID-19 patients treated in a tertiary hospital.

Materials and Methods

In this single-center retrospective study, patients ≥18 years of age who were admitted to our hospital for COVID-19 between December 1 and 31, 2021, were included. Patients were divided into two groups as deceased and survived. A comparative analysis was applied. Predictive abilities of the FIB-4, APRI, and SAD-60 scores for in-hospital mortality were evaluated.

Results

Of the 453 patients enrolled in the study, 248 (54.6%) were male, and the mean age was 52.2±14.7 years. Mortality was recorded in 39 (8.5%) of the patients. The median values of APRI (0.43 and 0.58; p=0.001), FIB-4 score (1.66 and 2.91; p<0.001), and SAD-60 (2 and 8.25; p<0.001) were higher in deceased patients than in survivors. The optimal cut-off value for predicting mortality in the receiver operating characteristic (ROC) curve analysis was 0.58 for APRI (sensitivity=56.4%, specificity=63.6%); 2.14 for FIB-4 score (sensitivity=79.5%, specificity=68.2%); 4.25 for SAD-60 (sensitivity=90%, specificity=73.8%). In Cox regression analysis with a model that included gender, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD), FIB-4 (hazard ratio [HR]=4.013, 95% confidence interval [CI]=1.643-9.803; p=0.002), and SAD-60 (HR=8.850, 95% CI=1.035-75.696; p=0.046) were independent risk factors for mortality.

Conclusion

SAD-60 and FIB-4 scores are easily applicable and may be used to predict mortality in COVID-19 patients.

COVID-19 and hepatic injury: cellular and molecular mechanisms in diverse liver cells

The coronavirus disease 2019 (COVID-19) represents a global health and economic challenge. Hepatic injuries have been approved to be associated with severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection. The viral tropism pattern of SARS-CoV-2 can induce hepatic injuries either by itself or by worsening the conditions of patients with hepatic diseases. Besides, other factors have been reported to play a crucial role in the pathological forms of hepatic injuries induced by SARS-CoV-2, including cytokine storm, hypoxia, endothelial cells, and even some treatments for COVID-19. On the other hand, several groups of people could be at risk of hepatic COVID-19 complications, such as pregnant women and neonates. The present review outlines and discusses the interplay between SARS-CoV-2 infection and hepatic injury, hepatic illness comorbidity, and risk factors. Besides, it is focused on the vaccination process and the role of developed vaccines in preventing hepatic injuries due to SARS-CoV-2 infection.

Prevalence and Prognostic Significance of Liver Fibrosis in Patients With Aneurysmal Subarachnoid Hemorrhage

Objectives

To report the prevalence, clinical associations, and prognostic consequences of liver fibrosis in patients with aneurysmal subarachnoid hemorrhage (aSAH).

Methods

In a retrospective study of patients with aSAH, we evaluated three validated liver fibrosis indices and modeled them as continuous-exposure variables, including the aspartate aminotransferase/platelet ratio index (APRI), the fibrosis-4 (FIB-4) index, and the Forns index. The primary outcome was mortality at 90 days. We compared the addition of fibrosis indices to the predictors of the full Subarachnoid Hemorrhage International Trialists model.

Results

A total of 3,722 patients with aSAH were included in the study. According to the APRI, FIB-4 index, and Forns index, 21.7, 17.7, and 11.4% of patients had liver fibrosis. After adjusting for potential confounding factors, liver fibrosis indices were associated with increased 90-day mortality, with odds ratios of 1.35 (95% CI 1.02–1.77) for the FIB-4 index, 1.39 (95% CI.08–1.78) for APRI, and 1.53 (95% CI 1.11–2.12) for the Forns index. Similarly, high liver fibrosis indices were associated with an increased risk of rebleeding. However, the Forns index was not significantly associated with mortality and rebleeding. The addition of FIB-4 indices and APRI into the standard model improved the mortality prediction.

Conclusions

Liver fibrosis is common in patients with aSAH, and high liver fibrosis indices are associated with mortality and rebleeding. The addition of liver fibrosis indices to a standard clinical model significantly improves risk stratification.