Fibrosis-4 (FIB-4) Index and mortality in COVID-19 patients admitted to the emergency department
Authors: Bucci Tommaso , Galardo Gioacchino , Gandini Orietta , Vicario Tommasa , Paganelli Carla , Cerretti Sara , Bucci Chiara , Pugliese Francesco , Pastori Daniele ,   the Research On Medical patients Admitted to the Emergency Department (ROMA-ED) study group, Fante Elisa , Urso Fabrizio , Baldini Enrico , Zinnamosca Laura , Alessandroni Maria , Loiudice Grazia , Boccardo Chiara , Petrillo Enrico , Della Grotta Giada , Magrini Leonardo , Colzi Marina , Gianni Cristiana , Biamonte Federica , Concistrè Antonio , Ponzio Antonella , Franchi Cristiana , Marinelli Cristiano , Pecci Tecla , Fabi Flavia , Roma Giona , Massi Alessandra , Diaczenko Alina , Bresciani Emanuela , Bresciani Emanuela , Suppa Marianna , Servello Adriana , Rosa Antonello , Coppola Alessandro , Mazzocchitti Anna Maria , Palladino Mariangela , Bertazzoni Giuliano , Minisola Salvatore , Petramala Luigi , Marino Luca , Marletta Andrea , De Cataldis Marco , Corbi Daniele , Ansalone Rosachiara , D’Ercole Adriana , Fontana Serena , Rapisarda Paolo , Piccari Pietro , Marcelli Giulia , Cascio Michela , Di Manno Valentina , Ruggiero Margherita , Cardillo Piccolino Giulia , Sinacori Pierfrancesco , Rossi Stefano , Di Vanna Domenico , Barbera Mauro , Cedrone Maria Civita , Di Biagio Valentina , Galati Elisabetta , Iacopelli Giulia , Leonardi Annalisa , Rigamonti Daria , Colantonio Marco , Leonardi Annalisa , Pellegrino Eugenia , Colafati Maria Antonietta , Milocco Mimosa , Berardi Rosaria , Menichelli Danilo , Franchino Giovanni , Criniti Anna , Lubrano Carla , Santulli Maria , Angeloni Antonio , Lorusso Emiliano , Giglio Simona 
Published: May 2022

Liver damage worsens the prognosis of coronavirus 19 disease (COVID-19). However, the best strategy to stratify mortality risk according to liver damage has not been established. The aim of this study is to test the predictive value of the validated Fibrosis-4 (FIB-4) Index and compared it to liver transaminases and to the AST-to-Platelet ratio index (APRI). Multicenter cohort study including 992 consecutive COVID-19 patients admitted to the Emergency Department. FIB-4 > 3.25 and APRI > 0.7 were used to define liver damage. Multivariable Cox regression and ROC curve analysis for mortality were performed. Secondary endpoints were (1) need for high-flow oxygen and (2) mechanical ventilation. 240 (24.2%) patients had a FIB-4 > 3.25. FIB-4 > 3.25 associated with an increased mortality (n = 119, log-rank test p < 0.001 and adjusted hazard ratio (HR) 1.72 (95% confidence interval [95%CI] 1.14–2.59, p = 0.010). ROC analysis for mortality showed that FIB-4 (AUC 0.734, 95% CI 0.705–0.761) had a higher predictive value than AST (p = 0.0018) and ALT (p < 0.0001). FIB-4 > 3.25 was also superior to APRI > 0.7 (AUC 0.58, 95% CI 0.553–0.615, p = 0.0008). Using an optimized cut-off > 2.76 (AUC 0.689, 95% CI 0.659–0.718, p < 0.0001), FIB-4 was superior to FIB-4 > 3.25 (p = 0.0302), APRI > 0.7 (p < 0.0001), AST > 51 (p = 0.0119) and ALT > 42 (p < 0.0001). FIB-4 was also associated with high-flow oxygen use (n = 255, HR 1.69, 95% CI 1.25–2.28, p = 0.001) and mechanical ventilation (n = 39, HR 2.07, 95% CI 1.03–4.19, p = 0.043). FIB-4 score predicts mortality better than liver transaminases and APRI score. FIB-4 score may be an easy tool to identify COVID-19 patients at worse prognosis in the emergency department.