Impact of liver injury in COVID-19 patients: Single-center retrospective cohort analysis

Coronavirus disease 2019 (COVID-19) has become a serious threat to global public health. Unfortunately, to date, there are no specific vaccines or targeted drugs, and the number of patients with positivity for systemic acute respiratory syndrome-novel coronavirus-2 infection is growing worldwide.1 Patients with COVID-19 may be at risk for liver injury, but the mechanism and clinical significance of injury remains unclear. Proposed mechanisms include direct virus-induced insults, immune-mediated damage (due to excessive inflammatory response), and drug-induced injury. COVID-19-related liver dysfunction is now gaining widespread attention; however, liver injury’s impact on the outcome of COVID-19 patients is not clearly understood. We have evaluated the impact of liver insults on the hospitalization outcome of COVID-19 patients admitted to a suburban New York safety-net hospital and would like to share our preliminary results in a Letter to the Editor instead of an Original Article for rapid dissemination to the worldwide audience. In our retrospective, unmatched, single-center analysis, we have identified the first 639 confirmed COVID-19 patients (ages ≥18 years) admitted to our facility from March 2020 to May 2020. Elevated liver-related enzymes [serum alanine aminotransferase (commonly referred to as ALT) >40 U/L, aspartate aminotransferase (commonly referred to as AST) >40 U/L, or alkaline phosphatase (commonly referred to as ALP) >120] were used to stratify patients with or without liver injury. The primary outcome was all-cause in-hospital mortality; other in-patient outcomes, including cardiac arrest, acute respiratory distress syndrome, arrhythmia, shock, and intubation rate, were also measured. The Pearson’s chi-square test and Student’s t-test were used for evaluating categorical and continuous variables, respectively. A two-step hierarchical multivariate regression model was performed to assess the risk of in-patient mortality and other hospitalization outcomes after adjusting for baseline characteristics and comorbidities. All statistical analyses were performed using SPSS® Corp. Version 22 (Armonk, NY, USA). This analysis was approved by the Institutional Review Board (IRB) of Nassau Health Care Corporation (NHCC) at Nassau University Medical Center (NUMC), under IRB reference # 20-277. Out of the total 639 COVID-19 patients, 476 (74.5%) [mean age of 58.89±15.61 years, 63.0% male] had evidence of liver injury. COVID-19 liver injury cohorts had statistically significant higher rates of all cause in-patient mortality [35.5% vs. 22.7%; adjusted odds ratio (aOR): 2.84; 95% confidence interval (CI): 1.71-4.71; p<0.001). COVID-19 liver injury was observed more often in our Hispanic patient population (38.2%). The COVID-19 liver injury group showed higher risk of other in-patient outcomes, such as cardiac arrest (26.1% vs. 14.1%; aOR: 2.65; 95% CI: 1.52-4.59; p≤0.001), requirement of intubation (30% vs. 14.7%; aOR: 2.87; 95% CI: 1.70-4.85; p<0.001), acute respiratory distress syndrome (43.1% vs. 30.7%; aOR: 1.89; 95% CI: 1.23-2.91; p=0.004), arrhythmia (5.2% vs. 0.6%; aOR: 3.16; 95% CI: 0.95-10.33; p=0.05) and shock (15% vs. 2.8%; aOR: 2.06; 95% CI: 1.15-3.70; p=0.016) compared to COVID-19 patients without evidence of liver injury (Tables 1 and ​and22). Table 1. Baseline characteristics of COVID-19 hospitalizations with vs. without liver injury Variable With liver injury, n=476 (74.5%) Without liver injury, n=163 (25.5%) p* Age in years at admission Mean age±standard deviation 58.89±15.61 61.92±17.32 0.038 Sex 0.041 Male 63.0% 54.0% Female 37.0% 46.0% Race 0.26 White 22.1% 21.5% African American 24.6% 30.7% Hispanic 38.2% 30.7% Asian or Pacific Islander 2.9% 6.1% Other 11.1% 9.8% Insurance status 0.23 Uninsured/self-pay 16.0% 16.0% Medicare/Medicaid 40.1% 45.4% Private insurance 41.8% 34.4% Unknown 1.9% 4.3% Comorbidities Alcohol abuse 14.9% 10.4% 0.268 Asthma/COPD 10.5% 11.0% 0.713 HIV/AIDS 1.1% 1.8% 0.789 Congestive heart failure 4.8% 8.6% 0.247 Diabetes mellitus 34.5% 43.6% 0.078 OSA/OHS 1.9% 0.6% 0.521 Hypertension 50.6% 58.9% 0.221 Malignancy 5.0% 3.7% 0.321 Chronic kidney disease 7.6% 15.3% 0.010 Coronary artery disease 8.0% 14.1% 0.05 In- hospital Outcomes All cause in-hospital mortality 35.5% 22.7% <0.001 Cardiac arrest 26.1% 14.1% <0.001 Intubation 30% 14.7% <0.001 ARDS 43.1% 30.7% 0.004 Arrhythmias 5.2% 0.6% 0.05 Shock 15% 2.8% 0.016 Open in a separate window *p≤0.05 at 95% confidence interval indicates statistical significance. Abbreviations: ARDS, acute respiratory response syndrome; COPD, chronic obstructive pulmonary disease; OSA/OHS, obstructive sleep apnea/obesity hypoventilation syndrome; HIV/AIDS, human immunodeficiency virus/acquired immunodeficiency syndrome.