Retrospective Cohort Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 7, 2021; 27(9): 835-853
Published online Mar 7, 2021. doi: 10.3748/wjg.v27.i9.835
Progressive liver injury and increased mortality risk in COVID-19 patients: A retrospective cohort study in China
Shui-Sheng Zhang, Li Dong, Gao-Ming Wang, Yuan Tian, Xiao-Fang Ye, Yue Zhao, Zheng-Yin Liu, Jia-Yu Zhai, Zhi-Ling Zhao, Jun-Hong Wang, Hui-Min Zhang, Xiao-Long Li, Chang-Xin Wu, Cai-Ting Yang, Li-Juan Yang, Hai-Xia Du, Hui Wang, Qing-Gang Ge, Dian-Rong Xiu, Ning Shen
Shui-Sheng Zhang, Gao-Ming Wang, Yue Zhao, Dian-Rong Xiu, Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
Li Dong, Chang-Xin Wu, Cai-Ting Yang, Institutes of Biomedical Sciences, Shanxi University, Taiyuan 030006, Shanxi Province, China
Yuan Tian, Department of Radiotherapy Oncology, Shandong Provincial Qianfoshan Hospital, The First Hospital Affiliated with Shandong First Medical University, Jinan 250014, Shandong Province, China
Xiao-Fang Ye, Department of Respiratory and Critical Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Zheng-Yin Liu, Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100005, China
Jia-Yu Zhai, Department of Rheumatology, Peking University Third Hospital, Beijing 100191, China
Zhi-Ling Zhao, Qing-Gang Ge, Department of Critical Care Medicine, Peking University Third Hospital, Beijing 100191, China
Jun-Hong Wang, Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
Hui-Min Zhang, Department of Cardiac Surgery, Peking University Third Hospital, Beijing 100191, China
Xiao-Long Li, Department of Urology, Peking University Third Hospital, Beijing 100191, China
Li-Juan Yang, Department of Gynecology, Peking University Third Hospital, Beijing 100191, China
Hai-Xia Du, Department of Rehabilitation, Peking University Third Hospital, Beijing 100191, China
Hui Wang, Department of Gastroenterology, Peking University Third Hospital, Beijing 100191, China
Ning Shen, Department of Respiratory and Critical Medicine, Peking University Third Hospital, Beijing 100191, China
Author contributions: All authors conceptualized and designed the study; Zhang SS, Dong L, Wang GM, Ye XF, Tian Y, Ge QG, Xiu DR, and Shen N contributed to the literature search; Zhang SS, Dong L, Wang GM, Tian Y, Ye XF, Zhao Y, Liu ZY, Zhai JY, Zhao ZL, Wang JH, Zhang HM, Li XL, Wu CX, Yang CT, Yang LJ, Du HX, and Wang H contributed to data collection; Zhang SS, Dong L, Wang GM, Ye XF, Tian Y, Ge QG, Xiu DR, and Shen N contributed to data analysis and interpretation; Zhao Y, Liu ZY, Zhai JY, Zhao ZL, Wang JH, Zhang HM, Li XL, Wu CX, Yang CT, Yang LJ, Du HX, and Wang H contributed to preparing the figures and tables; Zhang SS, Dong L, and Wang GM contributed to writing of the manuscript; all authors revised the final manuscript and approved the final version of the article, including the authorship list; Zhang SS, Dong L, Wang GM, Tian Y, and Ye XF should be considered joint first authors; Xiu DR, Ge QG, and Shen N should be considered co-corresponding authors.
Institutional review board statement: The study was approved by the Ethics Committee of Peking University Third Hospital (IRB00006761-M2020060).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment. Due to the particularity of the COVID-19 epidemic, all the data of patients could not be taken out and were sealed in place.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Dian-Rong Xiu, MD, PhD, Chief Doctor, Professor, Department of General Surgery, Peking University Third Hospital, No. 49 Huayuan North Road, Haidian District, Beijing 100191, China. xiudianrong@yeah.net
Received: November 21, 2020
Peer-review started: November 21, 2020
First decision: December 27, 2020
Revised: January 9, 2021
Accepted: February 4, 2021
Article in press: February 4, 2021
Published online: March 7, 2021
Processing time: 101 Days and 21 Hours
Abstract
BACKGROUND

Liver injury is common and also can be fatal, particularly in severe or critical patients with coronavirus disease 2019 (COVID-19).

AIM

To conduct an in-depth investigation into the risk factors for liver injury and into the effective measures to prevent subsequent mortality risk.

METHODS

A retrospective cohort study was performed on 440 consecutive patients with relatively severe COVID-19 between January 28 and March 9, 2020 at Tongji Hospital, Wuhan, China. Data on clinical features, laboratory parameters, medications, and prognosis were collected.

RESULTS

COVID-19-associated liver injury more frequently occurred in patients aged ≥ 65 years, female patients, or those with other comorbidities, decreased lymphocyte count, or elevated D-dimer or serum ferritin (P < 0.05). The disease severity of COVID-19 was an independent risk factor for liver injury (severe patients: Odds ratio [OR] = 2.86, 95% confidence interval [CI]: 1.78-4.59; critical patients: OR = 13.44, 95%CI: 7.21-25.97). The elevated levels of on-admission aspartate aminotransferase and total bilirubin indicated an increased mortality risk (P < 0.001). Using intravenous nutrition or antibiotics increased the risk of COVID-19-associated liver injury. Hepatoprotective drugs tended to be of assistance to treat the liver injury and improve the prognosis of patients with COVID-19-associated liver injury.

CONCLUSION

More intensive monitoring of aspartate aminotransferase or total bilirubin is recommended for COVID-19 patients, especially patients aged ≥ 65 years, female patients, or those with other comorbidities. Drug hepatotoxicity of antibiotics and intravenous nutrition should be alert for COVID-19 patients.

Keywords: COVID-19; Liver injury; Prognosis; Risk factors; Drugs; Alanine aminotransferase

Core Tip: The prevalence of liver injury in hospitalized patients with coronavirus disease 2019 (COVID-19) is high and also can be fatal. Therefore, high-risk population, especially patients aged ≥ 65 years, female patients, or patients with other comorbidities should be intensively monitored. On-admission total bilirubin has the strongest correlation with the prognosis of COVID-19 patients, which can be used for monitoring of COVID-19 patients at risk of liver injury. Intravenous nutrition and antibiotics are associated with abnormal liver biochemistry; these drugs should be given with caution. Hepatoprotective drugs are favorable for patients with liver injury.