ABSTRACT
Background: The coronavirus disease 2019 (COVID-19) pandemic has been detrimental to those with chronic diseases, even those without infection. Management of non-alcoholic fatty liver disease (NAFLD) centers on weight management and optimization of metabolic risk factors, requiring a multi-disciplinary approach. Periods of quarantine and inactivity therefore pose limitations on lifestyle modifications and potentially impact both liver-related and health-related quality of life (HRQOL) outcomes. This study aims to identify the effects of the COVID-19 pandemic and alterations in healthcare access on patients with NAFLD. Methods: This study utilized a prospectively enrolled cohort of patients with NAFLD seen at the Innovative Center for Health and Nutrition in Gastroenterology (ICHANGE), a multidisciplinary clinic which targets treatment of obesity and related diseases in New York. Patients included had a comprehensive initial evaluation during the pre-pandemic period within six months of the first COVID-19 case at our institution (October 1, 2019 to March 3, 2020) and had follow-up with repeat laboratory data. Studied outcomes included changes in alanine aminotransferase (ALT), aspartate aminotransferase (AST), metabolic markers (hemoglobin A1c and lipids), weight and body composition. 16 patients had follow-up HRQOL data measured by the Chronic Liver Disease Questionnaire (CLDQ) and Short-Form 26 (SF-36) Health Survey. Secondary analysis compared those with at least three provider visits to those with fewer to evaluate for impact of medical care during this period. Analysis was performed using the Wilcoxon signed-rank test and the Mann-Whitney U test. This study was approved by the Institutional Review Board of Weill Cornell Medicine. Results: Of the 29 patients included patients, the mean age was 52 years and pre-pandemic body mass index 33.54 kg/m2 (Table 1). Overall, there was no significant change in weight during this period (p= 0.07), though skeletal muscle and truncal fat mass both decreased (p=0.02). Hemoglobin A1c and AST decreased upon follow-up (p=0.002 and p=0.04, respectively), though there was no significant change in ALT or lipids. There was an increase in both CLDQ and SF-36 total and composite activity and emotional scores though not to a significant degree, and was irrespective of the number of provider visits (Table 2). Conclusion: This cohort of motivated patients with NAFLD following within a resource abundant multidisciplinary clinic showed mild improvement in select biomarkers and body composition, though there was no significant improvement in the remainder of objective measures to the degree expected, which may have been limited by the COVID-19 pandemic. Though not significant in this cohort, the overall trend in improvement in HRQOL highlights the importance of ongoing targeted care within this at-risk group. (Table presented.)
ABSTRACT
Background: Rhabdomyolysis (RM) is a potentially devastating breakdown of skeletal muscle leading to complications including renal failure. It has been associated previously with COVID-19, but there is a paucity of studies outside of case reports. Our study aims to quantify the rates of RM in hospitalized COVID-19 patients and assess its relationship with liver enzyme abnormalities and various outcomes. Methods: This study was a retrospective, observational study of the first 1,107 patients admitted at two academic hospitals in New York with a diagnosis of COVID-19 confirmed by nasopharyngeal PCR. RM was defined as a peak CK>5000 U/L or a CK>1500 U/L with a urine analysis (UA) within 7 days of peak CK with moderate to large blood on dipstick and the presence of either granular casts or <20 RBC/HPF. Patients without a CK and/or UA collected were presumed to have no RM. The primary outcome was prevalence of RM among those presenting with abnormal liver enzymes (defined as ALT and AST >40 U/L). Secondary outcomes analyzed in multivariable logistic regression controlling for age, gender, race, BMI and comorbidities (diabetes, HTN, CKD, cardiovascular disease, OSA, previous thromboembolism or cancer) included kidney injury, need for dialysis, ICU stay and death. Results: Of the 1,107 patients, 44 (4.0%) were found to have RM (Figure 1A). On admission, 591 patients (60%) of those with liver enzymes drawn had elevated levels. 69% of these had AST:ALT>1;patients presenting with this finding were much more likely to already have RM or develop it during their hospitalization (8.3% vs 1.6%, OR 5.67, 95% CI 2.69-11.95). 79% of patients with RM presented with elevated AST and AST:ALT>1. Mortality was much higher in those with RM (43.2% vs 16.6%, p<0.001). While admission serum creatinine was similar, those with RM had much higher peak creatinine (4.5 vs 2.1, p<0.01). All patients with elevated AST had higher prevalence of RM, new dialysis and death (Figure 1B). In multivariable logistic regression controlling for age, gender, race, BMI and preexisting comorbidities, RM was independently associated with need for ICU stay (OR 7.08, 95% CI 2.92-17.18, p<0.001), new dialysis (OR 6.90, 95% CI 2.73-17.47, p<0.001) and death (OR 3.35, 95% CI 1.38-8.13, p<0.001). Conclusion: RM is common in COVID-19 and is often associated with elevations in AST and AST:ALT ratio. While direct liver injury has been reported in RM, our findings are likely related to the presence of AST in skeletal muscle, leading to a rise in serum levels on breakdown. In our study, RM is independently associated with poor outcomes;thus early recognition in COVID patients is key, and presentation with elevated liver enzymes, especially AST>ALT should increase clinical suspicion.