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Introduction: Intensive care outcomes in patients with cirrhosis are relatively poor. The comparison between outcomes, especially related to infections, remains unclear in those with and without cirrhosis. With the emergence of resistant and fungal organisms, the changes in infection profiles over time are important to analyze. The aim of this study is to determine the impact of cirrhosis and infections on inpatient death over time in a qSOFA-matched cohort of patients with and without cirrhosis. Method(s): Inpatients admitted to ICUs throughout 2015-2021 were analyzed. Patients with cirrhosis were matched 1:1 by age, gender, and admission qSOFA to patients without;COVID-positive patients were excluded. Admission demographics, labs, the reasons for ICU transfer, infections, and inpatient death or hospice referral were obtained for each patient. Comparisons were made between patients with and without cirrhosis and those who died/referred to hospice versus not. Logistic regression for death/hospice was performed. In patients with cirrhosis, the culture results were compared over the years. Result(s): 1669 patients;833 cirrhosis and 836 non-cirrhosis patients were included. Patients with cirrhosis had higher rates of infection, positive culture, abdominal infection, and bacteremia. They also had higher gram-positive and fungal infections with a higher rate of VRE. They showed a greater organ failure load, death, and hospice referral compared to patients without cirrhosis. Logistic regression showed that cirrhosis (OR 4.0, p< 0.0001), admission qSOFA (1.60, p< 0.0001), WBC (1.02, p=0.003), reasons for ICU (altered mental status 1.69, hypotension 1.79, renal support 2.77, respiratory failure 1.79, CVA 1.96, all p< 0.0001) with Infection (1.77, p< 0.0001, >1 microbe isolated 1.86, p=0.05) were risk factors for death/hospice. The infection trend in the cirrhosis group showed a significant decrease in positive cultures and gram-negative infections and an increase in fungal and gram-positive infections over time. Conclusion(s): Despite matching for demographics and qSOFA, patients with cirrhosis had higher risks of death and organ failures. They were more likely to develop gram-positive and fungal infections with multiple organisms and VRE. Time trends in cirrhosis showed lower rates of positive cultures and gram-negative infections and an increase in fungal and gram-positive infections over time, which should encourage re-evaluation of diagnostic and prophylactic strategies in cirrhosis-related infections. (Figure Presented).
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Aim: COVID-19 is a viral pandemic that has affected the whole world in 2020. Our knowledge about this infection is improving each day. The emergency department (ED) management of COVID-19 patients is still unclear. Early warning scores (EWSs) and quick sequential organ failure assessment (qSOFA) are widely used scores in the ED. In this study, we aimed to compare EWSs and qSOFA scores in COVID-19 patients. Material(s) and Method(s): We evaluated patients diagnosed and hospitalized with COVID-19 between 10 April 2020 and 17 April 2020, including 63 COVID-19-positive patients. We calculated both EWSs and qSOFA scores for all patients and compared them by hospitalization unit (clinic or intensive care unit [ICU]), hospitalization length, and outcome. Result(s): EWS was positively correlated with hospitalization length, but we could not find a relationship between qSOFA and hospitalization length. The ICU hospitalization rate increases with high EWSs AND qSOFA scores. The mean EWS of patients hospitalized in the inpatient clinic was 1.39 and that of patients hospitalized in the ICU was 5.7. These scores were significantly different (p=0.000). The mean EWS of the patients who were discharged from the hospital was 1.6, and that of the exitus patients was 11.7 (p = 0.01). These values were 0.06 and 2.25 for qSOFA, respectively. Discussion(s): Both qSOFA and EWSs can predict the hospitalization unit and mortality, but EWSs are superior in determining the hospitalization length of COVID-19 patients.Copyright © 2022, Derman Medical Publishing. All rights reserved.
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Background: Predicting the severity of COVID-19 infection in advance is the key to success of its treatment outcome. Various scoring systems are used to detect the severity of this disease but this study targets three simple scoring systems based on the vital parameters and basic routine laboratory tests. Aims and Objectives: The aim of the study was to assess the predictability of three scoring systems (Quick sequential organ failure assessment [q SOFA], CURB-65, and Early Warning scoring system) for disease severity at presentation in a rural-based tertiary care center. Material(s) and Method(s): An observational, descriptive, retrospective, and cross-sectional study was conducted at Diamond Harbour Government Medical College Covid Hospital from January 2021 to January 2022 to assess the predictability of q SOFA, CURB-65, and Early Warning scoring system for disease severity at presentation. Result(s): The total number of participants was 561 among total admitted 1367 patients. A short descriptive analysis obtained from the variables to analyze the scorings showed among total sample collected, 57% were male and 43% were female. In this study, 87% of patients were survived and the rest 13% succumbed (death). There is no statistically significant difference in mortality between both genders. Age, pulse rate, and respiratory rate have a significant correlation with the outcome and altered sensorium is also highly associated with mortality. The accuracy was also found to be little higher for National Early Warning score (NEWS) score than CURB-65 scoring and q SOFA scoring (0.919, 0.914 and 0.907). Although all the scoring systems have high sensitivity (>90%) (CURB 65: Most sensitive [0.99]), the specificities of all three scoring systems are below 50%. Among these three-scoring systems, NEWS showed the highest specificity (0.492) than q SOFA (0.423) and CURB 65 (0.394). Conclusion(s): We suggest NEWS score and CURB-65 as a better predictor for in-hospital mortality in COVID-19 patients as it is significantly sensitive and reasonably specific. It can be recommended in less equipped hospitals where only basic laboratory facilities are available. qSOFA can be utilized where no laboratory facility is available like in safe home and isolation centers.Copyright © 2023, Mr Bhawani Singh. All rights reserved.
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Aim and background: Approximately 50% of the COVID-19 patients require intensive care due to pneumonia and respiratory failure. The CURB-65,3 CRB-654, A-DROP5 score, and Pneumonia Severity Index (PSI) scoring systems are established prognostic tools for community-acquired pneumonia (CAP). Similarly, the qSOFA score is a prognostic tool for critically ill patients. However, the utility of these scoring systems in the context of COVID-19 is yet to be established as a predictive tool for triage by means of rapid decision-making and preventive measures to combat the ongoing pandemic. Materials and methods: This observational, retrospective cohort study was conducted AIIMS, New Delhi during May to June, 2021 after obtaining institutional ethical committee approval (IEC-860/4.9.2020). Only the RT-PCR-proven patients >18 years among the institutionalized patients with severe acute respiratory infections (SARI) were included. Results: Out of the 235 included patients, 27.2% of patients required mechanical ventilation, and the overall period of hospital stay was 9 (5-13) days. While the SMART COP score with an AUC of 0.812 (95% CI 0.752-0.871), the PSI score with an AUC of 0.819 (95% CI 0.762- 0.877) obtained significant results for mortality, the A drop score with an AUC of 0.92 (0.897-0.954), and both the PSI (AUC of 0.964;95% CI 0.928-1.000), and the SMART COP (AUC of 0.925;95% CI 0.887-0.962) acquired the best result for intubation and thereby requirement of mechanical ventilation. Conclusion: Although the outcome of COVID-19 depends upon multiple factors the SMART COP, PSI, and A-drop scoring systems seem to be promising predictive tools for morbidity and mortality.
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Background: Diabetes is a common disease known to cause morbidity and mortality. Individuals with diabetes are at greater risk of complications from coronavirus and have recently gains attention of researchers and practitioners. Aim: To assess the effect of diabetes mellitus on clinical course and outcome of coronavirus infection. Study design: Prospective cohort study Place and duration of study: Coronavirus Disease High Dependency Unit Jinnah Hospital, Lahore from 01-01-2021 to03-04-2021. Methodology: Three hundred and seventy six patients of either genders and age range of 15-75 years were enrolled. They were divided into diabetic or non-diabetic groups. The various attributes such as demographic data, medical history, COVID-19 exposure history, symptoms and signs, laboratory findings, chest radiograph findings, the treatment measures and complications of diabetes and in hospital outcome were compared for both the groups. Result: Statistically different from each other in terms of oxygen requirement, lymphocyte %, neutrophil to lymphocyte ratio (P=0.026), alanine aminotransferase (P=0.038), C-reactive protein (P=0.048), ferritin (P=0.031), lactic acid dehydrogenase (LDH) (P=0.011), Ddimer (P=0.024), Quick sequential organ failure assessment score (qSOFA score) (P=0.001) and Chest X-ray (P=0.049), blood sugar random (P=0.000), treatment during hospital stay (P=0.000), insulin dose increase (P=0.000), complications during hospital stay (P=0.042) and shifting to the intensive care unit (P=0.002). Conclusion: Diabetic coronavirus patients have poorer prognosis due to higher risk of severe pneumonia and related complications including mortality than their non-diabetic counterparts.
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Patients with cirrhosis have a relatively poor prognosis in intensive care (ICU) that could be affected by the9 pandemic. However, the impact of cirrhosis care compared to noncirrhotic patients is unclear pre and post-pandemic. Aim: Define impact of cirrhosis on mortality in ICU patients before & after COVID-19. Methods: ICU pts from a large tertiary hospital who were admitted for >24 hours were divided into pre-COVID (2019) and postpandemic (2020) eras. We excluded patients where cirrhosis diagnosis was unclear. Within the 2020 cohort, we further divided pts into COVID-positive or negative based on PCR. Pts with cirrhosis were matched 1:1 to non-cirrhotic pts with respect to age, ICU admission qSOFA & ICU length of stay in both cohorts. Reasons for ICU admission, infections, organ failures and discharge information were collected. We first compared only COVID negative cirrhosis vs other pts in the pre and post cohorts & then further compared these within the COVID positive pts. Logistic regression with death/hospice as the outcome was used with cirrhosis status, qSOFA, reason for ICU admission and organ failures as independent variables in the three matched cohorts (pre-COVID, post-COVID positive & post-COVID negative). Finally, to evaluate the relative impact of cirrhosis vs COVID-19, we combined the 2020 cohort and determined death/hospice determinants. Results: We included 200 age/LOS/qSOFA-matched pts with/without cirrhosis in pre-COVID cohort. Post-COVID similarly, 200 pts were included in the COVID negative group. 64 COVID+ pts (with/ without cirrhosis) were also included. More non-cirrhotic pts were admitted for procedural observation & stroke while altered mental status (AMS) were similar. Remaining organ failures were higher in cirrhosis in pre- and post-COVID settings (Table 1). In COVIDpositive pts, cirrhosis had lower infections, respiratory failure and intubation but trended towards higher death. Cirrhosis comparison pre vs post-COVID: Post-COVID cirrhosis pts had a higher MELDNa score (15.4±7.9 vs 22.3±10.2, p=0.004)and qSOFA (2.4 vs 1.7, p<0.001) compared to pre-COVID. Logistic regression for death/hospice (Table 2): Pre COVID was significant for cirrhosis, qSOFA , altered mental status & Pressors. Post-COVID in COVID-negative pts it was again significant for cirrhosis, Infection, renal failure & qSOFA. For only COVID positive patients, only renal failure was significant. In the entire 2020 cohort, COVID-19 positive status was not significant in death/hospice prediction, but cirrhosis remained significant. Conclusions: Cirrhosis remains a major cause of mortality in patients admitted to intensive care that continues regardless of COVID-19 pandemic-induced changes in the health system. Cirrhosis is predictive of death independent of COVID-19 despite controlling for demographics and organ failure severity. (Table Presented)
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The health care burden and risks to health care workers imposed by novel coronavirus disease 2019 (COVID-19) mandated the need for a simple, noninvasive, objective, and parsimonious risk stratification system predicting the level of care, need for definitive airway, and titration of the ongoing patient care. Shock index (SI = heart rate/systolic blood pressure) has been evaluated in emergency triage, sepsis, and trauma settings including different age group of patients. The ever accumulating girth of evidences demonstrated a superior predictive value of SI over other hemodynamic parameters. Inclusion of respiratory and/or neurological parameters and adjustment of the cutoffs appropriate to patient age increase the predictability in the trauma and sepsis scenario. Being reproducible, dynamic, and simple, SI can be a valuable patient risk stratification tool in this ongoing era of COVID-19 pandemic.
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Objective: To determine the association between body weight and COVID-19 outcomes. Methods: This is a retrospective cohort study of COVID-19 patients admitted in a dedicated COVID-19 hospital, a tertiary health care center, between May and June 2021. Demographic data and baseline variables, including age, sex, body mass index (BMI), and comorbidities were collected. Outcomes (death or mechanical ventilation) of the patients with different BMI, age, comorbidities, and qSOFA scores were compared. Besides, the risk factors for death or mechanical ventilation were determined. Results: The mean age of the subjects was (51.8±14.7) years old, and 233 (74.2%) were male. There were 103 (32.8%) patients with normal weight, 143 (45.5%) patients were overweight, and 68 (21.7%) patients were obese. In-hospital deaths and need of mechanical ventilations were significantly higher in the obese and the overweight group compared to the normal weight group, in age group ≥65 years compared to <65 years, in patients with ≥1 comorbidities compared to patients without comorbidities, in patients with qSOFA scores ≥2 compared to patients with qSOFA scores<2. There was a significantly increased risk of death (RR: 4.1, 95% CI 1.0-17.4, P=0.04) and significantly increased need of mechanical ventilation (RR: 5.2, 95% CI 1.8-15.2, P=0.002) in the obese patients compared with those with normal weight after controlling other covariates. Conclusion: Obesity is one of the significant risk factors for adverse outcomes in COVID-19 patients and should be considered during management.
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Background. We aimed to explore a novel risk score to predict mortality in hospitalised patients with COVID-19 pneumonia. In additoon, we compared the accuracy of the novel risk score with CURB-65, qSOFA and NEWS2 scores. Methods. The study was conducted in hospitalised patients with laboratory and radiologically confirmed COVID-19 pneumonia between November 1, 2020 and November 30, 2020. In this retrospective multicenter study. independent predictors were identified using multivariate logistic regression analysis. A receiver operating characteristics (ROC) analysis with area under the curve (AUC) was used to evaluate the performance of the novel score. The optimal cut-off points of the candidate variables were calculated by the Youden's index of ROC curve. Mortality was defined as all cause in-hospital death. Results. A total of 1013 patients with COVID-19 were included. The mean age was 60,5 ±14,4 years, and 581 (57,4%) patients were male. In-hospital death was occured in 124 (12,2%) patients. Multivariate analysis revealed that peripheral capillary oxygen saturation (SpO2), albumin, D-dimer, and age were independent predictors for mortality (Table). A novel scoring model was named as SAD-60 (SpO2, Albumin, D-dimer, ≥60 years old). SAD-60 score (0,776) had the highest AUC compared to CURB-65 (0,753), NEWS2 (0,686), and qSOFA (0,628) scores (Figure). Conclusion. We demonstrated that SAD-60 score had a promising predictive capacity for mortality in hospitalised patients with COVID-19. Univariate and multivariate analysis of factors predicting mortality Comparison of CURB-65, qSOFA, NEWS-2 and SAD-60 for predicting pneumonia mortality in hospitalised patients with COVID-19 by ROC analysis.
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Background. Remdesivir (RDV), an antiviral agent, is approved by Food and Drug Administration (FDA) for the treatment of patients (pts) admitted with SARSCOV-2 infection (COVID-19). Earlier RDV studies (such as ACCT-1) prior to widespread use of corticosteroids (CS), showed a 30-day mortality of 11%. Advanced age, obesity, and certain comorbidities are known risk factors for death in COVID-19, but whether these risks vary in pts treated with RDV and CS is unknown. As of March 20, 2020 CS were routinely used for the treatment of pts admitted with COVID19 in our health care system. The objective of this study was to identify risk factors associated with 30 -Day mortality in a cohort of pts admitted with COVID-19 and who received RDV and CS. Methods. This retrospective cohort study evaluated pts admitted to a health system in South East Michigan with COVID-19 between March and November 2020 who received ≥1 dose RDV. Demographics, comorbidities, and characteristics including quick sequential organ failure assessment (qSOFA) score were collected and compared between patients who died versus survived. Primary outcome was 30 day mortality. Secondary outcomes were risk factors for death using logistic regression and time-to-event analysis. Results. A total of 1,591 pts received RDV and were included in the study;median age 67 years, 56% male and 18% Black. RDV use increased after emergency use authorization and FDA approval (Fig 1). Death within 30 days occurred in 15.3%. Patients who died were older males with higher rates of hypertension, kidney disease, diabetes, and were more likely to have qSOFA ≥2 on arrival (Table 1). In a multivariable logistic model, advanced age, male gender, pulmonary disease, CKD, obesity, and qSOFA≥2 were independent predictors of death (Figure 2). Among these, age and qSOFA≥2 were the most important risk factors (Figure 2). Patients receiving remdesivir (red) were included in the study. Routine use of corticosteroids was adopted on all patients in our health system beginning March 20, 2020. System-wide use of remdesivir increased following Food and Drug Administration approval in fall 2020. On both logistic regression and time-to-event analysis, advanced age and qSOFA ≥ 2 had the highest predictive value for mortality. Others comorbidities were similar and comparable in importance. Conclusion. The population in our Real-world study was older with more comorbidities as compared to ACCT-1, and the 30 day mortality was 15%. Despite the use of CS and RDV advanced age and qSOFA were the most important drivers of mortality. Future, therapeutic strategies need to focus on this group which is at the highest risk of dying from COVID-19 infection.
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Background. Growing evidence supports the use of remdesivir and tocilizumab for the treatment of hospitalized patients with severe COVID-19. The purpose of this study was to evaluate the use of remdesivir and tocilizumab for the treatment of severe COVID-19 in a community hospital setting. Methods. We used a de-identified dataset of hospitalized adults with severe COVID-19 according to the National Institutes of Health definition (SpO2 < 94% on room air, a PaO2/FiO2 < 300 mm Hg, respiratory frequency > 30/min, or lung infiltrates > 50%) admitted to our community hospital located in Evanston Illinois, between March 1, 2020, and March 1, 2021. We performed a Cox proportional hazards regression model to examine the relationship between the use of remdesivir and tocilizumab and inpatient mortality. To minimize confounders, we adjusted for age, qSOFA score, noninvasive positive-pressure ventilation, invasive mechanical ventilation, and steroids, forcing these variables into the model. We implemented a sensitivity analysis calculating the E-value (with the lower confidence limit) for the obtained point estimates to assess the potential effect of unmeasured confounding. Figure 1. Kaplan-Meier survival curves for in-hospital death among patients treated with and without steroids The hazard ratio was derived from a bivariable Cox regression model. The survival curves were compared with a log-rank test, where a two-sided P value of less than 0.05 was considered statistically significant. Figure 2. Kaplan-Meier survival curves for in-hospital death among patients treated with and without remdesivir The hazard ratio was derived from a bivariable Cox regression model. The survival curves were compared with a log-rank test, where a two-sided P value of less than 0.05 was considered statistically significant. Results. A total of 549 patients were included. The median age was 69 years (interquartile range, 59 - 80 years), 333 (59.6%) were male, 231 were White (41.3%), and 235 (42%) were admitted from long-term care facilities. 394 (70.5%) received steroids, 192 (34.3%) received remdesivir, and 49 (8.8%) received tocilizumab. By the cutoff date for data analysis, 389 (69.6%) patients survived, and 170 (30.4%) had died. The bivariable Cox regression models showed decreased hazard of in-hospital death associated with the administration of steroids (Figure 1), remdesivir (Figure 2), and tocilizumab (Figure 3). This association persisted in the multivariable Cox regression controlling for other predictors (Figure 4). The E value for the multivariable Cox regression point estimates and the lower confidence intervals are shown in Table 1. The hazard ratio was derived from a bivariable Cox regression model. The survival curves were compared with a log-rank test, where a two-sided P value of less than 0.05 was considered statistically significant. The hazard ratios were derived from a multivariable Cox regression model adjusting for age as a continuous variable, qSOFA score, noninvasive positive-pressure ventilation, and invasive mechanical ventilation. Table 1. Sensitivity analysis of unmeasured confounding using E-values CI, confidence interval. Point estimate from multivariable Cox regression model. The E value is defined as the minimum strength of association on the risk ratio scale that an unmeasured confounder would need to have with both the exposure and the outcome, conditional on the measured covariates, to explain away a specific exposure-outcome association fully: i.e., a confounder not included in the multivariable Cox regression model associated with remdesivir or tocilizumab use and in-hospital death in patients with severe COVID-19 by a hazard ratio of 1.64-fold or 1.54-fold each, respectively, could explain away the lower confidence limit, but weaker confounding could not. Conclusion. For patients with severe COVID-19 admitted to our community hospital, the use of steroids, remdesivir, and tocilizumab were significantly associated with a slower progression to in-hospital death while controlling for other predictors included in the models.
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Introduction: COVID-19 infection is associated with troponin elevation, which is associated with increased mortality. We wanted to evaluate whether troponin levels, GRACE scores, and TIMI scores were independently associated with mortality in COVID-19 patients. Methods: Out of 1500 COVID-19 patients admitted to our hospitals, 217 patients with troponin levels were included. Key variables were collected manually, and survival analysis was done. Results: Mortality was 26.5% in the normal troponin group and 54.6% in the elevated troponin group. Patients with elevated troponins had increased frequency of hypotension (P=0.01), oxygen support (P<0.01), low absolute lymphocyte count (P<0.01), elevated blood urea nitrogen (P<0.01), higher C-reactive protein (P<0.01), higher D-dimer (P<0.01), higher lactic acid (P<0.01), and higher qSOFA, SOFA, TIMI, and GRACE scores (all scores P<0.01). On cox regression, troponin elevation (HR 1.85, 95% CI 1.18-2.88, P<0.01), TIMI score >3 (HR 1.79, 95% CI 1.11-2.75, P=0.01), GRACE score >140 (HR 2.27, 95% CI 1.45-3.55, P<0.01) were highly associated with mortality whereas cardiovascular disease (HR 1.40, 95% CI 0.89-2.21, P=0.129) and cardiovascular risk factors (HR 1.15, 95% CI 0.73-1.81, P=0.52) were not. We created four separate multivariate cox regression models for troponin, GRACE score, TIMI score, and SOFA score while adjusting for age, use of nonrebreather or high flow nasal cannula, hemoglobin<8.5, suspected or confirmed source of infection, and qSOFA score. GRACE (HR 1.02, 95% CI 1.01-1.04, P<0.01) and SOFA scores (HR 1.19, 95% CI 1.08-1.31, P<0.01) were independently associated with mortality whereas Troponin (HR 1.08, 95% CI 0.63-1.85, P=0.76) and TIMI score (HR 1.02, 95% CI 0.99-1.06, P=0.12) were not. SOFA scores are positively correlated with GRACE scores (r=+0.39). Conclusion: Troponin elevation in COVID-19 patients is mostly due to demand ischemia rather than acute coronary syndrome-related. This was shown by the association of troponin with a higher degree of systemic inflammation and end-organ dysfunction. We recommend SOFA scores and GRACE scores in risk stratifying COVID-19 patients with myocardial injury.
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Background: Diabetes has often been indicated as one of the comorbidities in COVID-19 patients. Although infection with COVID-19 primarily affects the lungs causing respiratory complications, other organs are affected including the liver and kidney. The purpose of this study was to determine the effects of diabetes status, liver function and kidney function on COVID-19 severity and length of hospital stay. Methods: This retrospective study used medical records from patients admitted to the University Medical Center, El Paso, TX with COVID-19 (n = 754;age 54.86 ± 0.63 years;BMI 30.07 ± 0.26 Kg/m2). Diabetes status was assessed by glycated hemoglobin (HbA1c) ≥ 6.5%. Liver and Kidney functions were measured by Aspartate transaminase (AST;normal Female/Male 14-36/ 17-59 U/L) and blood urea nitrogen (BUN;normal Female/Male 7-17/ 9-20 mg/dl). Severity of COVID-19 was measured by quick sepsis-related organ failure assessment (qSOFA) and length of hospitalization was determined by the number of days spent in the hospital. Groups were compared using unpaired t-test. Results: Patients with high AST levels had greater COVID-19 severity, measured by qSOFA (high: 0.35 ± 0.03 vs. normal: 0.81 ± 0.05;p = 0.002) and greater length of hospital stay (high: 7.79 ± 0.54 vs. normal 6.35 ± 0.45 days;p = 0.04). Patients with high BUN levels also had greater COVID-19 severity, measured by qSOFA (high: 0.37 ± 0.04 vs. normal: 0.24 ± 0.021;p = 0.001) and greater length of hospital stay (high: 8.83 ± 0.57 vs normal: 5.89 ± 0.38;p < 0.0001). However, patients with diabetes were not different in terms of severity (qSOFA: Non-diabetes 0.34 ± 0.05, vs. Diabetes 0.28 ± 0.03;p = 0.30) and length of hospital stay (Non-diabetes 8.15 ± 0.74, vs. Diabetes 8.88 ± 0.61 days;p = 0.47). Conclusions: Liver and Kidney dysfunction indicates increased severity and length of hospital stay in COVID-19 patients while diabetes status did not. Early detection and supportive interventions that are protective of kidney and liver function may help reduce severity of COVID-19.