Liver Injury at Presentation in COVID-19 is Associated with Immuno-Inflammatory Response

ABSTRACT

Background: SARS-CoV-2 has been shown to affect liver and GI tract in addition to primary involvement of lungs. Liver injury in COVID-19 is hypothesized to be multifactorial with 14- 73% of patients showing evidence of deranged liver functional. Data regarding the liver injury due to SARS CoV-2 infection in a large cohort of unselected patients, is limited, especially from India. So, we conducted a retrospective study among consecutive patients admitted with COVID-19 disease to a tertiary care hospital during the first wave of pandemic. Methods: It was a retrospective observational study. Consecutive patients infected with SARS- CoV-2 and admitted to the COVID-19 ward or ICU of our hospital between 1/4/2020 to 30/6/2020 were included. Patients, < 18 years of age, pregnant ladies and those with underlying liver disease were excluded. Detail history along with data on laboratory parameters, treatment given and outcomes (need for oxygen therapy, ICU admission, need for ventilatory support and in-hospital mortality) was collected and analysed. Results: Data on 303 patients was analysed after exclusions. The mean age was 47.9(15.9) years and 214(69.5%) were males. Out of 303 patients 149 (49.2%) had liver injury. Mild liver injury was present in 95(31.3%), moderate to severe liver injury in 54 (17.8%) patients and only 5 (1.6%) had severe liver injury. Pure cholestatic liver injury was present 19 (6.2%) cases. Male sex (82.1% vs 58.5%;P<0.001) and presence of symptoms (97.3% vs 90.8%;P= 0.01) were associated with presence of liver injury. Patients who had liver injury had significantly longer duration of symptoms before presentation [6 (3-8) days vs 4 (3-7) days);P=0.02] and higher serum ferritin levels [322(156-552) vs 151(44.9-299.5) ng/ml;P=0.02]. On multivariate analysis, serum ferritin was the only factor, independently associated with liver injury (OR- 1.002;95% CI- 1.001-1.004;P=0.006). Serum ferritin had a positive correlation with AST [r=0.416;P=0.0001] and ALT [R=0.458;P =0.0001] in the entire cohort. Liver injury was not significantly associated with need of oxygen therapy, ICU stay, mechanical ventilation or mortality but patients with moderate-severe liver injury had a longer hospital stay than those without [12.2 (5.07) vs 10.3 (4.84) days;P=0.01]. Conclusion: In COVID-19 patients, liver injury at presentation is common in symptomatic male patients and occurs around the end of first week and correlates strongly with serum ferritin levels, suggesting that it might be driven by immuno-inflammation.