Author: Denise Baez
DG Alerts
Early elevation of the Fibrosis-4 (FIB-4) index score is independently associated with adverse outcomes among patients hospitalised with coronavirus disease 2019 (COVID-19), according to a study published in Clinical Infectious Diseases.
The FIB-4 index was developed to leverage inexpensive and routinely available laboratory results, such as platelet count, aspartate transaminase, and alanine transaminase, along with age, to noninvasively identify liver fibrosis among patients with viral hepatitis. However, FIB-4 has also been shown to predict all-cause inpatient mortality and all liver-related outcomes among individuals without known chronic liver diagnosis.
Jing Sun, MD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and Fangfei Xiang, MD, Guangzhou Eighth People’s Hospital, Guangzhou, China, and colleagues evaluated the FIB-4 index score in 267 patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who were admitted to the Guangzhou Eighth People’s Hospital between January 20, 2020, and February 10, 2020. All laboratory values were obtained within 24 hours of admission to the hospital.
Of the patients, 41 (15.4%) progressed to severe disease stage, 36 (13.5%) required high-flow oxygen support, 10 (3.7%) required mechanical ventilator support, and 7 (2.6%) required extracorporeal membrane oxygenation (ECMO) support during hospitalisation. By March 31, 2020, 1 patient had died, 5 were still in care, and the remainder had been discharged.
Severe disease stage was defined by ≥1 of the following occurring at any point during hospitalisation: (1) respiration rate ≥30 breaths/minute; (2) resting oxygen saturation <93%; (3) ratio of arterial oxygen partial pressure to fractional inspired oxygen ≤300 mm Hg; or (4) imaging demonstrating rapid lung disease progression within 48 hours.
Of the patients, 153 (57.3%) had a FIB-4 score <1.45, 89 (33.3%) had scores between 1.45 and 3.25, and 32 (12.0%) had a FIB-4 score >3.25.
A FIB-4 score between 1.45 and 3.25 was associated with a more than 5-fold increased hazard of high-flow oxygen use, over 4-fold increased odds of progression to severe disease stage, and over 3-fold increased odds of death or prolonged hospitalisation. A FIB-4 score >3.25 was associated with over 12-fold increased hazard of high-flow oxygen use and over 11-fold increased risk of progress to severe disease.
Compared with a FIB-4 score <1.45, a FIB-4 score >3.25 was associated with over 23-fold increased hazard of ventilator use, a 25-fold increased hazard of using high-flow oxygen, about a 21-fold increased risk of progress to severe disease, and over a 5-fold increased odds of death or prolonged hospitalisation.
All associations were independent of sex, number of comorbidities, and inflammatory markers, such as D-dimer and C-reactive protein.
Individuals who were older, had heavy alcohol consumption, or had a greater number of pre-existing conditions were more likely to have higher baseline FIB-4 scores. In terms of clinical presentation, patients with higher FIB-4 scores were more likely to have fever and fatigue at admission.
There were only 6 patients who self-reported liver disease, which was associated with an increased risk of death or prolonged hospitalisation.
“These results suggested a strong, dose-dependent association between high FIB-4 score at an early-stage of infection and adverse clinical outcomes among patients with COVID-19, and this association was not completely driven by acute inflammation,” the authors wrote. “Given that FIB-4 scores are easily available in most clinical settings, wide screening of liver fibrosis using FIB-4 among patients with COVID-19 may provide important insights to define high-risk groups and improve clinical outcomes. Underlying liver disease may place individuals with COVID-19 at greater risk to develop adverse outcomes. Therefore, healthcare providers should emphasise self-quarantine and preventive measures to patients with severe liver fibrosis. Further research using a larger sample size is warranted to better understand the mechanisms of underlying liver condition and poor prognosis among patients with COVID-19.”
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