Elevated Liver Fibrosis Index Scores May Predict Poorer COVID-19 Outcomes

COVID19 patient
COVID19 patient
A team of investigators assessed outcomes associated with advanced liver fibrosis in patients with COVID-19 infection.

Study data published in the Journal of Infectious Disease identified elevated liver fibrosis index (Fibrosis-4 Index for Liver Fibrosis [FIB-4]) score as a prognostic indicator of poor clinical outcomes in patients with coronavirus disease (COVID-19). In a cohort study of patients with COVID-19, those with an FIB-4 ≥2.67 were more likely to require mechanical ventilation compared with those with lower FIB-4 scores.

The FIB-4 is a noninvasive tool used to estimate liver scarring. This observational study assessed FIB-4 and other metrics of liver function in patients with laboratory-confirmed COVID-19.  Patients were recruited between February and March of 2020 from 5 hospitals in the Madrid region of Spain.  Demographic characteristics and laboratory values were collected at the time of COVID-19 diagnosis. Information on medication history, cardiovascular risk factors, and comorbid conditions was also captured. FIB-4 was computed using the results of blood tests taken at hospital admission. Patients with FIB-4 scores ≥2.67 were considered to be at high risk for advanced liver fibrosis; FIB-4 score <1.30 was used as the low-risk threshold. Logistic regression was used to assess the likelihood of mechanical ventilation among patients with and without high FIB-4 values.

The study cohort comprised 160 patients, among whom 41.3% were women. Median age was 55 years (interquartile range [IQR], 48-60). Median follow-up length was 29 days (IQR 26-33). Overall, 39.4% of patients had at least 1 cardiovascular risk factor, the most common of which were obesity (37%), hypertension (20%), and smoking (19.3%). A total of 38 patients (23.8%) required mechanical ventilation. Median FIB-4 score was 1.87 (IQR, 1.34-2.90), and 45 patients (28.1%) had FIB-4 scores ≥2.67. Patients with FIB-4 scores ≥2.67 were significantly more likely to require mechanical ventilation than patients with scores <1.30 (odds ratio [OR], 7.08; 95% CI, 1.88-26.6). This association remained significant after adjustments for cardiovascular risk factors, history of respiratory disease, and C-reactive protein levels (OR, 3.41; 95% CI, 1.30-8.92). Patients with FIB-4 scores between 1.30 and 2.67 (considered intermediate risk) did not have significantly different outcomes compared with patients with FIB-4 scores <1.30.

These data support the prognostic role of FIB-4 in patients with COVID-19. Even in adjusted analyses, patients with high-risk FIB-4 scores were more than 3 times likely to require mechanical ventilation than patients with intermediate- or low-risk scores. However, whether FIB-4 was a true measure of liver fibrosis or merely identified a change induced by COVID-19 remains unclear. Further study is necessary to confirm these findings and determine the best way to accommodate patients with advanced liver scarring and COVID-19. 

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Ibáñez-Samaniego L, Bighelli F, Usón C, et al. Elevation of liver fibrosis index FIB-4 is associated with poor clinical outcomes in patients with COVID-19 [published online June 21, 2020]. J Infect Dis. doi:10.1093/infdis/jiaa355