Non-alcoholic fatty liver disease (NAFLD) and risk of hospitalization for Covid-19

Abstract

Background: Covid-19 disease causes significant morbidity and mortality through increase inflammation and thrombosis. Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are states of chronic inflammation and indicate advanced metabolic disease. We sought to understand the risk of hospitalization for Covid-19 associated with NAFLD/NASH. Methods: Retrospective analysis of electronic medical record data of 6,700 adults with a positive SARS-CoV-2 PCR from March 1, 2020 to Aug 25, 2020. Logistic regression and competing risk were used to assess odds of being hospitalized. Additional adjustment was added to assess risk of hospitalization among patients with a prescription for metformin use within the 3 months prior to the SARS-CoV-2 PCR result, history of home glucagon-like-peptide 1 receptor agonist (GLP-1 RA) use, and history of metabolic and bariatric surgery (MBS). Interactions were assessed by gender and race. Results: A history of NAFLD/NASH was associated with increased odds of admission for Covid-19: logistic regression OR 2.04 (1.55, 2.96, p<0.01), competing risks OR 1.43 (1.09-1.88, p<0.01); and each additional year of having NAFLD/NASH was associated with a significant increased risk of being hospitalized for Covid-19, OR 1.86 (1.43-2.42, p<0.01). After controlling for NAFLD/NASH, persons with obesity had decreased odds of hospitalization for Covid-19, OR 0.41 (0.34-0.49, p<0.01). NAFLD/NASH increased risk of hospitalization in men and women, and in all racial/ethnic subgroups. Mediation treatments for metabolic syndrome were associated with non-significant reduced risk of admission: OR 0.42 (0.18-1.01, p=0.05) for home metformin use and OR 0.40 (0.14-1.17, p=0.10) for home GLP-1RA use. MBS was associated with a significant decreased risk of admission: OR 0.22 (0.05-0.98, p<0.05). Conclusions: NAFLD/NASH is a significant risk factor for hospitalization for Covid-19, and appears to account for risk attributed to obesity. Treatments for metabolic disease mitigated risks from NAFLD/NASH. More research is needed to confirm risk associated with visceral adiposity, and patients should be screened for and informed of treatments for metabolic syndrome.

Association of Bariatric Surgery with Clinical Outcomes of SARS-CoV-2 Infection: a Systematic Review and Meta-analysis in the Initial Phase of COVID-19 Pandemic

“…Our literature review yielded 3 retrospective studies [3,20,21] on 9022 unique patients including 590 patients who had a history of prior bariatric surgery (Fig. 1, Table 1).…”

“…4 Risk of bias in 7 domains for 3 included studies based on the ROBINS-I tool studies and lack of high-quality data, any strong conclusion on the protective effects of bariatric surgery after contracting SARS-CoV-2 infection in patients with obesity seems premature. At the time of conducting this meta-analysis, the study from the University of Minnesota [20] was available in preprint version and its peer-review process had not been completed yet. Although the amount of heterogeneity across the 3 studies was small, there was a substantial risk of bias in quality metrics including the risk of confounding and selection bias across the included studies.…”

“…This retrospective analysis of electronic medical record data of patients with a positive SARS-CoV-2 test from March 1, 2020, to August 25, 2020, showed that a history of nonalcoholic fatty liver disease (NAFLD) was associated with increased odds of hospital admission after SARS-CoV-2 infection. Among 373 patients with NAFLD, a subgroup of patients who had undergone bariatric surgery (n = 16) had significantly decreased odds of hospitalization (OR 0.22 [95% CI 0.05-0.98], P < 0.05) [20].…”

“…All 3 studies reported the mortality outcome [3,20,21]. The risk of mortality without previous bariatric surgery was 133 per 1000 cases and its risk with previous bariatric surgery was 33 per 1000 (summary OR 0.22, 95% CI 0.19-0.26, based on the random-effects meta-analysis).…”

“…The Cleveland Clinic [3] and the University of Minnesota [20] studies independently reported a lower risk of hospitalization in patients with prior bariatric surgery after contracting SARS-CoV-2 infection. In the pooled analysis, the hospitalization rate in patients without previous bariatric surgery was 412 per 1000 cases and its rate in patients with previous bariatric surgery was 164 per 1000 (summary OR 0.28, 95% CI 0.12-0.65, based on the random-effects meta-analysis).…”