Obesity is a well-known risk factor for the development of non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated liver disease (MAFLD) and is related to worse outcomes in COVID-19 patients. The population of Qatars population has a high prevalence of obesity and is also considered as one of the highest rates of COVID-19 cases per million population, with one of the lowest mortality rates. The authors of the present study evaluated whether NAFLD is an independent risk factor for adverse outcomes in hospitalized COVID-19 patients.

The present study included 589 patients with confirmed symptomatic COVID-19 who were hospitalized from May 2020 to June 2020. They were classified into 2 groups; NAFLD and no NAFLD, according to the hepatic steatosis index (HSI) as participants with an HSI index of 36 and above were diagnosed as having NAFLD. HSI index calculated the lowest aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values within the last 1 year before the COVID-19 diagnosis.

The primary outcome was mortality, and secondary outcomes were disease severity on presentation, and disease progression, and liver injury. Markers of advancement of disease included development of acute respiratory distress syndrome (ARDS), need for intensive care unit (ICU) admission, and mechanical ventilation. Disease severity was defined using the WHO classification into severe and non-severe. Liver injury was categorized as borderline if ALT or AST were less than twice the upper limit of normal (ULN), mild if elevated 2–5×, moderate if 5–15×, and severe if more than 15× the ULN. There were no patients with excessive use of alcohol in our study. 

The study showed that age, gender, diabetes mellitus, and increased BMI were remarkably correlated with mortality. NAFLD was considerably linked to an increased disease severity on admission, ICU admission, and requirement for mechanical ventilation. Multivariate regression analysis showed that age above 50 years was the only predictor of increased mortality. Only the presence of diabetes mellitus was a statistically important predictor. The only two important predictors of all three markers of disease progression in study were age above 50 years and a BMI above 25 kg/m².

Age was related to increased risk of ARDS (OR 2.57; 95% CI 1.80–3.66), ICU admission (OR 2.36; 95% CI 1.67–3.33) and mechanical ventilation (OR 2.03; 95% CI 1.42–2.90). While obesity was linked to increased risk of ARDS (OR 1.97; 95% CI 1.32–2.94), ICU admission (OR 1.83; 95% CI 1.26–2.65) and mechanical ventilation (OR 1.89; 95% CI 1.25–2.87). Although, the presence of NAFLD was not an independent predictor of increased mortality, disease severity on presentation, or disease progression, the presence of NAFLD was a predictor of the development of mild liver injury (OR 2.99; 95% CI 1.62–4.37) and moderate liver injury (OR 5.104; 95% CI 3.21–6.99).

Thus, it can be concluded that the presence of NAFLD is an independent predictor of mild to moderate liver injury and has been related with poor outcomes in hospitalized patients with COVID-19. NAFLD is an independent predictor of the development of mild to moderate liver injury. Nevertheless, NAFLD was not a predictor of mortality, disease severity, or markers of disease progression.

Source: Mushtaq K, Khan MU, Iqbal F, et al. NAFLD is a predictor of liver injury in COVID-19 hospitalized patients but not of mortality, disease severity on the presentation or progression - The debate continues. J Hepatol. 2021;74(2):482-484.