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. 2021 Oct 25;36(41):e291.
doi: 10.3346/jkms.2021.36.e291.

Non-alcoholic Fatty Liver Disease and COVID-19 Susceptibility and Outcomes: a Korean Nationwide Cohort

Hae Won Yoo #  1 , Hyun Young Jin #  2 , Dong Keon Yon #  3 , Maria Effenberger  4 , Youn Ho Shin  5 , So Young Kim  6 , Jee Myung Yang  7 , Min Seo Kim  8   9 , Ai Koyanagi  10   11 , Louis Jacob  11   12   13 , Lee Smith  14 , In Kyung Yoo  15 , Jae Il Shin  16 , Seung Won Lee  17
Affiliations

Non-alcoholic Fatty Liver Disease and COVID-19 Susceptibility and Outcomes: a Korean Nationwide Cohort

Hae Won Yoo et al. J Korean Med Sci. .

Abstract

Background: Evidence for the association between underlying non-alcoholic fatty liver disease (NAFLD), the risk of testing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive, and the clinical consequences of coronavirus disease 2019 (COVID-19) is controversial and scarce. We aimed to investigate the association between the presence of NAFLD and the risk of SARS-CoV-2 infectivity and COVID-19-related outcomes.

Methods: We used the population-based, nationwide cohort in South Korea linked with the general health examination records between January 1, 2018 and July 30, 2020. Data for 212,768 adults older than 20 years who underwent SARS-CoV-2 testing from January 1 to May 30, 2020, were obtained. The presence of NAFLDs was defined using three definitions, namely hepatic steatosis index (HSI), fatty liver index (FLI), and claims-based definition. The outcomes were SARS-CoV-2 test positive, COVID-19 severe illness, and related death.

Results: Among 74,244 adults who completed the general health examination, there were 2,251 (3.0%) who were SARS-CoV-2 positive, 438 (0.6%) with severe COVID-19 illness, and 45 (0.06%) COVID-19-related deaths. After exposure-driven propensity score matching, patients with pre-existing HSI-NAFLD, FLI-NAFLD, or claims-based NAFLD had an 11-23% increased risk of SARS-CoV-2 infection (HSI-NAFLD 95% confidence interval [CI], 1-28%; FLI-NAFLD 95% CI, 2-27%; and claims-based NAFLD 95% CI, 2-31%) and a 35-41% increased risk of severe COVID-19 illness (HSI-NAFLD 95% CI, 8-83%; FLI-NAFLD 95% CI, 5-71%; and claims-based NAFLD 95% CI, 1-92%). These associations are more evident as liver fibrosis advanced (based on the BARD scoring system). Similar patterns were observed in several sensitivity analyses including the full-unmatched cohort.

Conclusion: Patients with pre-existing NAFLDs have a higher likelihood of testing SARS-CoV-2 positive and severe COVID-19 illness; this association was more evident in patients with NAFLD with advanced fibrosis. Our results suggest that extra attention should be given to the management of patients with NAFLD during the COVID-19 pandemic.

Keywords: BARD Scoring System; COVID-19; Fatty Liver Index; Hepatic Steatosis Index; Non-alcoholic Fatty Liver Disease; SARS-CoV-2.

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Conflict of interest statement

The authors have no potential conflicts of interest to disclose.

Figures

Fig. 1
Fig. 1. Study profile.
SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2, HSI = hepatic steatosis index, FLI = fatty liver index, NAFLD = non-alcoholic fatty liver disease.
Fig. 2
Fig. 2. Flowchart of the study.
SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2, COVID-19 = coronavirus disease 2019.
Fig. 3
Fig. 3. The association between NAFLD and positive SARS-CoV-2 test results, severe COVID-19 illness, and COVID-19-related death in nationwide cohort of South Korea.
The x-axis indicates a log-scale; horizontal bars denote 95% CIs for each of the results; and blue dots indicate propensity score matched results. Severe COVID-19 comprised requirement of oxygen therapy, admission to the intensive care unit, invasive ventilation, or death. The figure was generated from our previous research and made further advance. COVID-19 = coronavirus disease 2019, HSI = hepatic steatosis index, FLI = fatty liver index, NAFLD = non-alcoholic fatty liver disease, OR = odds ratio, CI = confidence interval, SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.
See this image and copyright information in PMC

References

    1. Lee SW, Yang JM, Moon SY, Yoo IK, Ha EK, Kim SY, et al. Association between mental illness and COVID-19 susceptibility and clinical outcomes in South Korea: a nationwide cohort study. Lancet Psychiatry. 2020;7(12):1025–1031. - PMC - PubMed
    1. Kim MS, Jung SY, Lee SW, Li H, Koyanagi A, Kronbichler A, et al. Hepatobiliary adverse drug reactions associated with remdesivir: the WHO international pharmacovigilance study. Clin Gastroenterol Hepatol. 2021;19(9):1970–1972.e3. - PubMed
    1. Saviano A, Wrensch F, Ghany MG, Baumert TF. Liver disease and coronavirus disease 2019: from pathogenesis to clinical care. Hepatology. 2021;74(2):1088–1100. - PMC - PubMed
    1. Iavarone M, D'Ambrosio R, Soria A, Triolo M, Pugliese N, Del Poggio P, et al. High rates of 30-day mortality in patients with cirrhosis and COVID-19. J Hepatol. 2020;73(5):1063–1071. - PMC - PubMed
    1. Meijnikman AS, Bruin S, Groen AK, Nieuwdorp M, Herrema H. Increased expression of key SARS-CoV-2 entry points in multiple tissues in individuals with NAFLD. J Hepatol. 2021;74(3):748–749. - PMC - PubMed