Liver Scores in the Prognostication of COVID-19 Patients

Abstract

The implementation of easily accessible prognostic biomarkers for patients with COVID-19 remains an important area of clinical research. In this large monocentric study at a German tertiary care hospital, we determined the prognostic performance of different liver scores in 605 patients with COVID-19. We evaluated the Fibrosis-4 (FIB-4) index, the Aspartate Aminotransferase-to-Platelet Ratio Index (APRI), the Model for End-Stage Liver Disease (MELD) score, and the De Ritis ratio (DRR; AST/ALT ratio). The 30-day mortality was used as primary COVID-19 outcome measure. The need for intensive care unit (ICU) treatment and overall mortality were secondary endpoints. Univariable analyses showed that most of the investigated liver-related scores (FIB-4, MELD, and DRR), but not APRI for overall mortality, were significantly associated with key outcomes in COVID-19 patients. Concurrently, well-known risk factors-such as advanced age, diabetes, and cardiac or pulmonary comorbidities-were also linked to worse outcomes, except for the female sex having a preventive effect against ICU admission. A history of liver disease was rarely documented among the patients and showed no significant impact on the examined endpoints. Multivariable analyses further revealed that advanced age, DRR, and MELD were independent predictors of both 30-day and overall mortality, while FIB-4 emerged as an independent predictor specifically for overall mortality. Regarding ICU admission, obesity, underlying lung disease, and elevated APRI and MELD scores were identified as independent risk factors, whereas the female sex appeared to be protective. Overall, MELD demonstrated the strongest prognostic value for mortality and ICU admission, with DRR also exhibiting independent predictive power for mortality. These findings suggest that scores originally developed for chronic liver disease assessment-namely FIB-4, APRI, MELD, and DRR-hold promise as prognostic tools in COVID-19. In particular, MELD and DRR emerged as the most powerful biomarkers for predicting severe disease and mortality, highlighting the potential for incorporating these indices into risk stratification models for COVID-19 management. Further prospective multicenter studies are warranted to confirm these observations.

Keywords: SARS-CoV-2; coagulation; comorbidities; fibrosis; hepatic insufficiency; hepatitis; systemic immune-inflammation.