Unrecognized liver injury assessed by fibrosis indexes is associated with mortality in critically ill COVID-19 patients

Abstract Background Coronavirus disease (COVID-19) with acute respiratory distress syndrome is a life-threatening condition. A previous diagnosis of chronic liver disease is associated with poorer outcomes. Nevertheless, the impact of silent liver injury has not been investigated. We aimed to explore the association of pre-admission liver fibrosis indexes with the prognosis of critically ill COVID-19 patients. Methods Observational study in 214 patients with COVID-19 consecutively admitted to the ICU. Pre-admission liver fibrosis indexes were calculated. In-hospital mortality and predictive factors were explored with Kaplan-Meier and Cox regression analysis. Results The mean age was 59.58 (13.79) years. Sixteen patients (7.48%) had previously recognized chronic liver disease. Up to 78.84% of patients according to Forns, and 45.76% according to FIB-4, had more than minimal fibrosis. Fibrosis indexes were higher in non-survivors [Forns: 6.04 (1.42) vs 4.99 (1.58), p < 0.001; FIB-4: 1.77 (1.17) vs 1.41 (0.91), p = 0.020)], but no differences were found in liver biochemistry parameters. Patients with any degree of fibrosis either by Forns or FIB-4 had a higher mortality, which increased according to the severity of fibrosis (p < 0.05 for both indexes). Both Forns [HR 1.41 (1.11-1.81); p = 0.006] and FIB-4 [HR 1.31 (0.99-1.72); p = 0.051] were independently related to survival after adjusting for the Charlson Comorbidity Index, APACHE II and ferritin. Conclusion Unrecognized liver fibrosis, assessed by serological tests prior to admission, is independently associated with a higher risk of death in patients with severe COVID-19 admitted to the ICU.