The elevated De Ritis ratio on admission is independently associated with mortality in COVID-19 patients

Abstract Background: Besides the respiratory tract infection caused by COVID-19, 14-53% of COVID-19 patients had hepatic dysfunction on admission. Liver damage in COVID-19 patients was witnessed as increased alanine aminotransferase (ALT), aspartate aminotransferase (AST) or elevated AST/ALT ratio, known as the De Ritis ratio. However, the prognostic value of the elevated De Ritis ratio in COVID-19 patients is still unknown. The aim of our study was to evaluate the prognostic value of the De Ritis ratio compared to other abnormal laboratory parameters and the relation to mortality.Methods: 322 COVID-19 patients were selected in this retrospective study between November 2020 and March 2021. Laboratory parameters were measured on admission and followed till discharge or death. Multivariate binary logistic regression and Receiver Operating Characteristic (ROC) curves were performed to evaluate the impact of abnormal laboratory findings to predict mortality. In addition, clinical characteristics and laboratory data of COVID-19 patients were compared by different levels of De Ritis ratio.Results: Of the 322 COVID-19 patients, 57 (17.7%) had gastrointestinal symptoms on admission. Median age was 66 (54-77) years and 178 were men. The mortality rate was 11.2%. 30 patients (9.3%) had preexisting liver disease; 20 (6.2%) were liver cirrhosis. In COVID-19 recovered patients the De Ritis ratio was significantly smaller (p<.001) than in deaths (mean: 1.0 vs. 1.8). Mean values of AST, total bilirubin, albumin, CRP, PCT, IL-6 were significantly higher in COVID-19 deaths compared to survivors (p<.05). AST, De Ritis ratio, total bilirubin, IL-6, albumin and age were independently associated with mortality. The De Ritis ratio proved to be an independent risk factor for mortality with an OR of 29.967 (CI 5.266-170.514). In ROC analysis, AUC value of the the De Ritis ratio was 0.85 (95% CI 0.777-0.923, p<.05) with sensitivity and specificity 80.6% and 75.2%, respectively. Patients with De Ritis ratio ≥ 1.218 were significantly associated with mortality, severity, higher AST and IL-6, however with lower ALT.Conclusions: The elevated De Ritis ratio on admission is independently associated with mortality in COVID-19 patients. Patients with De Ritis ratio ≥1.218 are significantly susceptible to liver damage and cytokine released storm.