Coronavirus disease 2019 (COVID-19) is a global pandemic which has caused numerous deaths worldwide. The present study investigated the roles of hypoproteinemia in the clinical outcome and liver dysfunction of COVID-19 patients. In this retrospective study, we extracted data from 2,623 clinically confirmed adult COVID-19 patients (>18 years old) between January 29, 2020 and March 6, 2020 in Tongji Hospital, Wuhan, China. The patients were divided into three groups—non-critically ill, critically ill, and death groups—in accordance with the Chinese Clinical Guideline for COVID-19. Serum albumin, low-density lipoproteins cholesterol (LDL-C), and high-density lipoproteins cholesterol (HDL-C) concentrations and inflammatory cytokines levels were measured and compared among these three groups. The median age of these 2,623 patients was 64 years old (interquartile range (IQR), 52–71). Among the patients enrolled in the study, 2,008 (76.6%) were diagnosed as non-critically ill and 615 (23.4%) were critically ill patients, including 383 (14.6%) critically ill survivors and 232 (8.8%) critically ill deaths in the hospital. Marked hypoalbuminemia occurred in 38.2%, 71.2%, and 82.4% patients in non-critically ill, critically ill, and death groups, respectively, on admission and 45.9%, 77.7%, and 95.6% of these three groups, respectively, during hospitalization. We also discovered that serum low-density lipoprotein (LDL) and HDL levels were significantly lower in critically ill and death groups compared to non-critically ill group. Meanwhile, the patients displayed dramatically elevated levels of serum inflammatory factors, while a markedly prolonged activated partial thromboplastin time (APTT) in critically ill patients reflected coagulopathy. This study suggests that COVID-19-induced cytokine storm causes hepatotoxicity and subsequently critical hypoalbuminemia, which are associated with exacerbation of disease-associated inflammatory responses and progression of the disease and ultimately leads to death for some critically ill patients.
Arentz, M., Yim, E., Klaff, L., Lokhandwala, S., Riedo, F.X., Chong, M., and Lee, M. (2020). Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA 323, 1612.
Chai, X., Hu, L., Zhang, Y., Han, W., Lu, Z., Ke, A., Zhou, J., Shi, G., Fang, N., Fan, J., et al. (2020). Specific ACE2 expression in cholangiocytes may cause liver damage after 2019-nCoV infection. bioR-xiv, https://doi.org/10.1101/2020.02.03.931766.
Chen, C., Zhou, Y., and Wang, D.W. (2020). SARS-CoV-2: a potential novel etiology of fulminant myocarditis. Herz 45, 230–232.
Guan, W., Ni, Z., Hu, Y., Liang, W., Ou, C., He, J., Liu, L., Shan, H., Lei, C., Hui, D.S.C., et al. (2020). Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 382, 1708–1720.
Holshue, M.L., DeBolt, C., Lindquist, S., Lofy, K.H., Wiesman, J., Bruce, H., Spitters, C., Ericson, K., Wilkerson, S., Tural, A., et al. (2020). First case of 2019 novel coronavirus in the United States. N Engl JMed 382, 929–936.
Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., Zhang, L., Fan, G., Xu, J., Gu, X., et al. (2020). Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 395, 497–506.
Imaeda, A.B., Watanabe, A., Sohail, M.A., Mahmood, S., Mohamadnejad, M., Sutterwala, F.S., Flavell, R.A., and Mehal, W.Z. (2009). Acetaminophen-induced hepatotoxicity in mice is dependent on Tlr9 and the Nalp3 inflammasome. J Clin Invest 119, 305–314.
Liu, Y., Yan, L.M., Wan, L., Xiang, T.X., Le, A., Liu, J.M., Peiris, M., Poon, L.L.M., and Zhang, W. (2020a). Viral dynamics in mild and severe cases of COVID-19. Lancet Infect Dis https://doi.org/10.1016/S1473-3099(20)30232-2.
Liu, Y., Yang, Y., Zhang, C., Huang, F., Wang, F., Yuan, J., Wang, Z., Li, J., Li, J., Feng, C., et al. (2020b). Clinical and biochemical indexes from 2019-nCoV infected patients linked to viral loads and lung injury. Sci China Life Sci 63, 364–374.
Mao, R., Liang, J., Shen, J., Ghosh, S., Zhu, L.R., Yang, H., Wu, K.C., and Chen, M.H. (2020). Implications of COVID-19 for patients with preexisting digestive diseases. Lancet Gastroenterol Hepatol 5, 425–427.
Matthay, M.A., Aldrich, J.M., and Gotts, J.E. (2020). Treatment for severe acute respiratory distress syndrome from COVID-19. Lancet Respir Med 8, 433–434.
Murthy, S., Gomersall, C.D., and Fowler, R.A. (2020). Care for critically ill patients with COVID-19. JAMA 323, 1499.
National Health Commission of China. (2020). Chinese management guideline for COVID-19 (version 5.0). http://www.nhc.gov.cn/yzygj/s7653p/202002/d4b895337e19445f8d728fcaf1e3e13a.shtml.
Peiris, J.S.M., Guan, Y., and Yuen, K.Y. (2004). Severe acute respiratory syndrome. Nat Med 10, S88–S97.
Saghazadeh, A., and Rezaei, N. (2020). Immune-epidemiological parameters of the novel coronavirus—a perspective. Expert Rev Clin Immunol https://doi.org/10.1080/1744666X.2020.1750954.
Shi, S., Qin, M., Shen, B., Cai, Y., Liu, T., Yang, F., Gong, W., Liu, X., Liang, J., Zhao, Q., et al. (2020). Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol https://doi.org/10.1001/jamacardio.2020.0950.
Sun, D., Li, H., Lu, X.X., Xiao, H., Ren, J., Zhang, F.R., and Liu, Z.S. (2020). Clinical features of severe pediatric patients with coronavirus disease 2019 in Wuhan: a single center’s observational study. World J Pediatr https://doi.org/10.1007/s12519-020-00354-4.
Wang, C., Xie, J., Zhao, L., Fei, XC., Zhang, H., Tan, Y., Zhou, LT., Liu, ZH., Ren, Y., Yuan, L., et al. (2020). Aveolar macrophage activation and cytokine storm in the pathogenesis of critical COVID-19. Research Square, https://doi.org/10.21203/rs.3.rs-19346/v1.
Wilder-Smith, A., Chiew, C.J., and Lee, V.J. (2020). Can we contain the COVID-19 outbreak with the same measures as for SARS? Lancet Infect Dis 20, e102–e107.
Xu, Z., Shi, L., Wang, Y., Zhang, J., Huang, L., Zhang, C., Liu, S., Zhao, P., Liu, H., Zhu, L., et al. (2020). Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 8, 420–422.
This work was supported in part by the National Natural Science Foundation of China (81790624, 81630010, and 81800261).
Compliance and ethics The author(s) declare that they have no conflict of interest.
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Huang, W., Li, C., Wang, Z. et al. Decreased serum albumin level indicates poor prognosis of COVID-19 patients: hepatic injury analysis from 2,623 hospitalized cases. Sci. China Life Sci. (2020). https://doi.org/10.1007/s11427-020-1733-4
- hepatic injury