Liver damage in severe COVID-19 patients from Sichuan area CURRENT STATUS: UNDER REVIEW

Background: COVID-19 has spread worldwide, which becomes a huge threat to human beings. Materials: Severe COVID-19 patients from Sichuan area admitted to department of critical care medicine in Chengdu Public Health Clinical Medical Center were retrospectively enrolled. The liver function during the ICU hospitalization were record and analyzed. Results: The severe COVID-19 patients mainly presented with respiratory symptoms such as fever, cough and dyspnea, and the incidence was higher in the elderly patients and males. ALT, AST, TB, and PT increased to varying degrees during the course of the disease, and ALB decreased. The incidence of liver dysfunction in patients taking Lopinavir/Ritonavi was significantly higher than patient who did not have it, but there was no statistical difference ( p <0.05). Patients taking low-dose Lopinavir/Ritonavi had a smaller effect on liver function than patients receiving normal dosage. Conclusion : Severe COVID-19 patients have obvious liver damage early in the course of the disease and have a slower recovery. Pay attention to avoid using drugs that can aggravate liver damage while treating the primary disease. If there is no alternative drug, we can give some liver protection treatment appropriately. This study is a single-center retrospective study. Severe 2019-nCoV patients were defined as dyspnea, resting oxygen saturation ≤93%, oxygenation index ≤300mmHg, or lung imaging showing lesions significant progress > 50% within 24–48 hours in intensive care unit (ICU) who need intensive care treatment. There were 30 confirmed patients admitted to the ICU of Chengdu Public Health Clinical Medical Center from Jan 21, 2020 to Feb 24, 2020 who were diagnosed with severe 2019-nCoV pneumonia. All cases were diagnosed with 2019-nCoV pneumonia according to the WHO provisional guidelines[2]. All cases denied hepatobiliary disease or liver function impairment before 2019-nCoV infection. study was approved by the medical ethics committees of Chengdu Public Health Clinical Medical Center and informed consent from the patient or legal representative was obtained.

subsequently named by the WHO as 2019-nCoV [2]. Since the outbreak of 2019-nCoV in Wuhan, China, now there are more and more confirmed cases in multiple countries. As the 2019-nCoV is highly contagious and the transmission dynamics is still not fully understood. On January 24, Sichuan Province immediately launched the first-level response to major public health emergencies, and the Chengdu Public Health Clinical Medical Center was the designated hospital for treating severe COVID-19 patients.
Coronavirus can cause multiple organ and system infections in a variety of animals. Main target organ is the respiratory system, manifested as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) [3,4]. In most of the COVID-19 patients, the clinical symptoms are mild and the prognosis is good, sometimes combined with liver, kidney and coagulation dysfunction, while some severe patients can present severe pneumonia, Acute Respiratory Distress Syndrome (ARDS) or multiple organ dysfunction (MODS). Huang C [5]reported the clinical characteristics of 41 2019-nCoV pneumonia patients in Wuhan, China, with elevated aspartate aminotransferase (AST) levels in 15 of 41 patients(37%), including 8 of 13 ICU patients ( 62%) and 7 of 28 non-ICU patients(25%). Chen N [6]reported that they reviewed 99 2019-nCoV pneumonia patients in Wuhan and found that the overall mortality rate was close to 11%, of which 43 patients had different degrees of liver dysfunction, manifested by elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), severe liver damage in 1 patient (ALT 7590 U/L, AST 1445 U/L).
Xu Z [7]first reported worldwide that the anatomical features through liver biopsy from COVID-19 patients showed moderate microvascular steatosis and mild active inflammation of the hepatic lobular manifold area, suggesting that the injury might be caused by SARS-CoV-2 infection or druginduced. Therefore, analyzing the liver function changes in severe COVID-19 patients may provide some help in the management with severe COVID-19patients. A total of 30 severe COVID-19 patients from Sichuan area admitted to department of critical care medicine in Chengdu Public Health Clinical Medical Center were retrospectively enrolled, we analyzed and summarized the changes in liver function during the course of ICU hospitalization, which are reported as follows.

Research design
This study is a single-center retrospective study. Severe 2019-nCoV patients were defined as dyspnea, resting oxygen saturation ≤93%, oxygenation index ≤300mmHg, or lung imaging showing lesions significant progress > 50% within 24-48 hours in intensive care unit (ICU) who need intensive care treatment. There were 30 confirmed patients admitted to the ICU of Chengdu Public Health Clinical Medical Center from Jan 21, 2020 to Feb 24, 2020 who were diagnosed with severe 2019-nCoV pneumonia. All cases were diagnosed with 2019-nCoV pneumonia according to the WHO provisional guidelines [2]. All cases denied hepatobiliary disease or liver function impairment before

Statistical analysis
For continuous variables, we represent it as the mean (SD) if they fit a normal distribution, otherwise we represent it as the median (IQR) and categorical variables as counts (%). For laboratory inspection results we also evaluated whether the measured values are outside the normal range. We use SPSS (ver.17.0)for all data analysis.
Results 30 severe COVID-19patients were included in this study. Among them, 18 were males and 12 were females, with an average age of 61 years (33-87 years). 29 cases (97%) were mainly complained of fever. Other symptoms included cough (80%), dyspnea (67%), fatigue (20%), nausea (17%). 14 patients (47%) had chronic diseases, including cardiovascular and cerebrovascular diseases, endocrine system diseases, Chronic kidney disease, rheumatic immune disease, respiratory disease, malignant tumor and nervous system disease (Table 1).Up to Feb 24, there were 2 deaths, and 8 cases are still being treated in ICU, and the other20 patients are transferred out of the ICU, the average ICU stay in the 20 patients was 6.2 days. The laboratory indicators were selected for analysis within 1 week from the day admitted to ICU. 24 patients received different dosage of Lopinavir/Ritonavi for antiviral therapy, while 6 patients were not treated with it. There were 5 patients decreased the dosage due to gastrointestinal side effects (250mg bid), and 19 patients were treated with normal dose (500mg bid).
All patients' AST and ALT level were already at the upper limit of the normal range when they entered the ICU. They gradually increased with the progress of the disease, but the levels of TB, ALB and PT did not fluctuate greatly. ALB was always lower than normal. The PT was always higher than normal ( Fig. 1). 30 patients were divided into two groups according to whether they were taking Lopinavir/Ritonavi, group A was the patient who were not given Lopinavir/Ritonavi, and group B was the patient who had it. We found that the incidence of ALT, AST, TB and PT abnormalities in group B seemed to be higher than group A, but there was no statistical difference (p <0.05) (Fig. 2).
According to the different doses of Lopinavir/Ritonavi antiviral treatment, they were subdivided into normal dose group (B1) and reduced dose group (B2). Then compared the B1 and B2 group. The effects of Lopinavir/Ritonavito liver function in group B2 (ALB and TB) were not obvious. The values of ALB and TB on the second day between B1 and B2 were statistically different (p <0.05) (Fig.3, Fig.4).

Discussion
In our study, fever is the most common symptom in COVID-19 patients, of which 60% were male patients, which is consistent with previous research reports. But our patients are generally older than the previous studies, especially populations older than 80 years old [5,6,8,9]. It shows that older, male patients are more likely to be infected by 2019-nCoV, the same with the previous studied. There are currently no specific drugs to deal with the COVID-19. Most of the patients in our study received Lopinavir/Ritonavi antiviral therapy. Because of the small sample size, the efficacy of the drug cannot be analyzed.
According to previous research reports, most of the COVID-19 patients just suffer mild symptoms and almost have good prognosis. However, the mortality rate of critical COVID-19 patients was significantly higher, up to 49% [10]. Most of them were accompanied by multiple organ dysfunction, mainly involving lung, circulation, kidney, liver and myocardium [11]. 2019-nCoV, SARS-CoV and MERS-CoV are all belong to coronaviruses, which can cause different degrees of liver damage after infection [5,12,13]. Lee N [14]reported that the incidence of liver enzyme abnormalities in patients with ALT and AST are two indicators used to evaluate liver function. The liver damage caused by general viral infectious diseases is mainly manifested by the increase in liver enzymes. Xu Z [7]reported the pathological and anatomical characteristics of patient who was infected with 2019-nCoV and found that the liver biopsy specimens had moderate microvascular steatosis and mild active inflammation in the hepatic lobular duct area, which suggest that the damage may be caused by 2019-nCoV infection or drug-induced liver damage. Therefore, the virus itself has certain kind damage to the liver cell. The ALT and AST of all patients who were enrolled in our research had increased when they entered the ICU, and gradually rised with the progress of the disease. However, the use of drugs such as Lopinavir/Ritonavi may also cause liver damage when we gave for antiviral treatment. We compared the liver function between two groups of patients, and one of the group received the Lopinavir/Ritonavi therapy and another group not, and we found that the abnormal incidence of ALT, AST, TB and PT in the Lopinavir/Ritonavi group seems to be higher than another group of patient who did not take it, which proves that the drug did can aggravate liver damage in severe COVID-19

SARS-CoV infection in
patients, but there was not statistically difference, which may due to the small sample size. We then divided the patients into normal dose groups and reduction dose groups according to the different doses of Lopinavir/Ritonavi therapy. It showed that the reduction dose group had less damage effect to ALT, AST, ALB, and Tb, the ALB and TB values have statistical differences on the second day (P <0.05), which further illustrates that there was a dose-dependent effect on the liver function, but the drug effect or its pharmacokinetics after reduction dose is not clear yet, and whether it has an impact on the prognosis of the disease itself is unknown.

Limitations
The research only included 30 severe COVID-19 patients, the small sample size research conclusion can only be used as a guide and cannot confirm a certain hypothesis. Hopefully the findings of this study can encourage colleagues to conduct larger sample studies or multi-center randomized controlled trials. Although this is a retrospective study, the data in the study can provide some guidance on the treatment of critically ill COVID-19 patients.

Conclusion
In conclusion, severe COVID-19 patients had obvious liver function damage early in the course of the disease, and the recovery is slow. During the clinical diagnosis and treatment, we should pay attention to the liver function, and avoid using drugs that may aggravate liver damage while treating the primary disease. If there is no alternative medicine, liver protection treatment can be given appropriately. Dynamic monitoring of liver function changes during the course of severe COVID-19 is of great significance. L TL, DC, DQ, and CH collected the information that was used in this study, wrote the main manuscript text. LS, Y RM, and GY were the statistical team members, and prepared all figures and

Additional Information
The authors declare that they have no conflicts of interest in relation to this study.  Figure 1 Line chart of liver function index changes in 30 severe COVID-19 patients.  Dynamic changes of TB and PT in normal dose group (B1) and halved dose group (B2) within one week after hospitalization in ICU