Risk of severe illness from COVID-19 in patients with metabolic dysfunction-associated fatty liver disease and increased fibrosis scores

A recent study reported that patients with severe COVID-19 illness were more likely to have NAFLD compared to those with non-severe COVID-19 illness [1]. However, the prognosis of NAFLD (recently renamed metabolic associated fatty liver disease (MAFLD) [2]) is determined by the severity of liver fibrosis [3,4]. We therefore postulated that MAFLD patients with increased non-invasive liver fibrosis scores are at higher risk for severe illness from COVID-19. We studied 310 patients with laboratory-confirmed COVID-19, who were consecutively hospitalized at four sites in Zhejiang province, China, between January and February 2020. Some of these patients have been included in a prior study [5]. Patients with viral hepatitis, excessive alcohol intake, chronic pulmonary diseases or active cancers were excluded. Clinical and laboratory data were collected at hospital admission. All patients were screened for hepatic steatosis by computed tomography and subsequently diagnosed as MAFLD [6]. The originally validated cut-points for Fibrosis-4 (FIB-4) index and NAFLD fibrosis score (NFS) were used to categorize liver fibrosis probability as low, intermediate, or high [7]. COVID-19 severity was classified as severe and non-severe [8]. In our cohort, 94 (30.3%) patients had MAFLD. As shown in Table 1, patients with MAFLD and intermediate or high FIB-4 scores were more likely to be older, obese, have diabetes, and had higher NFS, higher liver enzymes, higher C-reactive protein, as well as lower levels of lymphocyte count, platelet count, triglycerides and HDL-cholesterol compared with their counterparts with low FIB-4 score or those without MAFLD. Notably, the severity of COVID-19 illness markedly increased amongst MAFLD patients with intermediate or high FIB-4 scores.