Elevated pancreatic enzyme level in covid-19 patients: Is it a silent bystander

Introduction: Initial reports indicate a high incidence of abnormal liver tests and acute kidney injury (AKI) in the novel coronavirus infection (COVID- 19). However, outcomes in hospitalized patients with COVID-19 and elevated aspartate transaminase (AST) and alanine transaminase (ALT) at admission and their associations with AKI are not well understood. Aims & Methods: The aim of the study was to investigate the incidence of elevated aminotransferases at admission and its contribution to the AKI development, disease severity and outcomes. A retrospective analysis of the register of patients with COVID-19 was performed. We included patients with COVID-19 laboratory-confirmed infection and presence of pneumonia on computer tomography (CT). We excluded patients with previously known liver diseases, re-hospitalization, single serum creati nine measurement during hospitalization. Abnormality in aminotransferases was defined as ALT and/or AST>40 U/L. Definition of AKI was based on KDIGO criteria. P value <0.05 was considered statistically significant. Results: In final analysis we included 832 patients (51.3% males, mean age 65±16 years, mean Charlson index 3±2.3, 70% with hypertension, 51% with obesity, 26% with diabetes mellitus). 25% (208) of patients spent at least 1 day in the intensive care unit (ICU), 14% (118) were treated with mechanical ventilation (MV). The median duration of hospitalization was 12 [9;15] days, median stay in the ICU-5 [2;9] days. 21% of patients died. At admission 41% (338) of the patients had elevated level of aminotransferases. Elevated AST was more common than ALT, (37% (304) vs 25% (208)). The median levels of AST and ALT at admission were 55 [44;72] and 44 [32;64] U/L in the group with abnormal levels of aminotransferases and 26 [21;32] and 18 [14;24] U/L in the group without it, respectively. There were no statistical differences in presence of comorbidities, statins and antibiotic intake before admission. The higher incidence of elevated ALT or/and AST in ICU patients compared with non-ICU (54% vs 36%, p<0.001) was observed. Patients with abnormal level of aminotransferases at admission were younger (63±16 vs 66±16 years, p=0.006), more often were female (54% vs 45%, p=0.01), had higher serum creatinine (93 [77;119] vs 89 [76;112] μmol/L, p=0.04), d-dimer (325 [192;592] vs 293 [147;593] ng/ml, p=0.02), C-reactive protein (CRP) (91 [37;146] vs 65 [24;109] mg/l, p<0.0001), lactate dehydrogenase (454 [333;660] vs 301 [234;412] U/l, p<0.0001), ferritin level (627 [404;747] vs 420 [192;618] ng/ml, p<0.0001), had more severe lung injury by CT scan at admission (26% vs 18%, p=0.005 with 50-75% lung injury;5.6% vs 1.6%, p=0.001 with 75-90% lung injury). In group with elevated ALT or/and AST at admission were statistically higher rate of AKI development (33% vs 23%, p=0.003), MV (20% vs 10%, p<0.001), and in-hospital mortality (25% vs 18%, p=0.03). Multivariate logistic regression found that index Charlson (OR 1.35 95%CI 1.16-1.58, p<0.001), chronic kidney disease (OR 2.04 95%CI 1.08-3.87, p=0.03), hypertension (OR 2.53 95%CI 1.35-4.73, p=0.004), CRP levels of more than 50 mg/l (OR 2.06 95%CI 1.29-3.27, p=0.002), and elevated ALT or/and AST at admission (OR 1.93 95%CI 1.30-2.87, p=0.001) were shown to be significantly associated with AKI development. Conclusion: Elevated aminotransferases at admission are common among patients hospitalized with COVID-19 and associated with disease severity and poor outcomes. Elevated AST or/and ALT at admission are a predictor of AKI development.