Don't blame the liver: Rhabdomyolysis in COVID-19 patients with elevated liver enzymes

Background: Rhabdomyolysis (RM) is a potentially devastating breakdown of skeletal muscle leading to complications including renal failure. It has been associated previously with COVID-19, but there is a paucity of studies outside of case reports. Our study aims to quantify the rates of RM in hospitalized COVID-19 patients and assess its relationship with liver enzyme abnormalities and various outcomes. Methods: This study was a retrospective, observational study of the first 1,107 patients admitted at two academic hospitals in New York with a diagnosis of COVID-19 confirmed by nasopharyngeal PCR. RM was defined as a peak CK>5000 U/L or a CK>1500 U/L with a urine analysis (UA) within 7 days of peak CK with moderate to large blood on dipstick and the presence of either granular casts or 40 U/L). Secondary outcomes analyzed in multivariable logistic regression controlling for age, gender, race, BMI and comorbidities (diabetes, HTN, CKD, cardiovascular disease, OSA, previous thromboembolism or cancer) included kidney injury, need for dialysis, ICU stay and death. Results: Of the 1,107 patients, 44 (4.0%) were found to have RM (Figure 1A). On admission, 591 patients (60%) of those with liver enzymes drawn had elevated levels. 69% of these had AST:ALT>1;patients presenting with this finding were much more likely to already have RM or develop it during their hospitalization (8.3% vs 1.6%, OR 5.67, 95% CI 2.69-11.95). 79% of patients with RM presented with elevated AST and AST:ALT>1. Mortality was much higher in those with RM (43.2% vs 16.6%, p ALT should increase clinical suspicion.