COVID-19 pandemic: Interaction of lockdown with liver disease and metabolic parameters

Chitranshu Vashishtha; Ankit Bhardwaj; Manoj Kumar Sharma

doi:10.4103/JCDM.JCDM_4_22

ORIGINAL ARTICLES

Year : 2022 | Volume : 2 | Issue : 1 | Page : 35-39

COVID-19 pandemic: Interaction of lockdown with liver disease and metabolic parameters

Chitranshu Vashishtha¹, Ankit Bhardwaj², Manoj Kumar Sharma¹
¹ Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
² Clinical Research Department, Institute of Liver & Biliary Sciences, New Delhi, India

Date of Submission	09-Apr-2022
Date of Decision	18-May-2022
Date of Acceptance	26-May-2022
Date of Web Publication	29-Jun-2022

Correspondence Address:
Chitranshu Vashishtha
Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCDM.JCDM_4_22

Abstract

Background: In current COVID-19 pandemic, India had lockdown from 25^th March 2020 followed by relaxation in phases from 1^st June. The aim of the study was assessment of lockdown impact on metabolic and liver disease status of non-COVID patients of liver diseases. Materials and Methods: OPD data of all consecutive patients of liver disease without COVID-19 infection from 1^st January 2020 to 31^st December was analyzed. The primary objective was to assess lockdown impact on liver stiffness. Fibroscan, BMI and laboratory data was compared before and after implementation of lockdown in three groups (Group1-noncirrhotics, Group2- compensated cirrhotics, Group3- decompensated cirrhotics). Results: 230 patients (77% M) were analyzed. In all the three groups, there was no significant change in the liver stiffness and fat content by fibroscan, complete blood count, liver and kidney function tests. In Group1, there was significant increase in BMI (25.3 ± 6.0 vs 26.4 ± 6.1, P < 0.01), sugar (mg/dl) fasting (101.5 ± 30.1 vs110.7 ± 31.8, P < 0.01), post prandial (131 ± 31.6 vs 156.5 ± 35.5, P < 0.01), LDL (mg/dl) (111.1 ± 33.1 vs 119.1 ± 26.8, P = 0.036), total lipid/HDL ratio (4.04 ± 1.39 vs 4.58 ± 1.58, P = 0.01) and reduction in HDL (mg/dl) (45.8 ± 12.7 vs 40.4 ± 10.1, P < 0.01). In Group2, significant increase in LDL (97.3 ± 32.5 vs 114.3 ± 29.8, P = 0.01), LDL/HDL ratio (2.36 ± 1.26 vs 2.70 ± 1.03, P = 0.04) and decrease in HDL (45.6 ± 12.1 vs 40.9 ± 11.2, P < 0.01) was seen, with no significant change in BMI, and sugar fasting, post prandial, HbA1c. In Group3, there was no significant change in any of the parameters analysed. Conclusions: There was no impact of lockdown due to Covid pandemic on liver disease status. However, lockdown worsened metabolic parameters of non-cirrhotics and compensated cirrhotics.

Keywords: COVID-19, liver stiffness, metabolic parameters

How to cite this article:
Vashishtha C, Bhardwaj A, Sharma MK. COVID-19 pandemic: Interaction of lockdown with liver disease and metabolic parameters. J Cardio Diabetes Metab Disord 2022;2:35-9

How to cite this URL:
Vashishtha C, Bhardwaj A, Sharma MK. COVID-19 pandemic: Interaction of lockdown with liver disease and metabolic parameters. J Cardio Diabetes Metab Disord [serial online] 2022 [cited 2023 Sep 22];2:35-9. Available from: http://www.cardiodiabetic.org/text.asp?2022/2/1/35/349199

Introduction

The novel corona virus disease (COVID-19), pandemic has costed lives of several hundred thousands and affected millions. Comorbidities such as metabolic syndrome components and chronic liver disease have been associated with more severe infection and increased risk of death in this pandemic.^[1],[2] Several measures have been taking by the governments across the world. An important step taken by the Indian government was the temporary lockdown of the whole country starting from 25^th March 2020 till 31^st May. This was followed by relaxation in phases across the country. This had both the direct and indirect consequences. The direct effect was the reduction in the number of new infections due to COVID-19. However, the indirect effect was the result of lockdown and social distancing with enormous impact on health of non-COVID patients, economics and social life. During this period, patients of various diseases had difficulty in access to health care and decreased mobility, affecting their health. Hence, it is reasonable to assume that the impact of these disruptions had the potential to affect the health of non-COVID patients.^[3] There is a negative impact of the lockdown on metabolic parameters in patients of type 2 diabetes mellitus and healthy people. However, the impact on liver disease patients is not known. The aim of the study was to assess the impact of nationwide lockdown due to COVID-19 on the metabolic and liver disease status of the non-COVID patients of liver diseases. We hypothesized that with lockdown implementation and hence prolonged staying at home with reduced mobility, reduced health care services availability, patients of liver disease without COVID-19 infection have worsening of their underlying liver disease and metabolic parameters.

Subjects and Methods

Participants and study design

It is a retrospective cohort study conducted at Institute of Liver and Biliary Sciences, New Delhi, which is a tertiary care hospital for patients of liver diseases in North India. We reviewed OPD records of all consecutive patients of liver disease without COVID-19 infection from the Institute database from 1^st January 2020 attending the liver clinic till 31^st December 2020. The patients were divided into 3 groups (Group1-noncirrhotics, Group2- compensated cirrhotics, Group3- decompensated cirrhotics). Presence of any complication of portal hypertension such as ascites, variceal bleed or hepatic encephalopathy was used as the criteria for decompensation. All the patients and relatives entering the out-patient department (OPD) were required to have negative rapid antigen test for COVID-19 within three days of the OPD visit. Patients of liver disease without atleast 2 valid fibroscan examinations (one before lockdown and the other after lockdown implementation) were excluded. The criteria for valid fibroscan examination were atleast ten valid measurements, success rate atleast 60% and interquartile range / median ratio (IQR/M) ≤ 0.30. In patients having more than one lockdown fibroscan examination, the one done at later time was taken into consideration. Patients of acute self-limiting hepatitis and sick patients requiring hospital admission were excluded from the study. Patients with incomplete records were also excluded from the study. The primary outcome of the study was change in liver stiffness measured by fibroscan before and after implementation of lockdown in patients of liver disease without COVID-19 infection. The secondary outcome was change in liver fat content measured by fibroscan as Controlled Attenuation Parameter (CAP) value, metabolic and laboratory parameters. Routine clinical and biochemical data collected during the OPD visits and used in this study were body weight, body mass index (BMI), complete blood count (CBC), liver function tests (LFT), kidney function test (KFT), HbA1c, fasting blood glucose, post prandial blood glucose, total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides and liver stiffness and CAP using Fibroscan.

The study was performed in accordance with the Declaration of Helsinki, and was approved by our Institutional Ethics Committee (IEC) / Institutional Review Board (IRB) (No. F.37/ (1)/9/ILBS/DOA /2020/20217/471, dated 1.10.2021). The Institute Ethics Committee waived the requirement for informed consent as it is a minimal risk research requiring retrospective data collected for routine clinical practice. The study was registered at ClinicalTrials.gov with identifier number NCT05028842.

Statistical analysis

Baseline parametric data was expressed as the proportion, mean± standard deviation and median with interquartile range as appropriate. Categorical variables were analyzed by chi squared test or Fisher exact test while the continuous variables were analyzed using unpaired t-test or Mann-Whitney test as appropriate. Paired t-test was used to compare the change before and after the intervention. The p value <0.05 was considered statistically significant. No additional analyses were done. All statistical tests were performed using SPSS for Windows version 24 (IBM Corp, Armonk, NY)

Results

A total of 769 consecutive case were screened. 230 patients who fulfilled the inclusion and exclusion criteria were enrolled in three groups. 145 patients were assigned to non-cirrhotic group (group 1), 62 compensated cirrhotic group (group 2) and 23 in decompensated cirrhotic group (group 3). Overall, NAFLD (n = 97, 42.2%) was the most common etiology followed by viral hepatitis (n = 63, 27.4%). Diabetes was seen in 34 (14.8%) of the patients at the baseline, 26 (11.3%) were obese and 82 (35.6%) were overweight (WHO criteria). The baseline parameters of the patients are given in [Table 1].

Table 1: Baseline parameters in the patients of liver disease before lockdown

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In group1, compared to pre-lockdown values, after 171.5 ± 56.7 days, there was no significant change in lockdown period in liver stiffness (kPa) median 6.1(IQR 4.5–8.8) vs 5.6 (IQR 4.5–8.4), P = 0.27) and CAP value (dB/m) 259.7 ± 62.6 vs 255.2 ± 63.4, P = 0.30) [Table 2]. However, there was significant increase in BMI (25.3 ± 6.0 vs 26.4 ± 6.1, P < 0.01), sugar (mg/dl) fasting (101.5 ± 30.1 vs110.7 ± 31.8, P < 0.01), post prandial (131 ± 31.6 vs 156.5 ± 35.5, P < 0.01), LDL (mg/dl) (111.1 ± 33.1 vs 119.1 ± 26.8, P = 0.036), total lipid/HDL ratio (4.04 ± 1.39 vs 4.58 ± 1.58, P = 0.01) and decrease in HDL (mg/dl) (45.8 ± 12.7 vs 40.4 ± 10.1, P < 0.01). There was no significant change in CBC, liver and kidney function tests, HbA1c, LDL/HDL ratio.

Table 2: Comparison of parameters at baseline and post lockdown in noncirrhotics

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In group 2, after 172.5 ± 61.4 days, there was no significant change in liver stiffness (kPa) median 17 (IQR11.8–25.4) vs 17.3 (IQR 11.78–24.9), P = 0.77) and CAP value (dB/m) 253.7 ± 60.4 vs 249.9 ± 60.9, P = 0.46) [Table 3]. There was significant increase in LDL (mg/dl) (97.3 ± 32.5 vs 114.3 ± 29.8, P = 0.01) and LDL/HDL ratio (2.36 ± 1.26 vs 2.70 ± 1.03, P = 0.04) and decrease in HDL (mg/dl) (45.6 ± 12.1 vs 40.9 ± 11.2, P < 0.01). However, there was no significant change in BMI, CBC, liver and kidney function tests, CTP, MELD, sugar fasting, post prandial, HbA1c, total lipid, triglyceride, total lipid/HDL ratio. Similarly in group 3, after 193.3 ± 54.1 days, there was no significant change in liver stiffness (kPa) median 29.1(IQR 14.4–70.8) vs 26.6 (IQR 14.4–55.6), P = 0.09) and CAP value (dB/m) 240.5 ± 53.8 vs 229.4 ± 65.5, P = 0.46 [Table 4]. Also, there was no significant change in BMI, CBC, liver and kidney function tests, CTP, MELD, sugar and lipid parameters. There was no significant difference between the duration of period between the baseline and post lockdown OPD visit between the three groups. There was no significant difference in change in liver stiffness, CAP value and other parameters when comparison was done between nondiabetics and diabetics, and between normal weight and obese-overweight patients (data not shown).

Table 3: Comparison of parameters in compensated cirrhotics at baseline and post lockdown

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Table 4: Comparison of parameters in decompensated cirrhotics at baseline and post lockdown

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Discussion

Multiple studies have concluded that presence of chronic liver disease, particularly those with cirrhosis have increased mortality in presence of COVID-19 infection compared to those infected with COVID-19 with a normal liver. To the best of our knowledge, this is the first study assessing the impact of lockdown in non-COVID patients with liver disease. Surprisingly, we found that lockdown had maximal negative impact on noncirrhotic patients of liver disease. This group of patients had significant weight gain and increase in BMI along with worsening of blood sugar levels and lipid profiles. This could be because lockdown would have maximally affected physical activity and dietary habits of this group of patients who would have been otherwise physically active before the lockdown. Patients in compensated cirrhosis group were affected to a lesser extent with significant worsening in blood lipids without affecting their weight, BMI and blood sugar levels. Understandably, decompensated cirrhotic patients were minimally affected as lockdown would not have affected their physical activities which already would have been compromised prior to the implementation of lockdown. Another reason for the difference in impact of lockdown could be due to lesser number of patients analyzed in the compensated and decompensated cirrhosis group. Studies analyzing the impact of lockdown on metabolic parameters on Indian population have shown variable results. In a study from North India, analyzing the impact of lockdown on lifestyle in patients of type II diabetes mellitus, it was noted that carbohydrate intake and snacking increased in more than 20% patients. 42% patients reported reduction in exercise and weight gain was seen in 19% of patients. Frequency of testing self-monitoring of blood glucose (SMBG) decreased in 23% of patients.^[4] Ghoshal S using a simulation model by using the impact of previous disasters on HbA1c concluded that there was worsening of glycaemic control and diabetes related complications in proportion to the duration of lockdown.^[5] On the other hand, Sankar P et al. noted that lockdown did not have an adverse impact on glycaemic control in 110 patients of diabetes mellitus. No significant change was seen in HbA1c and body weight before and after lockdown. More than 80% of the patients continued their usual physical activities and dietary restrictions as before the lockdown. This could be due to increased awareness of the impact of sedentary lifestyle and unhealthy dietary habits on diabetes mellitus and associated diseases and increased involvement in household work.^[6] Surprisingly, lockdown had no impact on liver stiffness and steatosis in any of the three groups. This could have been due to the relatively short time period between analyzing the fibroscan values in the three groups. Our study has several limitations. COVID-19 infection was based on results of Rapid Antigen Test (RAT) within 3 days of OPD visit. RAT has a low sensitivity compared to RT-PCR test. However, RT-PCR test result takes several hours and hence would not be practical approach, especially in OPDs. Also, patients might have developed COVID-19 infection between the OPD visits as well which would not be detected. This is a single center retrospective study. However, prospective studies on this subject are not possible. The study population were well aware group of patients visiting the hospital and the results may not be applicable to patients with poor access to the healthcare facilities which might have been more severely affected due to the lockdown. Due to the retrospective nature of the study, data on employment status, education and adherence to advised diet and physical activity was not available.

Conclusion

Lockdown did not have significant impact on liver fibrosis, steatosis and liver function tests on patients of liver disease. However, lockdown negatively impacted metabolic parameters in noncirrhotic and compensated cirrhosis patients.

Acknowledgement

The authors thank the outpatient department staff of the Institute of Liver and Biliary Sciences for the care of study participants during the COVID-19 pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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