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Letter| Volume 96, P120, February 2022

The relevance of nutritional and metabolic derangements in COVID-19 patients

Published:December 20, 2021DOI:https://doi.org/10.1016/j.ejim.2021.12.017
The relevance of nutritional and metabolic derangements in COVID-19 patients
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      Dear Editor,
      We are glad of the high interest received regarding our original data on the level of muscularity, comorbidities and outcomes among critically ill COVID-19 patients [
      • Molfino A.
      • Imbimbo G.
      • Rizzo V.
      • et al.
      The link between nutritional status and outcomes in COVID-19 patients in ICU: is obesity or sarcopenia the real problem?.
      Eur J Intern Med. 2021; 91: 93-95https://doi.org/10.1016/j.ejim.2021.06.028
      ,
      • Murat Kara A.M.A.
      • ̈zçakar Levent O.
      Sarcopenic obesity is the real problem in COVID-19!.
      Eur J Internal Med. 2021; 93: 103-104https://doi.org/10.1016/j.ejim.2021.08.007
      ,
      • Qaisar R.
      • Karim A.
      • Muhammad T.
      • et al.
      The coupling between sarcopenia and COVID-19 is the real problem.
      Eur J Intern Med. 2021; 93: 105-106https://doi.org/10.1016/j.ejim.2021.09.009
      ]. In particular, of note was that the prevalence of comorbidities in our cohort was approximately 2-times more common in those patients who died [
      • Molfino A.
      • Imbimbo G.
      • Rizzo V.
      • et al.
      The link between nutritional status and outcomes in COVID-19 patients in ICU: is obesity or sarcopenia the real problem?.
      Eur J Intern Med. 2021; 91: 93-95https://doi.org/10.1016/j.ejim.2021.06.028
      ] and that the non-survivors were older than survivors, suggesting the importance also of aging in the development of sarcopenia [
      • Molfino A.
      • Imbimbo G.
      • Rizzo V.
      • et al.
      The link between nutritional status and outcomes in COVID-19 patients in ICU: is obesity or sarcopenia the real problem?.
      Eur J Intern Med. 2021; 91: 93-95https://doi.org/10.1016/j.ejim.2021.06.028
      ,
      • Murat Kara A.M.A.
      • ̈zçakar Levent O.
      Sarcopenic obesity is the real problem in COVID-19!.
      Eur J Internal Med. 2021; 93: 103-104https://doi.org/10.1016/j.ejim.2021.08.007
      ]. In this light, we agree with the observation [
      • Murat Kara A.M.A.
      • ̈zçakar Levent O.
      Sarcopenic obesity is the real problem in COVID-19!.
      Eur J Internal Med. 2021; 93: 103-104https://doi.org/10.1016/j.ejim.2021.08.007
      ] that the presence of comorbidities (including obesity) - associated with aging - might have promoted the development of sarcopenia and in turn mortality in our cohort of patients.
      Regarding the most accurate diagnosis of sarcopenia, we believe that the assessment of muscle strength/performance is particularly important, however, not feasible in COVID-19 ICU patients, especially if ventilated. Therefore, the method we used was previously performed in the same clinical setting unveiling high reliability [
      • Weijs P.J.
      • Looijaard W.G.
      • Dekker I.M.
      • et al.
      Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients.
      Crit Care. 2014; 18: R12https://doi.org/10.1186/cc13189
      ].
      Moreover, the data by Qaisar et al. [
      • Qaisar R.
      • Karim A.
      • Muhammad T.
      • et al.
      The coupling between sarcopenia and COVID-19 is the real problem.
      Eur J Intern Med. 2021; 93: 105-106https://doi.org/10.1016/j.ejim.2021.09.009
      ] are of interest, indicating that individuals with sarcopenia at baseline or after the COVID-19 infection showed worse disease severity scores than those without sarcopenia, extending our findings [
      • Molfino A.
      • Imbimbo G.
      • Rizzo V.
      • et al.
      The link between nutritional status and outcomes in COVID-19 patients in ICU: is obesity or sarcopenia the real problem?.
      Eur J Intern Med. 2021; 91: 93-95https://doi.org/10.1016/j.ejim.2021.06.028
      ].
      Also, we agree with the authors [
      • Qaisar R.
      • Karim A.
      • Muhammad T.
      • et al.
      The coupling between sarcopenia and COVID-19 is the real problem.
      Eur J Intern Med. 2021; 93: 105-106https://doi.org/10.1016/j.ejim.2021.09.009
      ] that the measurement of novel circulating biomarkers may offer the possibility to diagnose sarcopenia in those conditions, including ICU, where muscle strength cannot be easily assessed. For these reasons, Qaisar et al. explored the association between c-terminal argin fragment 22 (CAF22) plasma levels (a product of neuromuscular junction degeneration) and sarcopenia in COVID-19 patients showing that, among the non-sarcopenic individuals, at baseline the group which developed sarcopenia presented with higher CAF22 levels than the remaining participants [
      • Qaisar R.
      • Karim A.
      • Muhammad T.
      • et al.
      The coupling between sarcopenia and COVID-19 is the real problem.
      Eur J Intern Med. 2021; 93: 105-106https://doi.org/10.1016/j.ejim.2021.09.009
      ]. This is in line with a previous study which evaluated the CAF22 levels in patients with a recent acute stroke performing rehabilitation [
      • Scherbakov N.
      • Knops M.
      • Ebner N.
      • et al.
      Evaluation of C-terminal Agrin Fragment as a marker of muscle wasting in patients after acute stroke during early rehabilitation.
      J Cachexia Sarcopenia Muscle. 2016; 7: 60-67https://doi.org/10.1002/jcsm.12068
      ]; in this study, CAF22 levels were associated with muscle performance, in particular patients who showed physical recovery presented a significant association with higher CAF22 concentrations and with markers of muscle integrity at the body composition analysis [
      • Scherbakov N.
      • Knops M.
      • Ebner N.
      • et al.
      Evaluation of C-terminal Agrin Fragment as a marker of muscle wasting in patients after acute stroke during early rehabilitation.
      J Cachexia Sarcopenia Muscle. 2016; 7: 60-67https://doi.org/10.1002/jcsm.12068
      ].
      Interestingly, also in non-ICU settings, patients with COVID-19 may experience severe nutritional derangements, mainly represented by unvoluntary body weight loss, which was associated with worse clinical outcomes, including a prolonged disease duration, increased systemic inflammation, and decreased renal function [
      • Di Filippo L.
      • De Lorenzo R.
      • D'Amico M.
      • et al.
      COVID-19 is associated with clinically significant weight loss and risk of malnutrition, independent of hospitalisation: a post-hoc analysis of a prospective cohort study.
      Clin Nutr. 2021; 40: 2420-2426https://doi.org/10.1016/j.clnu.2020.10.043
      ].
      Finally, recent preliminary data have shown a high percentage of malnutrition also among patients who survived at COVID-19 [
      • Cuerda C.
      • Sánchez López I.
      • Gil Martínez C.
      • et al.
      Impact of COVID-19 in nutritional and functional status of survivors admitted in intensive care units during the first outbreak. Preliminary results of the NUTRICOVID study.
      Clin Nutr. 2021; ([published online ahead of print, 2021 Nov 23]) (S0261-5614)https://doi.org/10.1016/j.clnu.2021.11.017
      ], highlighting the clinical relevance of poor nutritional status not only at baseline, conditioning patients outcomes during ICU stay, but also developed during hospital stay, suggesting the urgent need for clear nutritional therapeutic interventions in this setting.

      References

        • Molfino A.
        • Imbimbo G.
        • Rizzo V.
        • et al.
        The link between nutritional status and outcomes in COVID-19 patients in ICU: is obesity or sarcopenia the real problem?.
        Eur J Intern Med. 2021; 91: 93-95https://doi.org/10.1016/j.ejim.2021.06.028
        View in Article
        • Murat Kara A.M.A.
        • ̈zçakar Levent O.
        Sarcopenic obesity is the real problem in COVID-19!.
        Eur J Internal Med. 2021; 93: 103-104https://doi.org/10.1016/j.ejim.2021.08.007
        View in Article
        • Qaisar R.
        • Karim A.
        • Muhammad T.
        • et al.
        The coupling between sarcopenia and COVID-19 is the real problem.
        Eur J Intern Med. 2021; 93: 105-106https://doi.org/10.1016/j.ejim.2021.09.009
        View in Article
        • Weijs P.J.
        • Looijaard W.G.
        • Dekker I.M.
        • et al.
        Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients.
        Crit Care. 2014; 18: R12https://doi.org/10.1186/cc13189
        View in Article
        • Scherbakov N.
        • Knops M.
        • Ebner N.
        • et al.
        Evaluation of C-terminal Agrin Fragment as a marker of muscle wasting in patients after acute stroke during early rehabilitation.
        J Cachexia Sarcopenia Muscle. 2016; 7: 60-67https://doi.org/10.1002/jcsm.12068
        View in Article
        • Di Filippo L.
        • De Lorenzo R.
        • D'Amico M.
        • et al.
        COVID-19 is associated with clinically significant weight loss and risk of malnutrition, independent of hospitalisation: a post-hoc analysis of a prospective cohort study.
        Clin Nutr. 2021; 40: 2420-2426https://doi.org/10.1016/j.clnu.2020.10.043
        View in Article
        • Cuerda C.
        • Sánchez López I.
        • Gil Martínez C.
        • et al.
        Impact of COVID-19 in nutritional and functional status of survivors admitted in intensive care units during the first outbreak. Preliminary results of the NUTRICOVID study.
        Clin Nutr. 2021; ([published online ahead of print, 2021 Nov 23]) (S0261-5614)https://doi.org/10.1016/j.clnu.2021.11.017
        View in Article

      Article info

      Publication history

      Published online: December 20, 2021
      Accepted: December 17, 2021
      Received: December 13, 2021

      Identification

      DOI: https://doi.org/10.1016/j.ejim.2021.12.017

      Copyright

      © 2021 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

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