People with advanced liver cirrhosis are more likely
to develop severe COVID-19 complications and to die from it, but those who have
received liver transplants do not appear to be at greater risk, researchers
reported at the recent 2020 Digital
International Liver Congress.
People with various co-morbidities or advanced immune
suppression are more prone to severe COVID-19, and this may include those with
liver disease. An Asian study found that people with cirrhosis – especially those
with diabetes or obesity – are at greater risk for serious COVID-19
complications. Early studies of people with fatty liver disease who develop
COVID-19 have yielded conflicting findings.
Aiming to shed more light on the topic, Dr Thomas
Marjot of the University of Oxford and colleagues analysed data from two
international registries of people with liver disease and COVID-19. The SECURE-Cirrhosis
registry collects case reports from North and South America and parts of Asia,
while EASL's COVID-HEP
registry includes reports from the rest of the world.
As of 14 August 2020, the registries had
collected reports of 1097 cases from 35 countries. As previously reported,
an earlier analysis looked at data collected through 20 April. Dr Marjot
presented an updated analysis of reports through 8 July.
This analysis included 745 patients with
chronic liver disease and COVID-19, of whom 386 had progressed to cirrhosis. The
majority of reports came from the United Kingdom and the United States (each
contributing about 25% of cases) and China (16% of cases). Non-alcoholic fatty
liver disease (NAFLD) was the most common cause (38%), followed by alcoholic
liver disease (18%), hepatitis B (10%) and hepatitis C (9%). Liver transplant recipients
The analysis compared patients
without cirrhosis and those with three levels of cirrhosis severity: Child-Pugh
(CP) class A, B and C, with C being most severe.
For each higher level of liver
disease severity, the risk of adverse outcomes, including intensive care unit
admission, mechanical ventilation and death, increased in a stepwise fashion.
Most people without cirrhosis
survived, with mortality rates of 8% for those who were hospitalised and 21%
for those put on ventilators. Among those with CP class A, mortality rates were
22% once hospitalised and 52% once put on a ventilator. Among those with CP
class B, the respective rates were 39% and 74%. Among those with CP class C,
more than half of hospitalised patients (54%), and most of those put on
ventilators (90%) died.
The most common cause of death for
people with cirrhosis and COVID-19 was respiratory disease (71%), far exceeding
liver-related deaths (19%) and cardiac deaths (5%). Nearly half of people with cirrhosis (46%) experienced liver decompensation, but even in this subgroup lung
disease led to higher mortality than liver-related complications (64% versus
Mortality rates were much higher for people
with cirrhosis compared with those without cirrhosis in all age groups except
those age 80 and older, who had high mortality regardless of cirrhosis status. In
addition to age and cirrhosis severity, alcoholic liver disease was an
independent risk factor for death, but NAFLD and viral hepatitis were not
linked to elevated mortality after controlling for other factors.
Comparing these results against a UK
cohort of COVID-19 patients without liver disease, those in the registry who
had chronic liver disease but had not yet progressed to cirrhosis appeared to
have similar mortality after adjusting for sex, age and other co-morbidities.
A limitation of this analysis is that
most reports involved hospitalised patients. Dr Marjot noted that the findings may not be
applicable to people with
milder cases of COVID-19.
"There are diminishing chances
of survival as chronic liver disease patients require increasing levels of
medical support and diminishing chances with more severe baseline liver
disease," the researchers concluded.