High COVID-19 mortality rates among those with liver disease

A new international study has found high mortality rates from COVID-19 among people with chronic liver disease and cirrhosis.

The researchers, led by teams at Oxford University Hospitals NHS Foundation Trust and the University of North Carolina School of Medicine, set up an international registry to collect clinical details of patients with chronic liver disease and cirrhosis who develop COVID-19.

A. Sidney Barritt IV, MD, MSCR, associate professor in UNC's division of gastroenterology and hepatology, and Andrew Moon, MD, MPH, a fellow in the division of gastroenterology and hepatology, are co-authors of the study.

"These results provide important information for patients with liver cirrhosis by showing that COVID-19 infection could result in decompensation of the liver and mortality," Dr. Moon said. "In this registry, many patients with cirrhosis who tested positive for COVID-19 did not report any respiratory symptoms, suggesting that COVID-19 testing should be considered in patients with new complications of liver disease even in the absence of typical COVID-19 symptoms."

"It is only through the generous participation of busy health care providers on the front line and international collaboration that we learn the full impact of COVID-19 on our patients with liver disease," Dr. Barritt said.

Between 25 March 2020 and 20 April 2020, 152 cases were submitted to the registry, over 95% of which were hospitalized. Patients with cirrhosis had poor outcomes with an overall death rate of 40%. Those with advanced disease called 'decompensated cirrhosis' had the highest rate of death (between 43 and 63%), compared with 12% for patients with liver disease but without cirrhosis.

Dr. Thomas Marjot, who leads the project alongside Dr. Gwilym Webb and Professor Ellie Barnes at the Translational Gastroenterology Unit at Oxford's John Radcliffe Hospital, said: "Until now, very little was known about the impact of COVID-19 on patients with pre-existing liver disease.

"Our data, which were gathered from 21 countries, show that people with liver disease, and especially those with decompensated cirrhosis, have particularly poor outcomes once they develop COVID-19.

"Even when other risk factors for poor outcomes, such as age, obesity, diabetes and high blood pressure were taken into account, the severity of baseline liver disease was still associated with increased mortality," he explained.

The study also showed that many patients with cirrhosis and COVID-19 developed features of worsening liver function (encephalopathy, ascites, bleeding), and in 24% of cases this occurred even without any chest symptoms or breathing difficulties.

However, these preliminary findings should be interpreted with caution. Dr. Marjot explained, "our study is limited by selection bias; this is when doctors tend to report more severe cases with the worst outcomes. Many patients with cirrhosis and COVID-19 who have good outcomes will therefore not be included in the registry."

"Nonetheless, these findings do suggest high death rates with COVID-19 in patients with cirrhosis and that contracting the virus may lead to a deterioration in liver function. Therefore, anyone coming into hospital with worsening symptoms of liver disease should be considered for coronavirus testing."

The paper has been published online by the Journal of Hepatology.