Chronic liver disease can add risk of death in Covid-19 patients: Study

Forty-three percent of those who were in the advanced stages of the disease with cirrhosis or scarring due to the ailments died of Covid-19, according to the study recently published in the Hepatology International.

Coronavirus disease (Covid-19) patients with chronic liver conditions such as hepatitis B or C and fatty liver have higher chances of death and prolonged stay in intensive care units, found the Asia Pacific Covid-19 Liver Injury Spectrum Study conducted across 13 countries, including India.

Medical workers wearing personal protective equipment (PPE) tend to a patient suffering from the coronavirus disease (Covid-19), in the Intensive Care Unit (ICU) at Lok Nayak Jai Prakash (LNJP) hospital, in New Delhi. (REUTERS)

Forty-three percent of those who were in the advanced stages of the disease with cirrhosis or scarring due to the ailments died of Covid-19, according to the study recently published in the Hepatology International. This is much higher than the 3 to 5% mortality rate in the general population.

Among those with liver disease, the mortality was nearly twice among those with cirrhosis as compared to those without cirrhosis – 33% against 16.3%. About 20% of those with cirrhosis went into liver failure, according to the study.

“We found that if the bilirubin count is high meaning a patient is jaundiced then they have high mortality. Hence, the treating physicians must account for underlying liver disease other than conditions such as diabetes, hypertension, cancer and heart disease. And, monitor the liver enzymes closely,” said lead author Dr Shiv Sarin, director of the Institute of Liver and Biliary Sciences in Delhi.

“Also, the liver enzymes must be checked routinely for Covid-19 patients as many with chronic liver disease are unaware of it. The doctors must watch out for risk factors like obesity, diabetes, gall stones, high triglycerides and alcohol consumption given the high prevalence of metabolism related fatty liver disease – about one in four people in the country has it,” said Dr Sarin.

The study which observed the health and mortality in 228 patients with chronic liver diseases over 28 days, also found that these patients are at an increased risk of acute liver injury when they get Covid-19. The observation of the patient records showed that those without cirrhosis or scarring developed acute liver injury in the second week or early third week of the infection, but in the first week itself in cirrhotic patients.

Over 32% of the patients with cirrhosis had acute liver injury with Covid-19 as compared to 5.7% to 18% patients without cirrhosis. Along with the liver diseases, diabetes emerged to be one of the main risk factors for developing the liver injury – with 57.7% diabetics getting acute liver injury as compared to 39.7% of those without diabetes.

Complications of the liver and otherwise in Covid-19 patients with chronic liver disease resulted in longer ICU stay, the study found.

“Although the liver has ACE2 receptors that are used by the Sars-Cov-2 to enter the cells, the study shows that those with healthy livers are likely to get away with minor changes in their liver enzymes. However, in those already with chronic liver disease, it worsens with about 20% of those with cirrhosis ending up in liver failure,” said Dr AS Soin, one of the co-authors and chairman of the Liver Institute at Medanta hospital in Gurugram.

A strict monitoring of the liver parameters could help the doctors in understanding who is progressing towards the severe disease. It showed that the non-survivors had a high liver enzyme ratio of above 1.4 and the bilirubin level remained elevated at more than 9 mg/dl till death in non-survivors, the study showed.

While the true burden of liver disease is not known, the study says it accounts for 4.6% of all deaths.

“Those who have advanced liver disease and are in need of transplants must not delay it. As the study shows the mortality is extremely high – 43% -- among these patients. Initially, many thought that the infection would go away in a couple of months and had recommended delaying transplants. But, as the study shows, it could be life-saving in such patients. In fact, data from the Asia Pacific Association for the study of the Liver that did the trial and two other registries of liver patients shows that the mortality among those who have undergone transplants is just slightly higher than the general population,” said Dr Soin.

“What we have learnt is the dosage of immunosupressants needs to be tapered down in those who get the infection early post transplant; nothing needs to be done who get it months or years after the transplant. All seven of my transplant patients who got it months to years after their transplant and two who got it right after the transplant survived,” he added.

Dr Sanjay Negi, liver transplant surgeon at BL Kapur hospital, Delhi, said “Just as this study shows, it is very important to monitor the liver enzymes in Covid-19 patients. This is especially true because liver is the only organ that can regenerate after an injury so patients do not show symptoms of a liver disease till the liver is about 80% damaged.