Pre-existing liver disease is associated with poor outcome in patients with SARS CoV2 infection; The APCOLIS Study (APASL COVID-19 Liver Injury Spectrum Study)

Abstract

Background and aims: COVID-19 is a dominant pulmonary disease, with multisystem involvement, depending upon comorbidities. Its profile in patients with pre-existing chronic liver disease (CLD) is largely unknown. We studied the liver injury patterns of SARS-Cov-2 in CLD patients, with or without cirrhosis.

Methods: Data was collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with confirmed COVID-19.

Results: Altogether, 228 patients [185 CLD without cirrhosis and 43 with cirrhosis] were enrolled, with comorbidities in nearly 80%. Metabolism associated fatty liver disease (113, 61%) and viral etiology (26, 60%) were common. In CLD without cirrhosis, diabetes [57.7% vs 39.7%, OR = 2.1 (1.1-3.7), p = 0.01] and in cirrhotics, obesity, [64.3% vs. 17.2%, OR = 8.1 (1.9-38.8), p = 0.002] predisposed more to liver injury than those without these. Forty three percent of CLD without cirrhosis presented as acute liver injury and 20% cirrhotics presented with either acute-on-chronic liver failure [5 (11.6%)] or acute decompensation [4 (9%)]. Liver related complications increased (p < 0.05) with stage of liver disease; a Child-Turcotte Pugh score of 9 or more at presentation predicted high mortality [AUROC 0.94, HR = 19.2 (95 CI 2.3-163.3), p < 0.001, sensitivity 85.7% and specificity 94.4%). In decompensated cirrhotics, the liver injury was progressive in 57% patients, with 43% mortality. Rising bilirubin and AST/ALT ratio predicted mortality among cirrhosis patients.

Conclusions: SARS-Cov-2 infection causes significant liver injury in CLD patients, decompensating one fifth of cirrhosis, and worsening the clinical status of the already decompensated. The CLD patients with diabetes and obesity are more vulnerable and should be closely monitored.

Keywords: Acute liver injury; COVID-19; Chronic liver disease; SARS CoV2.

Fig. 1

Flow diagram. Enrolment of patients and acute liver injury. Acute liver injury was seen at presentation in 20% of CLD without cirrhosis, 16% of compensated and 55.6% of decompensated cirrhosis. Further acute liver injury was noted in 32.4% of those without cirrhosis and in 48% of compensated cirrhosis. Where as among the decompensated cirrhotics 27% had new onset acute liver injury

Fig. 2

COVID-19 and Spectrum of CLD. a The incidence of severe disease due to COVID-19 increases progressively among non-cirrhotics to compensated to decompensated cirrhosis (p = 0.03) as the synthetic function decreased. b There is similar trend for acute liver injury (p = 0.02). c The mortality increased with SARS CoV2 infection significantly among cirrhotics than those without cirrhosis (p < 0.001) and with decompensation. The mortality is highest (43%) in the spectrum with onset of liver injury. d Among cirrhosis those exposed to SARS CoV2 infection, the outcome is poor with CTP score 9 or more [AUROC 0.94, sensitivity 86% and specificity of 94%, HR = 19.2 (95 CI 2.3–163.3), p < 0.001]