ABSTRACT
Background: Recent reports have revealed that coronavirus disease 2019 (COVID-19) is associated with liver injury The burden of liver injury in liver transplant (LT) recipients remains unknown We conducted a multi-center study to evaluate the prevalence, pattern and predictors of liver injury in LT recipients with COVID-19 and its impact on clinical outcomes Methods: The was carried out by the consortium of investigators to study COVID-19 in chronic liver disease (COLD) (registered Clinicaltrials gov NCT04439084) Inclusion criteria constituted: age > 18 years, laboratory confirmed diagnosis of COVID-19 and history of LT. We collected de-identified data on patients diagnosed before May 30, 2020 For the analysis on liver injury, only patients who had laboratory values for aspartate aminotransferase (AST) and alanine aminotransferase (ALT) prior to- and during COVID-19 infection were included The primary outcome was the presence of acute liver injury The secondary outcome was all-cause mortality within 90 days of diagnosis Logistic regression analyses were used to determine interdependent risk factors of primary outcome Results: We included 112 adult LT recipients from 21 US medical centers with confirmed diagnosis of COVID-19 The median age of the cohort was 61 years (IQR 20), and 54 5% (n = 61) were male There were 39 3% (n = 44) Hispanic, 27 7% (n = 31) non-Hispanic white, and 25 9% (n = 29) non-Hispanic African-American The all-cause mortality was 22 3% (n = 25);72 3% (n = 81) were hospitalized and 26 8% (n = 30) were admitted to the intensive care unit (ICU) 81 patients had data for analysis of liver injury 34 6% of LT patients had liver injury, Mild to moderate liver injury (ALT 2-5x ULN) in 22 2% (n=18) and severe (ALT > 5x ULN) in 12.3% (n = 10). Younger age (p = 0 009, odds ratio (OR) 2 06 [1 20-3 54]), Hispanic ethnicity (p = 0 011;OR 6 01[1 51-23 9]), metabolic syndrome (p = 0 016;OR 5 87 [1 38-24 99]), receipt of vasopressors (p = 0 018;OR 7 34 [1 39-38 52]) and antibiotic use (p = 0 046;PR 6 93 [1 04-46 26]) were associated with independent risk of liver injury on multivariate logistic regression Immunosuppression was modified in approximately half the patients (49.4%, [n = 40]) Reduction in immunosuppression during COVID-19 was not associated with liver injury (p = 0 156) or risk for mortality (p = 0.084). Presence of liver injury was significantly and independently associated with higher overall mortality (p = 0 007;OR = 6 91 [95% CI: 1 68-28 48]) in LT recipients Conclusion: Mild to moderate liver injury was common in LT patients diagnosed with COVID-19 Immunosuppression was modified during COVID-19 in half the patients but was not associated with liver injury or mortality Younger age, Hispanic ethnicity, metabolic syndrome, vasopressor and antibiotic use were associated with independent risk of liver injury Lastly, liver injury was associated with higher mortality rate in LT recipients with COVID-19.
ABSTRACT
Background: Ascites is a common, painful, and dangerous complication of cirrhosis Body weight is a reliable proxy for ascites volume Therefore, daily weight monitoring is recommended to optimize ascites management Methods: In this feasibility study, cirrhotic patients requiring ascites management were enrolled in the inpatient or outpatient setting Patients were given a Bluetooth-connected scale, which transmitted weight data to the PGHD Connect Smartphone App, and then via the cloud to the electronic medical record (EMR) Weights were monitored every weekday In the event of a weight change 5lbs in 1 week, patients were called and administered a short symptom questionnaire, and providers received an email alert The primary outcomes were percentage of enrolled days during which weight data was successfully transmitted to the EMR, and the percentage of weight alerts which prompted a response by the provider Results: 37 patients were enrolled from January 2019 to June 2020: 19 (51%) male, mean MELD score of 15 8 (SD 5 6), mean age 61 years (range 35-81), and 22 (59%) were enrolled as inpatients Cirrhosis etiology was non-alcoholic steatohepatitis in 32%, alcohol in 32%, and viral in 11% Seven patients (19%) patients were on a single diuretic at enrollment, 24 (65%) were on two diuretics, and 6 (16%) were on no diuretics Weight data was successfully transmitted to the EMR during 71% of study enrollment days, with technology issues reported on 10% of days Patients were more likely to weigh themselves in the morning, with 1067 weights transmitted before noon and 142 transmitted after noon Of 111 weight alerts to date, 57 (51%) were triggered by weight loss and 54 (49%) by weight gain Providers responded in some way to 96 (79%) weight alerts, and actively intervened in response to 53 (43%), for example by contacting the patient, scheduling clinic or paracentesis appointments, modifying the diuretic dose or requesting laboratory workup 17 of 37 (46%) patients prompted both weight increase and weight decrease alerts during the study period, 10 (27%) prompted only weight decrease alerts, 5 (13%) prompted only weight increase alerts, and 5 (13%) patients prompted no alerts There were 22 readmissions for any reason over the course of the study period 24 (65%) patients opted to extend their participation beyond the initial 28-day study period Conclusion: We demonstrate feasibility of a telemonitoring system to facilitate ascites management We report excellent rates of patient and provider engagement, including during the COVID-19 era This innovation could enable early therapeutic intervention, decreasing the burden of morbidity and mortality among cirrhotic patients.