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1.
Minerva Gastroenterol (Torino) ; 67(3): 283-288, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1485664

ABSTRACT

World Gastroenterology Organization define acute on chronic liver failure (ACLF) a syndrome in patients with chronic liver disease with or without previously diagnosed cirrhosis, characterized by acute hepatic decompensation resulting in liver failure and one or more extrahepatic organ failures, associated with increased mortality up to three months. A-56-year-old gentleman with alcohol related liver cirrhosis (ARLC) and history of variceal bleeding with insertion of transjugular intrahepatic porto-systemic stent shunt presented with two days history of fever, dry cough and worsening of the sensory. The severe acute respiratory coronavirus-2 (SARS-CoV-2) nasopharingeal C-reactive protein test was positive. X-ray showed multiple patchy ground glass opacities in both lungs. Despite the therapy, the clinical and laboratory picture deteriorated rapidly. The patient succumbed on day 14 with multi-organ-failure. SARS-Cov-2 infection can overlap with pre-existing chronic liver disease or induce liver damage directly or indirectly. From the data of the literature and from what is inferred from the case report it clearly emerges that alcohol related liver disease (ALD) patients are particularly vulnerable to SARS-Cov-2 infection. Thereafter, some considerations can be deduced from the analysis of the case report. In subjects with pre-existing cirrhosis hepatologists should play more attention to hepatic injury and monitor risk of hepatic failure caused by coronavirus disease 2019 (COVID-19). It is appropriate to promptly define the alcoholic etiology and investigate whether the patient is actively consuming. In fact, withdrawal symptoms may be present, and the prognosis of these patients is also worse. Physicians should be alerted to the possibility of the development of ACLF in this population, hepatotoxic drugs should be avoided, it is recommended to use of hepatoprotective therapy to mitigate the negative impact of COVID-19, and it is mandatory to administer anti COVID-19 vaccine to patients with alcohol related liver cirrhosis.


Subject(s)
Acute-On-Chronic Liver Failure/etiology , Alcoholism/complications , COVID-19/complications , Liver Cirrhosis/complications , Humans , Male , Middle Aged
2.
J Postgrad Med ; 67(3): 174-176, 2021.
Article in English | MEDLINE | ID: covidwho-1485286

ABSTRACT

Scleredema adultorum of Buschke is a rare disorder of the connective tissue, involving the skin. Here, we present a 61-year-old male, who is a known case of compensated liver cirrhosis with a past history of being treated for autoimmune thyrotoxicosis, who presented with complaints of alopecia, skin tightening, dry skin, pruritus, and woody indurated plaques on the skin of the upper back, shoulder, and arms. Skin biopsy of the arm revealed the characteristic features of scleredema. He was extensively evaluated for known literature-cited causes of scleredema, and the work up revealed a negative result. He was also found to be hypothyroid on presentation. Hence, we present a case of scleredema occurring in a patient with hypothyroidism and chronic liver disease, which to our knowledge is being described for the first time in literature.


Subject(s)
Hypothyroidism/complications , Liver Cirrhosis/complications , Scleredema Adultorum/diagnosis , Alopecia/etiology , Betamethasone/therapeutic use , COVID-19/drug therapy , Fusidic Acid/therapeutic use , Glucocorticoids/therapeutic use , Humans , Male , Middle Aged , Pruritus/etiology , Thyrotoxicosis/complications
3.
BMJ Open Gastroenterol ; 8(1)2021 10.
Article in English | MEDLINE | ID: covidwho-1484025

ABSTRACT

BACKGROUND: COVID-19 continues to pose a significant healthcare challenge throughout the world. Comorbidities including diabetes and hypertension are associated with a significantly higher mortality risk. However, the effect of cirrhosis on COVID-19 outcomes has yet to be systematically assessed. OBJECTIVES: To assess the reported clinical outcomes of patients with cirrhosis who develop COVID-19 infection. DESIGN/METHOD: PubMed and EMBASE databases were searched for studies included up to 3 February 2021. All English language primary research articles that reported clinical outcomes in patients with cirrhosis and COVID-19 were included. The study was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The risk of bias was assessed using the Quality In Prognostic Score (QUIPS) risk-of-bias assessment instrument for prognostic factor studies template. Meta-analysis was performed using Cochrane RevMan V.5.4 software using a random effects model. RESULTS: 63 studies were identified reporting clinical outcomes in patients with cirrhosis and concomitant COVID-19. Meta-analysis of cohort studies which report a non-cirrhotic comparator yielded a pooled mortality OR of 2.48 (95% CI: 2.02 to 3.04). Analysis of a subgroup of studies reporting OR for mortality in hospitalised patients adjusted for significant confounders found a pooled adjusted OR 1.81 (CI: 1.36 to 2.42). CONCLUSION: Cirrhosis is associated with an increased risk of all-cause mortality in COVID-19 infection compared to non-cirrhotic patients. Patients with cirrhosis should be considered for targeted public health interventions to prevent COVID-19 infection, such as shielding and prioritisation of vaccination.


Subject(s)
COVID-19 , Hypertension , Bias , Humans , Liver Cirrhosis/complications , SARS-CoV-2
4.
BMC Infect Dis ; 21(1): 901, 2021 Sep 03.
Article in English | MEDLINE | ID: covidwho-1455938

ABSTRACT

BACKGROUND: The detection of severe acute respiratory syndrome coronavirus (SARS-CoV-2) is challenging, particularly in post-mortem human tissues. However, there is increasing evidence for viral SARS-CoV-2 manifestation in non-respiratory tissues. In this context, it is a current matter of debate, whether SARS-CoV-2 shows hepatotropism. CASE PRESENTATION: Here, we report a case of an 88-year-old women with massive SARS-CoV-2 viremia, severe jaundice and clinical signs of an acute hepatitis, who died within a few days from an acute liver failure without showing any clinical signs of pneumonia. Autopsy revealed a severe chronic and acute liver damage with bile duct infestation by SARS-CoV-2 that was accompanied by higher expressions of angiotensin-converting enzyme-2 (ACE2), Cathepsin L and transmembrane serine protease 2 (TMPRSS2). CONCLUSION: Our findings indicate an enhanced biliary susceptibility to viral infection with SARS-CoV-2, that might have resulted from pre-existing severe liver damage. Furthermore, our findings emphasize the differential diagnosis of coronavirus disease 2019 (COVID-19)-associated liver failure in the clinical setting of an inexplicable jaundice.


Subject(s)
COVID-19 , Liver Failure, Acute , Aged, 80 and over , Female , Humans , Liver Cirrhosis/complications , Liver Failure, Acute/etiology , Peptidyl-Dipeptidase A , SARS-CoV-2
5.
BMJ Case Rep ; 14(9)2021 Sep 20.
Article in English | MEDLINE | ID: covidwho-1430179

ABSTRACT

Hepatopulmonary syndrome (HPS) is a serious complication of chronic liver disease, characterised by portal hypertension and arterial hypoxaemia due to intrapulmonary vascular dilatation. We report an unusual case in which a 27-year-old man had a first presentation of portal hypertension and cirrhosis complicated by HPS. This patient presented with progressive dyspnoea on exertion and deterioration in mobility, with a type 1 respiratory failure and increased oxygen demand. A bubble echocardiogram showed a possible right-to-left shunt, CT aortogram displayed evidence of portal hypertension and cirrhosis, and liver biopsy findings were consistent with alpha-1 antitrypsin deficiency. The patient's increased oxygen demand was subsequently treated with continuous positive airway pressure before he was discharged with 8 L home oxygen. With no current established medical therapy for HPS, the patient was assessed for liver transplantation and a decision was made in favour of this.


Subject(s)
Hepatopulmonary Syndrome , Hypertension, Portal , Liver Transplantation , Adult , Hepatopulmonary Syndrome/complications , Hepatopulmonary Syndrome/diagnosis , Humans , Hypertension, Portal/complications , Liver Cirrhosis/complications , Male
8.
Hepatology ; 74(1): 322-335, 2021 07.
Article in English | MEDLINE | ID: covidwho-1384170

ABSTRACT

BACKGROUND AND AIMS: Whether patients with cirrhosis have increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the extent to which infection and cirrhosis increase the risk of adverse patient outcomes remain unclear. APPROACH AND RESULTS: We identified 88,747 patients tested for SARS-CoV-2 between March 1, 2020, and May 14, 2020, in the Veterans Affairs (VA) national health care system, including 75,315 with no cirrhosis-SARS-CoV-2-negative (C0-S0), 9,826 with no cirrhosis-SARS-CoV-2-positive (C0-S1), 3,301 with cirrhosis-SARS-CoV-2-negative (C1-S0), and 305 with cirrhosis-SARS-CoV-2-positive (C1-S1). Patients were followed through June 22, 2020. Hospitalization, mechanical ventilation, and death were modeled in time-to-event analyses using Cox proportional hazards regression. Patients with cirrhosis were less likely to test positive than patients without cirrhosis (8.5% vs. 11.5%; adjusted odds ratio, 0.83; 95% CI, 0.69-0.99). Thirty-day mortality and ventilation rates increased progressively from C0-S0 (2.3% and 1.6%) to C1-S0 (5.2% and 3.6%) to C0-S1 (10.6% and 6.5%) and to C1-S1 (17.1% and 13.0%). Among patients with cirrhosis, those who tested positive for SARS-CoV-2 were 4.1 times more likely to undergo mechanical ventilation (adjusted hazard ratio [aHR], 4.12; 95% CI, 2.79-6.10) and 3.5 times more likely to die (aHR, 3.54; 95% CI, 2.55-4.90) than those who tested negative. Among patients with SARS-CoV-2 infection, those with cirrhosis were more likely to be hospitalized (aHR, 1.37; 95% CI, 1.12-1.66), undergo ventilation (aHR, 1.61; 95% CI, 1.05-2.46) or die (aHR, 1.65; 95% CI, 1.18-2.30) than patients without cirrhosis. Among patients with cirrhosis and SARS-CoV-2 infection, the most important predictors of mortality were advanced age, cirrhosis decompensation, and high Model for End-Stage Liver Disease score. CONCLUSIONS: SARS-CoV-2 infection was associated with a 3.5-fold increase in mortality in patients with cirrhosis. Cirrhosis was associated with a 1.7-fold increase in mortality in patients with SARS-CoV-2 infection.


Subject(s)
COVID-19/etiology , Liver Cirrhosis/complications , SARS-CoV-2 , Veterans/statistics & numerical data , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/mortality , COVID-19/therapy , Female , Hospitalization/statistics & numerical data , Humans , Liver Cirrhosis/virology , Male , Middle Aged , Proportional Hazards Models , Respiration, Artificial/statistics & numerical data , Risk Factors , United States/epidemiology , Young Adult
9.
Korean J Intern Med ; 36(5): 1092-1101, 2021 09.
Article in English | MEDLINE | ID: covidwho-1360839

ABSTRACT

BACKGROUND/AIMS: The impact of liver cirrhosis (LC) on the clinical outcomes of patients with coronavirus disease 2019 (COVID-19) remains elusive. This study evaluated the association between LC and the development of severe complications from COVID-19. METHODS: We used the National Health Insurance claims data of Korea. We included 234,427 patients older than 19 years who tested for severe acute respiratory syndrome coronavirus 2. Patients with LC who were infected with COVID-19 (n = 67, LC+ COVID+) were matched with those with cirrhosis only (n = 332, LC+ COVID-) and those with COVID-19 only (n = 333, LC- COVID+) using a propensity score in a 1:5 ratio. The primary outcome was the development of severe complications. RESULTS: Of the matched patients, the mean age was 60 years and 59.7% were male. Severe complications occurred in 18, 54, and 60 patients in the LC+ COVID+, LC+ COVID-, and LC- COVID+ groups, respectively. After adjusting for comorbidities, there was no significant difference in the risk of developing severe complications from COVID-19 between the LC+ COVID+ and LC- COVID+ groups but significant difference exists between the LC+ COVID+ and LC+ COVID-. Older age, hypertension, cancer, chronic obstructive pulmonary disease, and a higher Charlson comorbidity index were associated with a higher risk of severe complications in patients with cirrhosis and COVID-19. CONCLUSION: Our study suggests that LC was not independently associated with the development of severe complications, including mortality, in patients with COVID-19. Our results need to be evaluated through a large, prospective study.


Subject(s)
COVID-19 , Aged , Cohort Studies , Comorbidity , Humans , Liver Cirrhosis/complications , Liver Cirrhosis/diagnosis , Liver Cirrhosis/epidemiology , Male , Middle Aged , Prospective Studies , Republic of Korea/epidemiology , Risk Factors , SARS-CoV-2
10.
World J Gastroenterol ; 27(26): 3951-3970, 2021 Jul 14.
Article in English | MEDLINE | ID: covidwho-1319754

ABSTRACT

Severe acute respiratory syndrome coronavirus 2 infection is the cause of coronavirus disease 2019 (COVID-19), which predominantly affects the respiratory system; it also causes systemic and multi-organic disease. Liver damage is among the main extrapulmonary manifestations. COVID-19-associated liver injury is defined as any liver damage occurring during the disease course and treatment of COVID-19 in patients with or without pre-existing liver disease, and occurs in approximately one in five patients. Abnormal liver test results have been associated with a more severe course of COVID-19 and other complications, including death. Mechanisms linking COVID-19 to liver injury are diverse. Particular consideration should be made for patients with pre-existing liver disease, such as metabolic dysfunction-associated fatty liver disease, chronic liver disease due to viral or autoimmune disease, liver transplant carriers, or cirrhosis, given the risk for more severe outcomes. This manuscript summarizes the current lines of evidence on COVID-19-associated liver injury regarding pathophysiology, clinical significance, and management in both patients with or without pre-existing liver disease, to facilitate clinicians' access to updated information and patient care. Finally, we mention the ideas and recommendations to be considered for future research.


Subject(s)
COVID-19 , Liver Diseases , Humans , Liver Cirrhosis/complications , SARS-CoV-2
11.
JAMA Intern Med ; 181(10): 1306-1314, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1306626

ABSTRACT

Importance: Two mRNA-based vaccines against coronavirus disease 2019 (COVID-19) were found to be highly efficacious in phase 3 clinical trials in the US. However, patients with chronic illnesses, including cirrhosis, were excluded from clinical trials. Patients with cirrhosis have immune dysregulation that is associated with vaccine hyporesponsiveness. Objective: To study the association of receipt of the Pfizer BNT162b2 mRNA or the Moderna mRNA-1273 vaccines in patients with cirrhosis compared with a propensity-matched control group of patients at similar risk of infection and severe disease from COVID-19. Design, Setting, and Participants: We performed a retrospective cohort study of patients with cirrhosis who received at least 1 dose of a COVID-19 mRNA vaccine at the Veterans Health Administration. Patients who received at least 1 dose of the vaccine (n = 20 037) were propensity matched with 20 037 controls to assess the associations of vaccination with new COVID-19 infection and COVID-19 hospitalization and death. Exposures: Receipt of at least 1 dose of the BNT162b2 mRNA or the mRNA-1273 vaccines between December 18, 2020, and March 17, 2021. Main Outcomes and Measures: COVID-19 infection as documented by a positive result for COVID-19 by polymerase chain reaction, hospitalization, and death due to COVID-19 infection. Results: The median (interquartile range) age of the vaccinated individuals in the study cohort was 69.1 (8.4) years and 19 465 (97.2%) of the participants in each of the vaccinated and unvaccinated groups were male, consistent with a US veteran population. The mRNA-1273 vaccine was administered in 10 236 (51%) and the BNT162b2 mRNA in 9801 (49%) patients. Approximately 99.7% of patients who received the first dose of either vaccine with a follow-up of 42 days or more received a second dose. The number of COVID-19 infections in the vaccine recipients was similar to the control group in days 0 to 7, 7 to 14, 14 to 21, and 21 to 28 after the first dose. After 28 days, receipt of 1 dose of an mRNA vaccine was associated with a 64.8% reduction in COVID-19 infections and 100% protection against hospitalization or death due to COVID-19 infection. The association of reduced COVID-19 infections after the first dose was lower among patients with decompensated (50.3%) compared with compensated cirrhosis (66.8%). Receipt of a second dose was associated with a 78.6% reduction in COVID-19 infections and 100% reduction in COVID-19-related hospitalization or death after 7 days. Conclusions and Relevance: This cohort study of US veterans found that mRNA vaccine administration was associated with a delayed but modest reduction in COVID-19 infection but an excellent reduction in COVID-19-related hospitalization or death in patients with cirrhosis.


Subject(s)
COVID-19 Vaccines , COVID-19/epidemiology , COVID-19/prevention & control , Hospitalization , Liver Cirrhosis/complications , Aged , Aged, 80 and over , Female , Humans , Liver Cirrhosis/mortality , Male , Middle Aged , Propensity Score , Retrospective Studies , Survival Rate , United States , Veterans
13.
BMJ Case Rep ; 14(4)2021 Apr 21.
Article in English | MEDLINE | ID: covidwho-1197249

ABSTRACT

A 35-year-old Hispanic man presented with fever, chills, dysuria, diarrhoea, scleral icterus, tachycardia and tachypnea. He was found to be COVID-19 positive, CT of the pelvis revealed prostatic abscess, and urine culture grew Klebsiella pneumoniae Additionally, he was found to have diabetes and cirrhosis. During treatment, the patient developed vision loss, and was diagnosed with endogenous Klebsiella endophthalmitis. The patient was treated with intravenous antibiotics, pars plana vitrectomy, intravitreal antibiotics and cystoscopy/suprapubic catheter placement. On follow-up, the patient has had the suprapubic catheter removed, and successfully passed a voiding trial, but suffers permanent vision loss in both eyes.


Subject(s)
COVID-19 , Diabetes Mellitus , Endophthalmitis , Klebsiella Infections , Prostatitis , Adult , Anti-Bacterial Agents/therapeutic use , Blindness , COVID-19/complications , Diabetes Mellitus/virology , Endophthalmitis/complications , Endophthalmitis/diagnosis , Endophthalmitis/therapy , Humans , Klebsiella Infections/complications , Klebsiella Infections/diagnosis , Klebsiella Infections/drug therapy , Klebsiella pneumoniae , Liver Cirrhosis/complications , Liver Cirrhosis/virology , Male , Prostatitis/complications , Prostatitis/microbiology , SARS-CoV-2 , Vitrectomy
14.
Virulence ; 12(1): 1199-1208, 2021 12.
Article in English | MEDLINE | ID: covidwho-1192789

ABSTRACT

Background: COVID-19 has rapidly become a major health emergency worldwide. The characteristic, outcome, and risk factor of COVID-19 in patients with decompensated cirrhosis remain unclear.Methods: Medical records were collected from 23 Chinese hospitals. Patients with decompensated cirrhosis and age- and sex-matched non-liver disease patients were enrolled with 1:4 ratio using stratified sampling.Results: There were more comorbidities with higher Chalson Complication Index (p < 0.001), higher proportion of patients having gastrointestinal bleeding, jaundice, ascites, and diarrhea among those patients (p < 0.05) and in decompensated cirrhosis patients. Mortality (p < 0.05) and the proportion of severe ill (p < 0.001) were significantly high among those patients. Patients in severe ill subgroup had higher mortality (p < 0.001), MELD, and CRUB65 score but lower lymphocytes count. Besides, this subgroup had larger proportion of patients with abnormal (PT), activated partial thromboplatin time (APTT), D-Dimer, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBL) and Creatinine (Cr) (p < 0.05). Multivariate logistic regression for severity shown that MELD and CRUB65 score reached significance. Higher Child-Pugh and CRUB65 scores were found among non-survival cases and multivariate logistic regression further inferred risk factors for adverse outcome. Receiver Operating Characteristic (ROC) curves also provided remarkable demonstrations for the predictive ability of Child-Pugh and CRUB65 scores.Conclusions: COVID-19 patients with cirrhosis had larger proportion of more severely disease and higher mortality. MELD and CRUB65 score at hospital admission may predict COVID-19 severity while Child-Pugh and CRUB65 score were highly associated with non-survival among those patients.


Subject(s)
COVID-19/mortality , Liver Cirrhosis/complications , SARS-CoV-2 , Severity of Illness Index , Adult , Aged , COVID-19/etiology , Female , Humans , Male , Middle Aged , Retrospective Studies , Risk Factors
15.
Dig Liver Dis ; 53(7): 799, 2021 07.
Article in English | MEDLINE | ID: covidwho-1163654
16.
Hepatology ; 74(3): 1674-1686, 2021 09.
Article in English | MEDLINE | ID: covidwho-1103301

ABSTRACT

Pulmonary disease in liver cirrhosis and portal hypertension (PH) constitutes a challenging clinical scenario and may have important implications with regard to prognosis, liver transplantation (LT) candidacy, and post-LT outcome. Pre-LT evaluation should include adequate screening for pulmonary diseases that may occur concomitantly with liver disease as well as for those that may arise as a complication of end-stage liver disease and PH, given that either may jeopardize safe LT and successful outcome. It is key to discriminate those patients who would benefit from LT, especially pulmonary disorders that have been reported to resolve post-LT and are considered "pulmonary indications" for transplant, from those who are at increased mortality risk and in whom LT is contraindicated. In conclusion, in this article, we review the impact of several pulmonary disorders, including cystic fibrosis, alpha 1-antitrypsin deficiency, hereditary hemorrhagic telangiectasia, sarcoidosis, coronavirus disease 2019, asthma, chronic obstructive pulmonary disease, pulmonary nodules, interstitial lung disease, hepatic hydrothorax, hepatopulmonary syndrome, and portopulmonary hypertension, on post-LT survival, as well as the reciprocal impact of LT on the evolution of lung function.


Subject(s)
Hypertension, Portal/complications , Liver Cirrhosis/complications , Liver Transplantation/mortality , Lung Diseases/complications , Adult , Asthma/diagnosis , Asthma/epidemiology , Asthma/mortality , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/mortality , COVID-19/virology , Child , Cystic Fibrosis , End Stage Liver Disease/complications , Hepatopulmonary Syndrome/diagnosis , Hepatopulmonary Syndrome/epidemiology , Hepatopulmonary Syndrome/mortality , Humans , Hypertension, Pulmonary/drug therapy , Hypertension, Pulmonary/etiology , Liver Transplantation/methods , Lung Diseases/epidemiology , Lung Diseases/pathology , Lung Diseases/physiopathology , Mass Screening , Patient Selection/ethics , Prognosis , Pulmonary Disease, Chronic Obstructive/diagnosis , Pulmonary Disease, Chronic Obstructive/epidemiology , Pulmonary Disease, Chronic Obstructive/mortality , Respiratory Function Tests/methods , SARS-CoV-2/genetics , SARS-CoV-2/isolation & purification , Sarcoidosis/diagnosis , Sarcoidosis/epidemiology , Sarcoidosis/mortality , Survival Rate/trends , Telangiectasia, Hereditary Hemorrhagic/diagnosis , Telangiectasia, Hereditary Hemorrhagic/epidemiology , Telangiectasia, Hereditary Hemorrhagic/mortality , alpha 1-Antitrypsin Deficiency/diagnosis , alpha 1-Antitrypsin Deficiency/epidemiology , alpha 1-Antitrypsin Deficiency/mortality
17.
Gut ; 70(3): 531-536, 2021 03.
Article in English | MEDLINE | ID: covidwho-1066908

ABSTRACT

OBJECTIVE: Comorbid conditions are associated with poor prognosis in COVID-19. Registry data show that patients with cirrhosis may be at high risk. However, outcome comparisons among patients with cirrhosis+COVID-19 versus patients with COVID-19 alone and cirrhosis alone are lacking. The aim of this study was to perform these comparisons. DESIGN: A multicentre study of inpatients with cirrhosis+COVID-19 compared with age/gender-matched patients with COVID-19 alone and cirrhosis alone was performed. COVID-19 and cirrhosis characteristics, development of organ failures and acute-on-chronic liver failure (ACLF) and mortality (inpatient death+hospice) were compared. RESULTS: 37 patients with cirrhosis+COVID-19 were matched with 108 patients with COVID-19 and 127 patients with cirrhosis from seven sites. Race/ethnicity were similar. Patients with cirrhosis+COVID-19 had higher mortality compared with patients with COVID-19 (30% vs 13%, p=0.03) but not between patients with cirrhosis+COVID-19 and patients with cirrhosis (30% vs 20%, p=0.16). Patients with cirrhosis+COVID-19 versus patients with COVID-19 alone had equivalent respiratory symptoms, chest findings and rates of intensive care unit transfer and ventilation. However, patients with cirrhosis+COVID-19 had worse Charlson Comorbidity Index (CCI 6.5±3.1 vs 3.3±2.5, p<0.001), lower presenting GI symptoms and higher lactate. Patients with cirrhosis alone had higher cirrhosis-related complications, maximum model for end-stage liver disease (MELD) score and lower BiPAP/ventilation requirement compared with patients with cirrhosis+COVID-19, but CCI and ACLF rates were similar. In the entire group, CCI (OR 1.23, 95% CI 1.11 to 1.37, p<0.0001) was the only variable predictive of mortality on multivariable regression. CONCLUSIONS: In this multicentre North American contemporaneously enrolled study, age/gender-matched patients with cirrhosis+COVID-19 had similar mortality compared with patients with cirrhosis alone but higher than patients with COVID-19 alone. CCI was the only independent mortality predictor in the entire matched cohort.


Subject(s)
COVID-19/mortality , Liver Cirrhosis/mortality , Pneumonia, Viral/mortality , COVID-19/complications , Female , Humans , Inpatients , Liver Cirrhosis/complications , Male , Middle Aged , Pneumonia, Viral/complications , Pneumonia, Viral/virology , Risk , SARS-CoV-2 , United States
18.
J Intensive Care Med ; 36(5): 511-523, 2021 May.
Article in English | MEDLINE | ID: covidwho-1029763

ABSTRACT

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.


Subject(s)
Acute-On-Chronic Liver Failure , COVID-19 , Critical Care , Echocardiography/methods , Liver Cirrhosis , Point-of-Care Systems , Remote Consultation , Shock , Acute-On-Chronic Liver Failure/etiology , Acute-On-Chronic Liver Failure/physiopathology , Acute-On-Chronic Liver Failure/therapy , COVID-19/epidemiology , COVID-19/prevention & control , Cardiology/trends , Critical Care/methods , Critical Care/organization & administration , Critical Illness/therapy , Delayed Diagnosis/prevention & control , Hemodynamic Monitoring/instrumentation , Hemodynamic Monitoring/methods , Humans , Infection Control , Liver Cirrhosis/complications , Liver Cirrhosis/physiopathology , Liver Cirrhosis/therapy , Organizational Innovation , Remote Consultation/instrumentation , Remote Consultation/methods , Remote Consultation/organization & administration , SARS-CoV-2 , Shock/diagnosis , Shock/etiology , Shock/therapy
19.
Hepatol Commun ; 5(3): 424-433, 2021 03.
Article in English | MEDLINE | ID: covidwho-963174

ABSTRACT

The novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) is the causative agent of coronavirus disease 2019 (COVID-19). The presenting symptoms of this virus are variable, and there is an increasing body of literature on risk factors for mortality. The aim of this study was to evaluate the effect of initial aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels and preexisting liver disease, including cirrhosis, in a cohort of patients admitted with COVID-19 infection at a tertiary care hospital network in the Bronx, New York. We reviewed 3,352 patients who had a positive SARS-CoV2 nasal swab, were over 18 years of age, and had an associated inpatient admission and discharge (or death) to the Montefiore Medical Center from February 28, 2020, to May 22, 2020. Of these, 39/86 (45%) patients died when the initial ALT was >5 times the upper limit of normal (ULN); 115/230 (50%) patients died when the initial AST was >3 times the ULN. The mortality of patients without preexisting liver disease was 26.6% compared to a mortality rate of 29.5% in patients with liver disease. Subgroup analysis showed a mortality of 36.1% in the patients with cirrhosis. Cirrhosis conferred a hazard ratio for mortality of 1.67 (95% confidence interval, 1.09, 2.55; P = 0.019). The baseline Model for End-Stage Liver Disease score was not prognostic in the cirrhosis cohort. There was no statistical difference between mortality in patients with a history of compensated or decompensated cirrhosis. The most common cause of death in the cirrhosis cohort was respiratory failure. Conclusion: COVID-19 hepatitis may lead to poor outcomes in patients who are hospitalized for the disease. Patients with cirrhosis are at a higher risk of COVID-19-related mortality.


Subject(s)
Alanine Transaminase/analysis , Aspartate Aminotransferases/analysis , COVID-19/mortality , Liver Cirrhosis/complications , Liver/physiopathology , Aged , Aged, 80 and over , COVID-19/diagnosis , Cohort Studies , Female , Hospitalization , Humans , Liver/virology , Male , Middle Aged , New York , Prognosis , Respiratory Insufficiency , Risk Factors , Severity of Illness Index , Survival Analysis , Tertiary Care Centers
20.
J Viral Hepat ; 28(1): 4-11, 2021 01.
Article in English | MEDLINE | ID: covidwho-944757

ABSTRACT

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a novel coronavirus causing coronavirus disease 19 (COVID-19), with an estimated 22 million people infected worldwide so far although involving primarily the respiratory tract, has a remarkable tropism for the liver and the biliary tract. Patients with SARS-CoV-2 infection and no antecedent liver disease may display evidence of cytolytic liver damage, proportional to the severity of COVID-19 but rarely of clinical significance. The mechanism of hepatocellular injury is unclear and possibly multifactorial. The clinical impact of SARS-CoV-2 infection in patients with underlying chronic liver disease, a cohort whose global size is difficult to estimate, has been assessed appropriately only recently and data are still evolving. Patients with cirrhosis are at higher risk of developing severe COVID-19 and worse liver-related outcomes as compared to those with non-cirrhotic liver disease. OLT patients have an intermediate risk. Specific interventions in order to reduce the risk of transmission of infection among this high-risk population have been outlined by international societies, together with recommendations for modified treatment and follow-up regimens during the COVID-19 pandemic. When a vaccine against SARS-CoV-2 becomes available, patients with fibrotic liver disease and those with OLT should be considered as prime targets for prophylaxis of COVID-19, as all other highly susceptible subjects.


Subject(s)
COVID-19/complications , Liver Diseases/complications , Liver/injuries , SARS-CoV-2/pathogenicity , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19/therapy , COVID-19 Vaccines/administration & dosage , Chronic Disease , Humans , Liver/virology , Liver Cirrhosis/complications , Liver Cirrhosis/epidemiology , Liver Cirrhosis/therapy , Liver Diseases/epidemiology , Liver Diseases/therapy , Risk
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