The impact of sars-cov2 infection in children with liver disease: An international observational registry study

ABSTRACT

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) on children with underlying liver disease (LD) is unknown. We aim to report outcomes for pediatric patients with LD from the joint North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the Society of Pediatric Liver Transplantation (SPLIT) SARS-CoV2 registry Methods: We collected data from patients younger than 21 years with LD from 6 countries and laboratory-confirmed SARS-CoV2 infection reported to a multicenter observational cohort study between April 2020 and May 2021. Results: Seventy-three (59% male,55% white, 23% Hispanic) children with a median age of 9 years were reported in the registry. The most common causes of LD were biliary atresia (22%) followed by autoimmune hepatitis (16%) and non-alcoholic fatty liver disease (16%). Five patients (7%) presented in acute liver failure (ALF);all recovered without the need for a liver transplant. Four patients presented with multisystem inflammatory syndrome in children (2 with ALF, 2 without ALF) with one death reported. The most common presenting symptoms were constitutional (49%) including fever and fatigue followed by respiratory symptoms (47%). Twenty two percent (n=16) of patients were asymptomatic at the time of diagnosis. Twentythree percent had radiologic evidence of pneumonia and 14% reported co-infections. Median peak INR was 1.4, peak total bilirubin 2.9 (mg/dl), peak ALT 129 (IU/l) and nadir albumin 3.1 (g/dl). Sixty-four percent of patients required hospitalization;40% (n=19) in the ICU and 60% (n=28) non-ICU for a median of 6 and 7 days, respectively. Twenty-two percent of patients required respiratory support including mechanical ventilation (n=6), high-frequency oscillatory ventilation (n=3), highflow nasal cannula (n=5) and regular nasal cannula (n=2) for a median of 6 days. Nine patients required vasoactive agents, 3 required renal replacement therapy and 2 patients required ECMO. Sixty-six percent did not receive any SARSCoV2 directed treatment. Twelve (16%) patients developed new liver-related complications including ascites (n=9), GI bleeding (n=2), encephalopathy (n=3), progression of endstage liver disease (n=2) and infection (n=1). There were a total of 3 (4.1%) deaths (20yr, 17yr and 6month of age at time of death) reported secondary to acute on chronic liver failure with respiratory failure and multiorgan failure Conclusion: Contrary to healthy children, almost 2/3rd pediatric patients with LD testing positive for SARS-CoV2 required hospitalization with death reported in 4% of cases. Acute liver failure is rare with SARS-CoV2 infection with recovery reported without the need for liver transplantation. Close monitoring is needed due to an increased risk of underlying liver disease complications and death, particularly in children with end-stage liver disease awaiting transplantation.