Natural history of non-severe COVID-19 in patients with liver disease

ABSTRACT

Background: Coronavirus disease of 2019 (COVID-19) has emerged as a major public health crisis across the globe. Severity of COVID-19 and the presence of underlying comorbidities are the key determinants of prognosis. In general, non-severe COVID-19 is associated with relatively good outcomes. However, the natural history of non-severe COVID-19 in patients with liver disease has not been well studied. We report our experience with non-severe COVID-19 in patients with liver disease. Methods: Patients with liver disease and positive COVID RT-PCR presenting to the emergency department at a tertiary care centre were prospectively recruited from August 2020 to November 2020. Patients with severe COVID-19 were excluded. All patients were followed up for 30 days. Results: Out of 52 patients with COVID-19 and underlying liver disease, 6 patients (11.53%) presented with severe COVID-19 and were excluded from further analysis. Out of the 46 patients with non-severe COVID-19, 39(84.78%) patients had underlying cirrhosis and 6(13.04%) patients were post liver transplant (LT). The median age of the cohort was 45[35-56.5] years and the majority were males (n=38;82.60%). Comorbidities were present in 37 patients (80.4%;12 (32.43%) diabetes mellitus;5(13.51%) hypertension;9(24.32%) obesity;7(18.91%) chronic kidney disease;2(5.4%) coronary artery disease and 2(5.4%) obstructive airway disease). Most of the patients were admitted with liver related complaints (22(47.82%) acuteon-chronic liver failure;15(32.6%) acute decompensation;1(2.17%) acute liver failure - Hepatitis E related;1(2.17%) post-LT rejection and 1(2.17%) post-LT non-anastomotic stricture with acute cholangitis). Only 14 patients (30.43%) were symptomatic for COVID-19. Twenty-three patients died at 30 days, including 1 post-LT recipient. Mortality at 30-days was 52.2% on Kaplan-Meier analysis. COVID-19 related deaths were seen in 8(34.78%) patients while liverrelated deaths were seen in 15(65.21%) patients. Thirty-day survival in patients who presented with ACLF was significantly worse than those without ACLF (18.2% vs 75%;p<0.001). On multivariate Cox proportional hazard analysis, younger age, high serum bilirubin and elevated D-Dimer were significant predictors of mortality. Conclusion: Non-severe COVID-19 is associated with high 30-day mortality in patients with liver disease. The presence of ACLF portends a particularly poor prognosis. Intriguingly, the presence of comorbidities did not influence survival.