COVID-19 in Chronic Liver Disease and Liver Transplantation

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has brought challenges to clinicians caring for patients with chronic liver disease. In the past 6 months, COVID-19 has led to over 150,000 deaths in the United States and over 660,000 deaths around the world. Mounting evidence suggests that chronic liver diseases can have an adverse effect on the clinical outcomes of patients with COVID-19. We present a comprehensive review of the latest literature on preexisting liver diseases and its interrelationship with COVID-19 infection in cirrhosis, hepatocellular carcinoma, nonalcoholic fatty liver disease, autoimmune hepatitis, and viral hepatitis B. As social distancing and telemedicine gain new footing, we synthesize recommendations from 3 major hepatology societies [American Association for the Study of Liver Disease (AASLD), the European Association for the Study of Liver (EASL), and the Asian Pacific Association for the Study of Liver (APASL)] to present the best approaches for caring for patients with liver diseases as well as those requiring liver transplantation.

COVID-19 and Pediatric Gastroenterology

“…Of note, their study reported 12% of their population as symptomatic for COVID-19 based on exposures, however only 0.5% of patients had a confirmed case via testing causing this data to be difficult to interpret. Regardless of the potential increased risk, treating patients with pre-existing liver disease is further complicated by the hepatotoxicity of many of the medications used to treat COVID-19 9 , 11 . The adult data supports cirrhosis as a risk factor for severe disease, however again the data in pediatrics is unclear 38 , 39 .When investigating autoimmune hepatitis (AIH) as compared to other etiologies of liver disease there was no difference in rate of severe disease 40 .…”

“…There is also diffuse microvascular small-bowel injury and inflammation-mediated tissue damage of the stomach, duodenum, and rectum 9 . Hepatobiliary injury is also multifactorial and may be due to ACE-2 mediated entry of SARS-CoV-2 directly into cholangiocytes damaging the biliary ducts 9 , 11 . While some series reported up to 37% of patients had abnormal liver tests 12 , a pooled data meta-analysis indicated no greater risk of abnormal transaminases or total bilirubin 13 .…”

COVID-19: biologic and immunosuppressive therapy in gastroenterology and hepatology

“…Based on the currently available data, several recommendations for AIH therapy in the context of COVID-19 have been made 98 – 100 . It has been suggested that hospitalized patients with AIH should receive standard therapy at the usual dose for treatment of acute flares 99 .…”

“…It has been suggested that hospitalized patients with AIH should receive standard therapy at the usual dose for treatment of acute flares 99 . Moreover, the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL) recommend that patients with AIH on immunosuppression without COVID-19 should not decrease immunosuppression 98 – 100 . By contrast, in the presence of COVID-19, lowering of immunosuppression — particularly of anti-metabolites in patients with lymphopenia — should be considered 98 – 100 .…”

“…Moreover, the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL) recommend that patients with AIH on immunosuppression without COVID-19 should not decrease immunosuppression 98 – 100 . By contrast, in the presence of COVID-19, lowering of immunosuppression — particularly of anti-metabolites in patients with lymphopenia — should be considered 98 – 100 . Moreover, EASL suggests that budesonide should be used for therapy in patients with AIH and with COVID-19 to reduce and minimize systemic glucocorticoid exposure for the management of acute flares of AIH.…”