Risk factors and outcomes for acute-on-chronic liver failure in COVID-19: a large multi-center observational cohort study

Abstract

Objective Coronavirus disease 2019 [COVID-19] infection in patients with chronic liver disease [CLD] may precipitate acute-on-chronic liver failure [ACLF]. In a large multi-center cohort of COVID-19-infected patients, we aim to analyze (1) the outcomes of patients with underlying CLD [with and without cirrhosis] and (2) the development and impact of ACLF on in-hospital mortality. Design We identified 192 adults with CLD from among 10,859 patients with confirmed COVID-19 infection (admitted to any of 12 hospitals in a New York health care system between March 1, 2020 and April 27, 2020). ACLF was defined using the EASL-CLIF Consortium definition. Patient follow-up was through April 30, 2020, or until the date of discharge, transfer, or death. Results Of the 84 patients with cirrhosis, 32 [38%] developed ACLF, with respiratory failure [39%] and renal failure [26%] being the most common. Hispanic/Latino ethnicity was particularly at higher risk of in-hospital mortality [adjusted HR 4.92, 95% 1.27–19.09, p < 0.02] in cirrhosis despite having lower risk of development of ACLF [HR 0.26, 95% CI 0.08–0.89, p = 0.03]. Hypertension on admission predicted development of ACLF [HR 3.46, 95% CI 1.12–10.75, p = 0.03]. In-hospital mortality was not different between CLD patients with or without cirrhosis [ p = 0.24] but was higher in those with cirrhosis who developed ACLF [adjusted HR 9.06, 95% CI 2.63–31.12, p < 0.001] with a trend for increased mortality by grade of ACLF [ p = 0.002]. There was no difference in in-hospital mortality between the CLD cohort compared to matched control without CLD (log rank, p = 0.98) and between the cirrhosis cohort compared to matched control without cirrhosis (log rank, p = 0.51). Conclusion Development of ACLF is the main driver of increased in-hospital mortality in hospitalized patients with COVID-19 infection and cirrhosis. Supplementary Information The online version contains supplementary material available at 10.1007/s12072-021-10181-y.

Is Ferroptosis a Key Component of the Process Leading to Multiorgan Damage in COVID-19?

“…Drug-induced liver damage is a plausible addictive factor to the observed liver blood marker abnormalities after the beginning of therapy [ 33 ]. Furthermore, as recently reported, COVID-19 in patients with chronic liver disease (CLD) may precipitate acute-on-chronic liver failure (ACLF) [ 36 ]: in-hospital mortality was similar between patients with CLD with or without cirrhosis but was higher in those with cirrhosis who developed ACLF, with a trend for increased mortality by grade of ACLF [ 36 ].…”

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“…Furthermore, another study about risk factors and outcomes for acute-on-chronic liver failure in COVID-19 across multi-center studies in the United States also indicated that the presence of chronic liver disease or cirrhosis by itself is not associated with a difference in in-hospital mortality after comparison with an age, sex, and comorbiditymatched control using propensity control methods [4]. Therefore, mechanical ventilation and day-30 mortality should be fairly compared by balancing the baseline characteristics between patients with and without chronic liver disease.…”

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“…However, mortality was not different when comparing CLD patients with or without cirrhosis. Moreover, mortality was similar between the CLD cohort and matched control without CLD [ 216 ].…”