Fatty liver, cirrhosis double mortality risk in COVID-19

Through an international registry presented at the Digital International Liver Congress, experts found COVID-19 in the presence of liver disease like non-alcoholic fatty liver disease or cirrhosis conferred a greater risk for mortality and morbidity.

“From everything that was written in the press when it comes to the pandemic, it was clear that comorbidities play a role in the outcome,” Prof. Thomas Berg, MD, head of the section of hepatology at the University Hospital in Leipzig, Germany, said during a virtual press briefing prior to the Congress. “Cardiovascular risk factors were well known ... but you don’t see anything about the liver.”

Berg showed the correlation between obesity and chronic liver disease with mortality during the pandemic.

“The most common form [of chronic liver disease] is non-alcoholic fatty liver disease and according to recent statistics, up to 25% of the world’s population may have non-alcoholic fatty liver disease and clearly linked to obesity, also a risk factor for COVID-19,” Berg said. “It seems to be especially a problem for the younger adults being less than 60 years old and if they have non-alcoholic fatty liver disease the risk of dying is nearly twofold.”

This correlation was not seen in older patients with COVID-19, but Berg attributed that to other comorbidities possibly masking the impact of NAFLD on COVID-19 risk.

In this registry of more than 1,000 patients with liver disease, Berg showed that non-cirrhotic liver disease did not confer an additional risk with COVID-19 but once a patient developed cirrhosis, their risk increases.

The proportion of patients who required ICU admission increased along the lines of liver disease severity (P < .001), Berg showed, as did mortality (P < .001).

“We see a step-wise increase in the rates of major adverse outcomes and disease with each liver disease stage. In other words, if you only have liver disease without cirrhosis, your death rate is relatively low,” Berg said. “But if you have very advanced cirrhosis, ... then the risk is nearly 50%. What is interesting here is that in patients with cirrhosis, it is independent of age. Young patients with cirrhosis have a very high risk in comparison to patients without cirrhosis.”

Berg also showed that in the transplant setting, risk does not increase for COVID-related mortality. The study presented included submissions from 18 countries and reported on the largest cohort of LT recipients with laboratory-proven COVID-19 infection.

These recipients did not show an increased risk compared with non-transplant patients with similar comorbidities.

“We should be reassured that clinicians and health policy makers should be aware that liver transplantation does not confer major additional susceptibility to adverse outcomes, and this should be considered when assessing the relative risk and benefits of delivering clinical follow up and monitoring of liver transplant patients.”

Other comorbidities such as age and renal function play a bigger role in the patients’ outcomes, he said.

“When taking immunosuppressive drugs ... this does not confer a very high risk. Even the contrary might be the case that it even lowers the risk because it might improve the inflammatory response,” he said.

A bigger concern than transplant patients may be those who defer care due to fear of the pandemic, Berg said. He explained that the inherent fear of going to a hospital for routine screening may lead to an increase of advanced liver disease, eventually leading to a second wave of morbidity and mortality when infected with COVID-19. Physicians and patients should both prioritize alternative methods of care to any patients with chronic liver disease.

“There is a concern that patients will be underserved because they are afraid to visit their doctors. ... There will also be waves that come from underserving patients during the pandemic leading to a second wave of backlog of deferred visits and seeing more decompensated liver disease because we are not able to care properly for these patients,” Berg said. “This may cause a third wave where we probably will see a higher rate of morbidity and mortality due to misdiagnosis, incomplete cancer screening and progressive liver disease.”

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