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Comparison of mortality risk in patients with cirrhosis and COVID-19 compared with patients with cirrhosis alone and COVID-19 alone: multicentre matched cohort
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Gut July 13 2020- Jasmohan S Bajaj ,1,2 Guadalupe Garcia-Tsao,3 Scott Biggins,4 Patrick S Kamath,5Florence Wong,6 Sara McGeorge,2 Jawaid Shaw,2 Meredith Pearson,4 Micheal Chew,3Andrew Fagan,2 Randolph de la Rosa Rodriguez,3 Janelle Worthington,5 Amy Olofson,5 Vanessa Weir,7 Calvin Trisolini,7 Sarah Dwyer,7 K Rajender Reddy7,8
Significance of this study
What is already known on this subject?
• COVID-19 is associated with higher mortality in patients with comorbidities.
• Whether COVID-19 adds to the mortality of hospitalised patients with cirrhosis and complications is unknown.
What are the new findings?
• In a multicentre North American experience, inpatients with cirrhosis and COVID-19 had higher mortality risk than inpatients with COVID-19 infection alone.
• The risk of mortality in hospitalised patients with cirrhosis+COVID-19 was not, however, significantly higher than those hospitalised with cirrhosis but without COVID-19.
• Patients with cirrhosis hospitalised for COVID-19 are more likely to develop complications related to the viral infection rather than the complications related to cirrhosis observed in those with cirrhosis alone.
• Patients with cirrhosis+COVID-19 are less likely to present with GI symptoms compared with those with COVID-19 alone.
How might it impact on clinical practice in the foreseeable future?
• In patients with COVID-19, underlying cirrhosis should be considered a high-risk comorbid condition.
• When patients with cirrhosis and COVID-19 infection are hospitalised, focus should not be taken away from prevention and early treatment of complications of cirrhosis. • Despite this pandemic, patients with cirrhosis without COVID-19 should not be discouraged from seeking essential medical care.
Objective Comorbid conditions are associated with poor prognosis in COVID-19. Registry data show that patients with cirrhosis may be at high risk. However, outcome comparisons among patients with cirrhosis+COVID-19 versus patients with COVID-19 alone and cirrhosis alone are lacking. The aim of this study was to perform these comparisons.
Design A multicentre study of inpatients with cirrhosis+COVID-19 compared with age/gender-matched patients with COVID-19 alone and cirrhosis alone was performed. COVID-19 and cirrhosis characteristics, development of organ failures and acute-on-chronic liver failure (ACLF) and mortality (inpatient death+hospice) were compared.
37 patients with cirrhosis+COVID-19 were matched with 108 patients with COVID-19 and 127 patients with cirrhosis from seven sites. Race/ethnicity were similar. Patients with cirrhosis+COVID-19 had higher mortality compared with patients with COVID-19 (30% vs 13%, p=0.03) but not between patients with cirrhosis+COVID-19 and patients with cirrhosis (30% vs 20%, p=0.16). Patients with cirrhosis+COVID-19 versus patients with COVID-19 alone had equivalent respiratory symptoms, chest findings and rates of intensive care unit transfer and ventilation. However, patients with cirrhosis+COVID-19 had worse Charlson Comorbidity Index (CCI 6.5±3.1 vs 3.3±2.5, p<0.001), lower presenting GI symptoms and higher lactate. Patients with cirrhosis alone had higher cirrhosis-related complications, maximum model for end-stage liver disease (MELD) score and lower BiPAP/ventilation requirement compared with patients with cirrhosis+COVID-19, but CCI and ACLF rates were similar. In the entire group, CCI (OR 1.23, 95% CI 1.11 to 1.37, p<0.0001) was the only variable predictive of mortality on multivariable regression.
Conclusions In this multicentre North American contemporaneously enrolled study, age/gender-matched patients with cirrhosis+COVID-19 had similar mortality compared with patients with cirrhosis alone but higher than patients with COVID-19 alone. CCI was the only independent mortality predictor in the entire matched cohort. This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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