Cirrhosis puts COVID-19 patients at higher risk of hospitalization, death

An analysis of U.S. veterans with and without cirrhosis who were tested for SARS-CoV-2 this spring found a 30-day mortality rate of 17.1% in patients with both conditions, compared to 2.3% in those with neither COVID-19 nor cirrhosis.

Patients with both cirrhosis and COVID-19 have significantly higher mortality risk than those with either condition alone, a recent study found.

The retrospective study included 88,747 patients in the Veterans Affairs health care system who were tested for SARS-CoV-2 between March 1 and May 14. Most (n=75,315) had neither COVID-19 nor cirrhosis, 9,826 tested positive for SARS-CoV-2 and didn't have cirrhosis, 3,301 had cirrhosis and no SARS-CoV-2, and 305 had both conditions. Results were published by Hepatology on Nov. 21.

Patients with cirrhosis were less likely to test positive for SARS-CoV-2 than patients without cirrhosis (8.5% vs. 11.5%; adjusted odds ratio, 0.83 [95% CI, 0.69 to 0.99]). However, rates of 30-day mortality were increased in patients with cirrhosis: 2.3% for those with neither condition, 5.2% for those with only cirrhosis, 10.6% for those with only SARS-CoV-2, and 17.1% for those with both. The same pattern was true for risk of mechanical ventilation, with rates of 1.6%, 3.6%, 6.5%, and 13.0%, respectively. The researchers calculated that among patients with cirrhosis, testing positive for SARS-CoV-2 was associated with adjusted hazard ratios (aHRs) of 4.12 (95% CI, 2.79 to 6.10) for mechanical ventilation and 3.54 (95% CI, 2.55 to 4.90) for 30-day mortality. Among the patients testing positive for SARS-CoV-2, cirrhosis was associated with significantly increased risk of hospitalization (aHR, 1.37; 95% CI, 1.12 to 1.66), ventilation (aHR, 1.61; 95% CI, 1.05 to 2.46), and death (aHR, 1.65; 95% CI, 1.18 to 2.30). The most significant predictors of mortality in patients with both conditions were advanced age, cirrhosis decompensation, and high Model for End-Stage Liver Disease score.

“These results demonstrate the grave, additional risks of SARS-CoV-2 infection in patients with cirrhosis,” the study authors said. The finding that patients with cirrhosis were less likely to test positive for SARS-CoV-2 does not have any plausible biological explanation and might be due to patients with cirrhosis practicing more preventive infection control measures, they speculated. The strengths of this study include its size and national scope, but limitations include the small number of women included, they said.

The authors called on clinicians to “be especially vigilant when caring for cirrhosis patients who are elderly or have a history of decompensated cirrhosis, since they have the highest risk for mortality” and to “carefully weigh the risks and benefits of in-person encounters or procedures” for all patients with cirrhosis, given the observed risks of infection for them.