People with advanced cirrhosis or alcohol use disorder were
significantly more likely to die from COVID-19 in France during 2020 compared
to the rest of the population, a study of the French national hospital database
The findings, presented to the 2021 International Liver Congress
by Dr Vincent Mallet of Cochin Hospital, Paris, and published in the Journal
of Hepatology, showed that people with advanced liver disease had an
increased risk of death, but people with less advanced liver disease or
transplant recipients did not.
However, the French researchers say that their findings may be
explained by triage decisions, described by Dr Mallet as “therapeutic effort limitations”,
by which scarce mechanical ventilation resources were allocated to patients
judged to have a better prognosis. The study found that people with decompensated
cirrhosis, alcohol use disorders or primary liver cancer admitted to hospital with
COVID-19 were at higher risk of dying but were less likely to receive mechanical
- compensated cirrhosis
The earlier stage of
cirrhosis, during which the liver is damaged but still able to perform most of
its functions. See also ‘cirrhosis’ and ‘decompensated cirrhosis’.
- decompensated cirrhosis
The later stage of
cirrhosis, during which the liver cannot perform some vital functions and
complications occur. See also ‘cirrhosis’ and ‘compensated cirrhosis’.
Previous reports from the United
States and from
international registries of COVID-19 cases in liver patients showed that in
the first wave of the pandemic in 2020, people with advanced cirrhosis had a
higher risk of death compared with people with less severe liver disease or
other people who were hospitalised with COVID-19.
The French study looked at the impact of liver conditions on the
outcomes of all people hospitalised with COVID-19, using the French National Hospital Discharge database. During 2020, 259,110 adults
were hospitalised in France with COVID-19. Of these, 38,203 died. The median
age of people treated for COVID-19 in France was 70 years, and 52% were men.
The analysis identified 15,476 people with a diagnosis of chronic
liver disease, categorised as either compensated
or advanced (defined as chronic liver disease with a previous liver-related
event). They accounted for 6% of all COVID-19 patients treated in 2020. Of
these, 3623 had alcoholic liver disease, 820 had hepatitis C, 2299 had a
non-viral, non-alcoholic cause of liver disease, 719 had liver cancer and 329
had undergone a liver transplant.
Underlying health conditions for each
case were identified from the French National Patient Registry. People with
chronic liver disease who were hospitalised with COVID-19 were significantly
more likely to be male and had a higher burden of co-morbidities, obesity,
hypertension, type 2 diabetes and smoking.
After hospital admission, people with
chronic liver disease were significantly more likely to require mechanical
ventilation and to experience a range of complications including acute kidney
injury, pulmonary embolism, portal vein thrombosis and acute liver failure, and
to die within 30 days of admission to hospital (19% vs 14%, p < 0.001).
However, people with chronic liver disease were not at higher risk of developing
acute respiratory distress syndrome.
Ten per cent of people with chronic
liver disease and 6.8% of those without liver disease required mechanical
ventilation. Multivariate analysis showed that people admitted to hospital in
the second wave of the pandemic, people aged 90 or over, people with an alcohol
use disorder, people with mild liver disease without cirrhosis, people with
compensated cirrhosis or decompensated cirrhosis, those with primary liver
cancer or a Charlson co-morbidity index score of 4 or above had lower odds of mechanical
Multivariate analysis showed that all
age groups had a raised risk of dying within 30 days of hospitalisation for
COVID-19, as did men, obese people and people with a history of smoking.
However, whereas people with primary liver cancer, advanced cirrhosis or an
alcohol use disorder had increased odds of dying, people with hypertension,
those with mild liver disease without cirrhosis and those with compensated
cirrhosis had reduced odds of dying. The odds of death increased as the Charlson
co-morbidity index score increased.
When the researchers compared the odds
of mechanical ventilation and the odds of dying from COVID-19, they observed
that several groups of patients had lower, or negative, odds of mechanical
ventilation and higher, or positive, odds of dying from COVID-19.
People with alcohol use disorders,
decompensated cirrhosis or untreated primary liver cancer had a lower chance of
mechanical ventilation and a higher chance of dying from COVID-19, they found.
Writing in the Journal of
Hepatology, Dr Mallet and colleagues conclude: “Our findings do not support
an excess in COVID-19 severity for patients with chronic liver disease, alcohol
use disorders, cirrhosis [and] primary liver cancer. […] Our results suggest
that the prognosis of COVID-19 patients with chronic liver disease or alcohol
use disorder could be more related to therapeutic effort, including mechanical