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Advanced cirrhosis or alcohol use disorder raised the risk of COVID-19 death in France

Higher risk of death may be a consequence of decisions not to provide mechanical ventilation, study authors conclude

Keith Alcorn
25 June 2021
Image by Francisco Àvia. Creative Commons licence.

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 has found.

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 ventilation.


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 ventilation.

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 ventilation.”


Mallet V et al. Chronic liver disease and the risk of mortality after Covid-19: a national, retrospective, cohort study for 2020. International Liver Congress, abstract GS-1587, 2021.

Mallet V et al. Prognosis of French COVID-19 patients with chronic liver disease: a national retrospective cohort study for 2020. Journal of Hepatology, published online, 13 May 2021.

Full image credit: Atenció casos de coronavirus SARS-CoV-2 (2)_09. Hospital Clínic de Barcelona. Francisco Àvia. Available at under a Creative Commons licence CC BY-ND 2.0.