The European Association for the Study of the Liver (EASL) and European Society of Clinical
Microbiology and Infectious Diseases (ESCMID) have
updated their guidance on chronic liver disease and COVID-19, issued in March
2020, to reflect emerging evidence.
They stress that people with chronic liver disease are not at
increased risk of COVID-19, but if they develop COVID-19, some people with
liver disease may have a more severe illness.
People with metabolic-associated fatty liver disease, also
known as non-alcoholic fatty liver disease, appear to have more severe COVID-19
and this is correlated with the presence of non-invasive fibrosis. However,
EASL and ESCMID say that larger analyses are needed to be certain that
metabolic-associated fatty liver disease leads to worse COVIOD-19 outcomes.
Drugs that prevent the clotting of blood.
- 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’.
No strong evidence has emerged to show that viral hepatitis
is associated with worse COVID-19 outcomes.
EASL and ESCMID say that people with cirrhosis are
particularly vulnerable if they become infected with SARS-CoV-2. They have a
higher risk of death than people without cirrhosis if they develop COVID-19
illness and should be admitted to hospital sooner than other COVID-19 patients.
However, it is not clear if people with cirrhosis who
develop COVID-19 are at significantly higher risk of acute liver failure or death
compared to people with cirrhosis without COVID-19 who suffer decompensation.
People with cirrhosis who are admitted to hospital with
liver failure or decompensation should be tested for SARS-CoV-2 as soon as
Corticosteroid treatment for autoimmune hepatitis does not
increase the risk of SARS-CoV-2 infection. Although there is some evidence to
show that people taking corticosteroids for autoimmune hepatitis may have more
severe COVID-19 illness, more evidence is needed and EASL and ESCMID do not
recommend any change in corticosteroid dose unless a patient develop lymphopenia
or a fungal or bacterial lung infection as a result of COVID-19.
In cases where people with COVID-19 develop an autoimmune
hepatitis flare, EASL and ESCMID encourage doctors to consider using budenoside
to treat the flare, to limit total glucocorticoid exposure in circumstances where
dexamethasone is given as respiratory support during COVID-19 treatment.
Liver transplant services should be restored as soon as
possible, as people with decompensated cirrhosis on the transplant waiting list
are at higher risk of death due to COVID-19. Candidates should strictly isolate
prior to admission and be screened for possible symptoms or contacts. Candidates
should be made aware that SARS-CoV-2 infection in patients undergoing major
surgery is associated with an increased risk of severe COVID-19 outcomes. Stringent
infection control measures throughout the care pathway are essential.
Immunosuppressive medication should not be discontinued or
reduced except in cases of lymphopenia or fungal or bacterial infection. Doctors
should discuss with patients the need to maintain immunosuppressive medication,
as patients with high anxiety regrading COVID-19 may choose to avoid taking
immunosuppressive drugs in the belief that this will reduce their risk of
In liver transplant patients who do develop COVID-19, calcineurin
inhibitor and mTOR inhibitor levels should be monitored if any medication is
used to treat COVID-19, especially HIV protease inhibitors, hydroxychloroquine
or new trial drugs.
EASL and ESCMID also highlight the emerging evidence on blood
clots (venous thromboembolism) in people with chronic liver disease and
COVID-19. Both chronic liver disease and COVID-19 increase the risk of blood
clots. The position paper recommends the use of anticoagulants in people with
cirrhosis and portal hypertension, with low molecular weight heparin as
standard-of-care preventive treatment in any patient with cirrhosis admitted to
hospital, but EASL and ESCMID say more evidence is needed about the potential
benefits of routine anticoagulant treatment for anyone with cirrhosis and