COVID-19 in chronic liver disease: advanced cirrhosis greatly raises risk of death

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People with chronic liver disease admitted to hospital with COVID-19 are dying at a much higher rate than the rest of the population, figures collated by liver specialists in Europe, Asia and North America show. Advanced cirrhosis greatly increased the risk of death, the study found.

People with severe cirrhosis were almost 30 times more likely to die after a COVID-19 diagnosis than people with chronic liver disease without cirrhosis, the figures show. The overall death rate in people with chronic liver disease was 39% among reported cases.

Two international registries were established in March 2020 to track the outcomes of people with chronic liver disease and cirrhosis after diagnosis with COVID-19. Investigators from 14 specialist liver clinics in the United States, Spain and the United Kingdom have now reported on the first 152 cases submitted to the registries, in a publication in the Journal of Hepatology.

Large case series published to date have not shown a high prevalence of chronic liver disease in people hospitalised with COVID-19, suggesting that people with chronic liver conditions are not at higher risk of developing severe symptoms because of SARS-CoV-2 infection.

However, no study has looked specifically at the clinical outcomes of people known to have chronic liver disease.

The registry and registry accumulated 152 consecutive physician reports of laboratory-confirmed cases of COVID-19 between 25 March and 20 April 2020, of cases with definite outcomes (either death or discharge from hospital).

One hundred and three were cases of cirrhosis. 22.3% of reported cases occurred in people with viral hepatitis, 22.4% in people with non-alcoholic fatty liver disease and 19.7% in alcoholic liver disease. The remainder had other causes or a combination of causes.

The median age of reported cases was 61 years and 59% were male. Twenty-one per cent were obese (BMI > 30 kg/m2), 21% had cardiovascular disease, 35% diabetes and 39% hypertension.

Ninety-five per cent of the reported cases were admitted to hospital, and 23% were admitted to an intensive care unit. Forty-seven of the 152 people died (39.8%).

"People with severe cirrhosis were almost thirty times more likely to die after a COVID-19 diagnosis."

Multivariable analysis showed that severe cirrhosis (Child-Pugh C stage) was strongly associated with an increased risk of death from COVID-19. People in Child-Pugh stage C, who comprised 17.8% of all reported cases, were 28 times more likely to die than people without cirrhosis (32.2% of cases) (odds ratio 28.07, 95% CI 4.42-178.46, p < 0.001). Sixty-three per cent of people with Child-Pugh stage C cirrhosis died compared to 12.2% of those without cirrhosis.

People with Child-Pugh stage B cirrhosis also had a higher risk of death (OR 4.90, 95% CI 1.16-20.61, p = 0.030).

Obesity was the other significant risk factor; obese people were approximately three-and-a half times more likely to die (OR 3.59, 95% CI 1.1-10.47, p = 0.033).

Older age had a borderline significant impact on the risk of dying, but other underlying conditions did not emerge as significant risk factors after controlling for other risk factors including cirrhosis stage.

Decompensation events (worsening ascites, variceal haemorrhage, hepatic encephalopathy or bacterial peritonitis) occurred significantly more often in those who died (51% vs 14%, p < 0.001) and 12.2% of deaths were classified as liver-related. Decompensation events occurred frequently in the reported cases; around half of people with Child-Pugh B or C cirrhosis suffered at least one new or worsening event after diagnosis with COVID-19 and these events often occurred in people without respiratory symptoms of COVID-19.

The investigators say that the findings regarding decompensation events, especially in the absence of respiratory symptoms, underline the importance of testing for SARS-CoV-2 in any patient with chronic liver disease who experiences a decompensation event.


Moon AJ et al. High mortality rate for SARS-CoV2 infection in patients with pre-existing chronic liver disease and cirrhosis: preliminary results from an international registry. Journal of Hepatology, advance online publication, 22 May 2020.