Outcomes following SARS-CoV-2 infection in patients with chronic liver disease: An international registry study

J Hepatol. 2021 Mar;74(3):567-577. doi: 10.1016/j.jhep.2020.09.024. Epub 2020 Oct 6.


Background & aims: Chronic liver disease (CLD) and cirrhosis are associated with immune dysregulation, leading to concerns that affected patients may be at risk of adverse outcomes following SARS-CoV-2 infection. We aimed to determine the impact of COVID-19 on patients with pre-existing liver disease, which currently remains ill-defined.

Methods: Between 25th March and 8th July 2020, data on 745 patients with CLD and SARS-CoV-2 (including 386 with and 359 without cirrhosis) were collected by 2 international registries and compared to data on non-CLD patients with SARS-CoV-2 from a UK hospital network.

Results: Mortality was 32% in patients with cirrhosis compared to 8% in those without (p <0.001). Mortality in patients with cirrhosis increased according to Child-Pugh class (A [19%], B [35%], C [51%]) and the main cause of death was from respiratory failure (71%). After adjusting for baseline characteristics, factors associated with death in the total CLD cohort were age (odds ratio [OR] 1.02; 1.01-1.04), Child-Pugh A (OR 1.90; 1.03-3.52), B (OR 4.14; 2.4-7.65), or C (OR 9.32; 4.80-18.08) cirrhosis and alcohol-related liver disease (OR 1.79; 1.03-3.13). Compared to patients without CLD (n = 620), propensity-score-matched analysis revealed significant increases in mortality in those with Child-Pugh B (+20.0% [8.8%-31.3%]) and C (+38.1% [27.1%-49.2%]) cirrhosis. Acute hepatic decompensation occurred in 46% of patients with cirrhosis, of whom 21% had no respiratory symptoms. Half of those with hepatic decompensation had acute-on-chronic liver failure.

Conclusions: In the largest such cohort to date, we demonstrate that baseline liver disease stage and alcohol-related liver disease are independent risk factors for death from COVID-19. These data have important implications for the risk stratification of patients with CLD across the globe during the COVID-19 pandemic.

Lay summary: This international registry study demonstrates that patients with cirrhosis are at increased risk of death from COVID-19. Mortality from COVID-19 was particularly high among patients with more advanced cirrhosis and those with alcohol-related liver disease.

Keywords: Acute-on-chronic liver failure; COVID-19; Chronic liver disease; Cirrhosis; SARS-CoV-2.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute-On-Chronic Liver Failure* / diagnosis
  • Acute-On-Chronic Liver Failure* / epidemiology
  • COVID-19* / mortality
  • COVID-19* / therapy
  • Disease Progression
  • Female
  • Global Health / statistics & numerical data
  • Hospitalization / statistics & numerical data
  • Humans
  • Liver Cirrhosis* / diagnosis
  • Liver Cirrhosis* / epidemiology
  • Liver Cirrhosis* / etiology
  • Liver Function Tests / methods
  • Male
  • Middle Aged
  • Mortality
  • Registries / statistics & numerical data
  • Risk Assessment / methods
  • Risk Factors
  • SARS-CoV-2 / isolation & purification
  • United Kingdom / epidemiology