Liver care during COVID-19 Pandemic

Almost year after start of COVID-19 pandemic, it has become increasingly evident that pre-existing liver diseases and liver injury during the disease course must be kept in mind when caring for patients with COVID-19.

Fatty liver disease:

Obesity associated with fatty liver represents a significant risk factor for a severe course of COVID-19 with severe pneumonia being particularly increased in men. It has been postulated that adipose tissue may serve both as a viral reservoir and also an immunological hub for the inflammatory response. Fatty liver also associated with hypertension and diabetes are commonly observed in patients with severe COVID-19.

Cirrhosis:

The risk of infection and/or the risk of a severe course of COVID-19 may be different depending on the nature of the chronic liver disease. Patients with cirrhosis are at increased risk of infections and associated complications due to cirrhosis-associated immune dysfunction, which is particularly important for patients with decompensated cirrhosis.

Liver transplantation recipients:

The clinical course of COVID-19 in immunosuppressed transplant recipients is different. Indeed, liver injury appears to be relatively less prevalent, kidney injury is more common in transplant recipients with COVID-19.

Recommendations for care of liver disease

· During COVID- 19 Pandemic it is essential to keep regular checks to monitor liver health, and avoid frequent hospital visits

· Use telemedicine/local laboratory testing for follow-up visits in patients with liver disease.

· Avoid potential adverse metabolic and hepatic consequences of social isolation, including more sedentary lifestyles and increased consumption of processed foods.

· Preventing liver disease progression through intensive lifestyle intervention, including nutritional guidance, weight loss advice, and diabetes management may help prevent the development of a severe disease course with future SARS-CoV-2 infection.

· Treatment of arterial hypertension should continue in accordance with existing guidelines.

· Guidelines on prophylaxis of spontaneous bacterial peritonitis, gastrointestinal haemorrhage, and hepatic encephalopathy should be closely followed to prevent decompensation and avoid admission.

· Early admission should be considered for all patients with cirrhosis who become infected with SARS-CoV-2.

· All patients with cirrhosis should receive vaccination for Streptococcus pneumoniae and influenza.

Liver transplant candidates

· Patients on the LT waiting list with decompensated cirrhosis are at high risk of severe COVID-19 and death following SARS-CoV-2 infection.

· LT should be prioritised for patients with poor short-term prognosis including those with acute liver failure, ACLF, high MELD score and HCC at the upper limits of the Milan criteria.

· Living-donor transplantations should be considered with careful risk stratification of donor and recipient, incorporating a combination of clinical history, chest radiology, and SARS-CoV-2 testing.