• liver cirrhosis
• infectious disease

COVID-19 has rapidly become a global challenge.1 We read with interest the article by Bezzio et al 1 that reported the characteristics and outcomes of COVID-19 patients with pre-existing IBD. Patients with pre-existing cirrhosis, who have immune dysfunction and poorer outcomes from acute respiratory distress syndrome (ARDS) than patients without cirrhosis, are also considered a high-risk population for COVID-19.2 3In previous studies, the proportion of COVID-19 patients with pre-existing liver conditions ranged from 2% to 11%.2 However, the clinical course and risk factors for mortality in these patients has not yet been reported.

This retrospective multicentre study (COVID-Cirrhosis-CHESS, ClinicalTrials.gov NCT04329559) included consecutive adult patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and pre-existing cirrhosis from 16 designated hospitals in China between 31 December 2019 and 24 March 2020. Patient characteristics are summarised in table 1. Twenty-one COVID-19 patients with pre-existing cirrhosis (Child-Pugh class A, B and C in 16, 3 and 2 patients, respectively) were included in the analysis. The median age was 68 years; 11 (52.4%) were male. Most patients had compensated cirrhosis (81.0%) and chronic HBV infection was the most common aetiology (57.1%). Comorbidities other than cirrhosis were present in most patients (66.7%). In previous studies, older age, male sex and pre-existing comorbidities were associated with higher risk of mortality for COVID-19.4 5 Here, there were no significant differences between survivors (n=16) and non-survivors (n=5) in age, sex, comorbidities, aetiology of cirrhosis, stage of cirrhosis, Child-Pugh class, Model for End-stage Liver Disease (MELD) score, interval between onset and admission, or onset symptoms of COVID-19. Comorbidities have been associated with adverse outcomes in cirrhosis,6 but our analysis did not show clear prognostic associations—possibly due to the small size and narrow composition of the study population.

Fever and cough were the most common symptoms on admission, similar to previous studies of COVID-19 among general populations.7 8 Elevations in aspartate transaminase, alanine aminotransferase and gamma-glutamyl transferase levels were present in 8 (38.1%), 5 (23.8%) and 5 (23.8%) patients, respectively. Leucopenia, lymphopenia and thrombocytopenia occurred in 8 (38.3%), 15 (71.4%) and 8 (38.1%) patients, respectively. Although abnormal haematological indices and portal hypertension are common in cirrhosis, patients with COVID-19 who died had lower total lymphocyte and platelet counts, and also higher direct bilirubin levels than patients who survived (p=0.040, 0.032 and 0.006, respectively). These findings are consistent with previous studies in the general COVID-19 population.9 10

Treatment and complications occurring during hospitalisation are summarised in table 2. The frequency of ARDS and GI bleeding were higher in non-survivors than survivors (100.0% vs 6.3%, p<0.001, and 60.0% vs 6.3%, p=0.028, respectively). Of the five non-survivors, all patients developed ARDS and two patients progressed to multiple organ dysfunction syndrome. One patient who died developed clear evidence of acute-on-chronic liver failure.

In contrast to Western populations, the main cirrhosis aetiology in this China-based study was chronic HBV, so it is unclear if our findings are generalisable to other geographic regions. To further define the clinical course of COVID-19 patients with pre-existing cirrhosis and confirm risk factors for mortality, larger prospective studies comprising patients with different cirrhosis aetiologies are expected.

In conclusion, we provide the first report of the demographic characteristics, comorbidities, laboratory and radiographic findings, and clinical outcomes in SARS-CoV-2-infected patients with pre-existing cirrhosis. The cause of death in most patients was respiratory failure rather than progression of liver disease (ie, development of acute-on-chronic liver failure). Lower lymphocyte and platelet counts, and higher direct bilirubin level might represent poor prognostic indicators in this patient population.