Impact of COVID-19 Infection on Patients with Chronic Liver Disease

INTRODUCTION

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the causative agent of Coronavirus Disease 19 (COVID-19), a highly contagious and dangerous virus that originated in Wuhan, China and rapidly expanded globally [1]. Regardless of the viral state, the term "long COVID" refers to the manifestation of several symptoms even weeks or months after contracting a SARS-CoV-2 infection. Another name for it is post-COVID syndrome. It may be on-going or exhibit intermittent or relapsing patterns [2]. One or more of the acute COVID symptoms may remain, or new symptoms may emerge. The majority of COVID-19 patients had negative PCR results, which suggests microbiological recovery. Thus, the interval between microbiological and clinical healing is known as post-COVID syndrome [3]. Post-acute COVID, which occurs when symptoms last longer than three weeks but less than twelve weeks, and chronic COVID, which occurs when symptoms last longer than twelve weeks, are the two phases of post-COVID, also known as long COVID [4].

Patients with COVID-19 may have unusually elevated liver enzyme values, suggesting at least transient damage. It's unclear, however, whether this is directly connected to the illness or to other variables. Furthermore, further study may be required to confirm the fair assumption that COVID-19 individuals who already have chronic liver disorders (CLD), such as cirrhosis or chronic hepatitis, would be at increased risk of significant liver damage [5]. As the number of COVID-19 patients rises, several studies Zu et al., [6], Mao et al., [7], Guan et al., [8] revealed that after lung disease, the liver is the organ most often impacted. Between 14.8 and 53.1% of infected individuals showed atypical levels of the transaminases aspartate aminotransferase (AST) and alanine aminotransferase (ALT). The majority of the rise in serum bilirubin was minor [9]. Research on COVID-19 infection and CLD patients is lacking in our area. Thus, our goal was to evaluate how COVID19 affected CLD patients [10].

PATIENTS/MATERIALS AND METHODS

Study design

Between 2020 and 2022, a retrospective cohort study centered in a hospital was carried out in the Post-COVID Outpatients Clinic at Assiut University Hospitals in Egypt.

The research was carried out in compliance with the guidelines of the Declaration of Helsinki and was authorized by the ethical committee of the Faculty of Medicine, Assiut University, Assiut, Egypt (IBR number 17101541). Patients gave their written, informed permission to participate in the trial.

Study population

Adult patients (with and without CLD) with history of COVID19 infection and recovery since more than one month before the recruitment in the study were eligible for the study. COVID19 infection was clinically, and laboratory suspected and confirmed by polymerase chain reaction (PCR). Chronic liver disease (CLD) was diagnosed by clinical, biochemical, and ultrasonography findings Patient were less than 18 years old, with concurrent COVID19 infection that wasn't completely recovered were excluded from the study.

Sample size calculation

Based on expected frequency of hepatic affection among recovered COVID19 patients that was 15.8% with assumption of 5% alpha error, 90% power and 95% confidence interval p value was significant if

Participants and study tools

The current study enrolled a total of 100 patients; 70 CLD patients and 30 non-CLD patients, who had a history of COVID19 infection and recovery since more than one month before the recruitment in the study. Only patients with CLD who were admitted to hospital, others not admitted. The medical records of those patients (during the course of COVID 19 disease and follow-up after recovery) were reviewed and the following data were gathered; thorough history taking including age, sex, comorbidities, duration of the infection, duration of hospital stay, admission to intensive care unit (ICU), fever, diarrhea, dyspnea, cough, jaundice, and other clinical data. Laboratory data included liver transaminases, serum bilirubin, albumin, creatinine, complete blood count (hemoglobin, leucocytes, lymphocytes, and platelet), and international randomized ratio (INR). Different regimens used for management of COVID19 infection (antibiotics, oxygen therapy, vitamins and/or supportive treatment) were recorded.

Chronic liver disease (CLD) included: Chronic hepatitis B, C, and D infections are the most common causes of chronic liver disease, autoimmune liver disease (autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis), drug induced liver injury, vascular: (Budd-Chiari syndrome), genetic: (Hereditary hemochromatosis and Wilson disease) and idiopathic/cryptogenic.

Statistical analysis

The statistical software for social sciences, version 20.0 (SPSS Inc., Chicago, Illinois, USA), was utilized to analyze the recorded data. Quantitative data were compared utilizing the Student or paired t test, and reported as mean ± Standard Deviation (SD). The Chi2 test was utilized to compare the frequency and proportion of qualitative data. Since there was a 95% level of confidence, a P value of less than 0.05 was considered significant.

RESULTS

This cohort study was performed on 100 COVID19 patients (70 patients with CLD and 30 without CLD). Their baseline demographic and clinical data were summarized in Table (1) where COVID19 patients with CLD were older and had more severe infection, lower hemoglobin level and platelets compared to those without CLD (P < 0.001, for all). In addition, patients with CLD showed higher frequency of symptomology including anosmia, fever, dyspnea and cough but without statistical significance. Moreover, patients with CLD had significant higher frequency of ICU admissions, non-invasive ventilation (P< 0.001) and mechanical ventilation (P< 0.001) with longer stay at ICU (P< 0.001) compared to patients without CLD (Table 2). At follow-up after recovery, a part of significant lower Hemoglobin and platelets in CLD patients, no substantial variations were found between both groups as regard laboratory variables (Table 3).

In the current research, we found that among those patients without CLD, 6 (20%) patients developed raised liver transaminases and another 3 (10%) patients developed jaundice during COVID 19 infection. At follow-up after recovery, all those 9 (30%) patients were completely improved without any hepatic sequel.

Table 1. Baseline clinical and demographic information for the participants under study

*Comorbid diseases included diabetes mellitus, ischemic heart disease, systemic hypertension, chronic kidney disease.

 CRP: C reactive protein.

Table 2. Lines of therapy and length of ICU stay among the studied COVID 19 patients.

*NIV: Noninvasive ventilation, MV : mechanical ventilation

Table 3: Follow-up laboratory data of the studied COVID19 patients

CRP: C-reactive protein