key: cord-0731349-hx2rq1qj
authors: Kumar, Pramod; Sharma, Mithun; Sulthana, Syeda Fathima; Kulkarni, Anand; Rao, Padaki Nagaraja; Reddy, Duvvuru Nageshwar
title: SARS-CoV-2 related Acute on chronic liver failure (S-ACLF)
date: 2020-12-30
journal: J Clin Exp Hepatol
DOI: 10.1016/j.jceh.2020.12.007
sha: e746649266345b663b049f41bd3508fca30ddb80
doc_id: 731349
cord_uid: hx2rq1qj

nan

Acute on chronic liver failure (ACLF) is a condition associated with hepatic and extrahepatic organ failure with high short-term mortality. (2) The data regarding severe acute respiratory syndrome-corona virus 2 (SARS-CoV-2) related ACLF (S-ACLF) are scarce. ( and higher mortality (30% vs.5%, p-0.01) as compared to patients without ACLF. The cause of death was respiratory failure in 5 (67%) and liver-related in 3 (37%) patients. There were no differences in laboratory parameters between those who died and survived in the S-ACLF group. Patients who died had significantly higher CLIF C score (56.8±4.8 vs.43.3±6.4, p-<0.001 ), CLIF C organ failure score (12.1±1.4 vs.9.7±1.6,p-0.005 ), and ACLF grade (3.1±0.9 vs.1.9±0.6,p-0.003).

Patients with ACLF are more prone to develop severe COVID-19 illness because of profound immune dysregulation. (1) It is unclear whether outcomes in S-ACLF will be different compared to the other causes of ACLF. Our cohort demonstrated lower mortality in cirrhosis patients, contrary to other studies despite having similar disease severity. Our cohort's better outcomes could be due to prompt usage of steroids in patients with moderate or severe COVID-19. (4) (5) (6) (7) (8) The patients tolerated steroids well, and four patients developed gram-negative sepsis, which responded to broad-spectrum antibiotics. The exact mechanism of S-ACLF is unclear, and the cytokine storm might serve as a trigger in these patients. It is J o u r n a l P r e -p r o o f also hypothesized that direct SARS-CoV-2 infection can cause significant liver injury because of the upregulated ACE2 expression and higher ACE2 internalization in hepatocytes, causing worsening of liver fibrosis and portal hypertension to ACLF in decompensated cirrhosis. (9) Also, a liver biopsy might have helped in better understanding of the cause and severity of S-ACLF. Excessive Systemic inflammation is a hallmark in ACLF, and these patients had higher leukocyte count and elevated D-dimer in our study. The inflammatory response observed in our study is comparable to that of patients with COVID-19 without cirrhosis, as described in recent metanalysis. (10) Whether immune dysregulation in S-ACLF is different from ACLF of other causes and cirrhosis needs further evaluation. We speculate that the SARS-CoV-2 infection predominantly determines immune dysregulation and outcomes irrespective of cirrhosis severity. In conclusion, S-ACLF is associated with a poor outcome, and early recognition and aggressive treatment of COVID-19 is warranted. Further multicentre studies with a larger sample size will provide more robust data on S-ACLF outcomes. All results are expressed in Mean ± standard deviation unless otherwise specified *Prior to the onset of COVID-19 illness, ACLF-Acute on chronic liver failure, MELD-Model for end stage liver disease, CLIF C-Chronic liver failure consortium, COVID-19-Corona virus disease 2019, SpO2-Oxygen saturation in pulse oximeter J o u r n a l P r e -p r o o f

Acute-on-Chronic Liver Failure

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Systematic review with meta-analysis: liver manifestations and outcomes in COVID-19

Acute on chronic liver failure from novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

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

Pre-existing liver disease is associated with poor outcome in patients with SARS CoV2 infection; The APCOLIS Study (APASL COVID-19 Liver Injury Spectrum Study)

Poor outcomes in patients with cirrhosis and Corona Virus Disease-19

High rates of 30-day mortality in patients with cirrhosis and COVID-19

ACE2: A Linkage for the Interplay Between COVID-19 and Decompensated Cirrhosis

Cytokine elevation in severe and critical COVID-19: a rapid systematic review, meta-analysis, and comparison with other inflammatory syndrome

Writing-original draft , review and editing Syeda Fathima sulthana : Compilation Anand Kulkarni: Reviewing and editing Mithun sharma: Reviewing and editing Padaki Nagaraj rao : Supervision Duvvuru Nageshwar Reddy: Supervision