Care of Patients With Liver Disease During the COVID-19 Pandemic – UPDATE

Overall, because only one person out of every hundred reported cases of COVID-19 had liver disease, it is thought that having chronic liver disease itself does not put someone at higher risk of becoming infected with SARS-CoV-2 (the virus that causes COVID-19) or getting a more severe COVID-19 than the average person. 

However, people with more advanced liver disease are at higher risk, as are some people with particular liver conditions. The lay summary describes how specific groups are affected, including people with advanced liver disease, with autoimmune hepatitis and those who have had transplants.

What is chronic liver disease? 

Chronic liver disease describes a liver disease that lasts a long time. Examples include hepatitis B, hepatitis C, autoimmune liver diseases, and fatty liver disease (NAFLD). 

Changes to liver blood test results have been reported in patients with COVID-19 who have liver disease and also in those who do not have liver disease, particularly in patients admitted to hospital. It is not known if this is a direct effect of the SARS-CoV-2 virus, or if this is a result of the COVID-19 attack on the body or even the drugs used to treat it. Studies are ongoing to investigate the processes involved, and it is not yet fully understood what these liver changes mean for patients who get COVID-19. 

Healthcare systems across the world have adapted to manage COVID-19 patients. This has affected and continues to affect healthcare for non-COVID-19 patients, including those needing liver services. For people with chronic liver disease, this means that routine appointments may be delayed, telemedicine may replace some face-to-face appointments, and laboratory tests and procedures may be delayed, cancelled or carried out in a different place (for example at general practitioners instead of your usual hospital).  

A serious knock-on effect of not receiving the usual care is that patient health gets worse: liver disease can progress untreated, people do not get diagnosed quickly enough, and liver cancers are not detected as quickly as usual. In turn, we know people with more advanced liver disease are at increased risk of severe COVID-19. To avoid a vicious cycle of liver disease and COVID-19, and to maintain the health and wellbeing of people with liver disease, EASL-ESCMID urges healthcare professionals and hospitals to tackle these challenges and aim to provide high quality care through: 

1. Continuing to use new technologies and ideas that worked well during the outbreak such as telemedicine when appropriate and using local services for monitoring disease progression.
2. Restarting clinical trials. 
3. Carefully prioritising patients in an informed way for care, procedures and treatments when resources are limited, balancing the risk of SARS-CoV-2 infection and individual patient needs. 

EASL-ESCMID’s vision is a return to gold standard liver disease care as soon as possible, with timely diagnosis, treatment and surveillance, ongoing patient education, and early intervention for high-risk patients with COVID-19. 

Some procedures carry a risk of SARS-CoV-2 transmission.

Endoscopy 

Endoscopy is a term used to describe invasive procedures where a tube goes inside the body to look closely at specific areas, take tissue samples, and do other tasks such as widening bile ducts or inserting/removing stents. SARS-CoV-2 can be transmitted during endoscopic procedures.  

EASL-ESCMID recommend that:  

• all patients have a SARS-CoV-2 test before their procedure if possible.  
• in patients who test negative and in areas where there is a low COVID-19 burden, endoscopic procedures should not be delayed for varices screening and treatment, bile duct widening or stent replacement in patients with primary sclerosing cholangitis (PSC) or people who have had a liver transplant.    
• in patients who have COVID-19, endoscopic procedures should be limited to emergencies only. Such emergencies include bacterial cholangitis and GI bleeds. 

Ultrasound 

An ultrasound scan is a routine procedure to check for signs of liver cancer in patients with liver disease. 

EASL-ESCMID recommend that:  

• your healthcare team should only delay your ultrasound scan (for liver cancer screening) where resources for screening and/or treatment are limited, and they should prioritise those patients at increased risk for HCC.  
• for patients who have COVID-19, screening for HCC can be delayed until the patient has recovered. 

Liver biopsy 

A liver biopsy is an invasive procedure where a needle is put into the liver and a tiny bit of the liver is removed. Liver biopsies are used to help diagnose some liver diseases and to assess how much damage there is in the liver. 

EASL-ESCMID recommend that:  

• in areas where there is a low COVID-19 burden, liver biopsies should go ahead following usual care guidelines. 
• in areas where there is a high COVID-19 burden, or limited resources, patients who need liver biopsies should be prioritised if liver blood tests are very high for no clear reason, when transplant rejection is suspected and if cancer is suspected. 
• for patients who have COVID-19, the risks and benefits of a liver biopsy need to be considered on a case-by-case basis. 

EASL-ESCMID recommend that all liver disease patients who need to be admitted into hospital should have a PCR test before admission. 

The paper makes specific recommendations for groups of patients:

• People with cirrhosis
• NAFLD patients 
• Viral hepatitis patients 
• Alcohol-related liver disease patients 
• Autoimmune liver disease patients 
• Patients who need a liver transplant 
• People who have had a liver transplant 
• Liver cancer patients