Letter regarding "High rates of 30-day mortality in patients with cirrhosis and COVID-19".

To the Editor:

We read with great interest the paper published in Journal of Hepatology by Iavarone et al. This paper is very important for our daily practice as hepatologists, particularly in Egypt, which has the highest prevalence of HCV in the world and is currently experiencing a peak in reported COVID-19 cases. The authors concluded that COVID-19 infection is associated with higher 30-day mortality rates in cirrhotic patients; however, we are not sure about the rationality of this generalization.

We think that the sample size is too small to evaluate the actual effect of COVID-19 infection on mortality rates in cirrhotic patients. Additionally, old age has been considered the most important prognostic factor for mortality in patients with COVID-19 since the onset of the pandemic. The median age of the study population is 67 years old (IQR 61–74), which is significantly older than the comparative group of cirrhotic patients with pneumonia (59, IQR 50–65), which may affect the mortality rate in the former group. A recently published meta-analysis on patients with COVID-19 reported mortality rates of 3%, 9.5%, and 22.5% for the following age groups, 50–59, 60–69, 70–79, respectively, and the median age of patients who died was 70 (IQR 61–80). Moreover, 48% of the patients included had decompensated cirrhosis at the time of their last outpatient visit, which carries a 1-year probability of mortality of about 20%, even in the absence of COVID-19 infection.

Multiple comorbidities other than cirrhosis were reported in the study group; so, high rates of mortality cannot be attributed to complications of cirrhosis alone. Regarding the group of cirrhotic patients with pneumonia, the number of patients with comorbidities was lower in this group relative to cirrhotic patients with COVID-19 infection, which may partly explain the lower mortality rate in patients without COVID-19.

The majority of deaths (12 out of 17) were due to respiratory failure, while only 5 were due to end-stage liver disease, which may indicate a modest effect of COVID-19 infection on mortality among cirrhotic patients. Furthermore, the authors did not document the occurrence of hepatopulmonary syndrome and/or porto-pulmonary hypertension in the recruited patients, which could affect the respiratory failure rate in this study. Chronic obstructive pulmonary disease was one of the reported comorbidities in this study; clarifying its relationship to the occurrence of respiratory failure in patients with acute-on-chronic liver failure is of great importance.

What was really interesting is that nosocomial SARS-CoV-2 infection was documented in 40% of the study patients, which emphasizes the importance of EASL and AASLD recommendations regarding the role of telemedicine in the management of cirrhotic patients during the COVID-19 pandemic, and the advice to postpone any in-hospital procedures for those patients whenever possible.

Finally, we thank Dr. Iavarone et al. for their important thoughts on the risks that face cirrhotic patients in the COVID-19 era, which pave the way for further studies to better evaluate this important issue. What's more, and with different observational studies merged into larger databases from various geographical areas, the issue of encountering specific impacts of COVID-19 on patients with chronic liver diseases may be much easier to ascertain.

Financial support

This work is non-funded.

Authors' contributions

MM and MK contributed equally to formulating the reply.

Conflict of interest

The authors declare no conflicts of interest that pertain to this work.

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