Letter to the Editor: Outcomes in chronic hepatitis B infection and COVID-19-Not always benign!

To the editor,

We read with great interest the article by Yip et al. concluding that current or past chronic hepatitis B (CHB) infections were not associated with more liver injury and mortality in COVID‐19.[ ] The study design was retrospective with a lot of missing data, which makes the interpretation of results difficult. Acute liver injury in the presence of COVID‐19 is multifactorial, and in the absence of liver biopsy, it is often difficult to determine the actual cause.

In the current study, only 3%–6% patients with CHB had liver cirrhosis. Patients with hepatitis B–related cirrhosis present unique challenges: (1) risk of treatment‐related severe hepatitis B reactivation and subsequent hepatic decompensation and mortality rates up to 80% and (2) immune dysfunction that can lead to increased susceptibility to infection and aberrant inflammatory response during infection—collectively known as cirrhosis‐associated immune dysfunction.[ ] Therefore, the preexisting liver disease severity is important and may predict the incidence and severity of acute liver injury. Data on clinical outcomes for these difficult‐to‐treat patients in the present study are limited. In the SECURE‐Cirrhosis and COVID‐Hep registries, hepatic decompensation events and mortality were more frequent with increasing severity of liver disease.[ ] Moreover, severe COVID‐19 might also precipitate acute‐on‐chronic liver failure.[ ]

Besides liver disease severity, mortality in COVID‐19 is also determined by severity of COVID‐19 at hospital admission and standards of intensive care unit care. Most of the specific drugs for moderate to severe COVID‐19 disease, including remdesivir, lopinavir–ritonavir, tocilizumab, and high‐dose dexamethasone, are contraindicated in the presence of severe liver disease. The current therapeutic armamentarium to treat severe COVID‐19 for hepatitis B–related cirrhosis is limited.

In summary, the clinical relevance of this important study on CHB and COVID‐19 disease could have been enhanced by accounting for the aforementioned factors.

CONFLICT OF INTEREST

Nothing to report.