Reduced rate of hospital admissions for liver-related morbidities during the initial COVID-19 outbreak

Complications of liver cirrhosis and acute hepatitis are major causes of liver-related morbidities that require hospital admission.¹ We aimed to investigate hospital admissions for liver-related conditions during the COVID-19 outbreak in our referral hepatology and transplant centre (Abu-Ali Sina Hospital, Shiraz, Iran).

We analysed hospital admissions for liver-related morbidities between Feb 19, 2020 (the date of the first confirmed patient with COVID-19 in the country), and April 30, 2020. Retrospectively, we manually reviewed the charts of all patients admitted to our hospital, including those with liver-related conditions. For patients who had more than one complication, the most prominent complication was considered the cause of admission. Liver-related conditions were defined as: acute hepatitis requiring hospital admission; complications in liver transplant recipients; and complications of liver cirrhosis including gastrointestinal bleeding, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic encephalopathy, and diuretic resistant ascites. Rates of hospital admission during the study period were compared with those between Feb 19, 2019, and April 30, 2019. This control period was selected to maximise similarities between the two time periods with regard to public holidays and seasonal differences fluctuations in hospital admissions. The study was approved by the institutional review board of Abu-Ali Sina Hospital.

Between Feb 19, 2020, and April, 30, 2020, 124 hospital admissions were recorded for liver-related disorders. The mean age of patients admitted to hospital during the study period was 51·3 years (SD 14·9); 68 (55%) of 124 patients were women and 56 (45%) were men. During the 2019 control period, 230 hospital admissions for liver-related disorders were recorded. The baseline characteristics of patients in the control and study periods are shown in the appendix (p 1). The mean duration of hospital stay was 7·44 days (SD 5·42) during the study period compared with 5·32 days (3·37) during the control time period (p<0·001). The Model For End-Stage Liver Disease (MELD) score for patients with cirrhosis admitted during the COVID-19 outbreak was 17·07 (SD 4·05) versus 15·18 (3·45) during the control time period (p<0·001). The mean rate of hospital admissions for liver-related disorders during the study period was 1·74 admissions per day (SD 0·95) compared with 3·23 admissions per day (1·33) during the control period (incidence rate ratio [IRR] 1·85, 95% CI 1·49–2·30; p<0·001). The mean admission rates for gastrointestinal bleeding (IRR 2·50, 95% CI 1·34–4·64), spontaneous bacterial peritonitis (1·78, 1·02–3·13), hepatic encephalopathy (1·94, 1·12–3·38) and hepatorenal syndrome (1·95, 1·18–3·23) were significantly lower during the COVID-19 outbreak than in the corresponding control period in the previous year (appendix p 2).

Our results showed a significant decrease in the number of hospital admissions for liver-related disorders during the COVID-19 pandemic compared with the control period in the previous year at a large hepatobiliary referral centre. The number of admissions for each cause of liver-related complications was also reduced (appendix p 2). This decrease is probably due to the implementation of physical distancing regulations, the psychosocial effects of the COVID-19 outbreak,² and recommendations to postpone clinical visits for patients with chronic liver diseases. Liver diseases are a major cause of morbidity and account for 2 million deaths worldwide every year.3, 4 The COVID-19 outbreak has resulted in a reduced number of hospital admissions for this group of patients. Additionally, our results suggest that MELD scores for patients with liver cirrhosis admitted to hospital and the mean duration of hospital stay were higher during the COVID-19 outbreak than the control period. This observation suggests that patients had been admitted only when it was unavoidable and usually with severe disease. Taken together, these factors might have considerable negative impact on the long-term management of patients with liver-related disorders. Hepatologists should be aware, and health-care systems should be modified and prepared to handle the future clinical challenges that might be encountered in this group of patients.