Table 3.

Guideline recommendations for patients with chronic liver diseases during coronavirus disease-2019 pandemic

Chronic Liver Diseases	AASLD recommendation1 and EASL-ESCMID Position article34,49,72
Chronic viral hepatitis (HBV and HCV)	•Continue treatment of hepatitis B or C if patient already receiving treatment •HBsAg and anti-HBc should be tested before initiating corticosteroid therapy, JAK 1/2 inhibitor, and tocilizumab therapy •Initiating hepatitis B treatment should be considered if hepatitis B flare is clinically suspected or when initiating immunosuppressive therapy, corticosteroids, or IL-6 monoclonal antibody therapy •Initiating hepatitis C treatment should be delayed until after resolution of COVID-19 infection
Autoimmune liver diseases	Without COVID-19 infection • Continue the same dosage of immunosuppressive agents to prevent a disease flare • Vaccination for Streptococcus pneumoniae and influenza should be emphasized With COVID-19 infection • In case of worsening pneumonia attributed to COVID-19 infection, lowering the overall level of immunosuppressive therapy should be considered (individualized adjustment) • If active AIH, initiating immunosuppressive therapy is recommended despite COVID-19 infection • In AIH patients with active COVID-19 infection and elevated liver biochemistries, do not presume flare of AIH without biopsy confirmation
NAFLD	•Preventing liver disease progression by intensive lifestyle modifications, including weight loss advice and diabetes control •Early admission should be considered for all patients with NAFLD who become infected with SARS-CoV-2
ALD	•Encourage alcohol cessation •Clinicians should weigh the risk of susceptibility for severe COVID-19 when initiating corticosteroids in patients with severe alcoholic hepatitis
Cirrhosis	•Prophylaxis for spontaneous bacterial peritonitis (SBP), gastrointestinal hemorrhage, and hepatic encephalopathy should be maintained to prevent hospitalization due to portal hypertension-related complications •Patients with new onset of hepatic decompensation or ACLF should be tested for SARS-CoV-2 even in the absence of respiratory symptoms •Early admission is recommended if COVID-19 is diagnosed •All patients should receive vaccination for S pneumoniae and influenza
Liver transplant recipients	Without COVID-19 infection • No reduction of immunosuppression to prevent acute rejection • Emphasize importance of vaccination for S pneumoniae and influenza With COVID-19 infection • Early admission is recommended • Do not assume acute cellular rejection without biopsy confirmation in LT recipients in the presence of active COVID-19 infection and elevated liver biochemistries • Minimizing dosage of immunosuppressive therapy should be considered case-by-case under specialist consultation based on severity of COVID-19 and risk of graft rejection • Lower the overall level of immunosuppression (eg, azathioprine or mycophenolate) to decrease the risks of superinfection, especially with antimetabolite therapies • Closely monitor calcineurin inhibitor levels, for features of acute kidney injury, and potential drug–drug interactions • Anti-IL-6 therapeutics have not been shown to increase the risk of acute cellular rejection
HCC	Without COVID-19 infection • Continue to perform surveillance in patients at risk for HCC as close to schedule as possible. Delay of schedule for 2 mo is reasonable • For HCC patients, care should be maintained according to guidelines, including continuing systemic treatments and evaluation for LT With COVID-19 infection • HCC surveillance can be deferred until after recovery • For HCC patients, early admission is recommended. Locoregional therapies should be postponed and immune-checkpoint inhibitors should be temporarily withdrawn

Abbreviations: AIH, autoimmune hepatitis; HBV, hepatitis B virus; HCV, hepatitis C virus; IL, interleukin; JAK, Janus kinase; LT, liver transplant.