Impact of the COVID-19 pandemic on the care and outcomes of people with NAFLD-related cirrhosis

Jesús Rivera-Esteban; Ramiro Manzano-Nuñez; Teresa Broquetas; Isabel Serra-Matamala; Octavi Bassegoda; Agnès Soriano-Varela; Gemma Espín; Joaquín Castillo; Juan Bañares; José A Carrión; Pere Ginès; Isabel Graupera; Juan M Pericàs

doi:10.1016/j.jhepr.2022.100574

Impact of the COVID-19 pandemic on the care and outcomes of people with NAFLD-related cirrhosis

JHEP Rep. 2022 Nov;4(11):100574. doi: 10.1016/j.jhepr.2022.100574. Epub 2022 Aug 27.

Authors

Jesús Rivera-Esteban^{1

2

3}, Ramiro Manzano-Nuñez^{1

2}, Teresa Broquetas^{4

5

6

7}, Isabel Serra-Matamala⁸, Octavi Bassegoda⁹, Agnès Soriano-Varela⁴, Gemma Espín⁸, Joaquín Castillo⁹, Juan Bañares^{1

2}, José A Carrión^{4

5

6

7}, Pere Ginès^{7

9}, Isabel Graupera^{7

9}, Juan M Pericàs^{1

2

3

7}

Affiliations

¹ Liver Unit, Vall d'Hebron University Hospital, Barcelona, Spain.
² Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain.
³ Universitat Autònoma de Barcelona, Barcelona, Spain.
⁴ Liver Section, Gastroenterology Department, Hospital del Mar, Barcelona, Spain.
⁵ IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.
⁶ Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
⁷ Centro de Investigación Biomédica en Red de enfermedades digestivas y hepáticas (CIBERehd), Madrid, Spain.
⁸ Dr Josep Trueta University Hospital, Girona, Spain.
⁹ Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain.

Abstract

Background & aims: The COVID-19 pandemic has had a major negative impact on health systems and many chronic diseases globally. We aimed to evaluate the impact of the first year of the pandemic on the outcomes of people with NAFLD cirrhosis.

Methods: We conducted a before-after study in four University hospitals in Catalonia, Spain. Study subperiods were divided into Pre-pandemic (March/2019-February/2020) vs. Pandemic (March/2020-February/2021). The primary outcome was the rate of first liver-related event (LRE). Overall clinical outcomes (LREs plus cardiovascular plus all-cause mortality) were also assessed.

Results: A total of 354 patients were included, all of whom were compensated at the beginning of the study period; 83 individuals (23.5%) had a history of prior hepatic decompensation. Mean age was 67.3 years and 48.3% were female. Median BMI was 31.2 kg/m² and type 2 diabetes was present in 72.8% of patients. The rates of first LRE in the Pre-pandemic and Pandemic periods were 7.4% and 11.3% (p = 0.12), respectively. Whilst the rate of overall events was significantly higher in the Pandemic period (9.9% vs. 17.8%; p = 0.009), this was strongly associated with COVID-19-related deaths. The rate of worsened metabolic status was significantly higher in the Pandemic period (38.4% vs. 46.1%; p = 0.041), yet this was not associated with the risk of first LRE during the Pandemic period, whereas type 2 diabetes (odds ratio [OR] 3.77; 95% CI 1.15-12.32; p = 0.028), albumin <4 g/L (OR 4.43; 95% CI 1.76-11.17; p = 0.002) and Fibrosis-4 score >2.67 (OR 15.74; 95% CI 2.01-123.22; p = 0.009) were identified as risk factors in the multivariable analysis.

Conclusion: Overall, people with NAFLD cirrhosis did not present poorer liver-related outcomes during the first year of the pandemic. Health system preparedness seems key to ensure that people with NAFLD cirrhosis receive appropriate care during health crises.

Lay summary: Mobility restrictions and social stress induced by the COVID-19 pandemic have led to increased alcohol drinking and worsened metabolic control (e.g., weight gain, poor control of diabetes) in a large proportion of the population in many countries. We aimed to analyze whether people with cirrhosis due to non-alcoholic fatty liver disease, who are particularly vulnerable to such lifestyle modifications, were significantly impacted during the first year of the pandemic. We compared the clinical situation of 354 patients one year before the pandemic and one year after. We found that although metabolic control was indeed worse after the first year of the pandemic and patients presented worse clinical outcomes, the latter was mostly due to non-liver causes, namely COVID-19 itself. Moreover, the care provided to these patients did not worsen during the first year of the pandemic.

Keywords: COVID-19; HCC, hepatocellular carcinoma; NAFLD, non-alcoholic fatty liver disease; Nonalcoholic fatty liver disease; OR, odds ratio; T2D, type 2 diabetes; VCTE, vibration-controlled transient elastography; cACLD, compensated advanced chronic liver disease; cirrhosis; health systems; liver outcomes.