Double trouble: Alcohol-related liver diseases take a turn for the worse during COVID-19

Higher intake of alcohol and reduced care during the COVID-19 pandemic have triggered a spike in alcohol-related liver diseases, leading to some serious consequences, according to new research.

The analysis included patients with alcoholic cirrhosis or alcoholic hepatitis who were treated at the Ohio State University Wexner Medical Center in Ohio, Columbus, US between March and August 2020.

Overall, 212 patients reported increased alcohol intake, 161 had little change over the past year, and 253 were abstinent. MODEL for End-Stage Liver Disease-sodium (MELD-Na) scores were highest in those who had increased alcohol intake (27), compared with patients who had little change in alcohol intake (24) and those who remained abstinent (23) (p=0.001).

“This has led to increased morbidity and mortality, specifically in patients that already had underlying liver diseases,” said one of the study investigators, Dr Lindsay Sobotka, assistant professor of gastroenterology, hepatology, and nutrition at the Ohio State University Wexner Medical Center in Ohio, Columbus, US. “This highlights the importance of alcohol cessation, counseling, and close physician monitoring, given that continued or relapsed alcohol consumption can significantly affect the quality of life, life expectancy, and liver transplantation candidacy.”

Hospital admissions, mortality rates up

The number of hospital admissions almost doubled from 86 to 162 among patients with alcoholic hepatitis (86 to 162). Four of 162 patients with alcoholic hepatitis and 14 of 528 patients with alcoholic cirrhosis had COVID-19 at the time of admission.

Higher mortality rates were seen during the pandemic, although this was only significant for alcoholic cirrhosis at 14.8 percent vs 7 percent for alcoholic hepatitis.

Among those with alcoholic hepatitis, there was no significant change in median Maddrey’s Discriminant Function score, a tool to determine the next step of treatment based on the severity of the disease. However, there was a significant reduction in steroid use (p=0.001).

“This may be due to a statistically significant increase in gastrointestinal bleeds and renal dysfunction during the pandemic,” said Dr Ayushi Jain, a resident at the Ohio State University Wexner Medical Center, who presented the results at ACG 2021.

Increased need for critical care, support

Hepatic decompensation increased, so was the need for critical care in those admitted for alcoholic hepatitis, hepatic encephalopathy (p=0.037), and gastrointestinal bleeding (p=0.01). There was also a need for increased oxygen (p=0.024), vasopressor support (p=0.005), and initiation of haemodialysis (p= 0.007). The median highest MELD-Na score during admission was also higher during the pandemic (24 vs 23; p=0.04).

Decompensation was greater in those with alcoholic cirrhosis as measured by ascites (p=0.01), therapeutic paracentesis (p=0.04), titration of diuretics (p=0.005), acute kidney injury (p=0.005), hepatorenal syndrome (p=0.002), and spontaneous bacterial peritonitis (p=0.04). This group also required increased vasopressor support (p=0.006), was more likely to initiate haemodialysis (p=0.015), and had higher mortality (p=0.001).

Clinicians must intervene

Session moderator Dr Paul Kwo, director of Hepatology at the Stanford University in Stanford, California, US, said the pandemic has presented dual challenges to patients with alcohol-related liver disease.

“The influx of COVID-19 cases not only pushed patients to compete for limited resources. The government-imposed lockdowns also impacted their support systems. We should be able to intervene and help these patients to re-engage in some support systems and harm reduction measures to reduce admissions for severe alcoholic hepatitis,” he pointed out.

Co-moderator Dr Patricia Jones from the University of Miami in Florida, US, agreed with Kwo. “Speaking to our patients about where they are would be really beneficial and if necessary, we need to connect them to a social worker.”