key: cord-0790455-fcycgfyr
authors: Piano, Salvatore; Marzioni, Marco; Angeli, Paolo
title: Effects of a reorganization of cirrhosis care during the lockdown for SARS-CoV-2 outbreak
date: 2021-01-19
journal: JHEP Rep
DOI: 10.1016/j.jhepr.2021.100229
sha: 268fa10d8a8416978b016d317ac0d94f2083ff00
doc_id: 790455
cord_uid: fcycgfyr

nan

The pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a relevant threat for humans [1] . High virulence and transmissibility of SARS-CoV-2 requires strong health-care policy actions to reduce its spread.

Since February 21 st the SARS-CoV-2 outbreak smashed Northern and Central Italy and on March 9 th the Italian government introduced a lockdown which lasted till May 3 rd . Meanwhile non-urgent clinical care activity was deferred with potential negative impact on patients with chronic diseases, including patients with cirrhosis [2] . Whether the lockdown determined clinical consequences in patients with cirrhosis is unknown. Herein we evaluated the characteristics, clinical course, inhospital and 90-day mortality as well as the 30-day readmission rate in patients hospitalized for an acute decompensation of cirrhosis since March 2020 to April 2020 in 2 centers in Northern/Center Italy. Their characteristics and outcomes were compared with those of patients admitted in March-April 2019.

Patients were retrospectively identified and demographic, clinical and laboratory data were collected reviewing electronic and paper charts. Data on readmissions and mortality at 90 days were collected as well.

During the lockdown non urgent visits were deferred and telemedicine/phone contacts were implemented. Day Hospital activity for planned procedure (e.g. large volume paracentesis) was maintained as well as outpatients visits for patients at high risk of readmissions (readmitted in the prior 30 days, with acute on chronic liver failure during hospitalization or CTP class C) [3, 4] .

Overall, we observed a 65% reduction in outpatients visits.

We identified 100 patients admitted for acute decompensation of cirrhosis, 55 were admitted in 2019 and 45 in 2020. Demographic characteristics and reasons for hospitalization were similar between the two groups (Table) . Bilirubin was significantly higher in patients admitted during the lockdown (116 vs 65 µmol/L; p=0.032). There was a trend toward a higher MELD-Na score in J o u r n a l P r e -p r o o f patients admitted during the lockdown (22 vs 19; p=0.071). In spite of similar rate of bacterial infections at admission, the level of C-reactive protein tended to be higher in patients admitted during the lockdown (45 vs 29 mg/l; p=0.057). Finally, patients admitted during the lockdown had more frequently acute kidney injury at admission (42 vs 22%; p=0.028). In-hospital mortality and probability of 90-day survival were not significantly different between the 2 groups (7 vs 7%; p=1.00; and 23 vs 25%; p=0.951; Figure) . The proportion of patients transplanted within 90 days was not significantly different between patients admitted during the lockdown and those admitted in 2019 (7% vs 13%; p=0.505). After discharge, 21 out of 40 patients discharged alive during the lockdown were referred to the outpatient clinic for early post discharge management (53% vs 81% in 2019; p=0.004) [3] , 4 were lost to follow up while the remaining were followed up by telemedicine/phone contact. The proportion of patients readmitted within 30-days was not significantly different in lockdown and control groups (23 vs 21%; p=0.920).

This study showed two main findings. The first one is that during the lockdown patients admitted to the hospital for an acute decompensation of cirrhosis had a more advanced liver disease, a higher proportion of AKI and higher inflammatory biomarkers. One may hypothesize that during the lockdown patients with cirrhosis delayed their access to medical care for concerns over contracting COVID-19 in hospital. The "stay at home" messages given by the media could have led to an atmosphere of fear of contracting COVID-19 by leaving home and going to hospital. This is relevant for patients with cirrhosis that are at risk of severe COVID-19 [5, 6] and is in keeping with the delayed access to care observed for patients with stroke and myocardial infarction during the peak of COVID-19 outbreak in Spain and England [7, 8] . Anyway, this is a speculation that has to be proven in well-designed studies. Despite a more severe disease at admission, we did not find an increase in mortality rate in patients admitted during the lockdown, however the sample size was underpowered to identify such a difference. In preparing to face the new waves of COVID-19 outbreaks worldwide, patients with cirrhosis should be advised to seek care without delay when signs of decompensation/infections occur.

In keeping with data of other Italian Hepatology units, outpatient activity was significantly reduced in our center during the lockdown [9] . One potential drawback of this reduction could be the increase of early readmissions for patients discharged. The second main finding of this study is that the reorganization of outpatient management program (prioritizing urgent visits and those for patients at risk of readmissions) could have mitigated the risk of early readmissions. This was obtained with no undermining of patient and staff safety. All physicians and nurses at our institutions maintained personal protective equipment during visits and a negative nasopharyngeal swab was required within a week for patients before their planned Day Hospital admission. During the study period none of the medical staff contracted SARS-CoV-2 infection.

In conclusion, a reorganization of outpatients cirrhosis management prioritizing visits for high risk patients and keeping day hospital activity mitigated the risk of 30-day readmissions and 90-day mortality for patients admitted for decompensated cirrhosis during the lockdown. Such a policy thus resulted effective for a short-term lockdown period. Whether that policy might be safe for longer periods of lockdown is yet to be explored; similarly, unintended long-term consequences for less sick patients should be better explored in future.

J o u r n a l P r e -p r o o f 

A pneumonia outbreak associated with a new coronavirus of probable bat origin

The COVID-19 pandemic will have a long-lasting impact on the quality of cirrhosis care

How to improve care in outpatients with cirrhosis and ascites: A new model of care coordination by consultant hepatologists

Predictors of Early Readmission in Patients with Cirrhosis after the Resolution of Bacterial Infections

High rates of 30-day mortality in patients with cirrhosis and COVID-19

Comparison of mortality risk in patients with cirrhosis and COVID-19 compared with patients with cirrhosis alone and COVID-19 alone: multicentre matched cohort

Break in the Stroke Chain of Survival due to COVID-19

Impact of COVID-19 on percutaneous coronary intervention for ST-elevation myocardial infarction

Assessing the impact of COVID-19 on the management of patients with liver diseases: A national survey