1
|
Rubin JB, Loeb R, Fenton C, Huang CY, Keyhani S, Seal KH, Lai JC. The burden of significant pain in the cirrhosis population: Risk factors, analgesic use, and impact on health care utilization and clinical outcomes. Hepatol Commun 2024; 8:e0432. [PMID: 38780295 PMCID: PMC11124725 DOI: 10.1097/hc9.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND We aimed to characterize pain and analgesic use in a large contemporary cohort of patients with cirrhosis and to associate pain with unplanned health care utilization and clinical outcomes in this population. METHODS We included all patients with cirrhosis seen in UCSF hepatology clinics from 2013 to 2020. Pain severity and location were determined using documented pain scores at the initial visit; "significant pain" was defined as moderate or severe using established cutoffs. Demographic, clinical, and medication data were abstracted from electronic medical records. Associations between significant pain and our primary outcome of 1-year unplanned health care utilization (ie, emergency department visit or hospitalization) and our secondary outcomes of mortality and liver transplantation were explored in multivariable models. RESULTS Among 5333 patients with cirrhosis, 32% had a nonzero pain score at their initial visit and 25% had significant (ie moderate/severe) pain. Sixty percent of patients with significant pain used ≥1 analgesic; 34% used opioids. Patients with cirrhosis with significant pain had similar Model for End-Stage Liver Disease-Sodium scores (14 vs. 13), but higher rates of decompensation (65% vs. 55%). The most common pain location was the abdomen (44%). Patients with abdominal pain, compared to pain in other locations, were more likely to have decompensation (72% vs. 56%). Significant pain was independently associated with unplanned health care utilization (adjusted odds ratio: 1.3, 95% CI: 1.1-1.5) and mortality (adjusted hazard ratio: 1.4, 95% CI: 1.2-1.6). CONCLUSIONS Pain among patients with cirrhosis is often not well-controlled despite analgesic use, and significant pain is associated with unplanned health care utilization and mortality in this population. Effectively identifying and treating pain are essential in reducing costs and improving quality of life and outcomes among patients with cirrhosis.
Collapse
Affiliation(s)
- Jessica B. Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
| | - Rebecca Loeb
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Cynthia Fenton
- Division of Hospital Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Chiung-Yu Huang
- Department of Surgery, University of California-San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Salomeh Keyhani
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
- Division of General Internal Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Karen H. Seal
- Department of Medicine, San Francisco VA Health Care System, San Francisco, California, USA
- Division of General Internal Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| |
Collapse
|
2
|
Ma J, Björnsson ES, Chalasani N. The Safe Use of Analgesics in Patients with Cirrhosis: A Narrative Review. Am J Med 2024; 137:99-106. [PMID: 37918778 DOI: 10.1016/j.amjmed.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/04/2023]
Abstract
Pain is prevalent in patients with cirrhosis. Due to potential alterations in drug metabolism, risk for adverse effects, and complications from cirrhosis, physicians are often faced with difficult choices when choosing appropriate analgesics in these patients. Overall, acetaminophen remains the preferred analgesic. Despite its potential for intrinsic liver toxicity, acetaminophen is safe when used at 2 g/d. In contrast, non-selective nonsteroidals should be avoided due to their multiple side effects, including worsening renal function, blunting diuretic response, and increasing risk of portal hypertensive and peptic ulcer bleeding. Celecoxib can be administered for short term (≤5 days) in patients with Child's A and Child's B cirrhosis (50% dose reduction). Opioids carry the risk of precipitating hepatic encephalopathy and should generally be avoided, when possible. If clinical situation demands their use, opioid use should be limited to short-acting agents for short duration. Gabapentin and pregabalin are generally safe. Duloxetine should be avoided in hepatic impairment. Topical diclofenac and lidocaine seem to be safe in patients with cirrhosis.
Collapse
Affiliation(s)
- Jiayi Ma
- Indiana University School of Medicine and Indiana University Health, Indianapolis
| | - Einar Stefán Björnsson
- Department of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland; Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Naga Chalasani
- Indiana University School of Medicine and Indiana University Health, Indianapolis.
| |
Collapse
|
3
|
Wang M, Auerbach A, Oreper SM, Hohmann SF, Lai JC, Rubin JB. Leveraging a New ICD-10 Diagnosis Code to Characterize Hospitalized Patients With Primary Sclerosing Cholangitis. Clin Gastroenterol Hepatol 2023; 21:2692-2694. [PMID: 36113826 PMCID: PMC10011011 DOI: 10.1016/j.cgh.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Melinda Wang
- Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Andy Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Sandra M Oreper
- Division of Hospital Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Samuel F Hohmann
- Department of Health Systems Management, Rush University, Chicago, Illinois, Vizient, Inc, Chicago, Illinois
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Jessica B Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California.
| |
Collapse
|
4
|
Johnson AW, Golzarri Arroyo L, Mahendraker N, Hosty J, Kroenke K. Hospital Opioid Usage and Adverse Events in Patients With End-Stage Liver Disease. J Pain Symptom Manage 2023; 65:326-334.e2. [PMID: 36496114 DOI: 10.1016/j.jpainsymman.2022.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 12/13/2022]
Abstract
CONTEXT Patients with end-stage liver disease (ESLD) commonly experience pain and other symptoms that result in a poor quality of life. Few studies have examined opioid usage, adverse events (AEs), and other outcomes in ESLD patients receiving opioid analgesia. OBJECTIVES This study aimed to compare outcomes in ESLD patients who received opioids to those who did not and to determine risk factors for AEs. METHODS This was a retrospective case-cohort study of 270 hospitalized patients with ESLD that used administrative and clinical data from the electronic medical record. RESULTS Two-thirds of patients with ESLD admitted during the study period received at least one opioid analgesic. Patients who received opioids presented with a greater number of liver related complications and higher rates of anxiety (32% vs. 17%, P= 0.007), had substantially worse initial and average pain scores (both P< 0.001), and received more palliative care consultations. The opioid group had somewhat more respiratory (22.2% vs. 11.1%, P= 0.02) and gastrointestinal (38.5% vs. 25.2%, P= 0.03) AEs, but no increase in CNS adverse events which included hepatic encephalopathy. Anxiety and disease severity (i.e., the number of liver related complications) but not opioid administration were risk factors for the number of AEs. CONCLUSION Opioid administration was not an independent risk factor for the number of AEs in hospitalized patients with ESLD, whereas anxiety and more liver-related complications increased AE risk. Our findings suggest that opioids have an appropriate and reasonably safe role in alleviation of pain in patients with ESLD.
Collapse
Affiliation(s)
- Amy W Johnson
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis.
| | - Lilian Golzarri Arroyo
- Department of Epidemiology and Biostatistics (L.G-A), School of Public Health, Bloomington
| | - Neetu Mahendraker
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis
| | - Jack Hosty
- Indiana University School of Medicine (J.H.), Indianapolis
| | - Kurt Kroenke
- Division of General Internal Medicine and Geriatrics (A.W.J,N.M.,K.K.), Indianapolis; Regenstrief Institute, Inc. (K.K.), Indianapolis, Indianapolis USA
| |
Collapse
|
5
|
Ramadan M, Alnashri Y, Ilyas A, Batouk O, Alsheikh KA, Alhelabi L, Alnashri SA. Assessment of opioid administration patterns following lower extremity fracture among opioid-naïve inpatients: retrospective multicenter cohort study. Ann Saudi Med 2022; 42:366-376. [PMID: 36444923 PMCID: PMC9706711 DOI: 10.5144/0256-4947.2022.366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Prescribing habits during admission have largely contributed to the opioid epidemic. Orthopedic surgeons represent the third-highest opioid-prescribing specialty. Since more than half of body fractures in Saudi Arabia have been lower extremity fractures, it is imperative to understand opioid administration patterns and correlates among opioid-naïve inpatients. OBJECTIVES Assess opioid administration patterns and correlates among opioid-naïve inpatients with lower extremity fractures. DESIGN AND SETTINGS Retrospective cohort PATIENTS AND METHODS: Opioid naïve individuals aged 18 to 64 years, admitted due to lower extremity fracture from 2016 to 2020 were included. Data was collected from health records of the Ministry of National Guard Health Affairs (MNG-HA) at five different medical centers. The high-dose (≥50 MME) patients were compared with low dose (<50 MME) patients. Any association between inpatient factors and high-dose opioid use was analyzed by multiple logistic regression. MAIN OUTCOME MEASURES Opioids taken during inpatient admission as measured by milligram morphine equivalents (MME)/per day. SAMPLE SIZE 1520 patients RESULTS: Most of the 1520 patients (88.5%) received an opioid medication, while (20.3%) received high-dose opioids at a median daily dose of 33.7 MME/per day. The proportion of patients received naloxone (20.7%) was double among high-dose opioid inpatients. High-dose opioid patients during admission were two times more likely to receive an opioid prescription after discharge (odds ratio, 2.32; 95% confidence interval, 1.53, 3.51), and three more times likely to receive ketamine during admission (odds ratio, 3.02; 95% confidence interval, 1.64, 5.54). CONCLUSION Notable variabilities exist in opioid administration patterns that were not explained by patient factors. Evidence-based opioid prescribing practices should be developed for orthopedic patients to prevent opioid overprescribing and potential opioid overdose among orthopedic patients. LIMITATIONS Retrospective, unmeasurable confounders might have biased our results. Since based on National Guard employees, results may not be generalizable. CONFLICT OF INTEREST None.
Collapse
Affiliation(s)
- Majed Ramadan
- From the Population Health, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yahya Alnashri
- From the Department of Family and Community Medicine, Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia
| | - Amjad Ilyas
- From the Department of Orthopedic Surgery, Dr. Soliman Fakeeh Hospital, Makkah, Saudi Arabia
| | - Omar Batouk
- From the Department of Surgery, King Khalid National Guard Hospital, Makkah, Saudi Arabia
| | - Khalid A Alsheikh
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Laila Alhelabi
- From the Population Health, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Suliman Abdulah Alnashri
- From the Population Health, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| |
Collapse
|
6
|
Schulte B, Tergast TL, Griemsmann M, Menti D, Deveci N, Kahlhöfer J, Dörge P, Hüffner L, Kraft ARM, Behrendt P, Wedemeyer H, Cornberg M, Stichtenoth DO, Maasoumy B. Metamizole-Associated Risks in Decompensated Hepatic Cirrhosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:687-693. [PMID: 35912424 PMCID: PMC9830680 DOI: 10.3238/arztebl.m2022.0280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/11/2022] [Accepted: 07/04/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Because of the increased risk of acute renal failure (ARF), the use of cyclooxygenase (COX) inhibitors is not recommended in patients with decompensated hepatic cirrhosis. Metamizole is not a classic COX inhibitor, but there are insufficient data to support its safe use. In this study, we investigate the effect of metamizole on the risk of ARF in these patients. METHODS Metamizole use, ARF incidence, and patient mortality were examined in a large, retrospective, exploratory cohort and validated with data from a prospective registry. RESULTS 523 patients were evaluated in the exploratory cohort. Metamizole use at baseline was documented in 110 cases (21%) and was independently associated with the development of ARF, severe (grade 3) ARF, and lower survival without liver transplantation at follow-up on day 28 (HR: 2.2, p < 0.001; HR: 2.8, p < 0.001; and HR: 2.6, p < 0.001, respectively). Interestingly, the risk of ARF depended on the dose of metamizole administered (HR: 1.038, p < 0.001). Compared to patients who were treated with opioids, the rate of ARF was higher in the metamizole group (49% vs. 79%, p = 0.014). An increased risk of ARF with metamizole use was also demonstrated in the independent validation cohort (p < 0.001). CONCLUSION Metamizole therapy, especially at high doses, should only be used with a high level of caution in patients with decompensated cirrhosis.
Collapse
Affiliation(s)
| | - Tammo L. Tergast
- * Joint first authors,Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School
| | - Marie Griemsmann
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School
| | - Denise Menti
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,Center for Individualized Infection Medicine (CiiM), Hannover
| | - Neslihan Deveci
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School
| | - Julia Kahlhöfer
- German Center for Infection Research (DZIF), German Liver Foundation, HepNet, Hannover
| | - Petra Dörge
- German Center for Infection Research (DZIF), German Liver Foundation, HepNet, Hannover
| | - Lucas Hüffner
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,Twincore, Center for Experimental and Clinical Infection Research, Hannover
| | - Anke R. M. Kraft
- * Joint first authors,German Center for Infection Research (DZIF), Hannover-Braunschweig
| | - Patrick Behrendt
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,German Center for Infection Research (DZIF), Hannover-Braunschweig
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,German Center for Infection Research (DZIF), Hannover-Braunschweig
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,Center for Individualized Infection Medicine (CiiM), Hannover,Twincore, Center for Experimental and Clinical Infection Research, Hannover,German Center for Infection Research (DZIF), Hannover-Braunschweig
| | | | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School,German Center for Infection Research (DZIF), Hannover-Braunschweig,*Klinik für Gastroenterologie, Hepatologie und Endokrinologie Medizinische Hochschule Hannover Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| |
Collapse
|
7
|
Rubin JB, Lai JC, Leonard S, Seal K, Hoggatt KJ, Keyhani S. Long-Term Opioid Use Among Veterans with Cirrhosis: High-Dose Prescriptions in an Exceedingly High-Risk Population. J Gen Intern Med 2022; 37:3205-3207. [PMID: 35037175 PMCID: PMC9485296 DOI: 10.1007/s11606-021-07282-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Jessica B Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, Box 0538, San Francisco, CA, 94143, USA.
- San Francisco VA Medical Center, San Francisco, CA, USA.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, Box 0538, San Francisco, CA, 94143, USA
| | - Samuel Leonard
- Northern California Institute for Research and Education, San Francisco, CA, USA
| | - Karen Seal
- San Francisco VA Medical Center, San Francisco, CA, USA
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Katherine J Hoggatt
- San Francisco VA Medical Center, San Francisco, CA, USA
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Salomeh Keyhani
- San Francisco VA Medical Center, San Francisco, CA, USA
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
8
|
Agbalajobi OM, Gmelin T, Moon AM, Alexandre W, Zhang G, Gellad WF, Jonassaint N, Rogal SS. Characteristics of opioid prescribing to outpatients with chronic liver diseases: A call for action. PLoS One 2021; 16:e0261377. [PMID: 34919585 PMCID: PMC8682904 DOI: 10.1371/journal.pone.0261377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022] Open
Abstract
Background Chronic liver disease (CLD) is among the strongest risk factors for adverse prescription opioid-related events. Yet, the current prevalence and factors associated with high-risk opioid prescribing in patients with chronic liver disease (CLD) remain unclear, making it challenging to address opioid safety in this population. Therefore, we aimed to characterize opioid prescribing patterns among patients with CLD. Methods This retrospective cohort study included patients with CLD identified at a single medical center and followed for one year from 10/1/2015-9/30/2016. Multivariable, multinomial regression was used identify the patient characteristics, including demographics, medical conditions, and liver-related factors, that were associated with opioid prescriptions and high-risk prescriptions (≥90mg morphine equivalents per day [MME/day] or co-prescribed with benzodiazepines). Results Nearly half (47%) of 12,425 patients with CLD were prescribed opioids over a one-year period, with 17% of these receiving high-risk prescriptions. The baseline factors significantly associated with high-risk opioid prescriptions included female gender (adjusted incident rate ratio, AIRR = 1.32, 95% CI = 1.14–1.53), Medicaid insurance (AIRR = 1.68, 95% CI = 1.36–2.06), cirrhosis (AIRR = 1.22, 95% CI = 1.04–1.43) and baseline chronic pain (AIRR = 3.40, 95% CI = 2.94–4.01), depression (AIRR = 1.93, 95% CI = 1.60–2.32), anxiety (AIRR = 1.84, 95% CI = 1.53–2.22), substance use disorder (AIRR = 2.16, 95% CI = 1.67–2.79), and Charlson comorbidity score (AIRR = 1.27, 95% CI = 1.22–1.32). Non-alcoholic fatty liver disease was associated with decreased high-risk opioid prescriptions (AIRR = 0.56, 95% CI = 0.47–0.66). Conclusion Opioid medications continue to be prescribed to nearly half of patients with CLD, despite efforts to curtail opioid prescribing due to known adverse events in this population.
Collapse
Affiliation(s)
- Olufunso M. Agbalajobi
- Department of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Theresa Gmelin
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Andrew M. Moon
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Wheytnie Alexandre
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Grace Zhang
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Walid F. Gellad
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, United States of America
| | - Naudia Jonassaint
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Shari S. Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, United States of America
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail: ,
| |
Collapse
|
9
|
Ge J, Pletcher MJ, Lai JC. Outcomes of SARS-CoV-2 Infection in Patients With Chronic Liver Disease and Cirrhosis: A National COVID Cohort Collaborative Study. Gastroenterology 2021; 161:1487-1501.e5. [PMID: 34284037 PMCID: PMC8286237 DOI: 10.1053/j.gastro.2021.07.010] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS In patients with chronic liver disease (CLD) with or without cirrhosis, existing studies on the outcomes with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have limited generalizability. We used the National COVID Cohort Collaborative (N3C), a harmonized electronic health record dataset of 6.4 million, to describe SARS-CoV-2 outcomes in patients with CLD and cirrhosis. METHODS We identified all patients with CLD with or without cirrhosis who had SARS-CoV-2 testing in the N3C Data Enclave as of July 1, 2021. We used survival analyses to associate SARS-CoV-2 infection, presence of cirrhosis, and clinical factors with the primary outcome of 30-day mortality. RESULTS We isolated 220,727 patients with CLD and SARS-CoV-2 test status: 128,864 (58%) were noncirrhosis/negative, 29,446 (13%) were noncirrhosis/positive, 53,476 (24%) were cirrhosis/negative, and 8941 (4%) were cirrhosis/positive patients. Thirty-day all-cause mortality rates were 3.9% in cirrhosis/negative and 8.9% in cirrhosis/positive patients. Compared to cirrhosis/negative patients, cirrhosis/positive patients had 2.38 times adjusted hazard of death at 30 days. Compared to noncirrhosis/positive patients, cirrhosis/positive patients had 3.31 times adjusted hazard of death at 30 days. In stratified analyses among patients with cirrhosis with increased age, obesity, and comorbid conditions (ie, diabetes, heart failure, and pulmonary disease), SARS-CoV-2 infection was associated with increased adjusted hazard of death. CONCLUSIONS In this study of approximately 221,000 nationally representative, diverse, and sex-balanced patients with CLD; we found SARS-CoV-2 infection in patients with cirrhosis was associated with 2.38 times mortality hazard, and the presence of cirrhosis among patients with CLD infected with SARS-CoV-2 was associated with 3.31 times mortality hazard. These results provide an additional impetus for increasing vaccination uptake and further research regarding immune responses to vaccines in patients with severe liver disease.
Collapse
Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California.
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California; Division of General Internal Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California
| |
Collapse
|
10
|
Ge J, Pletcher MJ, Lai JC. Outcomes of SARS-CoV-2 Infection in Patients with Chronic Liver Disease and Cirrhosis: a N3C Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.06.03.21258312. [PMID: 34127981 PMCID: PMC8202438 DOI: 10.1101/2021.06.03.21258312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background and Aims In patients with chronic liver diseases (CLD) with or without cirrhosis, existing data on the risk of adverse outcomes with SARS-CoV-2 infection have been mixed or have limited generalizability. We used the National COVID Cohort Collaborative (N3C) Data Enclave, a harmonized electronic health record (EHR) dataset of 5.9 million nationally-representative, diverse, and gender-balanced patients, to describe outcomes in patients with CLD and cirrhosis with SARS-CoV-2. Methods We identified all chronic liver diseases patients with and without cirrhosis who had SARS-CoV-2 testing documented in the N3C Data Enclave as of data release date 5/15/2021. The primary outcome was 30-day all-cause mortality. Survival analysis methods were used to estimate cumulative incidences of death, hospitalization, and mechanical ventilation, and to calculate the associations of SARS-CoV-2 infection, presence of cirrhosis, and demographic and clinical factors to 30-day mortality. Results We isolated 217,143 patients with CLD: 129,097 (59%) without cirrhosis and SARS-CoV-2 negative, 25,844 (12%) without cirrhosis and SARS-CoV-2 positive, 54,065 (25%) with cirrhosis and SARS-CoV-2 negative, and 8,137 (4%) with cirrhosis and SARS-CoV-2 positive. Among CLD patients without cirrhosis, 30-day all-cause mortality rates were 0.4% in SARS-CoV-2 negative patients and 1.8% in positive patients. Among CLD patients with cirrhosis, 30-day all-cause mortality rates were 4.0% in SARS-CoV-2 negative patients and 9.7% in positive patients.Compared to those who tested SARS-CoV-2 negative, SARS-CoV-2 positivity was associated with more than two-fold (aHR 2.43, 95% CI 2.23-2.64) hazard of death at 30 days among patients with cirrhosis. Compared to patients without cirrhosis, the presence of cirrhosis was associated with a three-fold (aHR 3.39, 95% CI 2.96-3.89) hazard of death at 30 days among patients who tested SARS-CoV-2 positive. Age (aHR 1.03 per year, 95% CI 1.03-1.04) was associated with death at 30 days among patients with cirrhosis who were SARS-CoV-2 positive. Conclusions In this study of nearly 220,000 CLD patients, we found SARS-CoV-2 infection in patients with cirrhosis was associated with 2.43-times mortality hazard, and the presence of cirrhosis among CLD patients infected with SARS-CoV-2 were associated with 3.39-times mortality hazard. Compared to previous studies, our use of a nationally-representative, diverse, and gender-balanced dataset enables wide generalizability of these findings.
Collapse
Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California – San Francisco, San Francisco, CA
- Division of General Internal Medicine, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | | |
Collapse
|