This article is part of the Topical Collection on Liver Keywords Cirrhosis I Spontaneous bacterial peritonitis I Bacterial translocation I Multidrug-resistant I Acute-on-chronic liver failure I Vaccination
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) has affected people from different parts of the World and has been a major cause for significant morbidity and mortality to date. Coronavirus disease 2019 (COVID-19), the disease caused by SARS-CoV-2, can present with various clinical features and while pulmonary manifestation is the most common, hepatic abnormalities can be encountered in up to 50% of infected individuals. 1,2 The spectrum is variable and can range from asymptomatic abnormalities in hepatic biochemical tests to severe liver injury with some reports of acute-on-chronic liver failure in patients with underlying cirrhosis. [3][4][5] Hepatic dysfunction has been associated with poor outcome and which has been noted to be more frequent in critically ill
While for many years investigators had worked on highly effective direct-acting antiviral agent (DAA) therapy, we are now encountering challenges on the appropriate timing of DAA therapy in patients with decompensated cirrhosis. Improvement in hepatic function and quality of life can be achieved following successful therapy but not in all patients. Predictors of improvement or failure to improve have been noted but these are currently not robust enough to ubiquitously apply them to clinical practice. The lowest probability of improvement in hepatic function and avoidance of Model for End-stage Liver Disease (MELD) ''purgatory'' appears to be in those with MELD >20 while the more likely scenario of improvements is in those with MELD <15. Ideally, patients with a MELD score >20 should be transplanted first and treated for hepatitis C virus (HCV) infection after liver transplantation (LT). Those with MELD score <15 should be considered readily for treatment while in those with MELD of 15-20, treatment has to be individualized with full discussion of the pros and cons of treating them pre-or post-LT. However, it is to be appreciated that the majority of patients with decompensated cirrhosis across the world may not be eligible for liver transplant or may not have access to LT; thus, these patients should be considered for HCV therapy with the hope and expectation that they still gain variable degrees of benefit from successful DAA therapy.
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