The study enrolled 143 consecutive patients with liver disease (70% males, mean age of 62 years) who were admitted either as outpatients or inpatients to the hepatology unit of our hospital. Among the 143 patients who were admitted for a first clinical evaluation, 95 patients also underwent a follow-up (second) evaluation. The median time from the first to the second evaluation was 95 days (IQR, 40–140 days). Outpatient admissions were typically for radiologic and/or laboratory examinations and drug infusion. Inpatient admissions were primarily for invasive diagnostic or therapeutic procedures (e.g. liver biopsy or angiography) or to perform loco-regional treatment for hepatocellular carcinoma (HCC). The main demographic and clinical characteristics of the patients who were admitted for a first clinical evaluation are presented in Table 1. Among the 143 patients enrolled, 38 (26.6%) had received a liver transplant. The main etiologies of liver disease in this patient cohort were alcohol-related conditions and HCC. We identified no significant differences regarding the etiologies of liver diseases between patients who had undergone transplantation procedures and those who had not. Among the patients who have not received liver transplants, 76/105 (72.4%) presented with cirrhosis and 13/105 (12.4%) were taking immunosuppressive drugs to treat autoimmune hepatitis. Patients who had undergone liver transplants were admitted as outpatients more frequently than were those who had not received transplants, typically for radiologic and/or laboratory examinations (34 of 38 [89.5%] vs. 76 of 105 [72.4%], p = 0.032). We identified no significant differences between these two groups with respect to reports of SARS-CoV-2, symptoms before admission and/or an earlier risk of exposure, which were recorded in 4/38 (10.5%) of the patients who had undergone liver transplants and 8/105 (7.6%) of those who had not (p = 0.580).
The primary laboratory parameters that were recorded at the first clinical evaluation of all patients are shown in Table 2. As anticipated, patients with liver transplants presented with significantly higher serum creatinine levels compared to those who had not received transplants. In contrast, patients who have not received liver transplants presented with significantly higher levels of serum bilirubin and international normalized ratios (INRs) and significantly lower platelet counts and serum sodium levels compared to transplanted patients.
Ninety-five patients, of whom 31 (32.6%) had received liver transplants, were admitted for a second clinical evaluation. Table 3 summarizes the main demographic and clinical characteristics of these patients. The only significant difference between the two groups was that a considerably longer period of time elapsed between the first and the second clinical evaluation among those who received liver transplants compared to those who did not (118 vs. 72 days, p < 0.02). As observed in patients evaluated at their first visit, we found no significant differences between those who had received liver transplants (2/31; 6.5%) and those who had not (6/64; 9.4%) when we examined these patient cohorts for symptoms including fever, chills, or cough or contacts with persons infected with SARS-CoV-2 during the 15 days immediately preceding the second clinical evaluation (p = 0.630).
The primary laboratory parameters obtained from these patients at the second clinical evaluation are shown in Table 4. Similar to those recorded in the first clinical evaluation, patients who had received a liver transplant presented higher serum creatinine levels compared to those who had not received transplants, while the latter group presented higher serum bilirubin and INR levels and lower platelet counts and serum sodium levels compared to those in the former group.
Incidence of nosocomial SARS-CoV-2 infection
None of the patients admitted for a first or a second clinical evaluation had positive nasopharyngeal swab RT-PCR tests for SARS-CoV-2. One outpatient had a positive anti-SARS-CoV-2 IgG but not IgM before the first clinical evaluation. This patient was a 67-year-old male who had received a liver transplant for decompensated hepatitis B-related cirrhosis 8 years before this hospital admission. At his interview, he reported a history of symptomatic SARS-CoV-2 infection 4 months before this admission. Serum anti-SARS-CoV-2 IgG antibodies were detected again after the 2 months that had elapsed between his first and second clinical evaluation, although the results of the RT-PCR test for SARS-CoV-2 in nasopharyngeal swabs remained negative throughout. No anti-SARS-CoV-2 antibodies were detected in any of the remaining 11 patients who were at increased risk for SARS-CoV-2 infection during the 15 days before a first admission (3 who had undergone liver transplantation and 8 who had not) or any of the 7 remaining patients (1 who had undergone liver transplantation and 6 who had not) who were at increased risk during the 15 days before the second admission.