Trends and Outcomes of Acute Liver Failure in patients with COVID-19 Infection: Insights from National Inpatient Sample Analysis 2020-2022

Background: COVID-19, in addition to its direct detrimental respiratory infection, is associated with multiple systemic complications involving different organs, including the liver. COVID-19 has been associated with liver injury through multiple mechanisms including direct viral effects on liver cells, immune mediated injury, cytokine-driven inflammation, ischemic hepatitis, microvascular thrombosis, and sepsis-related multiorgan dysfunction. Acute liver failure (ALF) is the acute form of liver damage, which has a high mortality, and recovery is dependent on various factors. We studied the effect of COVID-19 on clinical outcomes such as mortality, length of stay, and need for non-invasive and invasive ventilation in patients with acute liver failure. Methods: We performed a retrospective cohort analysis using the Nationwide Inpatient Sample (NIS) database from 2020 to 2022. Adult patients admitted to the hospital with acute liver failure were divided into 2 groups based on their COVID-19 infection status. We analyzed the difference in the mortality, length of stay and need for non-invasive or invasive ventilation using odds ratio, to evaluate effects on outcomes, and results were then adjusted to demographic and hospital factors. Results: Patients with acute liver failure with COVID-19 had significantly increased in-hospital mortality (63.7 vs 35.3%), increased use of noninvasive ventilation (15.0% vs 6.5%) and invasive mechanical ventilation (68.5% vs 40.9%), along with a longer hospital stay (17.1 vs 10.7 days). The findings were concurrent with statistical significance after adjusting for demographics and clinical factors. Conclusions: Patients with COVID-19 infection admitted to the hospital with acute liver failure have poor clinical out-comes, with higher in-hospital mortality, higher need for ventilatory support, and longer length of stay. COVID-19 independently is associated with worse outcomes, which was noted even in individuals with less baseline comorbidities. Early recognition of COVID-19 infection and acute hepatic failure and prompt management by the multidisciplinary team is essential for better clinical outcomes.