LAUSR

Dear Editor-in-Chief, The recently published paper by Xu et al 1 summarised the characteristics and mechanisms of liver injury caused by SARS-CoV-2, however, without considering all possible consequences of the epidemic in the management of patients with liver disease. SARS-CoV-2 pandemic started in February 2020 has distraught our working practice as healthcare providers.2 All countries healthcare systems were unprepared to handle an epidemic of this magnitude. The Servizio Sanitario Nazionale (SSN) in Lombardy, historically considered a health service model for efficiency and quality, has been hit hard with, up to date, the highest number of confirmed cases and the highest mortality globally.3 As the number of infected patients grew in our hospitals, emergency physicians, infectiologists,, pneumologists and intensivists were not enough and more manpower has been recruited from other medical specialities to manage patients with acute respiratory distress syndrome due to SARS-CoV-2. Even hepatologists who had to refresh knowledge on interpreting arterial blood gas analysis, managing non-invasive ventilators and prescribing antiretrovirals in subintensive respiratory care units. The ‘call of duty’ of hepatologists, however, put in danger the care of our patients with chronic liver diseases, especially the most advanced or those with acute pathologies of urgent nature, which might be neglected or overlooked. In the heat of managing the emergency, the standard of care of cirrhotic patients might reduce; this might even be counterproductive by increasing the rate of liver complications secondary to under management over the course of the epidemic. We need to ensure that treatments with direct antiviral agents for chronic hepatitis C patients are carried out and properly monitored; however, novel treatments are put off for the time being. For patients with chronic hepatitis B, we have effective antiviral therapies which do not need strictly controls and likewise for patients with chronic autoimmune diseases taking immunosuppressants. However, we must guarantee to all these patients the periodic supply of drugs and stress the adherence to treatment, the only guarantee of efficacy of the treatments which for the generalised anxiety could decrease. For specific drugs, efforts are directed to be ship supplies to patient's home, avoiding unnecessary access to the hospital. Patients with advanced liver disease should be monitored and managed with a web-based system or even a simple telephone contact, and all non-urgent medical visits should be postponed until the emergency is over. Effort should be directed to reduce patient's exposure to infection. Screening endoscopies for gastroesophageal varices should be postponed, particularly in consideration of the highrisk of infection in endoscopy facilities due to the orofaecal route of transmission.4 Ultrasound scan for hepatocellular carcinoma (HCC) surveillance should be preferentially performed in separate COVID-free facilities. Urgent procedures (ie paracentesis) should be organised using a separate (COVID-free) path (eg avoid access through the emergency department) or through home care. HCC treatment should be best referred to COVID-free centres. Hospitalisation should be limited as much as possible for all cirrhotic patients. Hepatologists should also keep in mind that liver injury has also been reported during the course of the SARS-CoV-2 and this can happen in patients with or without previous chronic liver disease. Abnormalities in liver enzymes may derive from a direct viral toxicity to the hepatocytes, ischemic hepatitis in patients in intensive care units, hepatotoxicity from empirically administered drugs (eg chloroquine and hydroxychloroquine) or worsening of the underlying chronic liver disease.1,5 In this moment, we cannot escape our duty of saving as many lives as possible among the SARS-CoV-2 infected; at the same time, we must continue to be liver specialists managing the ordinary adequately by identifying the most fragile patients who need urgent access to care, remotely monitoring the stable ones and offering the best care to liver patients who get infected. Based on our own experience, we believe that in order to enable this it is of key importance 1) identifying dedicated medical personnel (physician and nurses), not overburdened by the management of infected respiratory patients; 2) rapidly implement remote control systems that provide webor telephone consultations; and 3) allocate human resources (eg academic fellows, students) to collect and analyse data to explore the impact of the epidemics on the chronic liver disease population to fine tune live our efforts on the field.