Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Journal Pre-proof High Mortality Rates for SARS-CoV-2 Infection in Patients with Pre-existing Chronic Liver Disease and Cirrhosis: Preliminary Results from an International Registry Andrew M. Moon, MD MPH, Gwilym J. Webb, PhD MRCP, Costica Aloman, MD, Matthew J. Armstrong, PhD MRCP, Tamsin Cargill, PGDip MRCP, Renumathy Dhanasekaran, MD, Joan Genescà, MD, Upkar S. Gill, PhD MRCP, Theodore W. James, MD, MSCR, Patricia D. Jones, MD, MSCR, Aileen Marshall, PhD MRCP, George Mells, PhD MRCP, Ponni V. Perumalswami, MD, MSCR, Xiaolong Qi, MD, Feng Su, MD, MSCR, Nneka N. Ufere, MD, Eleanor Barnes, DPhil MRCP, A Sidney Barritt, IV, MD MSCR, Thomas Marjot, BSc MRCP PII: S0168-8278(20)30305-6 DOI: https://doi.org/10.1016/j.jhep.2020.05.013 Reference: JHEPAT 7758 To appear in: Journal of Hepatology Received Date: 24 April 2020 Revised Date: 8 May 2020 Accepted Date: 14 May 2020 Please cite this article as: Moon AM, Webb GJ, Aloman C, Armstrong MJ, Cargill T, Dhanasekaran R, Genescà J, Gill US, James TW, Jones PD, Marshall A, Mells G, Perumalswami PV, Qi X, Su F, Ufere NN, Barnes E, Barritt AS IV, Marjot T, High Mortality Rates for SARS-CoV-2 Infection in Patients with Pre-existing Chronic Liver Disease and Cirrhosis: Preliminary Results from an International Registry, Journal of Hepatology (2020), doi: https://doi.org/10.1016/j.jhep.2020.05.013. 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Title: High Mortality Rates for SARS-CoV-2 Infection in Patients with Pre-existing Chronic Liver Disease and Cirrhosis: Preliminary Results from an International Registry. 1 Authors: Andrew M Moon MD MPH* (1), Gwilym J Webb PhD MRCP* (2), Costica Aloman MD (3), Matthew J Armstrong PhD MRCP (4), Tamsin Cargill PGDip MRCP (2), Renumathy Dhanasekaran MD (5), Joan Genescà MD (6), Upkar S Gill PhD MRCP (7), Theodore W James MD, MSCR (1), Patricia D Jones MD, MSCR(8), Aileen Marshall PhD MRCP (9), George Mells PhD MRCP (10), Ponni V Perumalswami MD, MSCR (11), Xiaolong Qi MD (12), Feng Su MD, MSCR (13), Nneka N Ufere MD (14), Eleanor Barnes DPhil MRCP* (2), A Sidney Barritt IV MD MSCR* (1), Thomas Marjot BSc MRCP* (2). Affiliations: (1) Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA. (2) Oxford Liver Unit, Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK (3) Department of Medicine, Section of Hepatology, Rush University Medical Center, Chicago, Illinois, USA (4) Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK (5) Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA (6) Liver Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Spain. (7) Barts Liver Centre, Barts Health NHS Trust & Barts & The London School of Medicine & Dentistry, Queen Mary University of London, UK (8) Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA (9) Sheila Sherlock Liver Unit, Royal Free Hospital, London, UK 2 (10) Cambridge Liver Unit, Addenbrooke’s Hospital, Cambridge University Hospitals, Cambridge, UK (11) Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA (12) CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China (13) Division of Gastroenterology, University of Washington, Seattle, WA, USA (14) Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA Corresponding Author: Dr Thomas Marjot Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Trust, OX3 9DU Thomas.marjot@ndm.ox.ac.uk Author contributions: Concept and Design: TM, AMM, EB, ASB, GW, TWJ Acquistion of data: CA, MJA, TC, RD, JG, USG, TWJ, PDJ, AM, GM, PVP, XQ, FS, NNU Statistical analysis: TM, AMM, GW Interpretation of data: TM, AMM, EB, ASB, GW Drafting and critical revision of manuscript: TM, AMM, EB, ASB, GW * These authors contributed equally. 3 Acknowledgements: This work was supported by the National Institutes of Health grant T32 DK007634 (AMM and TWJ). We acknowledge the assistance of the NC Translational and Clinical Sciences (NC TraCS) Institute, which is supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number UL1TR002489. COVID-Hep.net was supported by the European Association for Study of the Liver (TM). Disclosures/Conflicts of Interest: The authors have no conflicts of interest or competing interests to disclose. Manuscript Word Count: 628 References/Word Count: 7/187 Tables 1 Figures 1 Abbreviations: CLD – chronic liver disease COVID-19 – coronavirus disease 2019 CTP – Child-Turcotte-Pugh MELD – Model for end-stage liver disease SARS-CoV-2 – Severe acute respiratory syndrome coronavirus 2 4 To the Editor: Chronic liver disease (CLD) and cirrhosis are common conditions1 associated with immune dysregulation2 leading to concerns that these patients are at increased risk for complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and resulting coronavirus disease 2019 (COVID-19).3 However, the effects of COVID-19 among patients with pre-existing liver disease are currently undefined. We report the outcomes of the first 152 consecutive submissions of clinician-reported cases of laboratory-confirmed COVID-19 in patients with CLD to two international reporting registries (COVID-Hep.net and COVIDCirrhosis.org) between 25 March 2020 and 20 April 2020. Our combined database includes 103 patients with cirrhosis and 49 with non-cirrhotic CLD from 21 countries across 4 continents (59.9% male, median age 61 years, aetiology 22.4% non-alcoholic fatty liver disease, 19.7% alcohol, 11.8% hepatitis B, 10.5% hepatitis C, 35.6% other/combination). Contributors were encouraged to enter data at the end of the patient’s disease course. For patients admitted to hospital, cases were only included in the analysis if a definitive outcome of death or discharge was reported. 95.2% of patients with cirrhosis were hospitalised with a median length of hospital stay until discharge or death of 10 days (IQR 5-14 days). Outcomes for patients with cirrhosis included admission to intensive care unit (ICU) in 23.3%, invasive ventilation in 17.5%, non-invasive ventilatory support in 18.6%, renal replacement therapy 4.9% and death in 39.8%. Mortality far exceeded that reported in unselected populations4, hospitalised patients with cirrhosis in the era preceding COVID-195, and in patients with cirrhosis admitted with influenza.6 In patients not admitted to ICU, 59.5 % had non-severe disease, 27.8% had severe disease but escalation of care was deemed inappropriate, and 3.7% were considered to require ICU but were not admitted due to lack of availability. Targeted antiviral therapy was used in 38.1% of total 5 cases. The most frequently used treatments were chloroquine/hydroxychloroquine (23.0%), lopinovir/ritonavir (6.6%), tocilizumab (3.3%), and interferon-alpha (3.3%). Cause of death in patients with cirrhosis was reported as COVID-19 lung disease in 78.7%, cardiac-related in 4.3%, and liver-related in 12.2%. Risk factors for poor COVID-19 outcomes in the general population including advanced age, obesity, renal impairment, heart disease, and diabetes mellitus were over-represented among those who died, although male sex and non-white ethnicity were not.7 Mortality correlated strongly with baseline Child-Turcotte-Pugh (CTP) class and model for end-stage liver disease (MELD) score (Table 1). Deaths occurred in 12.2% of CLD without cirrhosis, 23.9% CTP-A cirrhosis, 43.3% CTP-B cirrhosis, and 63.0% CTP-C cirrhosis (Fig. 1A). CTP-B and CTP-C cirrhosis remained associated with death after adjusting for baseline characteristics including comorbidities (Table 1). CTP-B and CTP-C cirrhosis remained significant predictors of mortality even when analysis was restricted to those with cirrhosis. Hepatic decompensation occurred in 36.9% and was associated with baseline CTP class (Fig. 1B). Decompensation events included worsening ascites (27.2%), spontaneous bacterial peritonitis (2.9%), hepatic encephalopathy (16.5%), and variceal haemorrhage (1%). Hepatic decompensation during COVID-19 was strongly associated with a subsequent risk of death: 63.2% of those with new decompensation died compared to 26.2% of those without new decompensation. Notably, 24.3% of those with new hepatic decompensation had no respiratory symptoms of COVID-19 at the time of diagnosis. This large, multicentre, international cohort of patients with chronic liver disease and cirrhosis allows for in depth assessment of the clinical factors associated with poor outcomes from COVID- 19. Accepting that data from registries are subject to selection bias, preliminary findings suggest that baseline liver disease severity is strongly associated with COVID-19-related morbidity and mortality. Furthermore, many SARS-CoV-2-infected patients with cirrhosis experienced hepatic 6 decompensation even in the absence of respiratory symptoms. These findings have important implications for clinicians regarding risk stratification and prognostication for patients with cirrhosis and COVID-19 and suggest the need to maintain a low threshold for SARS-CoV-2 testing in the presence of new hepatic decompensation. 7 Univariable analysis Multivariable analysis Total; n = 152 Survived; n = 105 Died; n = 47 Variable Median or n IQR or % Median or n IQR or % Median or n IQR or % p value† OR (95%CI) for death p value§ Age (years) 61 48-71 60 46-70 64 57-73 0.025 1.04 (1.00-1.09) 0.048 Sex (male) 91 59.9% 61 58.1% 30 63.8% 0.666 - - White ethnicity 86 56.6% 56 53.3% 30 63.8% 0.228 - - Smoker 9 5.9% 7 6.7% 2 4.3% 0.560 - - Obese (BMI >30 kg/m2) 33 21.7% 18 17.1% 15 31.9% 0.017 3.59 (1.10-10.47) 0.033 Cardiovascular disease 33 21.7% 18 17.1% 15 31.9% 0.041 1.87 (0.57-6.15) 0.303 Diabetes mellitus 54 35.5% 30 28.6% 24 51.1% 0.007 2.86 (1.00-8.20) 0.051 Hypertension 60 39.5% 35 33.3% 25 53.2% 0.021 0.71 (0.22-2.24) 0.555 Liver disease severity CLD without cirrhosis 49 32.2% 43 41.0% 6 12.8% 1.00 - CTP A cirrhosis 46 30.3% 35 33.3% 11 23.4% 1.21 (0.30-4.90) 0.789 <0.001 4.90 (1.16-20.61) 0.030 CTP B cirrhosis 30 19.7% 17 16.2% 13 27.7% 27 17.8% 10 9.5% 17 36.2% 28.07 (4.42-178.46) <0.001 CTP C cirrhosis MELD score* 10 7-17 9 7-17 13 9-17 0.014 - - Laboratory (baseline) Sodium (mmol/L) 138 135-141 139 136-141 137 134-140 0.058 1.06 (0.93-1.22) 0.377 Prothrombin time (s) 13 12-17 13 12-15 15 13-18 0.011 - - Bilirubin (mg/dL) 1.1 0.6-1.9 0.9 0.5-1.5 1.4 0.8-2.0 0.013 - - Albumin (g/dL) 3.4 2.8-4 3.8 3.0-4.0 2.9 2.4-3.3 <0.001 - - Creatinine (mg/dL) 0.9 0.6-1.1 0.8 0.6-1.0 0.9 0.7-1.1 0.010 0.88 (0.53-1.47) 0.634 Events after diagnosis Any decompensation 39 25.7% 15 14.3% 24 51.1% <0.001 - - New jaundice 27 17.8% 14 13.3% 13 27.7% 0.067 - - 8 Table 1. Characteristics of patients with laboratory-confirmed chronic liver disease and COVID-19 submitted to COVIDCirrhosis.org and COVID-Hep.net reporting registries between 25th March 2020 and 20th April 2020. † = p values for univariable analyses calculated using chi-squared or Wilcoxon ranksum tests as appropriate; § = p values for multivariable analysis calculated by multiple logistic regression with the dependent variable as death and the following independent variables: age, obesity, cardiovascular disease, diabetes mellitus, hypertension, chronic liver disease status as Child-Turcotte-Pugh class, baseline serum sodium, and baseline serum creatinine. Pseudo r2 = 0.256. * = MELD score presented is as calculated for all patients; when restricted to patients with cirrhosis, MELD was 11 (IQR 7-19) in those who survived and 14 (9-17) in those who died, p = 0.136. To explore the relationship of MELD with death, multiple logistic regression was repeated with death as the dependent variable and age, baseline MELD, obesity, cardiovascular disease, diabetes mellitus, hypertension, and baseline albumin as independent variables; here the OR for death for MELD was 1.05 (0.98-1.11) p = 0.204; other variables with p < 0.05 were age 1.05 (1.00-1.08) p = 0.038, obesity 3.61 (1.36-9.60) p = 0.010, and baseline albumin 0.97 (0.93-1.00) p = 0.029. Any decompensation defined as one or more of worsening ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, or variceal haemorrhage. BMI = body mass index; CI = confidence interval; CLD = chronic liver disease; CTP = Child- Turcotte-Pugh grade; IQR = interquartile range; MELD = model for end-stage liver disease (2016 revision); OR = odds ratio. 9 A B Fig. 1: Outcome in patients with non-cirrhotic chronic liver disease or cirrhosis with COVID-19. Graphs depict data from 152 submissions to COVID-Hep.net and SECURE- Cirrhosis registries submitted between 25th March 2020 and 20th April 2020. (A) Case fatality rate by liver disease stage. (B) Rates of hepatic decompensation by stage of cirrhosis (defined as one or more of new or worsened ascites, spontaneous bacterial peritonitis, new or worsened hepatic encephalopathy, or variceal haemorrhage). p values derived using chi-squared test. CLD = Chronic liver disease without cirrhosis; CTP = Child-Turcotte-Pugh stage of cirrhosis. 10 References: (1) Moon AM, Singal AG, Tapper EB. Contemporary Epidemiology of Chronic Liver Disease and Cirrhosis. Clinical Gastroenterology and Hepatology 2019 Aug 8 (2) Albillos A, Lario M, Álvarez-Mon M. Cirrhosis-associated immune dysfunction: distinctive features and clinical relevance. Journal of Hepatology 2014 Dec;61(6):1385-96 (3) Boettler T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Cornberg M et al. Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper. JHEP Rep 2020 Jun;2(3):100113 (4) Mehra MR, Desai SS, Kuy S, Henry TD, Patel AN. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19.N Engl J Med. 2020 May 1. (5) Schmidt ML, Barritt AS, Orman ES, Hayashi PH. Decreasing Mortality Among Patients Hospitalized With Cirrhosis in the United States From 2002 Through 2010. Gastroenterology. 2015 May;148(5):967-977.e2. (6) Schütte A, Ciesek S, Wedemeyer H, Lange CM. Influenza virus infection as precipitating event of acute-on-chronic liver failure. J Hepatol. 2019 Apr;70(4):797-799. (7) Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020 Mar 28;395(10229):1054-1062. 11 Supplementary appendix List of contributors to registry from 25th March 2020 – 20th April 2020; with thanks. Reporter / Responsible Consultant / Hospital / City / Country Abigail Ford / Matthew Hoare, Addenbrooke's Hospital / Cambridge University Hospitals, Cambridge, UK Ahmed Hashim / Aileen Marshall, Royal Free Hospital / London, UK Ahmed Hashim / David Patch, Royal Free Hospital / London, UK Ahmed Hashim / Rachel Westbrook, Royal Free Hospital / London, UK Ahmed Hashim / Rajiv Jalan, Royal Free Hospital / London, UK Alexandra Shingina, Vanderbilt University Medical Center, Nashville, Tennessee, USA Andrea De Gottardi, Ente Ospedaliero Cantonale, Switzerland Andrew Austin / Adrew Austin, Royal derby Hospital / Royal Derby Hospital, UK Andrew Yeoman, Gwent Liver Unit / Royal Gwent Hospital, Newport, Wales, UK Ane Soegaard Teisner, Herlev Hospital / Herlev Hospital, Denmark Anna Crawford / Jane Collier, John Radcliffe Hospital, Oxford / John Radcliffe Hospital, Oxford, UK Ben Hudson, Royal Devon and Exeter NHS Foundation Trust / Royal Devon and Exeter NHS Foundation Trust, UK Benjamin Mullish / Nowlan Selvapatt, St Mary's Hospital, London, UK Beth Lusina / Kelly Burak, Foothills Medical Centre / Peter Lougheed Centre, Calgary, Alberta, Canada Bruno Annibale / Massimo Marignani, Ospedale Universitario S. Andrea, Sapienza / Policlinico Umberto I, Italy Bulent Baran / Cihan Yurdaydin, Koç University Hospital, Turkey Carmen Cerron / Martin Padilla, Transplant Departament / Guillermo Amenara Hospital, Peru Catalina Toledo / Joan Genescà, Vall de Hebron, Spain Costica Aloman / Donald Jensen, Rush University Medical Center, Chicago, Illinois, USA 12 Costica Aloman / Sheila Eswaran, Rush University Medical Center, Chicago, Illinois, USA Costica Aloman, Rush University Medical Center, Chicago, Illinois, USA Cristina Montón Rodriguez / Martin Prieto, Hospital Universitario La Fe de Valencia / Hospital Clínico Universitario de Valencia, Spain Cristina Rigamonti, Division of Internal Medicine, Azienda Ospedaliero-Universitaria Maggiore della Carità , Novara, Italy, Italy Daniel Ochoche Amedu / Dr Paul, FRSC medical centre Gwarimpa, Nigeria David Harman / Jane Collier, Oxford University Hospitals, Oxford, UK Elton Dajti / Mariarosa Tamè, Sant'Orsola Hospital / Sant'Orsola Hospital, Italy Emily Glynn / John Ryan, Beaumont Hospital / Beaumont Hospital, Ireland Emma Avitabile / Elisa Pose, Hospital Clinic Barcelona, Spain Esteban Fuentes Valenzuela / Julia Gómez Barquero, Hospital Universitario Rio Hortega, Spain Ewan Forrest, Glasgow Royal Infirmary, UK Felipe Alconchel / Pablo Ramírez, Virgen de la Arrixaca University Hospital, Spain Feng Su / Charles Landis, Harborview Medical Center / Harborview Medical Center, USA Feng Su / Charles Landis, Harborview Medical Center / Providence Swedish, USA Feng Su / Michele Goodman, University of Washington Northwest Hospital / Harborview Medical Center, USA Feng Su / Paula Cox-North, Harborview Medical Center / Harborview Medical Center, USA Feng Su, Harborview Medical Center / Harborview Medical Center, USA Francesca Saffioti / Jeremy Cobbold, Oxford University Hospitals, Oxford / Horton General Hospital, UK Gloria Torres / Joan Genescà, Hospital Vall d'Hebron, Spain Gupse Adali, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey, Turkey Gwilym Webb / Jane Collier, Oxford University Hospitals, Oxford / John Radcliffe Hospitals, UK Gwilym Webb / Jane Collier, Oxford University Hospitals, Oxford, UK Hannes Hagström / Ammar Barakat, Karolinska University Hospital, Sweden Hannes Hagström / Annika Bergquist, Karolinska University Hospital, Sweden 13 Hannes Hagström, Karolinska University Hospital / Stockholm South Hospital, Sweden Hrishikesh Samant, Ochsner Louisiana State University Health, Shreveport, LA / Willis Knighton Medical Center (North), Shreveport, LA 71103, UK Ignacio García-Juárez, Instituto Nacional de Ciencias Médicas y Nutricíon Salvador Zubirán, Mexico Jihane Benhammou, University of California Los Angeles, USA Jonathan Crisostomo / Arlinking Ong-Go, Metropolitan Medical Center / Metropolitan Medical Center, Philippines Juozas Kupcinskas, Lithuanian University of Health Sciences / Kaunas Clinical Hospital, Lithuania Kevin Korenblat, Washington University School of Medicine / Christian Hospital Northeast, USA Konstantina Nikitopoulou / George Mells, Addenbrooke's Hospital / Cambridge University Hospitals, Cambridge, UK Konstantina Nikitopoulou / Keval Naik, Addenbrooke's Hospital / Cambridge University Hospitals, Cambridge, UK Konstantina Nikitopoulou / Matthew Hoare, Addenbrooke's Hospital / Cambridge University Hospitals, Cambridge, UK Konstantina Nikitopoulou / Michael Allison, Addenbrooke's Hospital / Cambridge University Hospitals, Cambridge, UK Konstantina Nikitopoulou / Michalis Kostapanos, Addenbrooke's Hospital / Cambridge University Hospitals, Cambridge, UK Konstantina Nikitopoulou / Paul Gibbs, Addenbrooke's Hospital / Cambridge University Hospitals, Cambridge, UK Konstantina Nikitopoulou / Victoria Snowdon, Addenbrooke's Hospital / Cambridge University Hospitals, Cambridge, UK Lorraine Blaise / Elia Gigante, Hepatology Unit Jean Verdier Hospital, Bondy / Avicenne Hospital Bobigny, France Lorraine Blaise / Elia Gigante, Hepatology Unit Jean Verdier Hospital, Bondy / Cochin Hospital, Paris, France Lorraine Blaise / Nathalie Ganne, Hepatology Unit Jean Verdier Hospital, Bondy / CHI Andre Gregoire Montreuil hospital, France Lorraine Blaise / Pierre Nahon, Hepatology Unit Jean Verdier Hospital, Bondy, France Lorraine Blaise / Véronique Grando, Hepatology Unit Jean Verdier Hospital, Bondy / Avicenne Hospital (Bobigny 93), France Marcella Salzano / Joan Genescà, Hospital Vall d'Hebron, Spain Maria Andreea Catana, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA Maria Torrens / Joan Genescà, Hospital Vall d'Hebron, Spain Martin Prince, Manchester Royal Infirmary / Manchester, UK Matias Estevez Escobar / Cristina Vinolo Ubina, Hospital de Poniente, Spain 14 Matias Estevez Escobar, Hospital de Poniente, Spain Matthew Armstrong / Fiona Thompson, Queen Elizabeth University Hospital Birmingham, UK Matthew Armstrong / Thamara, Queen Elizabeth University Hospital Birmingham / Whiston Hospital, UK Matthew Armstrong, Queen Elizabeth University Hospital Birmingham / Burton Hospital, UK Matthew Foxton, Chelsea & Westminster Hospital, UK Michael Andrew Yu / Ram Subramanian, Emory Transplant Center, Atlanta, Georgia / Emory Johns Creek Hospital, USA Michael Andrew Yu / Ram Subramanian, Emory Transplant Center, Atlanta, Georgia / Emory University Hospital, USA Mohamed Elfeki / Donald Hillebrand, Iowa Methodist Medical Center / Iowa Methodist Medical Center, USA Monica Cucco / Gianluca Svegliati Baroni, Department of Gastroenterology, Polytechnic University of Marche, Ancona, Italy / Senigallia Hospital, Italy Nancy Reau, Rush University Medical Center / Rush University Medical Center, USA Nneka Ufere, Massachusetts General Hospital, USA Patricia Jones, University of Miami, Jackson, Florida, USA Ponni Perumalswami / Charissa Chang, Mount Sinai Hospital, New York / Mount Sinai Queens, USA Ponni Perumalswami / Charissa Chang, Mount Sinai Hospital, New York / Saint Barnabus Medical Center, USA Ponni Perumalswami / Charissa Chang, Mount Sinai Hospital, New York, USA Ponni Perumalswami / Gene Im, Mount Sinai Hospital, New York, USA Ponni Perumalswami / Jawad Ahmad, Mount Sinai Hospital, New York / Mount Sinai Queens, USA Ponni Perumalswami / Jawad Ahmad, Mount Sinai Hospital, New York, USA Ponni Perumalswami / Jennifer Leong, Mount Sinai Hospital, New York, USA Ponni Perumalswami / Joseph Odin, Mount Sinai Hospital, New York / Mount Sinai Brooklyn, USA Ponni Perumalswami / Joseph Odin, Mount Sinai Hospital, New York, USA Ponni Perumalswami / Kamron Pourmand, Mount Sinai Hospital, New York, USA Ponni Perumalswami / Leona Kim-Schluger, Mount Sinai Hospital, New York, USA Ponni Perumalswami / Ritu Agarwal, Mount Sinai Hospital, New York, USA 15 Ponni Perumalswami / Thomas Schiano, Mount Sinai Hospital, New York / Danbury Hospital/Mount SInai Hospital, USA Ponni Perumalswami / Thomas Schiano, Mount Sinai Hospital, New York, USA Ponni Perumalswami, Mount Sinai Hospital, New York / New York Methodist Hospital, USA Ponni Perumalswami, Mount Sinai Hospital, New York / Wykoff, USA Ponni Perumalswami, Mount Sinai Hospital, New York, USA Rainer Guenther, Department of Internal Medicine/Liver Unit / Universitätsklinikum Schleswig-Holstein, Campus, ICU/Department of Internal Medicine, Germany Raymond Rubin / Rahul Maheshwari, Piedmont Atlanta Hospital, USA Raymond Rubin, Piedmont Atlanta Hospital / Piedmont Columbus Midtown Hospital, USA Raymond Rubin, Piedmont Atlanta Hospital, USA Richard Parker, Leeds Liver Unit / Leeds, UK Roger McCorry / Neil McDougall, Royal Victoria Hospital, Belfast / Antrim Hospital, UK Sarah Townsend / Douglas Thorburn, Royal Free Hospital / John Radcliffe, UK Sarang Thaker / Dr. Mikolajczyk, University of Illinois, Chicago, USA Sathish Subramanian, Massachusetts General Hospital, USA Sheila Eswaran, Rush University Medical Center, Chicago, Illinois, USA Sonia Blanco Sampascual / Fernando Menéndez, Hospital Universitario Basurto, Spain Stephen Barclay, Glasgow Royal Infirmary, UK Steve Scaglione, Maria Cabrera / Loyola University Medical Center, Maywood, Illinois, USA Thines Karunakaran / Chirag Oza, Broomfield Hospital / Broomfield Hospital, UK Thomas Marjot / Ramasamy, Tony Ellis / John Radcliffe Hospital, Oxford, UK Ulrich Thalheimer, Royal Shrewsbury Hospital / Royal Shrewsbury Hospital, UK Upkar Gill / Graham Foster, Royal London Hospital (Barts Health NHS Trust), UK Upkar Gill / Janet Dearden, Whipps Cross University Hospital (Barts Health NHS Trust) / Whipps Cross University Hospital (Barts Health NHS Trust), UK 16 Upkar Gill / Janet Dearden, Whipps Cross University Hospital (Barts Helath NHS Trust), UK Upkar Gill / Patrick Kennedy, Royal London Hospital (Barts Health NHS Trust), UK Upkar Gill / Richard Marley, Royal London Hospital (Barts Health NHS Trust), UK Upkar Gill / Sudeep Tanwar, Whipps Cross University Hospital (Barts Health NHS Trust), UK Upkar Gill / Sushma Saksena, Royal London Hospital (Barts Health NHS Trust), UK Upkar Gill / Vikram Sharma, Newham University Hospital (Barts Health NHS Trust), UK Upkar Gill / Vikram Sharma, Royal London Hospital (Barts Health NHS Trust), UK Upkar Gill / William Alazawi, Royal London Hospital (Barts Health NHS Trust), UK Vanessa de Villa, The Medical City / The Medical City, Philippines Veronica Nguyen / Geoffrey Block, Banner University Medical Center/University of Arizona, Tucson / Banner University Medical Center/University of Arizona, Tucson, USA Wim Laleman, University Hospitals Leuven, Belgium Xavier Verhelst, Ghent University Hospital Belgium / AZ Oudenaarde, Belgium Xiaolong Qi / CHESS, CHESS / Hubei, China Xiaolong Qi / CHESS, CHESS / Jiangsu, China Xiaolong Qi / CHESS, CHESS / Tianjin, China Xiaolong Qi / CHESS, Hubei, China Zurabi Lominadze, University of Maryland Medical Center / University of Maryland Medical Center, USA COVID-Hep.net and COVIDCirrhosis.org would also like to thank the following societies for their endorsement European Association for Study of the Liver (EASL), United European Gastroenterology (UEG), International Liver Cancer Association (ILCA), British Society of Gastroenterology (BSG), British Association for Study of the Liver (BASL), Hepatology Society of the Philippines, Gastroenterological Society of Australia (GESA), Australia and New Zealand Liver and Intestinal Transplant Registry (ANZLITR), British Liver Trust, European Liver Patients’ Association (ELPA) Chinese Portal Hypertension Diagnosis and Monitoring Study Group (CHESS). 17