Hello, and welcome to the liver meeting digital experience, COVID-19 and chronic liver disease. I'm Karen Hoyt, a liver disease patient and advocate at iHelpC.com. It's been my honor to serve the AASLD by being the co-chair for Dr. John Lake from the COVID-19 Task Force Subcommittee. Under Dr. Lake's guidance, we've written many patient-facing documents, even as the coronavirus seemed to change at every turn. What an encouragement it is to know that we're surrounded by medical specialists in liver disease who are providing up-to-date information on every aspect of patient care. First up, you'll hear a patient experience from David Urich on how COVID-19 affects the hearts and minds of everyone who has chronic liver disease. We're all acutely aware of the fragility of life with liver ailment and do our best to preserve our health. David will share his own diagnosis and also offer his unique insight and thoughts on living through the pandemic. Next, you'll hear an overview, prognosis, and risk factors with Dr. Verna by following her into the epicenter of the coronavirus in New York City. Betsy is a transplant hepatologist, clinical researcher, and educator at Columbia University. She's the director of clinical research for Columbia's Transplant Clinical Research Center and has a long list of many accomplishments. Her practice is at ground zero at New York Presbyterian, Columbia University Medical Center, and Cornell Medical Centers in New York. Be prepared to hear amazing stats and stories. Finally, you'll get to hear from Dr. Ryan Kwok, a gastroenterologist who practices at Walter Reed National Military Medical Center in Bethesda, Maryland. His practice with veterans and other patients offer great insight into how COVID-19 affects the liver. Like all AASLD physicians, he offers compassionate care with coronavirus. In addition, his continued work in research and hepatology has led to increased activity and involvement during this era of coronavirus pandemic. He also serves the AASLD by offering ongoing support through various committees and educations for patients, clinicians, and physicians. John Lake, MD, will provide the closing remarks. He's the chairman of the COVID-19 and the Liver Patient Subcommittee. His leadership has helped our team deliver the best in medical advice for the liver disease global community and to all practicing medical clinicians and physicians. He's the professor of medicine at the University of Minnesota Medical School at the Division of Gastroenterology, Hepatology, and Nutrition. He's a board-certified hepatologist, gastroenterologist, and chief of hepatology and director of the liver transplant program at the University of Minnesota Medical Center. I hope you enjoy this COVID-19 and chronic liver disease. Every day, I devote around 30 minutes to reading articles about the COVID-19 pandemic. Just enough to keep me informed and not enough to make me overly stressed. I try to fill the rest of my day with rollerblading, my favorite form of exercise, cooking, working my direct care job, spending time with my lovely girlfriend, and practicing self-care. Love and gratitude for my family and friends has helped me through moments of uncertainty and despair. Some of the articles I've read have included people's fear and uncertainty about infecting their loved ones. After reading them, I found myself replaying thoughts and feelings I've had throughout my life about infecting another person with hepatitis B. If I were to make a word bubble regarding this, the most commonly used words would be fear, shame, guilt, disconnectedness, and uncertainty. For the first few months of the pandemic, my fears were all over the place, as virtually nothing was known publicly about this virus. The most prominent fears I had were wondering if my hepatitis B would result in a higher chance for me to catch COVID-19, or spread it, or be severely sickened by it. Would catching COVID-19 make my hep B worse? As new information arrived and was confirmed by various health organizations, such as the Hep B Foundation and its sister org, Hep B United, those specific fears subsided. However, with communication coming from so many different organizations around the world, I worried about what was fact and what wasn't. I found solace in the words of Dr. Fauci and others that spoke directly to the science and nothing else. I was worried about going to the clinic for a blood draw, or even visiting the hospital to speak with my hepatologist. My last in-person meeting was March 11th, the day that the very first COVID-19 patient was admitted to the University of Michigan Hospital, which is where I was that day. I remember feeling shocked, fearful, and confused about the risk of me even being there. Thankfully, the candidness and effort put forth from my team of doctors went above and beyond and made me feel like I was in the best hands possible. I was told about my hepatitis B for the first time when I was 13 years old. I remember my parents taking me to the clinic and hearing about this thing called hepatitis B. I was in middle school. I was thinking about dating, participating in sports, not about living with a chronic illness. The doctor said, you can live a long healthy life, but nobody helped me talk about the things that mattered to me at that time. Was I going to be able to date? Was I going to be able to have a family? Was I going to be able to be physically active for the rest of my life? Was I going to be able to keep striving for my dreams and goals? I remember feeling like I'd gotten some answers, but also felt completely overwhelmed knowing I have a chronic infectious disease. Throughout my 20s, I alternated between not caring, being worried, and wanting to ignore it. I didn't go to the doctor as often as I should have. Then in November of 2018, I found out my liver wasn't doing well. My AST-ALT numbers were alarmingly high. The doctor suggested a liver biopsy, and I eventually agreed to the procedure after some careful deliberation. It went well, and I've been taking a medication for almost a year now. My viral load is undetectable, and I feel no side effects from this medication. Being proactive with my health and being 100% honest, and I can't stress that enough, 100% honest with my doctors about my lifestyle choices, is a habit I'm going to keep for the rest of my life. Most of my memory from years ago is blurry and unreliable. One thing I can clearly remember was a strong fear of spreading hepatitis B throughout most of my teenage years and my early 20s. Even after talking with liver doctors and reading countless online articles, I still felt like I needed to quarantine myself away from the world. During the first few years of knowing I had hepatitis B, if I fell down and started bleeding, I didn't know what to do. Moments like those made me feel like I was a bad person for even existing. Knowing what I know now, I wish I would have spoken out more about my feelings and worries. The chance of transmitting hepatitis B to another person through blood is very low if proper precautions are taken. Just knowing my viral load as a hepatitis B chronic carrier empowers me in this regard. I'm thankful that I had a good enough education to be able to discern between fear mongering and fact reporting. Whenever I watch press briefings, I feel anxiety, confusion, and sadness because the questions that I care about aren't being focused on or even asked. I tend to stick with reading the Associated Press, publicly funded journalist organizations, and the daily briefings of Dr. Fauci and Dr. Briggs. The fact that they didn't sugarcoat things or mislead gave me comfort and hope that there are competent people working towards figuring this virus out and doing the best we can to save lives and prevent lifelong complications from getting COVID-19. However, this can only go so far. I think liver disease patients need a very trusted and reliable source of information regarding their liver health and how it relates to this pandemic and their lives in general. They need to have specific fears and questions answered in a way that they can understand. I think if patients have a candid and communicative relationship with their liver doctors, this can be enough. However, all patients don't have that, or perhaps all patients don't have the ability to see their liver doctor as much as I do. The Hepatitis B Foundation and other groups like it have been a source of relevant information regarding this. Paul Desmond from the Hepatitis B Facebook group is able to break down information that is digestible to any Hep B patient, regardless of how learned they are. That is a valuable resource for many of us around the world. This pandemic is many things to me. It's terrible, heartbreaking, and scary to name a few. But it's also an opportunity for consistent empathy for my past health choices and others. Instead of focusing negatively on Hep B and how my life relates to it, I think of all the recent choices I've made to better my health, and that makes me happy. I especially want to thank the American Association for the Study of Liver Disease for their amazing work in the field and with helping patients like me find their voice. And most importantly, I remember that I'm not alone. Good morning and welcome to this session in which I will try to provide for you an overview on the prognosis and risk factors in COVID-19. My name is Elizabeth Verna, and I'm from Columbia University in New York. These are my disclosures. So what is coronavirus? Coronaviruses are actually a family of viruses that usually cause the common simple cold. So these are viruses that we have all been exposed to many times throughout our lives. However, when new strands of the virus emerge, sometimes they can cause more severe diseases, and this has happened several times in the past. But this new coronavirus is called the Severe Acute Respiratory Syndrome 2 virus, or SARS-CoV-2. And this is the virus that causes the coronavirus disease 19, or COVID-19. And as you can see here, COVID-19 continues to be a challenge throughout the United States. Unfortunately, as of October 15th, we've had over 7 million cases in the United States diagnosed and over 216,000 people have died. And while this map shows the overall number of people that were diagnosed with the virus in different states, as you can see when you look at maps that just show the last seven days, this virus has spread across the country and continues to come and go in different areas. And you can see here, these are projections that are made by mathematical models from a number of different expert groups around the country to see if they can predict what will happen in terms of the number of deaths or the number of new cases related to COVID-19 in the weeks and months to come. And I just included this to show you that basically, even when experts in mathematical modeling and infectious disease and outbreaks get together to try to understand what the future holds, that there's obviously a lot of discrepancy about what we expect in the next weeks and months. So who is at risk of having severe COVID-19? There's a lot of information now throughout the world and also here in the United States about what the risk of dying from COVID-19 is if you're to contract the virus. So these are data displayed in a format where we're trying to understand what is the case fatality ratio, meaning if you are to contract the virus, how likely are you to die from it? And you can see here that in the United States, the case fatality ratio is almost 3%, meaning almost 3% of people in the United States that have had COVID-19 have died. We also express the amount of deaths from COVID-19 in a different way. So here we're looking at the number of deaths in terms of the total population of the country. So in the United States, so far we've had 66 deaths for every 100,000 people. And we trail behind only a small number of countries in terms of this measure. So who is at risk of getting severe COVID-19? And as you can see here, when you have other chronic medical problems, these medical problems may put you at risk of having a severe course if you do contract the virus. So for example, patients with high blood pressure have about three times the risk of being hospitalized because they have COVID-19 compared to people that don't have high blood pressure. The same with diabetes, four times higher risk of hospitalization in patients with chronic kidney disease. And another important thing to know is that the more of these chronic conditions you have, the higher your risk of being hospitalized is. So if you have three or more conditions, for example, high blood pressure, diabetes, and chronic kidney disease, you may be five times as likely to be hospitalized if you get COVID-19. Another important risk factor that has emerged is age. And as you can see here, we're looking both at hospitalization and also at the risk of death if you contract the virus. And when we compare to patients that are 18 to 29 years old, for example, people in their forties have a three times higher risk of being hospitalized and a 10 times higher risk of death. And while most of us don't think of people in their forties as being at advanced age, you can see that basically every decade that you increase in age, that there's an increasingly higher risk of being hospitalized and a much higher risk of dying from the disease. And finally, there has been very, very important work done to understand how race and ethnicity impact outcomes among patients that have COVID-19. So what you see here is compared to patients who are white and non-Hispanic, Native Americans, Black Americans, and Hispanic and Latino Americans have a much higher rate of acquiring COVID-19, of being hospitalized because of the disease, and ultimately dying from the disease. And there's probably lots of reasons for this, but this is clearly something that we need to focus on in our public health initiatives. This is just another way to show you a similar information. So this is when, even when you take into account and adjust for age, there's a big difference in the risk of being hospitalized when you have COVID-19 that is based upon race and ethnicity. So you can see here, if there are 80 people that are hospitalized per 100,000 population among patients that are non-Hispanic and white, there's a many fold higher risk of being hospitalized for Native Americans, for Latino and Hispanic Americans, and for Black Americans. So how can we prevent the spread of COVID-19? This is really the $64,000 question I would say right now, is how do we balance getting back to our daily life, going back to work, going back to school, having more social interactions, with really the safety of ourselves, our loved ones, and our community. So one really important thing that everybody should do is to really understand what is going on in their own community. So I showed you maps before where we looked at how much COVID-19 was diagnosed in each state, but that probably is really not enough to understand what is going on in your own local community. So my advice is to look for local, state, and even county websites where you can actually track how many new cases are diagnosed in your local area so that you can adjust your behaviors accordingly. It's important to know that the main way that people can track the virus is through what we call the mucous membranes, meaning the mouth, the nose, and the eyes. If those surfaces are coming in contact with the virus, that's really the most likely way for the virus to enter your body. So it's very important to avoid crowded situations, close physical contact in closed spaces, and another major risk factor is the duration of exposure. So the longer that you're in a closed space or in close physical contact with somebody with the virus, the more likely it is that you're going to contract it. So how can you protect yourself from this? So there's lots of ways to do this. Obviously avoid touching your eyes and nose and mouth, especially when you're in public spaces before you've been able to sanitize your hands. Frequent hand washing is incredibly important. Social distancing with at least six feet between you and everybody else, especially when you're indoors, is really important. Cover your coughs and sneezes. Make sure you wear a mask really at all times. Clean and disinfect surfaces. Monitor yourself and your loved one for symptoms. And again, I just want to hammer hone how important wearing a mask is. And this is one example of how masks can really help. So this was a report of two hairstylists who were diagnosed with COVID-19. And when they tried to do some contact tracing after they were diagnosed, they realized that these two hairstylists had spent at least 15 minutes in contact with 139 clients, but every one wore face masks, including the hairstylist and all the clients, and in fact, not one of these 139 people ended up contracting the virus. So this is just one example. There's many other examples and also lots of scientific data out there about mask wearing, and I can't stress enough how important that is. How else can you minimize the risks? Well, again, we're trying to balance getting back to our lives and making sure we're taking care of our own livelihood, but also remaining safe. So these are some considerations in specific situations. So what about going back to work? Is it an option to work from home or even work from home part time? For many people, that is not an option. And if not, it's important to know what safeguards are in place in your workplace. Wear a mask at all times. I would hope that your coworkers wear masks as well. Make sure, again, you're practicing hand hygiene, social distancing in the workplace. Think about safe places to eat where you're going to get your food, whether you're going to be around people while you're eating because you'll have your mask off, and make sure there's a plan for disinfecting and also for managing infected workers in your workspace. What about meeting loved ones and friends in person? Try to stay outside. This is obviously going to get more difficult in parts of the country as the fall and the winter comes, but think about warm clothing, outdoor heaters, and really maintain social distancing as much as possible. Understand the risk of family gatherings, emphasize trusted small circles, and try to interface online and in other creative ways rather than meeting indoors. What about travel? I think that's one thing that many of us miss. We miss loved ones that are also far away, but when you're planning for travel, you really have to ask yourself, is this travel really necessary? What are the local risks at your destination? This is another thing that you can look up online for state and county websites for your destination as well as where you are now. How are you going to get there? Do you have to take public transportation? Are you able to travel in your own car? Are you going to have accommodations there for an overnight stay? Will you have to make accommodations also to eat? And will quarantining be necessary either when you arrive or when you come back to back home? And finally, something on everyone's mind these days is what about voting? So one thing to consider where you are is whether mail-in voting is possible. By the time you watch this recording, you know, voting will have taken place. But this is something on everyone's mind right now and something we may have to think about going into the year to come. For in-person voting, is early voting possible? Think about the least crowded times if possible. Wear a mask, bring hand sanitizer and a black pen, and social distance when possible. So how are we going to move forward and actually be able to really get back to our lives? Well, I think a lot of us are placing a lot of hope in having a vaccine relatively soon that will start to allow us to open up again. There are multiple vaccines that are in clinical trials right now. It's important to realize that these trials are probably not going to include immunosuppressed patients at the beginning, including transplant recipients. When the vaccines become available, supply will really dictate who has access to them. And there are still a lot of unknowns, including how likely the response really is and whether the response to the vaccine is going to last for a long period of time, whether there are any risks associated with the vaccine, how many people around you are going to actually agree to take the vaccine, and whether we will actually reach herd immunity. But again, it seems as though vaccines are being produced and tested at really record paces, and I think many people are hopeful that sometime next year this will start to come to our community. So here are some key takeaways from what I talked about today. COVID-19 continues to spread throughout the United States and around the world. Advanced age, other medical problems like diabetes, hypertension, and kidney disease can increase the risk of severe disease that requires hospitalization or leads to death. And there are many, many resources online for patients to learn more about how to make sure that they take the steps needed to minimize their own risk. And I've just provided some examples of these websites here, including from the CDC. We have our own ASLD website that also has some patient information posted on it. There's information on the World Health Organization website. And don't forget about your own state and local departments of health. Thank you for attention, and I hope you have a wonderful meeting. Greetings. My name is Ryan Kwok. Today I'll be talking to you about the interaction between COVID-19 and the liver. I have nothing to disclose. As you may have just heard from the excellent talk from Dr. Verma, we know that there is a complex interplay between the coronavirus and many organ systems in the body. As I think most of us know by now, the virus primarily infects the lungs, causing inflammation and difficulty with breathing. However, we also know that the virus can directly impact the cells of the liver. Secondarily, inflammation in the lung can lead to decreased oxygenation, which can cause problems in the liver itself. Furthermore, this inflammation in the lungs can also lead to increased strain in the heart, which can then cause problems with the blood perfusion to the liver. Finally, we know that there are many, many drugs that are being used in the treatment of the virus and patients infected with it, and these drugs in and of themselves can cause inflammation or injury to the liver. We know that patients with chronic liver disease who are infected with COVID-19 tend to have more severe outcomes. In this study of over 2,700 American-based patients infected with COVID-19, approximately 10% of those that were studied were found to have pre-existing liver disease. Most common among them were NAFLD and NASH, which we will talk about shortly. Of these patients, 50, or near 2%, had cirrhosis. When compared to patients without chronic liver disease, those with pre-existing liver diseases were found to have a three times higher death rate, and those with cirrhosis were found to have an over four and a half times higher death rate. As you can tell, we take this infection very seriously in our patients. Just some overarching principles I'd like to offer as we navigate our way through this talk. First, all recommendations that you hear in this talk should be held in adherence with local public health and local health system guidance. We know that though there are promising treatments for the virus, there is no better way to manage your liver's health than preventing the problem at all. This comes through strict adherence to hand hygiene, PPE through things like mask wearing, and adherence to social distancing guidelines. We recommend discussing any possible changes to your care plan with the team that takes care of your liver. And we at AASLD are committed to you as patients and have developed patient focused resources, which can be found at Let's talk about some primary liver diseases. First, viral hepatitis, most commonly marked by hepatitis B and hepatitis C. Thankfully, we have no convincing evidence at this point that patients with these infections without advanced fibrosis or cirrhosis are any higher risk of contracting the virus or having a more severe course when infected with COVID-19. Questions have been put forward about whether or not we should start treating or treating patients with hepatitis B or hepatitis C in the era of COVID. We believe that treatment and initiation of medications for these viruses in COVID negative patients may be a reasonable thing to do, as discussed with and decided by your treatment team. It may be reasonable to start hepatitis B medications in COVID positive patients in certain circumstances, and these things would be decided upon by your treatment team. However, in patients with COVID, we would likely defer initiation of hepatitis C medications until the virus has been cleared. Overall, I strongly recommend against stopping any medicines that are being used to treat hepatitis B or C without prior consultation, as abrupt stopping or inappropriate stopping may have significant consequences to your health. Autoimmune hepatitis is a disease that is controlled with immunosuppressive medications, and thankfully, studies to date have showed that immunosuppressed patients, such as those with autoimmune hepatitis, do not seem to be at any increased risk for severe complications of COVID-19. So one may ask, what should be done then with the immunosuppressive medications used to treat autoimmune hepatitis? As with viral hepatitis, we would recommend against stopping or reducing the medications without first consulting your hepatology care team. Stopping could lead to flares of the autoimmune hepatitis, which can be dangerous and even fatal in some circumstances, and ultimately may lead to increases in immunosuppression to get the flare under control. This increase in immunosuppression could then increase your risk for having complications related or a more severe course related to COVID. If you or a loved one is struggling with alcoholic liver disease, we know that alcohol, even prior to the time of COVID, may serve to suppress the immune system. Overall, this may lead to increased susceptibility to severe respiratory complications associated with the infection. Furthermore, we know the results of social isolation through quarantining and social distancing may be associated with increased alcohol consumption. There is emerging and quite strong anecdotal evidence of increased admissions for alcohol-related liver disease in transplant centers across the country. It's been asked, if I have alcoholic liver disease, how much alcohol can I drink while I'm in quarantine? To which we would recommend the complete avoidance or, at very most, the absolute minimization of any alcohol intake. Certainly avoid intoxication in times of quarantine. There is one myth that I'd like to address and dispel in this setting. Upon my research, I discovered that there are some rumors that alcohol, ethanol being the form that is ingested through alcoholic beverages, is protective against COVID-19. This is absolutely not true and there are no evidence or data to show that alcohol is protective against COVID-19 virus infection. For patients with non-alcoholic fatty liver disease and its sub-disease, non-alcoholic steatohepatitis, NAFLD, and NASH, studies have been conducted which compare patients with these diseases to those without. Unfortunately, patients with NAFLD and NASH appear to have more severe liver injury, are at a higher risk for hospitalization, and may have a more severe course with COVID-19 infections. Similarly, some of the diseases that are associated with NAFLD and NASH are associated with worst outcomes when infected. These include patients with high blood pressure, high cholesterol, diabetes, and obesity. So you may be asking, how can you maintain optimal liver health for you or your loved ones who have NAFLD or NASH during the pandemic? Well, the first thing would be to control the diseases that we discussed above there through continuing of medication to control the risk factors. Continue to practice healthy lifestyle behaviors to include regular exercise, consideration, initiation, or continuation of a healthy diet such as the Mediterranean diet, and again, limitation or elimination of alcohol. So let's shift gears here a little bit. We know that there is an interplay between patients with cirrhosis and COVID-19. I'll point your attention to the right-hand column. In patients with cirrhosis who are infected with COVID-19, unfortunately, there's an increased risk for decompensations to include bleeding from the intestinal tract, jaundice, ascites, or fluid on the belly, and encephalopathy, which is marked by confusion or sleep disruptions. Additionally, we know as a result of social distancing and isolation that patients with cirrhosis are also undergoing less frequent surveillance for things like varices or cancers of the liver. Moving our attention to the left column, we know that patients who are diagnosed with and infected with COVID-19 are, one, at increased risk for infection, period, and two, when they are infected, may experience a more severe course with, in some cases, increased mortality associated with these infections, which begs us to ask what we should do about our routine appointments in terms of trying to minimize our exposure to the health care system and thus the risk of infections. Specifically related to blood work and other labs, I would recommend consideration of deferring non-urgent labs, again, in conjunction with your hepatology treatment team. Cancer screening, which is most commonly done with modalities such as ultrasound or MRI, should also be discussed with your treatment team, and it may be reasonable to defer these modalities for up to two months. After that time, it may be worthwhile to continue that conversation with your care team and take into consideration your local prevalence and guidance and resume those surveillance studies. If you are infected with COVID-19, I would recommend avoidance of these studies, as this may increase the risk of exposure to other health care workers or other patients who are utilizing the facilities. Similarly, endoscopy carries a theoretical risk for airborne transmission to other patients and health care workers. As such, it is worthwhile to have a conversation with your treatment team about alternate modalities for assessment or treatment of varices. Specifically, there are certain blood tests and non-invasive testing, such as the FibroScan test, and treatments can be undertaken with medicines instead of through endoscopy, as is often done. Poticellular carcinoma is the most common primary liver cancer, most commonly found in patients with cirrhosis. Unfortunately, we know that patients with any form of cancer, including those with primary liver cancers, may be at increased risk of infection and a more severe course if infected. As such, again, we recommend limitation of health care facility visits. If you are on treatment for your liver cancer through things like TACE or Y90, also called local regional therapies, I'd recommend discussion of the timing and use of these modalities with your treatment team, as these things may be impacted by the pandemic. If you're on systemic therapies, such as serafinib or nivolumab, those dosing regimen to include timing and doses may be modified and should be discussed with your team. A couple words about our pediatric colleagues and patients. Thankfully, we know that overall pediatric patients with COVID-19 rarely have severe liver injury. Among all US cases, patients less than 18 year olds make up less than 2% of the cases, and overall, the liver injury is mild to moderate. However, it should be known that COVID-19 is implicated in the so-called pediatric multisystem inflammatory syndrome, which is marked by fevers and other organ inflammation. Thankfully, liver injury in these cases is mild and for recovery is the most common course. I would point your attention to an excellent resource for additional pediatric considerations in this webinar that was given by several societies several months ago. It can be found at this website. If you're a patient or have a loved one who is listed for a liver transplant, we know that unfortunately patients who are listed, specifically those with cirrhosis or some chronic liver diseases, do appear to have increased risk for liver-related and even fatal complications. Thankfully, there are some encouraging data in liver transplant. These are data published by UNOS, and you can see on the left side of the graph there the early weeks of the year when compared to this fall, and you'll see that numbers of transplants are approximately the same as they were prior to the shutdown related to the pandemic. There are some special considerations for our patients who are listed for and awaiting liver transplantation during this pandemic, specifically consideration for alternate ways for ongoing evaluations with your liver transplant team through modalities such as telemedicine versus coming in and having face-to-face appointments. I would recommend you inform your transplant team if you have any symptoms concerning for COVID-19 or if in fact you're infected, as this may impact your waitlist status. As you can see from the graph, waitlist times may be impacted as a result of the virus's effects on the health care system. How about if you received a liver transplant or a loved one has received a liver transplant? As we mentioned with autoimmune hepatitis, thankfully immunosuppressed patients do not seem to be at increased risk for severe complications of COVID-19. Furthermore, transplant recipients who are infected do not appear to have a more severe course when compared to those who have not received a transplant. Again, there are some special considerations to include clear communication with your treatment team regarding your immunosuppression and how that should be managed, particularly if you have concern for COVID-19 infection. Again, do not change immunosuppression dosing or regimen without first consulting with your treatment team. So in closing, just a few key takeaways. We know that COVID-19 has had unprecedented impacts on the care of chronic liver disease patients, but thankfully knowledge and experience are rapidly evolving. Once again, regular and frequent communication with your hepatology care team is essential, and they should be notified if you suspect you've been exposed or if you have in fact contracted the virus. Once again, do not make any changes to your medications or treatment plan without prior consultation. Prevention is the best defense for the health of your liver. Please adhere to social distancing guidelines and appropriate PPE. And last, please, please, please practice care of yourselves. This is a very stressful time, and we know that this is difficult for our whole society, but particularly our patients with chronic liver disease. We encourage you to care for yourself emotionally and spiritually and physically through regular exercise, healthy eating habits, and minimization or even elimination of all alcohol and tobacco. Overall, we want the best for you and your loved ones. Thank you very much. I'd like to acknowledge the members of the subcommittees listed here as they have made this talk possible. First of all, I would like to thank all of you for attending this program. We hope that you found it educational and meeting the special needs of people with liver disease facing the COVID-19 pandemic. I certainly want to thank our three speakers today, David Urick, Betsy Verna, Ryan Ryan Kwok. I thought they all did a fabulous job. I've been an ASLD member for almost 40 years now and have been on the AASLD governing board for the past three years. I don't know I've ever been more proud of our society as I have been in their response to the COVID-19 pandemic. Shortly after it became apparent that the United States was facing rapidly increasing infections with the SARS-CoV-2 virus, almost immediately a number of AASLD members formed an ad hoc group to begin assembling and disseminating information regarding COVID-19 and liver disease. This led to the establishment of the AASLD COVID-19 task force which is led by Ray Chung and Raj Reddy. It was truly amazing how quickly the task force came together and four subcommittees were formed to do the bulk of the work. This included a research committee, an education and outreach committee, a clinical oversight committee, and the patient engagement and advocacy committee which is chaired by Karen Hoyt and me. It was this committee which felt that developing a patient-oriented program regarding COVID-19 and the liver would be valuable to patients with liver disease. I hope you all agree that our program met this goal. In addition, I want to reemphasize what Ryan Kwok said in his talk that AASLD has developed a series of patient-facing documents to specifically address COVID-19 in specific liver diseases. The link is shown here. I will leave this up for a bit so you can copy down the link. The diseases we have developed for patient-facing documents include those with viral hepatitis, non-alcoholic fatty liver disease, hepatocellular carcinoma, cirrhosis, pediatric liver diseases, autoimmune liver diseases, liver transplant recipients, and alcoholic liver disease. I also want to acknowledge the other members of the patient engagement and advocacy committee who put so much work into this program and in developing these documents. As I mentioned, the committee was chaired by Karen Hoyt and me. The other members included Ryan Kwok, Emily Prieto, Doug Labreck, and Tamar Tadai. I can't thank the members of the committee enough for all their dedication and efforts. Julie Diehl was our staff liaison and I can't say enough about her efforts. She was clearly the one who kept us on task and allowed us to accomplish our goals. One of the aims of the strategic plan recently developed by the ASLD governing board is patient engagement. This program is one step towards accomplishing that strategic aim. In talking with staff, we believe that this was perhaps the first program at the liver meeting specifically targeted to patients and David may have been the first patient to actually present at the liver meeting. Again, I want to thank all of our speakers today. I also want to thank you, the audience, for participating in this program. I hope that you have had or will have the opportunity to attend some of the Meet the Expert programs which have been developed in conjunction with this program. Be well and stay safe.

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