We thank Dr. Duan for the interest in our paper that reported the association between postvaccination and overall and coronavirus disease 2019 (COVID-19)–related mortality among participants with cirrhosis. We adjusted for the etiology of alcohol-associated liver disease versus others based on studies that showed a worse prognosis of COVID-19 associated with alcohol.^[1-4] However, as suggested, we now include the various etiologies of liver disease in the baseline characteristics (Table S1). The most common cause of cirrhosis in both the postvaccination and unvaccinated COVID-19 cohorts was NAFLD (28.7% and 28.2%, respectively), and the two groups were well matched with respect to liver disease etiology. We agree that exposure to proton pump inhibitors (PPIs) may be a potential confounder. Participants with postvaccination COVID-19 were more likely to be exposed to PPIs than those with unvaccinated COVID-19 (80.3 vs. 65.8%; p < 0.0001). Third, Dr. Duan suggests socioeconomic status as a potential confounder. Although we did not have data on individual income levels, we examined the socioeconomic status by identifying participant locations using residential zip codes and the median household income associated with these locations. Median household incomes were similar between the two groups ($47,400 vs. 47,100; p = 0.64).

We repeated the analysis by including these three variables in the multivariable model (Table 1). Compared with NAFLD cirrhosis, alcohol and HCV cirrhosis were not associated with an increase in overall or COVID-19-related death. We observed no association between the median household income and overall (per $1000 change in household income; adjusted HR [aHR] 0.98, 95% CI 0.93–1.07; p = 0.16) or COVID-19-related death (aHR 0.99, 95% CI 0.97–1.03; p = 0.11). However, PPI exposure was associated with an increase in overall mortality (aHR 1.61, 95% CI 1.06–2.15; p = 0.001), but not COVID-19-related death (aHR 1.08, 95% CI 0.55–1.54; p = 0.75). After inclusion of these variables, postvaccination COVID-19 continued to be associated with a decrease in overall (aHR 0.25, 95% CI 0.12–0.49; p < 0.0001) and COVID-19-related death (aHR 0.27, 95% CI 0.13–0.60; p = 0.001).

These analyses reveal similar associations described in our original estimates, indicating that postvaccination COVID-19 is associated with consistent reductions in overall and COVID-19-related death.

我们感谢段博士对我们的论文感兴趣，该论文报告了肝硬化参与者中疫苗接种后与 2019 年冠状病毒病 (COVID-19) 相关死亡率之间的关联。根据显示与酒精相关的 COVID-19 预后较差的研究，我们对酒精相关性肝病的病因学与其他疾病的病因学进行了调整。 ^{[ 1-4 ]}然而，正如所建议的，我们现在将肝病的各种病因纳入基线特征中（表 S1）。在接种疫苗后和未接种疫苗的 COVID-19 队列中，最常见的肝硬化原因是 NAFLD（分别为 28.7% 和 28.2%），并且两组在肝病病因方面非常匹配。我们同意接触质子泵抑制剂（PPI）可能是一个潜在的混杂因素。接种了 COVID-19 疫苗后的参与者比未接种疫苗的 COVID-19 参与者更有可能接触 PPI（80.3% vs. 65.8%； p < 0.0001）。第三，段博士认为社会经济地位是一个潜在的混杂因素。尽管我们没有个人收入水平的数据，但我们通过使用住宅邮政编码和与这些地点相关的家庭收入中位数来确定参与者的位置来检查社会经济状况。两组的家庭收入中位数相似（47,400 美元 vs. 47,100 美元； p = 0.64）。

我们通过将这三个变量包含在多变量模型中来重复分析（表 1）。与 NAFLD 肝硬化相比，酒精和 HCV 肝硬化与总体死亡或 COVID-19 相关死亡的增加无关。我们观察到家庭收入中位数与总体收入（家庭收入每变化 1000 美元；调整后 HR [aHR] 0.98，95% CI 0.93–1.07； p = 0.16）或与 COVID-19 相关的死亡（aHR 0.99，95%）之间没有关联。 CI 0.97–1.03； p = 0.11）。然而，PPI 暴露与总死亡率增加相关（aHR 1.61，95% CI 1.06-2.15； p = 0.001），但与 COVID-19 相关死亡无关（aHR 1.08，95% CI 0.55-1.54； p = 0.75） ）。纳入这些变量后，接种后 COVID-19 继续与总体死亡率（aHR 0.25，95% CI 0.12-0.49； p < 0.0001）和 COVID-19 相关死亡（aHR 0.27，95% CI 0.13-）的下降相关。 0.60； p = 0.001）。

这些分析揭示了我们最初估计中描述的类似关联，表明接种疫苗后 COVID-19 与总体死亡人数和与 COVID-19 相关的死亡人数持续减少有关。