I review the link between COVID-19 and the liver in this blog.
SARS-CoV-2 is a novel coronavirus, like the viruses SARS-CoV and MERS-CoV, which caused the SARS outbreak in 2002-2003 and the MERS outbreak beginning in 2012.
Overall, up to half of patients admitted to the hospital for COVID-19 have elevations in liver tests. Up to 50% of patients with COVID-19 have elevated liver enzymes, primarily elevated serum AST and ALT which are typically between 1-2 times the upper limit of normal. Liver injury occurs more commonly in severe COVID-19 cases than in mild cases.
A recent international study examined whether patients with chronic liver disease are at increased risk of complications with COVID-19. Patients with chronic liver disease have an increased risk of death even after considering other risk factors such as age, presence of obesity, diabetes, and high blood pressure (Journal of Hepatology, online May 21, 2020). Between March 25 and April 20, 2020, 152 patients were entered into an international registry, of whom 95% were hospitalized. Patients with cirrhosis had a 40% overall risk of death with the highest risk in those with decompensated or advanced liver disease compared to 12% risk of death among hospitalized patients with liver disease but without cirrhosis. However, several important factors must be considered in interpreting these results. It is likely that there was substantial “selection bias”, meaning that the population described in this study was much sicker than the average patient with liver disease. In addition, this report was compiled from patients already hospitalized due to COVID-19. For example, in a large database from the CDC, one-third of 7,162 patients with COVID-19 had an underlying disease but <1% had chronic liver disease as an underlying condition (MMWR Morb Mortal Wkly Rep 2020 April 3;69:382-386). This study is limited by likely incomplete information on liver disease diagnosis, so may have undercounted patients with liver disease.
Overall, we can conclude that underlying chronic liver disease, especially cirrhosis is associated with an increased risk of death in patients who are hospitalized with COVID-19.
What should patients with liver disease do to protect themselves from COVID-19?
Patients with chronic liver disease without cirrhosis, especially those with chronic hepatitis B or C, primary biliary cholangitis or primary sclerosing cholangitis do not appear to be more susceptible to SARS-Cov-2 ( Zhang c et al. Lancet Gastroenterol Hepatol 2020 March4. Doi:10.1016/S2468-1253(20)30057-1. [Epub ahead of print]. Patients who are on immunosuppressive therapy (patients with autoimmune hepatitis or post-liver transplant) and without COVID-19 should not have changes made to the current immunosuppressive therapy ( AASLD-COVID-19 Clinical Insights May 14). For patients who are on immunosuppressive therapy who have COVID-19 the management should be under the direction of the hepatologist and/or transplant center as appropriate.
Patients should practice social distancing according to recommended guidelines and use masks as appropriate. It may be wise to use gloves when in high-traffic areas, such as grocery stores, pharmacies etc. Those on chronic medications for hepatitis B, autoimmune hepatitis or primary biliary cholangitis should make sure that there are in communication with their hepatologist to make sure they do not run out of medications and ask if telemedicine visits are possible.
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