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Cirrhosis raises the risk of liver injury in COVID-19 patients

Keith Alcorn
13 July 2020

People with cirrhosis, especially those with diabetes or obesity, are more likely to suffer significant liver injury after contracting SARS-CoV-2 than others with chronic liver disease, Asian liver specialists report in a multi-centre study published in the journal Hepatology International.

SARS-CoV-2 causes COVID-19 – severe respiratory illness that may progress to pneumonia and multi-organ disease. Liver injury caused by severe inflammation, restricted oxygen flow caused by pneumonia or medication used to treat COVID-19 has been reported in up to half of patients in some cohort studies, chiefly in the form of raised liver enzymes.

Although liver injury is transient in most people, it has been unclear if people with underlying liver disease are at greater risk of more severe liver injury after developing COVID-19.


decompensated cirrhosis

The later stage of cirrhosis, during which the liver cannot perform some vital functions and complications occur. See also ‘cirrhosis’ and ‘compensated cirrhosis’.

Investigators in 13 countries in the Asia-Pacific region collected data on COVID-19 outcomes in people with chronic liver disease, including predictors of mortality.

Patients were eligible for analysis if they had been admitted to hospital with symptoms of COVID-19 and had confirmation of infection by virological test. Outcomes were assessed up to 28 days after admission and data were gathered between January and the end of April 2020.

The APASL COVID-19 Liver Injury Spectrum study (APCOLIS) accumulated data on 185 people with chronic liver disease without cirrhosis and 43 people with cirrhosis.

In those without cirrhosis, the predominant cause of liver disease was metabolic-associated fatty liver disease (MAFLD) (61%) or viral hepatitis (23%).

In those with cirrhosis, the predominant cause was viral hepatitis (60%) or MAFLD (32%).

Approximately 80% of both groups had at least one underlying co-morbidity and the average age was 48 years in the cirrhosis group and 51 years in the non-cirrhosis group.

People with cirrhosis were significantly more likely to have new acute liver injury at admission (32% vs 20%) and during hospitalisation (39% vs 7%) (P < 0.001). Decompensation after admission was significantly more common in the cirrhosis group (7% vs 0%). They were also more likely to develop more severe liver-related complications (32% vs 14%, p = 0.007) and more likely to die from liver injury (16% vs 2%, p = 0.002).

People with cirrhosis were also more likely to experience severe COVID-19 complications such as acute kidney injury (18% vs 5%), respiratory failure (23% vs 8%) and hypotension (14% vs 3%) (all p < 0.001).

Severity of COVID-19 was associated with severity of cirrhosis. People with decompensated cirrhosis prior to admission (18 out of 43) were five times more likely to present with severe COVID-19 symptoms (severe pneumonia, acute respiratory distress syndrome, acute kidney, heart or circulatory failure) (odds ratio 5.5) and six times more likely to present with acute liver injury at admission (odds ratio 6.2).

In people with cirrhosis, liver injury was more frequent in those with diabetes and people who developed liver injury were more likely to die (7 of 43 people with cirrhosis died). Obese people with cirrhosis were almost nine times more likely to develop liver injury than cirrhotic patients of normal weight (OR 8.9).

In those without cirrhosis, liver injury was associated with diabetes (OR 2.06). Although liver injury was associated with a higher frequency of intensive care unit admission and liver-related complications, people without cirrhosis who experienced liver injury did not have a higher death rate and did not spend longer in hospital than those without liver injury.

Two patterns of liver injury were seen. In people with cirrhosis, liver injury was usually present at the time of admission and was characterised by high AST levels and rapid and worsening jaundice. The pattern suggests liver injury due to low oxygen levels (hypoxia, a result of severe pneumonia) or the effect of medication used to treat COVID-19, say the investigators. The pattern of liver injury seen in cirrhotic patients means that doctors should be careful in choosing drugs to treat COVID-19 in these patients, say the investigators.

In people without cirrhosis, liver injury tended to develop at the end of the second week or in the third week after admission and was characterised by high ALT levels, suggesting direct hepatocellular injury.


Sarin SK et al. Pre-existing liver disease is associated with poor outcome in patients with SARS CoV2 infection; the APCOLIS study (APASL COVID-19 Liver Injury Spectrum study). Hepatology International, 4 July 2020.