Liver Injury Common With COVID-19

By Will Boggs MD

March 13, 2020

NEW YORK (Reuters Health) - As many as 54% of patients with COVID-19 develop liver enzyme abnormalities during disease progression, according to a brief review.

Liver impairment was reported in up to 60% of patients with Severe Acute Respiratory Syndrome (SARS) and in patients infected with the Middle East respiratory syndrome coronavirus, both of which share genome sequence similarity with SARS coronavirus 2 (SARS-CoV-2), which is responsible for COVID-19.

Dr. Fu-Sheng Wang and colleagues from National Clinical Research Center for Infectious Diseases, Beijing, China used data from seven case studies and from The Fifth Medical Center of PLS General Hospital, Beijing, China to evaluate how the liver is affected in COVID-19.

Overall, 2-11% of patients with COVID-19 had liver abnormalities, and 14-53% of COVID-19 cases had abnormal levels of alanine aminotransferase and aspartate aminotransferase during disease progression.

Patients with severe COVID-19 appeared to have higher rates of liver dysfunction, and symptomatic patients were more likely to have elevated liver enzymes compared with patients with subclinical disease, according to the online report in The Lancet Gastroenterology and Hepatology.

Gamma-glutamyl transferase, a diagnostic biomarker for cholangiocyte injury, was elevated in 54% of COVID-19 patients hospitalized at Fifth Medical Center, whereas only one patient (1.8%) had elevated alkaline phosphatase levels.

Elsewhere, pathological analysis of liver tissue from a patient who died from COVID-19 did not find viral inclusions in the liver.

Chronic liver disease affects about 300 million people in China, but so far the interaction between existing liver disease and COVID-19 has not been studied.

"Considering their immunocompromised status, more intensive surveillance or individually tailored therapeutic approaches is needed for severe patients with COVID-19 with pre-existing conditions such as advanced liver disease, especially in older patients with other comorbidities," the authors conclude. "Further research should focus on the causes of liver injury in COVID-19 and the effect of existing liver-related comorbidities on treatment and outcome of COVID-19."

Dr. Hongcui Cao from The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China, who recently reported the clinical characteristics of imported cases of COVID-19 in Jiangsu province, told Reuters Health by email, "This comment article presented a novel idea that hepatocytes and cholangiocytes might be potential targets during SARS-CoV-2 infection, as angiotensin-converting enzyme 2 (ACE2), which serves as the viral receptor, is detected (even though at low levels) in endothelial cells, occasional bile ducts, and perivenular hepatocytes in healthy livers."

"Meanwhile, previous researchers have stated that chronic liver injury in rats and humans upregulates ACE2," she said. "Combining this evidence, patients with pre-existing liver conditions might be more susceptible to SARS-CoV-2."

"Patients with pre-existing liver dysfunctions should be more carefully monitored and be given liver protective drugs when needed," Dr. Cao said. "For patients with severe liver damage, artificial liver blood purification system is recommended. This system is capable of removing inflammatory mediators and blocking cytokine storm that are potentially hazardous to liver and other organs, and simultaneously balances the electrolyte and acid-base level of body fluid. This system has previously shown improved therapeutic efficacy for treating SARS patients."

Dr. Wang did not respond to a request for comments.

SOURCE: The Lancet Gastroenterology and Hepatology, online March 4, 2020.