Liver Involvement Is Not Associated With Mortality: Results From a Large Cohort of SARS-CoV-2-positive Patients

Francesca Romana Ponziani; Fabio Del Zompo; Antonio Nesci; Francesco Santopaolo; Gianluca Ianiro; Maurizio Pompili; Antonio Gasbarrini


Aliment Pharmacol Ther. 2020;52(6):1060-1068. 

In This Article

Abstract and Introduction


Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is frequently associated with liver test abnormalities.

Aims: To describe the evolution of liver involvement during SARS-CoV-2 infection and its effect on clinical course and mortality.

Methods: Data of 515 SARS-CoV-2-positive patients were collected at baseline and during follow-up, last evaluation or death. Stratification based on need for hospitalisation, severe disease and admission to intensive care unit (ICU) was performed. The association between liver test abnormalities (baseline and peak values) and ICU admission or death was also explored.

Results: Liver test abnormalities were found in 161 (31.3%) patients. Aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma glutamyl transferase (GGT) were increased in 20.4%, 19% and 13.6% of patients, respectively. Baseline liver test abnormalities were associated with increased risk of ICU admission (OR 2.19 [95% CI 1.24–3.89], P = 0.007) but not with mortality (OR 0.84 [95% CI 0.49–1.41], P = 0.51). Alkaline phosphatase (ALP) peak values were correlated with risk of death (OR 1.007 [95% CI 1.002–1.01], P = 0.005) along with age, multiple comorbidities, acute respiratory distress syndrome, ICU admission and C-reactive protein. Alterations of liver tests worsened within 15 days of hospitalisation; however, in patients with the longest median follow-up, the prevalence of liver test alterations decreased over time, returning to around baseline levels.

Conclusions: In SARS-CoV-2-positive patients without pre-existing severe chronic liver disease, baseline liver test abnormalities are associated with the risk of ICU admission and tend to normalise over time. The ALP peak value may be predictive of a worse prognosis.


On December 31, 2019, Chinese authorities reported a group of pneumonia cases in Wuhan. A zoonotic infection was suspected, and a novel pathogenic human coronavirus (CoV) with a certain homology with respect to severe acute respiratory syndrome (SARS)-CoV and Middle East respiratory syndrome (MERS)-CoV was sequenced and identified as SARS-CoV-2.

The human-to-human transmission of SARS-CoV-2 was rapid, and due to the increase in the number of cases outside China, the World Health Organization (WHO) defined the infection as a pandemic on March 12, 2020. Italy was the second country to be hit after China, but Spain, Germany, France and other European countries, as well as the United States, are also facing heavy consequences of this pandemic.

During the past SARS outbreak, hepatic impairment was described in up to 60% of patients,[1] and was associated with elevation of serum transaminases, hypoproteinaemia and prolongation of prothrombin time.

Chinese data on patients with SARS-CoV-2 infection report a prevalence of abnormal liver test as high as 76.3%, while the prevalence in Western patients seems to be lower.[1–4] However, these studies report baseline or short-term follow-up evaluations. Therefore, the evolution of liver involvement, its correlation with patients' mortality or resolution of SARS-CoV-2 infection is still unknown.

In this paper, we report the experience of a tertiary care centre in Italy facing the emergency of the SARS-CoV-2 infection, describing the prevalence and the evolution of liver involvement over time and its impact on patients' clinical course and mortality.