Impact of Chronic Liver Disease on Outcomes of Hospitalized Patients With COVID-19

A Multicentre United States Experience

Nikroo Hashemi; Kathleen Viveiros; Walker D. Redd; Joyce C. Zhou; Thomas R. McCarty; Ahmad N. Bazarbashi; Kelly E. Hathorn; Danny Wong; Cheikh Njie; Lin Shen; Walter W. Chan


Liver International. 2020;40(10):2515-2521. 

In This Article

Abstract and Introduction


Liver injury has been described with COVID-19, and early reports suggested 2%-11% of patients had chronic liver disease (CLD). In this multicentre retrospective study, we evaluated hospitalized adults with laboratory-confirmed COVID-19 and the impact of CLD on relevant clinical outcomes. Of 363 patients included, 19% had CLD, including 15.2% with NAFLD. Patients with CLD had longer length of stay. After controlling for age, gender, obesity, cardiac diseases, hypertension, hyperlipidaemia, diabetes and pulmonary disorders, CLD and NAFLD were independently associated with ICU admission ([aOR 1.77, 95% CI 1.03–3.04] and [aOR 2.30, 95% CI 1.27–4.17]) and mechanical ventilation ([aOR 2.08, 95% CI 1.20–3.60] and [aOR 2.15, 95% CI 1.18–3.91]). Presence of cirrhosis was an independent predictor of mortality (aOR 12.5, 95% CI 2.16–72.5). Overall, nearly one-fifth of hospitalized COVID-19 patients had CLD, which was associated with more critical illness. Future studies are needed to identify interventions to improve clinical outcomes.


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first emerged in the fall of 2019 and has since become a global pandemic. This virus, which causes coronavirus disease 2019 (COVID-19), has led to over 4.8 million infections and 316,000 deaths worldwide to date.[1] Prior studies have demonstrated advanced age, chronic cardiopulmonary diseases, immunosuppression and obesity as potential risk factors for worse clinical outcomes among patients with COVID-19 – with mortality often driven by disease-associated cardiopulmonary failure.[2,3] While the virus primarily affects the lungs, experience from China and the USA also suggests that SARS-CoV-2 may impact extra-pulmonary systems, including the gastrointestinal and hepatobiliary systems.[4,5]

Chronic liver disease (CLD), including non-alcoholic fatty liver disease (NAFLD), alcohol-related liver disease and chronic viral hepatitis, comprise a large global burden of disease.[6] Published reports indicate that up to half of adults hospitalized with COVID-19 have abnormal aminotransferase levels and 2%-11% have underlying liver conditions.[7–12] A meta-analysis of 11 observational studies of 2034 adults with COVID-19 from China revealed an overall CLD prevalence of 3%.[13] However, there are limited reports on the nature of liver disease among COVID-19 patients and it remains unclear how underlying CLD influences hepatic injury and clinical outcomes in these patients. Higher rates of liver dysfunction have been observed in patients with more severe cases of COVID-19 and among those requiring admission to the intensive care unit (ICU).[12,14] Given the high prevalence of NAFLD in the USA, as well as metabolic syndrome and obesity being potential poor prognostic factors for COVID-19, we hypothesized that CLD, particularly NAFLD, may be associated with more severe clinical course and worse outcomes among patients with COVID-19. We therefore aimed to describe the characteristics of CLD and study the effect of existing liver-related comorbidities on the manifestations and outcomes of hospitalized adult patients with COVID-19.