SARS-CoV-2 Infection in Patients With a Normal or Abnormal Liver

Giuseppe Cabibbo; Giacomo Emanuele Maria Rizzo; Caterina Stornello; Antonio Craxì


J Viral Hepat. 2020;28(1):4-11. 

In This Article

Abstract and Introduction


Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a novel coronavirus causing coronavirus disease 19 (COVID-19), with an estimated 22 million people infected worldwide so far although involving primarily the respiratory tract, has a remarkable tropism for the liver and the biliary tract. Patients with SARS-CoV-2 infection and no antecedent liver disease may display evidence of cytolytic liver damage, proportional to the severity of COVID-19 but rarely of clinical significance. The mechanism of hepatocellular injury is unclear and possibly multifactorial. The clinical impact of SARS-CoV-2 infection in patients with underlying chronic liver disease, a cohort whose global size is difficult to estimate, has been assessed appropriately only recently and data are still evolving. Patients with cirrhosis are at higher risk of developing severe COVID-19 and worse liver-related outcomes as compared to those with non-cirrhotic liver disease. OLT patients have an intermediate risk. Specific interventions in order to reduce the risk of transmission of infection among this high-risk population have been outlined by international societies, together with recommendations for modified treatment and follow-up regimens during the COVID-19 pandemic. When a vaccine against SARS-CoV-2 becomes available, patients with fibrotic liver disease and those with OLT should be considered as prime targets for prophylaxis of COVID-19, as all other highly susceptible subjects.


Since the first evidence of its transmissibility and infectivity, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and coronavirus disease 2019 (COVID-19)[1] have been an international health concern, so much that the World Health Organization (WHO) declared public health emergency and pandemic status on March 2020. As of 20 August 2020, around 22,500,000 cases worldwide have been reported according to the Center for Systems Science and Engineering (CSSE) at John Hopkins University, mostly in United States, Brazil and Russia, causing totally around 800,000 deaths.[2] In order to track seroprevalence estimates, it has also been developed a custom-built dashboard, which systematically monitors and synthesizes findings from hundreds of global SARS-CoV-2 serological studies.[3] A growing number of patients with COVID-19 continue to succumb worldwide, mostly due to respiratory complications but also showing impairment of other organ systems, including the liver.

During the early phase of the pandemic, most case series reporting liver damage did not make a clear distinction between subjects infected by SARS-CoV-2 and a previously normal liver and those in whom the infection occurred in the setting of a pre-existing liver disease. Even less information was available on the stage of liver disease (ie non-fibrotic vs fibrotic: compensated vs decompensated), which may be of major importance since patients with cirrhosis are often fragile and may be immunocompromised. In fact, infections of all types are the major determinant of acute-on-chronic liver failure (ACLF), a leading cause of mortality in cirrhosis.[4] When facing patients with COVID-19 who have liver disease, clinicians may have problems both in terms of choosing the putative treatment for COVID-19 and of managing the higher risk of hepatic decompensation.

We shall review from a clinical perspective some practice points relevant for the hepatologist caring for COVID-19 patients: (1) Is the liver merely a bystander to severe COVID-19? (2) Are patients with liver disease at risk for a severe outcome of COVID-19? (3) How should we alter the management of liver patients during the pandemic?