COVID-19 and the Liver: A 2021 Update

Catherine W. Spearman; Alessio Aghemo; Luca Valenti; Mark W. Sonderup


Liver International. 2021;41(9):1988-1998. 

In This Article


SARS-CoV-2, which is responsible for COVID-19, has resulted in significant morbidity and mortality not only from pneumonia and complicating ARDS but also as a result of many extrapulmonary manifestations. Liver injury due to SARS-CoV-2 is most likely multifactorial involving direct viral cytopathic liver injury, immune-mediated injury, complications of COVID-19 including hypoxia/ischaemia and micro/macrovascular thromboses and drug-induced liver injury. The main risk factors for adverse outcomes in individuals with CLD and COVID-19 are increasing age, advanced stage of liver disease and ArLD. Although about a quarter of patients with CLD and COVID-19 have no respiratory symptoms, the majority of patients die as a result of respiratory complications. Cirrhotic patients with COVID-19 are at increased risk of decompensation, and cirrhotic patients presenting with decompensation must be screened for SARS-CoV-2. International registry data suggest that liver transplantation is not independently associated with mortality but increasing age and comorbidities are. Whilst limiting in-person visits to clinics and hospital are important in the height of the pandemic to limit nosocomial infections, it is essential to ensure an adequate supply of medications and access to telephonic/videoconsultation advice. The long-term effects of missed diagnoses, follow-ups and postponed HCC surveillance will need to be strategized and addressed. Hepatology services including liver transplantation need to be actively resumed to prevent further detrimental outcomes for patients with both acute and CLDs. The understanding around the pathophysiology of COVID-19 and recommendations around best management practices is rapidly expanding, and this requires constant re-evaluation of the appropriate approach to the optimal care of our patients during the ongoing COVID-19 pandemic.