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

COVID-19 and Liver Transplantation

It is not clear whether liver transplant recipients are at increased risk of SARS-CoV-2 infection. Data from United Kingdom and Spain suggest that SARS-CoV-2 infections are more frequently diagnosed in liver transplant recipients than in the general population, but this might reflect regular monitoring and a lower threshold for testing in these patients.[87,88]

The combined SECURE-Cirrhosis and COVID-Hep registries, ELITA/ELTR Multi-centre European Study and the US multicentre COLD consortium have all reported similar outcomes for liver transplantation and COVID-19.[89–91] The overall mortality is around 20%-25%, and outcomes are determined by age and co-morbid conditions such as type 2 diabetes mellitus, obesity, renal impairment and extrahepatic malignancies.[88,90,92] COVID-19 lung disease is the main cause of death. Of interest, liver transplant recipients with COVID-19 appear to have a high frequency of gastrointestinal symptoms, particularly diarrhoea.[92]

The immune response is an important driver for pulmonary injury attributable to COVID-19, and immunosuppression may thus be protective. Corticosteroids improve survival in critically ill patients with COVID-19 requiring oxygen support. Tacrolimus has been associated with better survival in liver transplant recipients with COVID-19 [HR, 0.55; 95% CI, 0.31–0.99],[90] whereas mycophenolate mofetil (MMF) was an independent predictor of severe COVID-19 [RR = 3.94; 95% CI 1.59–9.74; P = .003], especially doses higher >1 g/day (P = .003).[88]

COVID-19 in liver transplant recipients has similar mortality rates compared to the general population in contrast to the increased mortality in cirrhotics suggesting that CAID is more immunosuppressive than pharmaceutical immunosuppressive agents.[23]