People with cirrhosis, especially those with diabetes or
obesity, are more likely to suffer significant liver injury after contracting SARS-CoV-2
than others with chronic liver disease, Asian liver specialists report in a multi-centre
study published in the journal Hepatology International.
SARS-CoV-2 causes COVID-19 – severe respiratory illness that
may progress to pneumonia and multi-organ disease. Liver injury caused by severe
inflammation, restricted oxygen flow caused by pneumonia or medication used to
treat COVID-19 has been reported in up to half of patients in some cohort
studies, chiefly in the form of raised liver enzymes.
Although liver injury is transient in most people, it has
been unclear if people with underlying liver disease are at greater risk of
more severe liver injury after developing COVID-19.
- decompensated cirrhosis
The later stage of
cirrhosis, during which the liver cannot perform some vital functions and
complications occur. See also ‘cirrhosis’ and ‘compensated cirrhosis’.
Investigators in 13 countries in the Asia-Pacific region
collected data on COVID-19 outcomes in people with chronic liver disease, including
predictors of mortality.
Patients were eligible for analysis if they had been admitted
to hospital with symptoms of COVID-19 and had confirmation of infection by
virological test. Outcomes were assessed up to 28 days after admission and data
were gathered between January and the end of April 2020.
The APASL COVID-19 Liver Injury Spectrum study (APCOLIS)
accumulated data on 185 people with chronic liver disease without cirrhosis and
43 people with cirrhosis.
In those without cirrhosis, the predominant cause of liver
disease was metabolic-associated fatty liver disease (MAFLD) (61%) or viral
In those with cirrhosis, the predominant cause was viral
hepatitis (60%) or MAFLD (32%).
Approximately 80% of both groups had at least one underlying
co-morbidity and the average age was 48 years in the cirrhosis group and 51 years
in the non-cirrhosis group.
People with cirrhosis were significantly more likely to have
new acute liver injury at admission (32% vs 20%) and during hospitalisation
(39% vs 7%) (P < 0.001). Decompensation after admission was significantly more
common in the cirrhosis group (7% vs 0%). They were also more likely to develop
more severe liver-related complications (32% vs 14%, p = 0.007) and more likely
to die from liver injury (16% vs 2%, p = 0.002).
People with cirrhosis were also more likely to experience
severe COVID-19 complications such as acute kidney injury (18% vs 5%),
respiratory failure (23% vs 8%) and hypotension (14% vs 3%) (all p < 0.001).
Severity of COVID-19 was associated with severity of
cirrhosis. People with decompensated cirrhosis prior to admission (18 out of 43)
were five times more likely to present with severe COVID-19 symptoms (severe
pneumonia, acute respiratory distress syndrome, acute kidney, heart or
circulatory failure) (odds ratio 5.5) and six times more likely to present with
acute liver injury at admission (odds ratio 6.2).
In people with cirrhosis, liver injury was more frequent in
those with diabetes and people who developed liver injury were more likely to
die (7 of 43 people with cirrhosis died). Obese people with cirrhosis were almost nine
times more likely to develop liver injury than cirrhotic patients of normal
weight (OR 8.9).
In those without cirrhosis, liver injury was associated with
diabetes (OR 2.06). Although liver injury was associated with a higher
frequency of intensive care unit admission and liver-related complications,
people without cirrhosis who experienced liver injury did not have a higher
death rate and did not spend longer in hospital than those without liver
Two patterns of liver injury were seen. In people with
cirrhosis, liver injury was usually present at the time of admission and was
characterised by high AST levels and rapid and worsening jaundice. The pattern
suggests liver injury due to low oxygen levels (hypoxia, a result of severe
pneumonia) or the effect of medication used to treat COVID-19, say the
investigators. The pattern of liver injury seen in cirrhotic patients means
that doctors should be careful in choosing drugs to treat COVID-19 in these
patients, say the investigators.
In people without cirrhosis,
liver injury tended to develop at the end of the second week or in the third
week after admission and was characterised by high ALT levels, suggesting direct