Clinical Best Practice Advice for Hepatology and Liver Transplant Providers During the COVID‐19 Pandemic: AASLD Expert Panel Consensus Statement

Fix, Oren K.; Hameed, Bilal; Fontana, Robert J.; Kwok, Ryan M.; McGuire, Brendan M.; Mulligan, David C.; Pratt, Daniel S.; Russo, Mark W.; Schilsky, Michael L.; Verna, Elizabeth C.; Loomba, Rohit; Cohen, David E.; Bezerra, Jorge A.; Reddy, K. Rajender; Chung, Raymond T.

doi:10.1002/hep.31281

Cited by 409 publications

(705 citation statements)

References 48 publications

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“…Previous studies have shown that SARS‐CoV‐2 may aggravate liver injury in patients with viral hepatitis. ( 22,23 ) Therefore, liver injury in patients with chronic liver disease needs to be investigated and monitored.…”

Section: Discussionmentioning

confidence: 99%

Longitudinal Association Between Markers of Liver Injury and Mortality in COVID‐19 in China

et al. 2020

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Background and Aims: COVID-19 is a dominant pulmonary disease, with multisystem involvement, depending upon co morbidities. Its pro le in patients with pre-existing chronic liver disease (CLD) is largely unknown. We studied the liver injury patterns of SARS-Cov-2 in CLD patients, with or without cirrhosis. Methods: Data was collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with con rmed COVID-19. Result: Altogether, 228 patients [185 CLD without cirrhosis and 43 with cirrhosis] were enrolled, with comorbidities in nearly 80%. Metabolism associated fatty liver disease (113, 61%) and viral etiology (26, 60%) were common. In CLD without cirrhosis, diabetes [57.7% vs 39.7%, OR=2.1(1.1-3.7), p=0.01] and in cirrhotics, obesity, [64.3% vs. 17.2%, OR=8.1(1.9-38.8), p=0.002) predisposed more to liver injury than those without these. Forty three percent of CLD without cirrhosis presented as acute liver injury and 20% cirrhotics presented with either acute-on-chronic liver failure [5(11.6%)] or acute decompensation [4(9%)]. Liver related complications increased (p<0.05) with stage of liver disease; a Child-Turcotte Pugh score of 9 or more at presentation predicted high mortality [AUROC-0.94, HR=19.2(95CI 2.3-163.3), p<0.001, sensitivity 85.7% and speci city 94.4%). In decompensated cirrhotics, the liver injury was progressive in 57% patients, with 43% mortality. Rising bilirubin and AST/ALT ratio predicted mortality among cirrhosis. Conclusions: SARS-Cov-2 infection causes signi cant liver injury in CLD patients, decompensating one fth of cirrhosis, and worsening the clinical status of the already decompensated. The CLD patients with diabetes and obesity are more vulnerable and should be closely monitored.

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Section: Discussionmentioning

confidence: 99%

Longitudinal Association Between Markers of Liver Injury and Mortality in COVID‐19 in China

et al. 2020

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“…(8) Given the high incidence of abnormal liver biochemistries in our cohort, we agree with the guidance from the American Association for the Study of Liver Diseases (AASLD) that liver biochemistries should be monitored in all hospitalized patients with COVID-19. (21) Viral hepatitis classically leads to an ALT-predominant hepatocellular injury; however, patients with COVID-19 did not match that pattern. Given that AST is also produced in muscle and patients with COVID-19 develop elevated markers of muscle injury, the AASLD and others have recommended consideration of myositis or cardiac injury as contributors to the AST elevation.…”

Section: Accepted Articlementioning

confidence: 99%

Liver Biochemistries in Hospitalized Patients With COVID‐19

et al. 2020

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Background and Aims Coronavirus disease 2019 (COVID‐19) leads to elevated liver biochemistries in approximately half of patients on presentation. To date, data are limited regarding the trend of liver biochemistries over the course of illness. We aimed to evaluate the trend, etiology, and outcomes associated with liver biochemistries in COVID‐19. Approach and Results A total of 60 patients with COVID‐19 were admitted between March 21 and March 28, 2020. The mean age was 57 years, 65% were male, and 28% were Hispanic. At the study conclusion, 6 patients were deceased, 28 were discharged, and 26 remained admitted. Patients who remained admitted were followed for a median of 12 days. Of 60 patients, 41 (69%) had at least one abnormal liver biochemistry on admission. Median aspartate aminotransferase (AST) was higher than alanine aminotransferase (ALT) at admission (46 vs. 30 U/L) and during the hospital course. Aminotransferases rose above normal in 54 (93%) patients, whereas alkaline phosphatase and total bilirubin elevations were rare. Ten (17%) patients developed aminotransferases more than 5 times the upper limit of normal. AST highly correlated with ALT throughout the illness course (r = 0.97; P < 0.0001), whereas correlations with markers of muscle injury and inflammation were weak. Statin use was common before (40%) and during admission (80%) at our center, with no difference in peak liver biochemistries between users and nonusers. No demographic or comorbid illness was associated with liver injury. Admission AST (69 vs. 49; P < 0.05), peak AST (364 vs. 77; P = 0.003), and peak ALT (220 vs. 52; P = 0.002) were higher in intubated patients. Conclusions AST‐dominant aminotransferase elevation is common in COVID‐19, mirrors disease severity, and appears to reflect true hepatic injury.

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“…There are still no data on decompensated cirrhosis, patients on the transplantation DOI: 10.1159/000508116 list and, patients in the immediate posttransplant period or with rejection. Decisions about transplantation should be considered on a case-by-case basis at this stage of the pandemic [28].…”

Section: The Impact Of Preexisting Liver Disease On Covid-19mentioning

confidence: 99%

“…Liver biopsy should be deferred when not essential. Follow-up of liver patients will be increased when collaboration with primary care doctors is possible [28,29].…”

Section: Health Services and Facilitiesmentioning

confidence: 99%