Liver injury, SARS‐COV‐2 infection and COVID‐19: What physicians should really know?

Abstract

Background & Aims Severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) is responsible for coronavirus disease 2019 (COVID‐19), which in males, especially in advanced age, can sometimes evolve into acute respiratory distress syndrome. In addition, mild to moderate alterations in liver function tests (LFTs) have been reported in the worst affected patients. Our review aims to analyse data on the incidence and prognostic value of LFT alterations, the underlying mechanisms and the management of pre‐existing liver disease in COVID‐19 affected patients. Methods We searched available literature through online PubMed database using terms as “SARS‐CoV‐2,” “Liver damage,” “Liver Function tests,” “COVID‐19,” “pre‐existing liver disease,” “drug‐induced liver injury.” Results Available evidence suggest that there could be a relationship between SARS‐CoV‐2 infection and liver damage, although the underlying involved mechanism remains unclear. Cohort studies have shown that high ALT levels, low platelet counts and low albumin levels at admission and during hospitalisation are associated with a high mortality rate. Unfortunately, little is known about the impact of COVID‐19 on pre‐existing liver damage. While chronic viral infections or NAFLD are associated with an increased risk of COVID‐19 progression, patients with cirrhosis may have increased susceptibility to SARS‐CoV‐2 infection due to their systemic immunocompromised status. DILI seems common among hospitalised patient with severe pneumonia. Conclusion Mild to moderate liver impairment during Covid‐19 is common, especially in patients with pre‐existing liver disease. Further studies should be performed in order to understand how pre‐existing liver conditions may influence and worsen progression of liver disease in COVID‐19 patients.

Acute liver injury in the course of COVID-19

“…These include, apart from the already mentioned antipyretic drugs and antibiotics (e.g. azitromycin), antiviral drugs like remdesivir and lopinavir/ ritonavir, immunomodulators (tocilizumab, glucocosteroids) and antimalarics (hydroxychloroquine) [17,18,19,20].…”

“…The use of tocilizumab can result in the elevation of liver enzymes [24] and suppression of liver regeneration [25]. It is worth noting that pre-existing, non-alcoholic fatty liver disease (NAFLD) can be responsible for higher susceptibility to liver damage caused by acetaminophen, compared to the healthy population [18]. In addition, patients with COVID-19 who require treatment and hospitalization are treated with numerous drugs, the hepatotoxic effects of which may overlap and intensify [20].…”

The Spectrum of COVID-19-Induced Liver Injury in Various Age and Risk Groups

“…It can also cause a hypercoagulable state. An imbalance in coagulation homeostasis as a result of systemic inflammation leads to a condition of a pro-coagulant state manifesting as micro-thrombosis, disseminated intravascular coagulation, and multiorgan failure [ 4 ].…”

Hepatic manifestations of coronavirus disease 2019 infection: Clinical and laboratory perspective

“…Finally, studies have also reported variable degrees of hepatotoxicity with medications used in the treatment of COVID-19[ 10 , 11 ]. Hundt et al [ 12 ] reported the use of medications needed to treat COVID-19 virus (remdesivir, hydroxychloroquine, lopinavir/ritonavir and tocilizumab) as a significant predictor of raised transaminases [> 5 × upper limit of normal (ULN)] during hospitalization for COVID-19.…”