COVID-19: Abnormal liver function tests

Abstract

Background & aims: Recent data on the coronavirus disease 2019 (COVID-19) outbreak caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has begun to shine light on the impact of the disease on the liver. But no studies to date have systematically described liver test abnormalities in patients with COVID-19. We evaluated the clinical characteristics of COVID-19 in patients with abnormal liver test results.

Methods: Clinical records and laboratory results were obtained from 417 patients with laboratory-confirmed COVID-19 who were admitted to the only referral hospital in Shenzhen, China from January 11 to February 21, 2020 and followed up to March 7, 2020. Information on clinical features of patients with abnormal liver tests were collected for analysis.

Results: Of 417 patients with COVID-19, 318 (76.3%) had abnormal liver test results and 90 (21.5%) had liver injury during hospitalization. The presence of abnormal liver tests became more pronounced during hospitalization within 2 weeks, with 49 (23.4%), 31 (14.8%), 24 (11.5%) and 51 (24.4%) patients having alanine aminotransferase, aspartate aminotransferase, total bilirubin and gamma-glutamyl transferase levels elevated to more than 3× the upper limit of normal, respectively. Patients with abnormal liver tests of hepatocellular type or mixed type at admission had higher odds of progressing to severe disease (odds ratios [ORs] 2.73; 95% CI 1.19-6.3, and 4.44, 95% CI 1.93-10.23, respectively). The use of lopinavir/ritonavir was also found to lead to increased odds of liver injury (OR from 4.44 to 5.03, both p <0.01).

Conclusion: Patients with abnormal liver tests were at higher risk of progressing to severe disease. The detrimental effects on liver injury mainly related to certain medications used during hospitalization, which should be monitored and evaluated frequently.

Lay summary: Data on liver tests in patients with COVID-19 are scarce. We observed a high prevalence of liver test abnormalities and liver injury in 417 patients with COVID-19 admitted to our referral center, and the prevalence increased substantially during hospitalization. The presence of abnormal liver tests and liver injury were associated with the progression to severe pneumonia. The detrimental effects on liver injury were related to certain medications used during hospitalization, which warrants frequent monitoring and evaluation for these patients.

Keywords: 2019-nCoV; Bilirubin; Critical care; Liver injury; Liver tests; Pneumonia; SARS-Cov-2.

Graphical abstract

Fig. 1

Liver test abnormality during hospitalization in patients with COVID-19 by severity of disease. (Bars represent number of patients).

Fig. 2

Adjusted odds ratios (95% CIs) for liver injury associated with use of drugs in patients with COVID-19. All results were adjusted for radiography image grade at admission, age, sex, body mass index and comorbidities. Triangle legends for results from multivariable regression and circle legends for inverse probability weighting. Levels of significance: both p values <0.01 for lopinavir/ritonavir; all p values >0.05 for other drugs (multivariable logistic regression). IPW, inverse probability weighting; NSAIDs, non-steroidal anti-inflammatory drugs.

Fig. 3

Liver biopsy of 1 patient aged 69 years who died from the COVID-19. (A) (20×) There was no obvious inflammation in the portal area. The structure of interlobular bile duct, interlobular vein and interlobular artery was clear; the hepatocytes in the interlobular were arranged orderly, and a few hepatocytes were observed slightly vesicular steatosis and watery degeneration (possibly related to ischemia and hypoxia). (B) (40×) The hepatocytes were observed slightly vesicular steatosis and watery degeneration, and a few inflammatory cells (neutrophils, plasma cells and Kupffer cells) were found in hepatic sinuses.