COVID-19-Induced Hepatic Injury: A Systematic Review and Meta-Analysis

Abstract

Background The current pandemic of the novel coronavirus disease (COVID-19) is a global health challenge. Pulmonary dysfunction is the main outcome of COVID-19 infection. In critically ill patients, however, liver complications have also been reported. Thus, we conducted a systematic review and meta-analysis to draw generalized conclusions regarding impaired liver biochemistry and its potential relationship with COVID-19 disease severity. Materials and Methods We searched the PubMed, Scopus, and Web of Science databases for all the related literature published up to June 20, 2020. The data were analyzed using R statistical software. A random-effects model was employed for pooling the data. The risk of bias and quality of included studies was assessed using the modified Newcastle-Ottawa Scale (NOS) for cohort studies. Results The present meta-analysis comprises 10 retrospective and two prospective studies (6,976 COVID-19 patients). The serum analysis revealed significantly higher levels of alanine aminotransferases and aspartate aminotransferases and significantly lower albumin levels. Moreover, insignificant increases in serum levels of total bilirubin were observed. Upon subgroup analysis of six studies (severe cases, n=131; non-severe cases, n=334) stratified on the basis of disease severity, we found that these abnormalities were relatively higher in severe cases of COVID-19 (albumin [weighted mean difference (WMD), 34.03 g/L; 95% CI, 27.42 to 40.63; p<0.0001; I²=96.83%); alanine transaminase (ALT) [WMD, 31.66 U/L; 95% CI, 25.07 to 38.25; p<0.0001; I²=55.64%]; aspartate aminotransferase (AST) [WMD, 41.79 U/L; 95% CI, 32.85 to 50.72; p<0.0001; I²=51.43%]; total bilirubin [WMD, 9.97 μmol/L; 95% CI, 8.46 to 11.48; p<0.0001; I²=98%]) than in non-severe cases. Conclusion Deranged liver enzymes serve as prognostic factors to assess the severity of COVID-19. Liver markers should, therefore, be observed and monitored continuously.

Keywords: covid-19; hepatic injury; lfts; liver injury; liver injury biomarkers; sars-cov-2; systematic review and meta-analysis.

Figure 1. PRISMA flowchart showing the study selection process for the meta-analysis

PRISMA: Preferred Reporting Items for Systemic Reviews and Meta-Analyses

Figure 2. Forest plots for pooled analysis of serum levels of albumin using a random‐effects model

CI: confidence interval

Figure 3. Forest plots for pooled analysis of serum levels of ALT using a random‐effects model

CI: confidence interval; ALT: alanine aminotransferase

Figure 4. Forest plots for pooled analysis of serum levels of AST using a random‐effects model

CI: confidence interval; AST: aspartate aminotransferase

Figure 5. Forest plots for pooled analysis of serum levels of total bilirubin using a random‐effects model

CI: confidence interval