key: cord-0889832-tnumapk4 authors: Chen, Peng; Zhou, Benhong title: Clinical characteristics of COVID-19 patients with abnormal liver tests date: 2020-04-26 journal: J Hepatol DOI: 10.1016/j.jhep.2020.04.028 sha: 40eca484078cd74c4d2251558d948b5b6c4bf027 doc_id: 889832 cord_uid: tnumapk4 nan authors contributed to data acquisition, data analysis, or data interpretation, and reviewed and approved the final version. We read with great interest the research article "Characteristics of Liver Tests in COVID-19 Patients" by Cai et al published recently in Journal of Hepatology. 1 The authors assessed the clinical characteristics of COVID-19 in patients with abnormal liver tests and found that patients with abnormal liver tests, especially in hepatocyte type or mixed type, had higher risks of progressing to severe disease and the liver impairment associated with COVID-19 patients mainly related to certain medications used during hospitalization. This study is important and interesting; however, there are still some concerns about it. 2 First, selection bias cannot be entirely excluded, although it is likely to be minimal as all COVID-19 patients (severe group and non-serve group) during the study period were included and matched for age, sex, body mass index, illness severity, some biochemistry indicators and the admission time point. However, whether these included patients had took some medication before admission was still completely unclear in this study. It is noteworthy that mild liver test derangement would also be present at baseline in confirmed cases of COVID-19 who had received some medication use such as antipyretics (acetaminophen), antibiotics (macrolides, quinolones) or steroids before admitting to hospital. 2 Furthermore, it has been reported that another possible contributing factor for hepatic injury in COVID-19 patients may be the high levels of positive end expiratory pressure that can cause hepatic congestion by increasing right atrial pressure and impeding venous return. 3 However, whether the patients with COVID-19 received mechanical ventilation remained unclear in current study. Additionally, it has been found that remdesivir treatment during COVID-19 can also induce liver impairment. In a paper describing the first 12 patients with COVID-19 in the United States (U.S.), the three hospitalized patients, who received remdesivir at the time of clinical worsening, reported elevated liver enzymes. 4 However, this issue has not been mentioned in the current study, and the authors should give some interpretation and explanation of these data in the text. Another issue is that the specific ratio of COVID-19 patients with liver comorbidities was still unknown in this study. Preliminary data reported by Zhang C et al indicate 2-11% of patients with COVID-19 had liver comorbidities, and whether the results in this study contradict the data of Zhang C et al or not, was still completely unclear in this study. 5 If the conflict occurs, it is presumed that the main reason is due to different subjects in these two studies, the patients in the current study were mainly aged less than 50 years old and more than half of the patients were from Hubei. Furthermore, the exact cause of 3 pre-existing liver conditions has not yet been outlined in this study. In a study of 1099 patients with laboratory confirmed COVID-19, 23 (2.1%) patients had hepatitis B infection. Severe cases were more likely to have hepatitis B infection (2.4% vs 0.6%) than non-severe cases. 6 SARS patients with HBV/HCV infection were more prone to develop severe hepatitis, probably due to enhanced viral replication during SARS-CoV infection to liver injury in patients with COVID-19 who are critically ill. 7 These data suggest more intensive immunotherapy may be required to minimize COVID-19, an issue that warrants further study. However, in patients with COVID-19 with autoimmune hepatitis, the effects of administration of glucocorticoids on disease prognosis is unclear. Given the expression of the ACE2 receptor in cholangiocytes, whether infection with SARS-CoV-2 aggravates cholestasis in patients with primary biliary cholangitis, also needs to be studied in this study. Finally, as a cohort study, this research can reflect the "real-world" findings and further support the conclusion, but the cohort data may be influenced by bias due to the patient selection process. Therefore, a large-scale study should be conducted in the future. Characteristics of Liver Tests in COVID-19 Patients Clinical Features of COVID-19-Related Liver Damage. bioRxiv Clinical Characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China The COVID-19 Investigation Team. First 12 patients with coronavirus disease 2019 (COVID-19) in the United States. bioRxiv Liver injury in COVID-19: management and challenges Clinical characteristics of novel coronavirus infection in China Study of the relationship SARS and hepatitis virus B We thank Fuchao Chen, the Department of Pharmacy, Dongfeng Hospital, Hubei University of Medicine, Shiyan, Hubei 442008, P.R. China, for providing relevant literature. This work was supported by grants from the National Natural Science Foundation of China (31770381).