key: cord-1050203-lvg9k6pr
authors: Fierro, N. A.
title: COVID-19 and the liver: What do we know after six months of the pandemic?
date: 2020-09-18
journal: Ann Hepatol
DOI: 10.1016/j.aohep.2020.09.001
sha: 980e827b9398edc233eea13fca7d354f5247e0db
doc_id: 1050203
cord_uid: lvg9k6pr

Despite liver injury in patients infected with severe acute respiratory syndrome (SARS) coronavirus (CoV)-2 (SARS-CoV-2) is associated with prolonged hospitalization, and liver dysfunction is mainly described in patients with severe viral disease. How liver abnormalities may affect virus infection is still unknown. Improved understanding of host genetics, lifestyle, underlying comorbidities and adequate follow-up of patients with liver damage are critical in the new scenario of the pandemic virus.

March 2020, presents primarily as a lower respiratory tract infection, but the multisystemic nature of the disease is apparent in severe cases. Indeed, a broad spectrum of symptoms associated with COVID-19 have been identified, which range from asymptomatic disease to mild and moderate symptoms and severe symptoms associated with critical illness resulting in acute respiratory distress syndrome, respiratory failure or multiorgan dysfunction and/or death.

Currently, fever and cough remain the most prevalent symptoms in adults infected by SARS-CoV-2 (2). Cardiovascular and hematological complications are frequent and have been associated with poor prognosis. Gastrointestinal symptoms are also frequently encountered. Furthermore, recent studies have reported that over one-third of infected patients develop a broad spectrum of neurological symptoms. The skin, kidneys, endocrine organs, eyes and liver are also affected by systemic COVID-19 disease (1) .

Although data on COVID-19-related liver abnormalities in patients remain limited, liver injury in patients is associated with prolonged hospitalization (3) .

In this context, the article by Wong and colleagues in Annals of Hepatology J o u r n a l P r e -p r o o f reporting a systemic meta-analysis to assess the prevalence and degree of liver disease in severe and nonsevere SARS-CoV-2 infected individuals reveals that liver injury is mostly associated with severe forms of COVID-19 rather than nonsevere disease (4) . The mean levels of ALT, AST and bilirubin are higher in the severe COVID-19 group than in the nonsevere group. This is in agreement with the elevated ALT/AST levels reported in 16-53% of patients at the beginning of the pandemic (5). In addition, the incidence of hyperbilirubinemia is 1.7-fold increased among COVID-19 patients who are critically ill, and indirect markers of liver injury, including hypoalbuminemia, have been found to be increased by seven-fold in patients with severe COVID-19 (4). To avoid transmission, follow-up by telemedicine has been recommended for the routine care of patients with chronic liver diseases. It is accepted that telemedicine improves the efficiency of healthcare delivery at reasonable cost opportunities for patients with chronic liver diseases by increasing their access to tertiary care. However, telemedicine may not be available in many J o u r n a l P r e -p r o o f countries, and strategies including phone calls ad/or virtual consultation for remote care must be used (12) . By taking into account that the severity of most COVID-19-associated liver injuries is considered mild, suggesting that liver failure is uncommon among critical COVID-19 patients and the fact that liver dysfunction has been mainly described in patients with severe disease upon presentation. Optimal follow-up of patients with liver damage by telemedicine or virtual consultation are needed. This allow to physicians to be alert to the potential of clinical deterioration when COVID-19-associated liver injury is observed.

The COVID-19 pandemic reveals the need for effective mitigation measures for the most prevalent diseases worldwide. Such is the case for chronic metabolic disorders such as diabetes, obesity and hypertension. Diabetes and obesity can also impact liver function, resulting in complications and unfavorable scenarios in emergency situations such as the one we are currently experiencing. Close monitoring of patients with liver disease is necessary to understand the physiopathology associated with SARS-CoV-2 infection. This allows for the design of detailed guidelines for handling COVID-19 cases with the ultimate goal of containing the virus.

There are no conflicts of interest to declare.

J o u r n a l P r e -p r o o f

Organ-specific manifestations of COVID-19 infection

The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): A systemic review and meta-analysis of 148 studies from

Liver injury in COVID-19: management and challenges

A systemic review and meta-analysis of the COVID-19 associated liver injury

The liver in times of COVID-19: What hepatologists should know

Potential implications of COVID-10 in nonalcoholic fatty liver disease

The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990-2017: a systemic analysis for the Global Burden of Disease Study

Impact of obesity on hospitalizations and mortality, due to COVID-19: A systemic review

The role of host genetics in the immune response to SARS-CoV-2 and COVID-19 susceptibility and severity

Genetic, metabolic and environmental factors involved in the development of liver cirrhosis in Mexico

COVID-19 and liver disease: Revamping remote care initiatives in hepatology