The Liver’s Fate amid COVID-19 pandemic

Muhammad Begawan Bestari, Siti Aminah Abdurachman


Corona-virus disease (COVID-19) affected medical services worldwide because of its pandemic nature; including patients with chronic liver disease (CLD). Generally, there are three situations in which CLD patients can be affected by the coronavirus. Patients who have pre-existing liver conditions, especially those that need constant follow-up, will be exposed during follow-up visits to the hospital and are more vulnerable to infection. Second, patients with COVID-19 who have liver function derangements and incidental findings of ongoing CLD, especially those with cirrhosis will have more severe courses of the disease and possible acute-on-chronic liver failure. Finally, patients who undergo treatment for CLD who are infected with COVID-19, where drug-drug interactions are possible (e.g. lopinavir-ritonavir) that may increase the concentration of the protease inhibitor DAA for Hepatitis C treatment. This review is aims to provide guidelines for managing patients with CLD amid the pandemic, and how we move forward after the lockdown.


chronic liver disease, hepatitis B, hepatitis C, cirrhosis, COVID-19


Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F, Ma X, Wang D, Xu W, Wu G, Gao GF, Tan W. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020;382:727-33. [DOI: 10.1056/NEJMoa2001017 PMCID: PMC7092803]

World Health Organization (WHO). Coronavirus disease (COVID-19) Weekly Epidemiological Update, 1 November 2020. Available at: Accessed: 4 November 2020.

Lee IK, Wang CC, Lin MC, Kung CT, Lan KC, Lee CT. Effective strategies to prevent coronavirus disease-2019 (COVID-19) outbreak in hospital. J Hosp Infect. 2020;105:102-3. [ DOI: 10.1016/j.jhin.2020.02.022 PMCID: PMC7124248 PMID: 32142886]

Yetmar ZA, Issa M, Munawar S, Burton C, Pureza V, Sohail MR, Mehmood T. Inpatient Care of Patients with COVID-19: A Guide for Hospitalists. Am J Med. 2020;Apr 25. [DOI: 10.1016/j.amjmed.2020.03.041 PMCID: PMC7182745 PMID: 32339477]

Mantovani A, Beatrice G, Dalbeni A. Coronavirus disease 2019 and prevalence of chronic liver disease: A meta-analysis. Liver Int. 2020;40:1316-20. [DOI: PMID: 32329563]

Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during highly pathogenic human coronavirus infections. Liver Int. 2020;40:998-1004. [DOI: 10.1111/liv.14435 PMID: 32170806 PMCID: PMC7228361]

Lippi G, de-Oliveira MHS, Henry BM. Chronic liver disease is not associated with severity or mortality in Coronavirus disease 2019 (COVID-19): a pooled analysis. Eur J Gastroenterol Hepatol. 2020;Apr 10. [DOI: 10.1097/MEG.0000000000001742 PMID: 32282549]

APASL Covid-19 Task Force; Lau G, Sharma M. Clinical practice guidance for hepatology and liver transplant providers during the COVID-19 pandemic: APASL expert panel consensus recommendations. Hepatol Int. 2020;14:415-28. [DOI: 10.1007/s12072-020-10054-w PMID: 32447721 PMCID: PMC7245190]

Zou X, Fang M, Li S, Wu L, Gao B, Gao H, Ran X, Bian Y, Li R, Yu S, Ling J, Li D, Tian D, Huang J. Characteristics of Liver Function in Patients With SARS-CoV-2 and Chronic HBV Coinfection. Clin Gastroenterol Hepatol. 2020;S1542-3565:30821-1. [DOI:10.1016/j.cgh.2020.06.017 PMID: 32553907 PMCID: PMC7294291]

Chen X, Jiang Q, Ma Z, Ling J, Hu W, Cao Q, Mo P, Yang R, Gao S, Gui X, Xiong Y, Li J, Zhang Y. Clinical Characteristics of Hospitalized Patients with SARS-CoV-2 and Hepatitis B virus Co-infection. medRxiv. 2020. [DOI: https ://]

Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, Barnaby DP, Becker LB, Chelico JD, Cohen SL, Cookingham J, Coppa K, Diefenbach MA, Dominello AJ, Duer-Hefele J, Falzon L, Gitlin J, Hajizadeh N, Harvin TG, Hirschwerk DA, Kim EJ, Kozel ZM, Marrast LM, Mogavero JN, Osorio GA, Qiu M, Zanos TP. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. 2020;323:2052-5059. [DOI: 10.1001/jama.2020.6775 PMCID: PMC7177629 PMID: 32320003]

Ji D, Qin E, Xu J, Zhang D, Cheng G, Wang Y, Lau G. Non-alcoholic fatty liver diseases in patients with COVID-19: A retrospective study. J Hepatol. 2020;73:451-3. [DOI: PMID: 32278005 PMCID: PMC7141624]

Zhou Y-J, Zheng KI, Wang X-B, Yan H-D, Sun Q-F, Pan K-H, Wang T-Y, Ma H-L, Y-P.Chen, J.George, Zheng M-H. Younger patients with MAFLD are at increased risk of severe COVID-19 illness: A multicenter preliminary analysis. J Hepatol. 2020;73:719-21. [DOI:]

Ryan PM, Caplice NM. Is Adipose Tissue a Reservoir for Viral Spread, Immune Activation, and Cytokine Amplification in Coronavirus Disease 2019? Obesity. 2020;28:1191-4. [DOI: PMID: 32314868 PMCID: PMC7264526]

Qi X, Liu Y, Wang J, Fallowfield J, Wang J, Li X, Shi J, Pan H, Zou S, Zhang H, Chen Z, Li F, Luo Y, Mei M, Liu H, Wang Z, Li J, Yang H, Xiang H, Li X, Liu T, Zheng M-H, Liu C, Huang Y, Xu D, Li X, Kang N, He Q, Gu Y, Zhang G, Shao C, Liu D, Zhang L, Li X, Kawada N, Jiang Z, Wang F, Xiong B, Takehara T, Rockey DC. for the COVID-Cirrhosis-CHESS Group. Clinical course and risk factors for mortality of COVID-19 patients with pre-existing cirrhosis: a multicentre cohort study. Gut. 2020. [DOI: doi:10.1136/gutjnl-2020-321666 PMID: 32434831]

Qi X, Wang J, Li X, Wang Z, Liu Y, Yang H, Li X, Shi J, Xiang H, Liu T, Kawada N, Maruyama H, Jiang Z, Wang F, Takehara T, Rockey DC, Sarin SK. for the COVID-Cirrhosis-CHESS Group. Clinical course of COVID‑19 in patients with pre‑existing decompensated cirrhosis: initial report from China. Hepatol Int 2020. [DOI:10.1007/s12072-020-10051-z PMCID:PMC7242176 PMID:32440857]

Bajaj JS, Garcia-Tsao G, Biggins S, Kamath PS, Wong F, McGeorge S, Shaw J, Pearson M, Chew M, Fagan A, Rodriguez RdlR, Worthington J, Olofson A, Weir V, Trisolini C, Dwyer S, Reddy KR. Comparison of mortality risk in patients with cirrhosis and COVID-19 compared with patients with cirrhosis alone and COVID-19 alone: multicentre matched cohort. Gut. 2020. [DOI:10.1136/gutjnl-2020-322118 PMCID:PMC7371484 PMID:32660964]

Wong GL-H, Wong VW-S, Thompson A, Jia J, Hou J, Lesmana CRA, Susilo A, Tanaka Y, Chan W-K, Gane E, Ong-Go AK, Lim S-G, Ahn SH, Yu M-L, Piratvisuth T, Chan HL-Y. on behalf of the Asia-Pacific Working Group for Liver Derangement during the COVID-19 Pandemic. Management of patients with liver derangement during the COVID-19 pandemic: an Asia-Pacific position statement. Lancet Gastroenterol Hepatol. 2020;5:776-87. [DOI: PMID: 32585136 PMCID: PMC7308747]

Fix OK, Hameed B, Fontana RJ, Kwok RM, McGuire BM, Mulligan DC, Pratt DS, Russo MW, Schilsky ML, Verna EC, R.Loomba, Cohen DE, Bezerra JA, Reddy KR, Chung RT. AASLD. Clinical Best Practice Advice for Hepatology and Liver Transplant Providers During the COVID-19 Pandemic: AASLD Expert Panel Consensus Statement. Released June 25, 2020. Hepatology. 2020. [DOI:10.1002/hep.31281 PMCID: PMC7262242 PMID: 32298473]

Boettler T, Marjot T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Jalan R, Moreau R, Cornberg M, Berg T. Impact of COVID-19 on the care of patients with liver disease: EASL-ESCMID position paper after 6 months of the pandemic. JHEP Rep. 2020. [DOI:10.1016/j.jhepr.2020.100169 PMID: 32835190 PMCID: PMC7402276]

Cai Q, F.Chen, Wang T, Luo F, Liu X, Wu Q, He Q, Wang Z, Liu Y, Liu L, Chen J, Xu L. Obesity and COVID-19 Severity in a Designated Hospital in Shenzhen, China. Diabetes Care. 2020;42:1392-8. [DOI:10.2337/dc20-0576 PMID: 32409502]

Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, Holden KA, Read JM, Dondelinger F, Carson G, Merson L, Lee J, Plotkin D, Sigfrid L, Halpin S, Jackson C, Gamble C, Horby PW, Nguyen-Van-Tam JS, Ho A, Russell CD, Dunning J, Openshaw PJM, Baillie JK, Semple MG. on behalf of the ISARIC4C investigators. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. BMJ. 2020. [DOI: 10.1136/bmj.m1985 PMID: 32444460 PMCID: PMC7243036]

Tapper EB, Asrani SK. The COVID-19 pandemic will have a long-lasting impact on the quality of cirrhosis care. J Hepatol. 2020;73:441-5. [DOI: 10.1016/j.jhep.2020.04.005 PMID: 32298769 PMCID: PMC7194911]

Gralnek IM, Hassan C, Beilenhoff U, Antonelli G, Ebigbo A, Pellisé M, Arvanitakis M, Bhandari P, Bisschops R, Hooft JEV, Kaminski MF, Triantafyllou K, Webster G, Pohl H, Dunkley I, Fehrke B, Gazic M, Gjergek T, Maasen S, Waagenes W, de Pater M, Ponchon T, Siersema PD, Messmann H, Dinis-Ribeiro M. ESGE and ESGENA Position Statement on gastrointestinal endoscopy and the COVID-19 pandemic. Endoscopy. 2020;52:483-90. [DOI:10.1055/a-1155-6229 PMID: 32303090 PMCID: PMC7295280]

American Society for Gastrointestinal Endoscopy (ASGE). Gastroenterology Professional Society Guidance on Endoscopic Procedures During the COVID-19 Pandemic. Available at: Accessed: 20 July 2020.

Franchis RD. Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 215;63:743-52. [DOI: 10.1016/j.jhep.2015.05.022 PMID: 26047908]

Wong GLH, Kwok R, Hui AJ, Tse Y-K, Ho K-T, Lo AOS, Lam KLY, Chan HCH, Lui RA, Au KHD, Chan HLY, Wong VWS. A new screening strategy for varices by liver and spleen stiffness measurement (LSSM) in cirrhotic patients: A randomized trial. Liver Int. 2018;38:636-44. [DOI:10.1111/liv.13560 PMID: 28853196]

Fan Z, Chen L, Li J, Cheng X, Yang J, Tian C, Zhang Y, Huang S, Liu Z, Cheng J. Clinical Features of COVID-19-Related Liver Functional Abnormality. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2020;18:1561-6. [DOI:10.1016/j.cgh.2020.04.002 PMID:32283325 PMCID: PMC7194865]

Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu Y, Wang J, Liu Y, Wei Y, Xia J, Yu T, Zhang X, Zhang L. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395:507-13. [DOI: 10.1016/S0140-6736(20)30211-7 PMID:32007143 PMCID: PMC7135076 ]

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497-506. [DOI: PMID: 31986264 PMCID: PMC7159299]

Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, Wu Y, Zhang L, Yu Z, Fang M, Yu T, Wang Y, Pan S, Zou X, Yuan S, Shang Y. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory medicine. 2020;8:475-81. [DOI:10.1016/S2213-2600(20)30079-5.7102538 PMID: 32105632 PMCID: PMC7102538]

Chai X, Hu L, Zhang Y, Han W, Lu Z, Ke A, Zhou J, Shi G, Fang N, Fan J, Cai J, Fan J, Lan F. Specific ACE2 Expression in Cholangiocytes May Cause Liver Damage After 2019-nCoV Infection. bioRxiv. 2020. [DOI:]

Kumar P, Sharma M, Kulkarni A, Rao PN. Pathogenesis of Liver Injury in Coronavirus Disease 2019. J Clin Exp Hepatol 2020. [DOI:10.1016/j.jceh.2020.05.006 PMID: 32837092 PMCID: PMC7237376]

European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. Journal of hepatology. 2017;67:370-98. [DOI:10.1016/j.jhep.2017.03.021 PMID: 28427875]

Sarin SK, Kumar M, Lau GK, Abbas Z, Chan HL, Chen CJ, Chen DS, Chen HL, Chen PJ, Chien RN, Dokmeci AK, Gane E, Hou JL, Jafri W, Jia J, Kim JH, Lai CL, Lee HC, Lim SG, Liu CJ, Locarnini S, Al Mahtab M, Mohamed R, Omata M, Park J, Piratvisuth T, Sharma BC, Sollano J, Wang FS, Wei L, Yuen MF, Zheng SS, Kao JH. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update. Hepatology international. 2016;10:1-98. [DOI:10.1007/s12072-015-9675-4 PMID:26563120 PMCID: PMC4722087 ]

He Q, Song X, Huang Y, Huang W, Ye B, Luo H, Luo H, Wu L, Wang Z, Chen W, Zhang L. Dexamethasone Stimulates Hepatitis B Virus (HBV) Replication Through Autophagy. Medical science monitor : international medical journal of experimental and clinical research. 2018;24:4617-24. [DOI: 10.12659/MSM.906250 PMID: 29972684 PMCID: PMC6064191]

Alzghari SK, Acuna VS. Supportive Treatment with Tocilizumab for COVID-19: A Systematic Review. J Clin Virol. 2020;127:104380. [DOI:10.1016/j.jcv.2020.104380 PMID: 32353761 PMCID: PMC7194791]

Sonneveld MJ, Murad SD, van der Eijk AA, de Man RA. Fulminant Liver Failure due to Hepatitis B Reactivation During Treatment With Tocilizumab. ACG Case Rep J. 2019;6:e00243. [DOI: 10.14309/crj.0000000000000243 PMID: 32042838 PMCID: PMC6946203]

Horby P, Lim WS, Emberson J, Mafham M, Bell J, Linsell L, Staplin N, Brightling C, Ustianowski A, Elmahi E, Prudon B, Green C, T. Felton, Chadwick D, Rege K, Fegan C, Chappell LC, Faust WN, Jaki T, Jeffery K, Montgomery A, Rowan K, Juszczak E, Baillie JK, Haynes R, Landray MJ. RECOVERY Collaborative Group. Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report. N Engl J Med. 2020 Jul 17;NEJMoa2021436 [DOI: 10.1056/NEJMoa2021436 PMID: 32678530 PMCID: PMC7383595]

Luo P, Liu Y, Qiu L, Liu X, Liu D, Li J. Tocilizumab treatment in COVID-19: A single center experience. J Med Virol. 2020;92:814-8. [DOI: 10.1002/jmv.25801 PMID: 32253759 PMCID: PMC7262125]

Marshall MC, Herrera JL. Lack of Patient Compliance in Real-World Practice Negatively Affects Sustained Viral Response Rates to Direct Acting Agent Therapy for Hepatitis C. Dig Dis Sci. 2018;63:3228-32. [DOI: 10.1007/s10620-018-5247-5 PMID: 30128645]

Full Text: PDF HTML


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 3.0 License.