SARS-CoV-2 infection-related liver function abnormality linked to longer hospital stay
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Over one-third of patients admitted to the hospital with SARS-CoV-2 infection had abnormal liver function that correlated with longer hospital stay than patients with normal liver function, according to a study published in Clinical Gastroenterology and Hepatology.
“[Abnormal] liver tests are common in COVID-19 patients,” Zhenyu Fan, MD, from the department of gastroenterology and hepatology at the Shanghai Public Health Clinical Center at Fudan University in Shanghai, China, and the department of gastroenterology at The Shanghai Tenth People’s Hospital of Tongji University, and colleagues wrote. “SARS-CoV-2 may cause liver function damage, and liver functional abnormality after admission may be related to the use of [Kaletra (lopinavir/ritonavir, AbbVie)]. Abnormal liver function is associated with prolonged hospital stay.”
Researchers performed a retrospective study of 148 consecutive patients with a confirmed COVID-19 diagnosis at the Shanghai Public Health Clinical Center between January 20 through January 31, 2020. They followed patient outcomes until February 19, 2020, and Evaluated patients for clinical features, laboratory parameters including liver function rests, medications and length of hospital stay. Increased levels of alanine and aspartate aminotransferase, gamma glutamyl-transferase, alkaline phosphatase and total bilirubin were used to define abnormal liver function.
At hospital admission, 55 patients (37.2%) had abnormal liver function. Of these patients, 14.5% had a high fever vs. 4.3% among patients with normal liver function (P=.027). Men and patients with higher levels of procalcitonin and C-reactive protein were more likely to have abnormal liver function. Groups were not statistically different regarding medications taken before hospitalizations. However, a significantly higher proportion of patients with abnormal liver function received lopinavir/ritonavir after admission compared with patients with normal liver function (57.8% vs. 31.3%). According to researchers, patients with abnormal liver function, compared with patients with normal liver function, had a longer mean hospital stay (15.09 days vs. 512.76 days; P= .021).
“We analyzed the prehospital medications and found that there was no statistical difference between the two groups,” Fan and colleagues wrote. “Therefore, we believe that the onset of liver function damage of COVID-19 patients had nothing to do with the medications. In another study from our hospital, lopinavir/ritonavir did not enhance the clearance of SARS-CoV-2. For this reason, we would not recommend lopinavir/ritonavir as a treatment for COVID-19, even in mild patients with normal liver function.”
Perspective
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Nancy S. Reau, MD, FAASLD, AGAF
Multiple observational cohorts of patients infected with COVID-19 have confirmed that liver test abnormalities are common and are more likely to occur in those with severe infection. Additionally, low albumin and low platelets have been linked to poor clinical outcomes from COVID-19. It is important to separate these abnormal lab values from true liver function abnormalities and liver injury.
This study must be interpreted carefully as it looks only at patients hospitalized for COVID-19, already biasing the population to more severe infection. Further, increased liver enzymes do not always reflect liver injury as COVID-19 myocarditis and rhabdomyolysis have been described. And many medications can cause transient elevations in alanine transaminase and aminotransferase including NSAIDs. The group with higher liver enzymes in this cohort had higher rates of exposure to lopinavir/ritonavir, which can cause liver tests abnormalities. There also have been reports of HBV reactivation, especially with immunomodulation used in severe COVID-19 infections.
Clinicians should be aware that liver enzyme abnormalities are frequently seen with COVID-19. It is important to test for treatable conditions, like hepatitis B and C and exclude drug induced liver injury. Even with liver test abnormalities, patients should still be considered for treatment with investigational agents when appropriate. Most importantly, despite millions of COVID-19 infections, liver failure due to COVID-19 is exceedingly rare.
References:
https://www.ncbi.nlm.nih.gov/books/NBK547961/
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