COVID-19 and the liver

COVID-19, the disease caused by the SARS-CoV-2 coronavirus, is mainly a respiratory infection, but it can also affect the liver. In most people that effect is mild and temporary: during the infection the liver enzymes rise a little and then return to normal. The question that worries our patients most is a different one: if you already have liver disease, are you at greater risk? The answer is that people with cirrhosis and with advanced chronic liver disease do have a higher risk of severe COVID, and that is why a few concrete measures are worth knowing.

This article was written at the start of the pandemic, in May 2020, and we have updated it with what we learned afterward. Those first months were marked by uncertainty, lockdowns and the absence of vaccines. Today COVID-19 is no longer a global health emergency and we have vaccines and treatments, so the perspective is calmer, although care of the patient with liver disease remains important.

Does COVID-19 damage the liver?

In most cases, not seriously. It is common for a mild rise in liver enzymes (ALT and AST) to appear during the infection, sometimes together with an increase in gamma-glutamyl transferase (GGT). This change is usually transient and resolves as the illness improves, without leaving lasting damage.

Several mechanisms explain this. The virus can affect the liver indirectly through generalized inflammation, lack of oxygen in severe cases and the effect of some medications used during hospitalization. Direct liver damage by the virus itself appears to be less relevant. When liver enzymes rise sharply, it usually reflects more severe COVID rather than a primary liver problem.

Am I at higher risk if I already have liver disease?

It depends on the stage of your disease. People with a healthy liver or with mild abnormalities tolerate the infection much like the general population. The risk rises as liver disease becomes more advanced.

The international registries that gathered data from hundreds of patients during the pandemic showed that:

• In people with cirrhosis, mortality from COVID-19 was clearly higher than in those with liver disease but no cirrhosis.
• The risk increased with the severity of cirrhosis, measured by the Child-Pugh classification: the worse the liver function, the worse the prognosis.
• The infection could trigger a decompensation of cirrhosis (the appearance of ascites, encephalopathy or liver failure), sometimes even without prominent respiratory symptoms.

Among people with fatty liver, the obesity and diabetes that usually accompany it are also associated with more severe forms of COVID-19. On a reassuring note, however, patients with autoimmune hepatitis who take immunosuppressive drugs did not have a worse course on that account alone, so stopping those treatments is not recommended.

Should people with liver disease be vaccinated?

Yes. COVID-19 vaccination is recommended in people with chronic liver disease, in those with cirrhosis and in those who have had a liver transplant, precisely because they are the groups at highest risk of severe illness. Liver societies, including the European one (EASL), supported this recommendation early on.

One nuance is worth keeping in mind. The response to the vaccine may be somewhat weaker in patients with advanced cirrhosis and, above all, in transplant recipients on immunosuppressive drugs, because their immune system responds less strongly. That is why booster doses are especially important in these groups. The indication and vaccination schedule should always be discussed with your physician.

Are COVID-19 treatments safe for the liver?

Generally yes, but drug interactions require caution. Some oral antivirals used against COVID-19, in particular the combination nirmatrelvir/ritonavir, can interact with several medications, including the immunosuppressants taken by transplant patients. So if you are prescribed an antiviral for COVID-19, it is essential that your doctor review all of your usual medications before you start.

If you have liver disease, avoid self-medicating. In particular, do not exceed the recommended dose of acetaminophen (paracetamol) for fever or discomfort, and check before taking anti-inflammatory drugs or other medicines.

Do not stop your medications or your check-ups

This advice, which we gave at the start of the pandemic, still holds. You should not stop or reduce the dose of your medications without your doctor’s instruction. This includes corticosteroids such as prednisone, immunomodulators such as azathioprine and, all the more so, immunosuppressants if you are a transplant recipient. Stopping them on your own risks a decompensation or a flare of the disease.

Do not miss your check-ups either. Continuity of care is key to preventing complications such as ascites, hepatic encephalopathy or a flare of hepatitis. Telemedicine, which became widespread during the pandemic, remains a good alternative for keeping up follow-up when attending in person is difficult.

Look after the rest of your health too

The pandemic left some lessons that still hold value:

• Alcohol. People with liver disease, and especially with cirrhosis, should not drink alcohol. Stress and isolation increased harmful drinking in many places. If you find it hard to control, ask your doctor for help.
• Other vaccines. In addition to the COVID-19 vaccine, people with chronic liver disease should keep up to date with the annual influenza vaccine and the pneumococcal vaccine.
• Healthy routines. Keeping regular hours, gentle physical activity and social contact, even at a distance, helps you cope better with any period of isolation.

When should I seek care?

With fever or respiratory symptoms such as cough, sore throat or shortness of breath, contact your doctor. Difficulty breathing is always a symptom that requires immediate attention at an emergency department.

If you have cirrhosis, also watch for signs of decompensation: increasing abdominal size, swelling of the legs, confusion or unusual drowsiness, or yellowing of the skin and eyes. COVID-19 can trigger these complications, sometimes before respiratory symptoms appear.

See also

• Cirrhosis
• Liver enzymes (ALT and AST)
• Liver transplant
• Fatty liver disease