Systematic review with meta‐analysis: liver manifestations and outcomes in COVID‐19

Abstract

Summary Background The incidence of elevated liver chemistries and the presence of pre‐existing chronic liver disease (CLD) have been variably reported in COVID‐19. Aims To assess the prevalence of CLD, the incidence of elevated liver chemistries and the outcomes of patients with and without underlying CLD/elevated liver chemistries in COVID‐19. Methods A comprehensive search of electronic databases from 1 December 2019 to 24 April 2020 was done. We included studies reporting underlying CLD or elevated liver chemistries and patient outcomes in COVID‐19. Results 107 articles (n = 20 874 patients) were included for the systematic review. The pooled prevalence of underlying CLD was 3.6% (95% CI, 2.5‐5.1) among the 15 407 COVID‐19 patients. The pooled incidence of elevated liver chemistries in COVID‐19 was 23.1% (19.3‐27.3) at initial presentation. Additionally, 24.4% (13.5‐40) developed elevated liver chemistries during the illness. The pooled incidence of drug‐induced liver injury was 25.4% (14.2‐41.4). The pooled prevalence of CLD among 1587 severely infected patients was 3.9% (3%‐5.2%). The odds of developing severe COVID‐19 in CLD patients was 0.81 (0.31‐2.09; P = 0.67) compared to non‐CLD patients. COVID‐19 patients with elevated liver chemistries had increased risk of mortality (OR‐3.46 [2.42‐4.95, P < 0.001]) and severe disease (OR‐2.87 [95% CI, 2.29‐3.6, P < 0.001]) compared to patients without elevated liver chemistries. Conclusions Elevated liver chemistries are common at presentation and during COVID‐19. The severity of elevated liver chemistries correlates with the outcome of COVID‐19. The presence of CLD does not alter the outcome of COVID‐19. Further studies are needed to analyse the outcomes of compensated and decompensated liver disease.

Letter: elevated liver enzymes and outcomes in COVID Authors' reply

“…3 Again CLD in the quoted study included chronic hepatitis B, NASH and cirrhosis, which is similar to our study. 2 We agree that the outcomes of COVID-19 in cirrhotic patients are probably poor, given the information currently available. 4 Unfortunately, the studies quoted by Dr.…”

“…Moreover, patients with other CLD, such as non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) and chronic viral hepatitis are likely to have better outcomes. 2 Similarly, in a recent study of 788 COVID-19 patients, the prevalence of CLD was 3.9%, and although a significant number of patients with CLD had higher enzyme elevation, the outcomes were no different. 3 Again CLD in the quoted study included chronic hepatitis B, NASH and cirrhosis, which is similar to our study.…”

“…We thank Dr. Elhence and colleagues for their interest in our systematic review. 1,2 Their concern regarding the presence of chronic liver disease (CLD) not altering the outcome of COVID-19 is understandable. The likely reason for this observation is the small proportion of the included patients with cirrhosis (11.6%).…”

“…However, in the articles that we included, we found no difference in outcomes among patients with CLD (NASH, chronic viral hepatitis and cirrhosis) and non-CLD (general population). 2 Multiple causes could explain the elevation of liver chemistries in COVID-19. 2,5 Despite this, the elevation of liver chemistries seems to be associated with poor outcomes in COVID-19.…”

Letter: elevated liver enzymes and outcome in COVID‐19

“…We read with great interest the systematic review with meta‐analysis by Kulkarni et al 1 in which they have described the liver manifestations and outcomes in COVID‐19 from pooled data of 107 studies. We appreciate the painstaking efforts of the authors to summarise such extensive data.…”