COVID-19 and the Liver: Lessons Learnt From the EAST and the WEST, A Year Later

Sirina Ekpanyapong; Chalermrat Bunchorntavakul; K. Rajender Reddy


J Viral Hepat. 2022;29(1):4-20. 

In This Article

Abstract and Introduction


Globally, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) has been a major cause for significant morbidity and mortality. Since the start of the pandemic, several hepato-biliary manifestations in coronavirus disease 2019 (COVID-19) have been described and unique considerations raised. The review aims to summarize the pathogenesis and hepato-biliary manifestations in COVID-19 and discuss the similarities, contrasting features and disease-specific management across a range of hepato-biliary diseases from the EAST and the WEST. Published studies and regional society guidelines from the EAST and the WEST were comprehensively reviewed and summarized. A wide range of hepato-biliary manifestations, including the infrequent and chronic manifestation of cholangiopathy, has been observed in COVID-19. The pathogenesis of liver injury is multifactorial and with scant evidence for a direct SARS-CoV-2 infection of the liver. Patients with non-alcoholic fatty liver disease, cirrhosis, and liver cancer are potentially at increased risk for severe COVID-19, and there are unique considerations in chronic hepatitis B or C, hepatocellular carcinoma, and in those immunosuppressed such as autoimmune hepatitis or liver transplant recipients. With the surges in SARS-CoV-2 infection, liver transplant activity has variably been impacted. Preliminarily, SARS-CoV-2 vaccines appear to be safe in those with chronic liver disease and in transplant recipients, while emerging data suggest the need for a third dose in immunosuppressed patients. In conclusion, patients with chronic liver disease, particularly cirrhosis, and liver transplant recipients, are vulnerable to severe COVID-19. Over the past year, several unique considerations have been highlighted across a spectrum of hepato-biliary diseases. Vaccination is strongly recommended for those with chronic liver disease and liver transplant recipients.


The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) has affected people from different parts of the World and has been a major cause for significant morbidity and mortality to date. Coronavirus disease 2019 (COVID-19), the disease caused by SARS-CoV-2, can present with various clinical features and while pulmonary manifestation is the most common, hepatic abnormalities can be encountered in up to 50% of infected individuals.[1,2] The spectrum is variable and can range from asymptomatic abnormalities in hepatic biochemical tests to severe liver injury with some reports of acute-on-chronic liver failure in patients with underlying cirrhosis.[3–5] Hepatic dysfunction has been associated with poor outcome and which has been noted to be more frequent in critically ill patients.[6] The cause for hepatic dysfunction is hypothesized to be based on one or more factors such as ischaemic liver injury, immune-mediated liver injury, drug-induced liver injury, pre-existing liver diseases or a direct cytopathic effect of the virus.[1,7] Further, it has been noted that up to 2%–11% of patients with COVID-19 had pre-existing liver disease[2] and that patients with underlying cirrhosis had higher mortality.[1] This review highlights several observations, and the lessons learnt since the pandemic started, on liver manifestations in COVID-19, from the EAST and the WEST, including prevalence, severity and pathogenesis. Further, we also summarize on the similarities and contrasting features in outcomes and disease-specific management in those on immunosuppressive therapy, post-transplantation state, hepatocellular carcinoma (HCC), patients with chronic liver disease, compensated/decompensated cirrhosis, viral hepatitis, non-alcoholic fatty liver disease (NAFLD) and autoimmune liver diseases and also provide emerging data on the safety and efficacy of vaccines in those with chronic liver disease, as well as the immunosuppressed. While COVID-19 patients are encountered by a wide range of providers, including primary care, emergency room, infectious disease, gastroenterology, hepatology, critical care and palliative care specialties, this review aims to provide information specifically for those who evaluate and provide care to those with a spectrum of liver-related clinical situations in the context of COVID-19.