Clinical features and potential mechanism of coronavirus disease 2019-associated liver injury

Table 2 Management of coronavirus disease 2019 patients with liver disease

	Management of COVID-19 patients with liver disease
Out-patient care	Use telemedicine or visits by phone wherever possible. Consider seeing in person only patients with urgent issues and clinically significant liver disease (e.g., jaundice, elevated ALT or AST > 500 U/L, or recent onset of hepatic decompensation)[40,84,86]. Seeing at the fever clinic[40]
Hospital treatment	Separate management from non-COVID-19 patients[40,85]. Monitor liver biochemistries regularly, particularly in patients treated with remdesivir or tocilizumab[40]. Avoid ultrasound or other advanced imaging unless it is likely to change management, for example, clinical suspicion for biliary obstruction or venous thrombosis[40]. Hospitalize COVID-19 patients with advanced liver disease as soon as possible[85]
Patients with hepatitis B, hepatitis C	Document discussion with patient regarding CLD diagnosis and management[84]. Delay starting DAA therapy until after their recovery from COVID-19 disease if there is no suspicion of advanced liver disease[87]. Continue treatment and provide 90-d supplies for HBV oral antiviral drugs or a full course of DAA medications to complete HCV treatment[87]
Patients with autoimmune liver disease	Continue immunosuppressive therapy in stable patients with AIH[87]. Lower the doses of azathioprine or mycophenolate mofetil when patients develop lymphopenia[87]. Avoid liver biopsy and start empiric therapy in new patients presenting with features of AIH[87]. Avoid high doses of prednisone in AIH patients on corticosteroids[87]
Patients with HCC	Continue HCC surveillance schedule for high-risk subjects[40]. Document discussion of risks and benefits of delaying surveillance with patient[40]. Proceed with HCC treatments as appropriate[40]. Postpone elective transplant and resection surgery, withhold immunotherapy[84]
Pretransplant and post-transplant patients	Have low threshold for admitting patients on transplant waiting list diagnosed with COVID-19[40,84]. Consider reduction of immunosuppression therapy as appropriate for posttransplant patients with moderate COVID-19[40,84]. Avoid reductions in immunosuppressive therapy in patients with mild COVID-19 disease[40,84]

AIH: Autoimmune hepatitis; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; CLD: Chronic liver disease; COVID-19: Coronavirus disease 2019; DAA: Direct acting antiviral; HBV: Hepatitis B virus; HCC: Hepatocellular carcinoma; HCV: Hepatitis C virus.