Retrospective Cohort Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 21, 2022; 28(39): 5735-5749
Published online Oct 21, 2022. doi: 10.3748/wjg.v28.i39.5735
Effects of COVID-19 on the liver: The experience of a single center
Valentina Liakina, Ieva Stundiene, Gabriele Milaknyte, Ramune Bytautiene, Rosita Reivytyte, Roma Puronaite, Gintare Urbanoviciute, Edita Kazenaite
Valentina Liakina, Ieva Stundiene, Gabriele Milaknyte, Ramune Bytautiene, Edita Kazenaite, Centre of Hepatology, Gastroenterology and Dietetics, Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
Valentina Liakina, Department of Chemistry and Bioengineering, Faculty of Fundamental Sciences, VILNIUS TECH, Vilnius 10223, Lithuania
Rosita Reivytyte, Gintare Urbanoviciute, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
Roma Puronaite, Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
Roma Puronaite, Institute of Data Science and Digital Technologies, Faculty of Mathematics and Informatics, Vilnius University, Vilnius 01513, Lithuania
Edita Kazenaite, Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius 01513, Lithuania
Author contributions: Puronaite R, Milaknyte G, Reivytyte R and Urbanoviciute G performed raw data collection; Liakina V, Stundiene I, Bytautiene R and Kazenaite E revised collected data for relevance and sufficiency; Liakina V, Stundiene I, Milaknyte G and Bytautiene R wrote the manuscript draft; Liakina V edited draft and prepared the final version of the manuscript; Kazenaite E revised manuscript for important intellectual content.
Institutional review board statement: The study was reviewed and approved by the Vilnius Regional Biomedical Research Ethics Committee and by Institutional Review Board (approval No. 2022/2-1411-882).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous data that were obtained after each patients agreed to treatment by written consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Valentina Liakina, PhD, Senior Research Fellow, Centre of Hepatology, Gastroenterology and Dietetics, Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 3 Universiteto Street, Vilnius 01513, Lithuania. valentina.liakina@santa.lt
Received: June 22, 2022
Peer-review started: June 22, 2022
First decision: August 1, 2022
Revised: August 12, 2022
Accepted: September 21, 2022
Article in press: September 21, 2022
Published online: October 21, 2022
Abstract
BACKGROUND

The coronavirus disease 2019 (COVID-19) was perhaps the most severe global health crisis in living memory. Alongside respiratory symptoms, elevated liver enzymes, abnormal liver function, and even acute liver failure were reported in patients suffering from severe acute respiratory disease coronavirus 2 pneumonia. However, the precise triggers of these forms of liver damage and how they affect the course and outcomes of COVID-19 itself remain unclear.

AIM

To analyze the impact of liver enzyme abnormalities on the severity and outcomes of COVID-19 in hospitalized patients.

METHODS

In this study, 684 depersonalized medical records from patients hospitalized with COVID-19 during the 2020-2021 period were analyzed. COVID-19 was diagnosed according to the guidelines of the National Institutes of Health (2021). Patients were assigned to two groups: those with elevated liver enzymes (Group 1: 603 patients), where at least one out of four liver enzymes were elevated (following the norm of hospital laboratory tests: alanine aminotransferase (ALT) ≥ 40, aspartate aminotransferase (AST) ≥ 40, gamma-glutamyl transferase ≥ 36, or alkaline phosphatase ≥ 150) at any point of hospitalization, from admission to discharge; and the control group (Group 2: 81 patients), with normal liver enzymes during hospitalization. COVID-19 severity was assessed according to the interim World Health Organization guidance (2022). Data on viral pneumonia complications, laboratory tests, and underlying diseases were also collected and analyzed.

RESULTS

In total, 603 (88.2%) patients produced abnormal liver test results. ALT and AST levels were elevated by a factor of less than 3 in 54.9% and 74.8% of cases with increased enzyme levels, respectively. Patients in Group 1 had almost double the chance of bacterial viral pneumonia complications [odds ratio (OR) = 1.73, P = 0.0217], required oxygen supply more often, and displayed higher biochemical inflammation indices than those in Group 2. No differences in other COVID-19 complications or underlying diseases were observed between groups. Preexisting hepatitis of a different etiology was rarely documented (in only 3.5% of patients), and had no impact on the severity of COVID-19. Only 5 (0.73%) patients experienced acute liver failure, 4 of whom died. Overall, the majority of the deceased patients (17 out of 20) had elevated liver enzymes, and most were male. All deceased patients had at least one underlying disease or combination thereof, and the deceased suffered significantly more often from heart diseases, hypertension, and urinary tract infections than those who made recoveries. Alongside male gender (OR = 1.72, P = 0.0161) and older age (OR = 1.02, P = 0.0234), diabetes (OR = 3.22, P = 0.0016) and hyperlipidemia (OR = 2.67, P = 0.0238), but not obesity, were confirmed as independent factors associated with more a severe COVID-19 infection in our cohort.

CONCLUSION

In our study, the presence of liver impairment allows us to predict a more severe inflammation with a higher risk of bacterial complication and worse outcomes of COVID-19. Therefore, patients with severe disease forms should have their liver tests monitored regularly and their results should be considered when selecting treatment to avoid further liver damage or even insufficiency.

Keywords: COVID-19, SARS-CoV-2, Liver enzymes, Complications, Underlying disease, Disease severity

Core Tip: In our study, elevated liver enzymes were detected in 88.2% of patients hospitalized with coronavirus disease 2019 (COVID-19). Alanine aminotransferase and aspartate aminotransferase were elevated by a factor of less than 3 in 54.9% and 74.8% of cases, respectively. Regardless of underlying diseases, including hepatitis, these patients had higher biochemical indices of inflammation, required an O2 supply, and exhibited bacterial pneumonia complications more often than those with normal liver tests. Male gender, older age, diabetes, and hyperlipidemia were confirmed as independent factors associated with a more severe course of COVID-19. All deceased patients (2.9%) had underlying diseases - most often heart disease, hypertension, and urinary tract infections.