Liver injury has fascinated a lot of attention since the outbreak of COVID-19, which might be attributed to pre-existing liver disease, virus infection of liver cells, and certain medications. Although various researchers have studied the effect of virus infection and antiviral drugs on liver injury, the report and diagnosis on chronic liver disease is still inadequate. A recent large cohort study showed that only 1.3% of COVID-19 patients recorded a history of chronic viral hepatitis, which was remarkably lower than the population prevalence in China, a country in which COVID-19 was emerged.

It has been estimated that patients with pre-existing liver disease are a high-risk population for COVID-19. The authors of the present study aimed to determine the clinical course of COVID-19 patients with chronic hepatitis B virus (HBV) infection and offer a reference for clinical treatment of patients.

The study included patients with confirmed COVID-19 and chronic HBV infection were admitted to 2 designated hospitals for COVID-19. Diagnosis of COVID-19 was done by the detection of severe acute respiratory syndrome coronavirus 2 RNA in throat swabs by reverse-transcription polymerase chain reaction in patients from January 24, 2020, to February 29, 2020. Patients with abnormal liver enzyme levels at admission or a history of chronic liver diseases might undergo HBV assays. HBV infection was typified by a positive test result for hepatitis B surface antigen and these patients are classified as hepatitis B virus carriers, chronic hepatitis B, and hepatitis B cirrhosis. Liver injury in the enrolled patients was characterized as any parameter exceeding the upper limit of normal value of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBIL).

The outcome showed that all of the patients had a COVID-19 exposure history. Of the 23 patients, the mean age was 44.7 ± 11.5 years, and had male predominance. A total of 26.1% patients reported a history of being a HBV carrier, 17.4% patients had a history of chronic hepatitis B, but the remaining patients (56.5%) did not have a history of HBV infection. These patients had no other underlying diseases. Nevertheless, laboratory tests at admission showed that 15 patients were HBV carriers, 30.4% had chronic hepatitis B, and 4.4% had hepatitis B cirrhosis.

Approximately 26.0% patients had liver test result deviations, among which 2 patients were HBV carriers, 3 patients had chronic hepatitis B, and 1 patient had hepatitis B cirrhosis at admission. A total of ten patients had increased liver enzyme levels during hospitalization, with AST, ALT, and TBIL ranges of 44 to 277 U/L, 52 to 575.1 U/L, and 17.5 to 309.18 μmol/L, respectively. Although all patients were mild/moderate on admission, 13.0% patients advanced to severe, and 8.7% progressed to critically ill. Among these, 23 patients were treated with antiviral drugs and 13 were treated with liver-protecting drugs and all patients got discharged. The results demonstrated no significant variations in all clinical features except for sex, exposure history, activated partial thromboplastin time, AST, ALT, γ-glutamyl transpeptidase (GGT), TBIL, and direct bilirubin. Moreover, disease severity or length of hospital stay was not different between these 2 groups.

The 5 severe/critically ill patients were admitted to the intensive care unit, 3 needed noninvasive mechanical ventilation and all were treated with corticosteroids. Case A developed deep venous thrombosis, cases B and C developed acute respiratory distress syndrome, and case D developed upper gastrointestinal hemorrhage, liver failure, and renal insufficiency.  The increase in ALT level was remarkably higher than AST, which is the primary indicator of liver injury in COVID-19.The GGT increase was not substantial. Moreover, liver function of the 5 patients could not return be normalized and return to baseline before discharge.

The report and diagnosis on chronic HBV infection has become inadequate due to the emergence of COVID-19, thus, the effect of HBV infection on liver injury might be underestimated. However, most HBV carriers with COVID-19 will not progress to becoming severely or critically ill. Nevertheless, 26% of patients had abnormal liver function test results at admission, among which 19% who were advanced to severely or critically ill, were not correlated to HBV infection status. Therefore, monitoring of liver function in COVID-19 patients with liver test abnormalities at admission is necessary.

Source: Clin Gastroenterol Hepatol. 2020 Oct;18(11):2633-2637.