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What to Know About Liver Disease and COVID-19 | by heidi


If you're living with liver disease during the COVID-19 pandemic, you may have many questions about whether you are more susceptible to the disease, if it might be more severe, and how it might alter your current treatment.

Liver disease does carry an increased risk of susceptibility, as well as a risk for more serious outcomes for COVID-19 for some, but this can vary among different liver conditions.

In this article, you'll learn about the potential complications, how your treatments may be affected during the pandemic, and what you should know about receiving the COVID-19 vaccine.

Doctor talking with patient

What Is Chronic Liver Disease?

Chronic liver disease (CLD) includes a wide range of medical conditions of different severity. CLD includes conditions such as:

Chronic hepatitis B and chronic hepatitis C infections

Alcohol-associated liver disease

Nonalcoholic fatty liver disease (NAFLD)

Autoimmune liver disease

Cirrhosis (end-stage liver disease due to any of the above conditions)

Liver cancer

Liver transplant recipients

Some conditions, especially nonalcoholic fatty liver disease, often occur in combination with obesity and/or diabetes—conditions that alone increase the risk of severe disease with COVID-19.

Now that COVID-19 has been around for some time, researchers are learning more about the risks, as well as complications that might be expected with people with chronic liver disease who acquire the virus.

Liver Disease and COVID-19 Risk

When looking at potential risks related to COVID-19 with liver disease, you want to consider your risk of exposure to the virus, susceptibility (risk of infection when exposed), and the risk of developing serious illness if infected with COVID-19.

It's not known exactly whether people living with liver disease are more likely to be exposed to SARS-CoV-2, the virus that leads to the COVID-19 illness, than the general population. It likely depends on the particular liver disease, the amount of time in public needed for visits, scans, and picking up prescriptions, and whether hospitalization may be required.

Susceptibility Risk

Concern about increased susceptibility to COVID-19 for people living with chronic liver diseases was raised when the virus first appeared, as liver disease is associated with both dysfunctions of the immune system and inflammation.1

We now have some data looking at this risk for a few different liver diseases, including:

Hepatitis B and C: For those who have chronic hepatitis B or C, but not cirrhosis, it's unclear whether susceptibility is greater than in the general population. The prevalence of chronic viral hepatitis in people hospitalized with COVID-19 has been relatively low. This may mean having hepatitis B or C may not put you at a significant risk for getting COVID-19.2

Nonalcoholic liver disease: In contrast, a pooled analysis looking at people with nonalcoholic fatty liver disease found increased susceptibility to COVID-19 infection.3

Cirrhosis: In a large study, it was found that people with cirrhosis were less likely to test positive for SARS-CoV-2 than the general population. This is somewhat surprising given the immune effects and inflammation seen with cirrhosis. Other factors, such as increased adherence to prevention measures by people with cirrhosis, could account for some of this difference.4

Liver transplant recipients: People who have had a liver transplant have a significantly higher risk of testing positive for COVID-19 and are thought to be more susceptible to developing the illness. This could be due to immune dysfunction from their underlying condition or immunosuppressive medications used to prevent rejection.5

Risk for Others

If people with liver disease who are on immunosuppressive treatment (such as prednisone) are infected with COVID-19, they may shed the virus (release active viral compounds that can infect others) for longer periods of time. As such, they may need to extend precautions to reduce transmission risk to other, such as being diligent about wearing a mask in public places.6

Risk of Serious Disease

People with liver disease have a greater risk of serious disease from COVID-19 (illness that can lead to hospitalization and death) overall. However, there are some people who are at greater risk than others.

Overall Risk

Two separate reviews of studies have looked at the relative risk of chronic liver disease and disease severity with COVID-19 and found fairly consistent conclusions.

In one review, people with liver disease as a whole had a risk of death that was 1.6 times that of the general population.7 Another meta-analysis (a review that looks at the result of many different studies) found that the risk of death in people with liver disease who were hospitalized with COVID-19 was 1.8 times that of the general population.8

The above studies looked at all causes of death related to COVID-19, but at least one study found that among people who have cirrhosis, their cause of death was a worsening of their underlying liver disease due to COVID-19.9

In looking at averages, however, it's important to keep in mind that there is a wide range of severity in liver disease, and not everyone with liver disease will experience serious outcomes due to COVID-19.

Liver Disease With or Without Cirrhosis

People who have liver disease with cirrhosis do not have good outcomes when they acquire infections. In fact, one study found that 38% of people with cirrhosis who were hospitalized with COVID-19 died. This seemed to be tied to dysfunction of their immune systems.1

Another study compared people with liver disease and cirrhosis to those with liver disease without cirrhosis. The risk of hospitalization in those with liver disease alone was 22.9%, while hospitalization for people with cirrhosis was 50.1%. The presence of cirrhosis was also correlated with 3.31 times greater risk of death over a 30-day period, compared to people with liver disease but no cirrhosis.10

Transplant Recipients

While mortality rates among people who have had a liver transplant appear to be lower than in the general population, study sizes are small and further data is needed.5

Despite this and another study showing no increase in mortality rate, the risk of hospitalization was almost twice as high among liver transplant recipients.11

Factors Associated With Greater Risk

In addition to differences in risk between various liver diseases, people with liver disease are more likely to have a serious COVID-19 outcome if they fit into one or more of the following risk categories:

Advanced age

Current smokers

Hispanic ethnicity

Those who have nausea and vomiting at the time of admission

Those with certain liver diseases, including alcohol-related liver disease, liver cancer, and decompensated (worsened) cirrhosis

A history of some other medical conditions, including diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD) 12

Risk of Long COVID-19

When looking at risks related to COVID-19, it's important to look not only at hospitalizations and mortality, but the risk of long-term problems or "long COVID-19." Physicians who care for people with liver disease are particularly concerned about how COVID-19 may impact the progression of their liver disease.

For COVID-19 survivors who do not have liver disease, significant long-term liver problems have not been seen.13

 Long Covid

While developing COVID-19 can lead to liver-related deaths and complications (see below), the precise impact that COVID-19 has on liver disease progression is still uncertain.14


People with liver disease are not likely to have an increased risk of exposure to COVID-19. However, those with certain conditions, including nonalcoholic fatty liver disease, cirrhosis, and liver transplant recipients, are thought to be more susceptible to infection.

Patients with liver disease are also at a higher risk of developing serious disease (including hospitalization or death) overall. Transplant recipients and those with cirrhosis should be especially careful and take public health measures, such as wearing a mask in public and washing hands frequently, to avoid infection when possible.

Complications of Liver Disease and COVID-19

COVID-19, both the disease and changes in medical care due to the pandemic itself, can lead to direct and indirect complications among those coping with liver disease.

Pandemic-Related Complications

The pandemic has impacted people with liver disease who have not contracted COVID-19 in a number of ways.

With the pandemic still ongoing, it's difficult to quantify the impact of concerns such as missed medical appointments, changes in diet and exercise, and an overall decrease in the diagnosis, treatment, and follow-up for people with liver disease. Increased wait times until liver transplant are likely significant as well.

Overall, several researchers feel that the effect of the pandemic on healthcare for people with liver disease will likely lead to worsening (decompensation) of disease for some and reduced survival for others.15

COVID-19 Related Complications

In people with liver disease, complications of COVID-19 are similar to those experienced by the general population, but liver disease can exacerbate health issues and lead to unique problems.

Effects on the Liver/Liver Complications

The liver has ACE-2 receptors—the receptors the SARS-CoV-2 virus binds to in order to enter cells. Abnormal liver function tests are common with severe COVID-19.

Yet, it's unknown if the virus itself damages liver cells. That said, inflammation associated with infections, a reduced level of blood oxygen (hypoxia) in people who have respiratory failure, the toxicity of medications used to treat COVID-19 may all impact the liver.

Liver problems seen in people with COVID-19 (with or without underlying chronic liver disease) can range from slightly abnormal liver function tests to liver failure.9

Many liver disease complications have been seen in people with liver disease who develop COVID-19. Some of these (and the incidence with severe COVID-19) include:9

Liver decompensation: 36.9%

Ascites or worsening ascites (fluid buildup in the abdominal cavity): 27.2%

Spontaneous bacterial peritonitis (an infection within the abdominal cavity): 2.9%

Hepatic encephalopathy (a condition in which toxins build up in the blood due to liver disease and lead to such complicatons as confusion, disorientation, and difficulties with problem-solving): 16.5%

Bleeding from esophageal varices (bleeding from veins in the esophagus): 1%

People who develop liver decompensation or these other complications have a higher mortality rate with COVID-19.

In one study, causes of death from COVID-19 in people who had cirrhosis included:16

Lung disease (78.8%)

Liver-related causes (12.2%)

Heart-related causes (4.3%)17

Pneumonia and Respiratory Failure

People with liver disease may develop pneumonia and respiratory failure similar to the general population. It's recommended that intensive care treatment and mechanical ventilation be offered if needed, just as with those without liver disease or cirrhosis.18

Late Complications

COVID-19 can worsen liver disease while the person has the infection, but little is known whether there is long-term worsening of the disease or whether medications used to treat COVID-19 can cause long-term liver toxicity. There are potential long-term complications, however, related to the liver and the system involved in the production and transportation of bile.

A late complication that has been seen in some people with liver disease and COVID-19 is cholangiopathy. Cholangiopathy is a condition in which the bile ducts are damaged due to insufficient blood flow. It's not known how often this occurs, but in one study, 12 out of 2047 people with severe COVID-19 developed the complication.19

This condition may not occur during COVID-19 infection and should be monitored for months after recovery. The average time to cholangiopathy after COVID-19 infection was 118 days. Treatment may involve liver transplantation and supportive care.20


Severe COVID-19 can worsen liver disease during the infection. This may lead to complications such as liver failure or a buildup of fluid in the abdominal cavity. Damage to the bile ducts is a rare complication that should also watched for.

Liver Disease Treatments and COVID-19

If you're taking the following medications for liver disease, you may be wondering how your treatment could be affected by the pandemic in general, as well as if you contract COVID-19.

Liver treatments

Corticosteroid medications: For people who have autoimmune liver disease, corticosteroids such as prednisone are often a mainstay of treatment to reduce or stop a flare-up, but these medications have immunosuppressive effects. At the current time, it's recommended that these meds be continued, but at the lowest dose possible to control your liver disease. These medications should not be discontinued abruptly.

Immunosuppressive medications: For those with autoimmune liver disease, the dose of immunosuppressive medications such as Imuran (azathioprine) should generally not be changed. People who have had a liver transplant and are receiving medications such as Myfortic (mycophenolate) but do not have COVID-19 should also continue with the meds to prevent rejection.

Hepatitis B and C treatments: If someone has already been on medications to treat hepatitis B or C, they should continue taking the drugs. Whether these treatments should be started, however, depends on how many cases of COVID-19 are currently occurring in the community. When cases are high, holding off on starting hepatitis C treatment (and hepatitis B treatment unless someone is having a flare) may be wise, as medications can increase susceptibility to COVID-19.

Liver monitoring: People with liver diseases may be monitored on a regular basis to watch for the development of cirrhosis or liver cancer. For the most part, monitoring should be continued, but visits can be delayed 2 months if the incidence of COVID-19 in the community is high.

Transplant candidates: Those who have severe liver disease and high MELD scores (a measure of liver failure progression) should continue to undergo evaluation for a liver transplant.21

COVID-19 Treatments

For people with liver disease who develop COVID-19, there are now a number of recommendations for treatment.

Because the infection may lead to liver decompensation, liver function tests (ALT and AST) should be monitored regularly, especially if medications that have potential liver toxicity are also being used.

Since COVID-19 can lead to abnormal liver function tests, however, it's important for doctors and patients not to immediately assume the abnormality is due to worsening liver disease. For example, if someone has had a liver transplant and has an increase in liver enzymes, a biopsy (removal of a small tissue sample to be tested) should be done to see if it is rejection vs. effects of COVID-19.

Below are some of the recommendations for people with liver disease who acquire COVID-19. It's important to keep in mind that these are general recommendations meant to cover a wide variety of people with differing liver dysfunction. For that reason, your doctor may make recommendations for you that are different.

General treatments: For symptoms such as pain or fever, the preferred treatment is Tylenol (acetaminophen) even though it is metabolized by the liver. Nonsteroidal anti-inflammatory medications such as Advil (ibuprofen) may also be used.

Corticosteroids: If people are on high-dose prednisone, consideration should be given to minimizing the dose (but being careful not to lower the dose too much and create adrenal insufficiency, a condition where the adrenal glands can't produce enough of the hormone cortisol). For those who are not on prednisone/prednisolone, caution should be taken in initiating treatment. (There are settings where there may be a clearer benefit such as with alcohol-associated liver disease).2122

Immunosuppressive medications: Consideration should be given to reducing the dose of medications such as calcineurin inhibitors, azathioprine or mycophenolate, especially with a fever, low white blood cell count, or pneumonia. However, if strong symptoms of rejection develop in liver transplant recipients during COVID-19 treatment, immunosuppressive therapy may be started.21

Antiviral therapies: Medications such as remdesivir may be considered even though they can have liver toxicity. A rough cutoff is to hold off on these drugs unless AST or ALT levels are more than 5 times the upper limit.23

Note: There are a number of drug interactions between medications used for some liver diseases and antivirals used for COVID-19. Using these drugs will need to be carefully evaluated by your healthcare team.21

COVID-19 in Liver Transplant Recipients

If a liver transplant patient develops COVID-19, withdrawal or reduction of immunosuppressive medications may not be needed. But if reducing meds is necessary, the outcome can still be positive. A multicenter study looking at people with liver transplants found that, even when immunosuppression was reduced during COVID-19, it did not appear to increase the risk of either organ failure or mortality.24

 COVID-19 Treatments


Treatments for liver disease should mostly be continued throughout the pandemic unless otherwise directed by your healthcare provider. If you do contract COVID-19, your healthcare provider will advise you on the best course of treatment. This may include whether to reduce or stop certain treatments like corticosteroids or immunosuppressant medications, to improve your prognosis.