COVID-19 and Liver Disease Patients

Dr. Govarthanan Rajendiran Hepatologist Sioux Falls, SD

Dr. Govarthanan Rajendiran is a hepatologist practicing in Sioux Falls, SD. Dr. Rajendiran specializes in the study of body parts such as the liver, the biliary tree, the gallbladder and the pancreas. Hepatologists manage disorders in these areas and are specifically known for treating viral hepatitis. Patients who have... more

In December 2019, an outbreak of a novel coronavirus (SARS-CoV-2) started in Wuhan, China. (1)  It was named COVID-19, and the abbreviation is ‘CO’ for ‘corona,’ ‘VI’ for ‘virus,’ ‘D’ for ‘disease” and ‘19’ represents ‘the year when the outbreak started.’ It has spread worldwide and resulted in a pandemic, which is unprecedented in terms of its impact on physical, mental, and economic welfare.  At the time of writing this article, the number of COVID-19 cases was almost 2 million worldwide, and roughly 128,000 deaths were attributed to it.

In the United States, there were 614,180 confirmed cases, and approximately 26,000 deaths were have been reported. The incubation period is thought to within 14 days following exposure, and most cases present within 4 - 5 days of exposure. Person to person spread occurs mainly via respiratory droplets when an infected person coughs, sneezes, or talks, similar to the spread of influenza. There are other modes of transmission that are considered possible routes but yet to be confirmed. Initial symptoms are fever, fatigue, cough, body aches, and shortness of breath. (1,2,3)

It is widely reported that patients with chronic disease are at high risk for severe illness from the COVID-19 infection, so there is a lot of concern among chronic liver disease and liver transplant patients.  Of all the chronic liver disease conditions, patients with an autoimmune liver condition or post-liver transplant on immunosuppressive treatment can be considered high risk. This virus binds to target cells through angiotensin-converting enzyme 2 (ACE2), which is abundant on the liver and biliary epithelial cells, so the liver is considered a potential target for infection. Up to 11% of the patients with COVID-19 infection had co-morbid liver conditions, and abnormal levels of liver enzymes (ALT and AST) were noticed in 14-53% of cases during disease progression.

In mild cases, the liver enzyme elevation was transient and improved without any treatment. In patients with severe COVID-19 disease, higher rates of liver dysfunction were seen. In critically ill COVID-19 patients, liver injury or failure is suspected secondary to multiple factors like inflammatory cytokines, hypoxia, hypotension, and toxicity from the medications. There is no clear evidence that the virus causes direct injury to the liver. (1,3) There is a global effort to assess the impact of COVID-19 on liver and healthcare providers are highly encouraged to report all COVID-19 patients with chronic liver disease on any stage and post-liver transplant, regardless of the severity of the infection.  There are two registries – SECURE-Cirrhosis and COVID-HEP – and the links are listed in the reference. (4,5) 

Since this pandemic is rapidly evolving, and there is no proven treatment or vaccine, prevention is the key. Liver disease patients should follow measures that are recommended to reduce the transmission of infection. Diligent hand washing, use of hand sanitizer, cover the cough/sneeze, wearing a facemask in public, and social distancing (at least 6 feet away from other person or staying home as much as possible) are widely accepted methods. Avoid crowds and close contact with ill individuals. Otherwise, continue the current treatment for your liver condition.  Self-discontinuing medications can be detrimental as it can lead to a flare-up of the native liver condition or rejection of the transplanted liver. If you have any specific question, then it is better to discuss with your healthcare team. (3,6)


  1. Zhang CShi LWang FS. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol. 2020 May;5(5):428-430.
  2. Guan WJNi ZYHu YLiang WHOu CQHe JX et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032. [Epub ahead of print]
  3. AASLD: Clinical insights for hepatology and liver transplant providers during the COVID-19 pandemic.
  4. SECURE-Cirrhosis Registry -
  5. COVID-HEP Registry -
  6. Centers for Disease Control and Prevention. Strategies to Prevent the Spread of COVID-19 in Long-Term Care Facilities (LTCF).