Abnormal Liver Tests in COVID-19: A Retrospective Observational Cohort Study of 1827 Patients in a Major U.S. Hospital Network.

Abnormal Liver Tests in COVID-19: A Retrospective Observational Cohort Study of 1827 Patients in a Major U.S. Hospital Network.

Publication date: Jul 29, 2020

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, is associated with significant morbidity and mortality due to pneumonia, acute respiratory distress syndrome (ARDS) and multiorgan failure. Liver injury has been reported as a non-pulmonary manifestation of COVID-19 but characterization of liver test abnormalities and their association with clinical outcomes is incomplete. We conducted a retrospective cohort study of 1827 patients with confirmed COVID-19 who were hospitalized within the Yale-New Haven Health System (YNHHS) between March 14, 2020 and April 23, 2020. Clinical characteristics, liver tests (AST, ALT, ALP, TBIL, albumin) at three time points (pre-infection baseline, admission, peak hospitalization), and hospitalization outcomes (severe COVID-19, ICU admission, mechanical ventilation, death) were analyzed. Abnormal liver tests were commonly observed in hospitalized patients with COVID-19, both at admission (AST 66.9%, ALT 41.6%, ALP 13.5%, TBIL 4.3%) and peak hospitalization (AST 83.4%, ALT 61.6%, ALP 22.7%, TBIL 16.1%). Most patients with abnormal liver tests at admission had minimal elevations 1-2x ULN (AST 63.7%, ALT 63.5%, ALP 80.0%, TBIL 75.7%). A significant proportion of these patients had abnormal liver tests pre-hospitalization (AST 25.9%, ALT 38.0%, ALP 56.8%, TBIL 44.4%). Multivariate analysis revealed an association between abnormal liver tests and severe COVID-19, including ICU admission, mechanical ventilation, and death; associations with age, male gender, BMI, and diabetes mellitus were also observed. Medications used in COVID-19 treatment (lopinavir/ritonavir, hydroxychloroquine, remdesivir, and tocilizumab) were associated with peak hospitalization liver transaminase elevations >5x ULN. Conclusion: Abnormal liver tests occur in most hospitalized patients with COVID-19 and may be associated with poorer clinical outcomes.

Concepts Keywords
Albumin Pre infection
ARDS Mechanical ventilation
AST Medical specialties
BMI Clinical medicine
Cohort Hepatology
Diabetes Mellitus Glutamate
Gender Atypical pneumonias
Hepatology Coronavirus disease
Hydroxychloroquine Liver function tests
Infection Elevated transaminases
Liver Hepatitis
Mechanical Ventilation Alanine transaminase
Multiorgan Failure
New Haven


Type Source Name
disease MESH pneumonia
disease MESH acute respiratory distress syndrome
disease MESH abnormalities
disease MESH infection
disease MESH death
disease MESH diabetes mellitus
drug DRUGBANK Lopinavir
drug DRUGBANK Ritonavir
drug DRUGBANK Hydroxychloroquine
drug DRUGBANK Tocilizumab
disease MESH hepatitis

Original Article