COVID-19 is a serious infectious disease. It’s caused by the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) virus.
It can spread quickly from one person to another and affects people of all ages. About 40% of people infected with the virus show no symptoms, while others may experience mild or more severe symptoms and complications.¹
Health experts know about some risk factors for severe COVID-19. However, the exact causes of severe cases are still unclear.
People with underlying conditions or diseases are susceptible to complications. If you have liver disease, you probably want to know if you are particularly vulnerable to the virus and how it could affect your treatment options.
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Liver disease makes you more susceptible and at risk of developing more severe COVID-19 effects. The level varies between different liver conditions.
Autopsies of people who had COVID-19 have identified acute liver inflammation.² There have also been COVID cases where otherwise healthy people have presented with acute liver failure.³ This ultimately led to the term COVALI — COVID-19-associated liver injury.
COVID-19 can damage the liver and increase liver enzyme levels, such as alanine transaminase (ALT) and aspartate aminotransferase (AST). This indicates temporary damage to the liver in healthy people. A substantial percentage of COVID-19 patients (up to two-thirds of those with severe COVID) have demonstrated liver injury, indicated by increased transaminase levels.⁴ ⁵
Experts believe the liver is susceptible to the SARS-CoV-2 virus. This is due to angiotensin-converting enzyme 2 (ACE2) receptors in the biliary and liver epithelial cells.⁶ The virus binds to the ACE2 receptors to enter and replicate inside the cell.
Immune responses, hypoxic damage, and vascular changes that occur due to the vascular nature of the SARS-CoV-2 virus may speed up virus-induced liver damage.⁷ The term “vascular” relates to your body’s network of blood vessels.
An international study looked at how COVID-19 impacts people with pre-existing chronic liver disease (CLD) and cirrhosis (scarring of the liver that prevents it from working properly).⁸ Researchers studied data from 759 people with CLD and compared it to people without CLD. Of the 759 CLD patients, 386 had cirrhosis.
32% of participants with cirrhosis died from COVID-19 infection. The likelihood of death increased with cirrhosis severity. Alcoholic liver disease and age were also identified risk factors. Researchers concluded that liver disease stage and alcohol-related liver disease are independent risk factors for COVID-19 mortality.
Furthermore, a meta-analysis by the Centers for Disease Control and Prevention (CDC) found that people who are immunocompromised or have chronic liver disease have a higher risk of COVID-19 complications.⁹ Even milder types of chronic liver disease, such as nonalcoholic fatty liver disease (NAFLD), have been shown to cause a higher risk of severe COVID-19. This risk is unrelated to gender and underlying metabolic syndrome.¹⁰
The CDC research, which included over 900,000 patients, found that those with CLD had 2.45 times the risk of severe COVID-19 and 2.35 times the risk of death compared to those without CLD.
According to research, 14–53% of people diagnosed with COVID-19 experience liver damage.¹¹ That includes people without pre-existing liver disease.
COVID-19-related liver injury can occur due to the toxic effects of the virus on the cells (cytotoxicity), activation of the immune system, drug-related liver damage, pre-existing liver disease being reactivated, or decreased blood flow to the liver (hypoxic hepatitis).
Most cases of liver injury are mild and temporary. People without pre-existing liver disease have a good prognosis. However, people who already have a liver condition when they are diagnosed with COVID-19 are more likely to be hospitalized or pass away.
Those with cirrhosis are believed to be at the greatest risk because they have a dysregulated immune response to the virus.
A study found that in people hospitalized by COVID-19 with NAFLD, acute liver injury rates were about 4%.¹² In people with chronic viral hepatitis, the data clearly demonstrates worse outcomes and hastening of liver disease from COVID-19.¹³ Interestingly, the data also suggests that antiviral therapy against hepatitis may not be effective in patients with viral hepatitis that become infected with SARS-CoV-2 and have a sustained virological response.
Here are some of the complications that may arise from liver damage in people diagnosed with COVID-19:¹⁴
Cirrhosis decompensation (deterioration of liver function due to cirrhosis)
Hepatic encephalopathy (deterioration of brain function caused by the buildup of toxins)
Ascites (buildup of fluid in the abdomen)
The literature is full of cases demonstrating acute liver injury weeks after recuperation from COVID-19 in otherwise healthy people.¹⁵
Multiple studies have revealed damage in multiple organs, including the liver, in up to 70% of people after COVID-19. This statistic is 59% after one year, including in those with mild infections.¹⁶ ¹⁷
More and more evidence is accumulating to show that the virus or remnants of it are found in tissues after recovery from acute COVID-19. This indicates the possibility of “viral reservoirs” in the development of long COVID. The phenomenon of viral reservoirs has been extensively demonstrated in the liver alongside other gastrointestinal organs.¹⁸ Liver damage may therefore continue after you have recovered from acute COVID-19.¹⁹
Research also reports that COVID-19 infection causes fibrosis in the long term that may last for months after diagnosis.²⁰ Liver stiffness indicates fibrosis (thickening or scarring of the liver tissue) or inflammation, which are common in various chronic diseases. These issues may progress to cirrhosis or hepatocellular carcinoma (a type of liver cancer).
One possible explanation for fibrosis may be NAFLD in the context of COVID-19. Recent studies demonstrated increasingly prevalent NAFLD after COVID-19 infection independent of diabetes.²¹
Getting vaccinated and staying up to date on your boosters is the best thing you can do to protect yourself against serious COVID-19 outcomes. This guidance is supported by experts as well as countless studies demonstrating the vaccines’ effectiveness in preventing severe health complications and mortality.²²
Although data demonstrates that COVID-19 vaccines cannot provoke an immune response as effectively in people with chronic liver disease, they still aid in the creation of antibodies in most people.²³ ²⁴
However, some data demonstrates that antibody titers fall early in people with liver cirrhosis.²⁵ You may want to discuss the implications of this with your doctor. They may recommend you receive booster doses of the vaccine more frequently.
Regardless of immune response or antibody levels, studies have repeatedly demonstrated almost 80% lower mortality rates in people who have had the COVID-19 vaccine.²⁶
To aid prevention, you should also wear a well-fitting KN95 mask or respirator with high filtration. The CDC and the World Health Organization (WHO) recommend you wear a mask, particularly in crowded indoor settings. This applies to everyone, regardless of vaccine status.²⁷ ²⁸
You should also try to optimize your liver health by abstaining from alcohol as much as possible, making sure you’re taking your medications properly, and doing enough exercise/losing weight (if you are overweight). You may also want to discuss switching to less immunosuppressive medications with your doctor.
Your doctor may recommend the medications molnupiravir (Lagevrio) or nirmatrelvir/ritonavir (Paxlovid) to help prevent worse outcomes from COVID-19.²⁹ These medications can help reduce symptoms and prevent disease progression.
Tell your doctor that you have liver disease before taking Paxlovid. The US Food and Drug Administration (FDA) advises caution when prescribing Paxlovid to people with pre-existing liver conditions.³⁰ The medication contains both ritonavir and nirmatrelvir. Ritonavir helps keep nirmatrelvir in the blood for longer, which can cause liver issues in extremely rare cases.
According to the WHO, over 13 billion COVID-19 vaccinations have been given globally.³¹ There have been more than 668 million vaccinations given in the US alone.³²
The latest data demonstrates that globally, there have been less than 300 cases of acute liver issues after a COVID-19 vaccination.³³ This indicates that there has been one issue per 400 million vaccine recipients.
Furthermore, correlation does not prove causation. It’s impossible to establish causality with COVID-19 vaccinations. According to UK spontaneous reports of pharmacovigilance (a passive reporting method that relies on healthcare providers making reports and does not establish causality), between December 2020 and May 2021, there were 45 reports of abnormal liver function analysis following COVID-19 vaccinations. There were three presumed drug-induced liver injury reports in people who had the BNT162b2 Pfizer vaccine.³⁴
People with liver disease may develop a severe infection if they catch COVID-19. Below are proven ways to improve liver function.³⁵
Eating a balanced diet
Maintaining a healthy weight
Avoiding using illicit drugs and contaminated needles
Using alcohol responsibly
Practicing safe sex
Washing your hands
Following directions on all medications
Liver disease can increase your susceptibility to the COVID-19 virus and your overall risk of severe illness if you get infected. This is why it’s best to fight liver disease and avoid COVID.
COVID-19 infection is a life-threatening condition. People with underlying liver disease may sometimes have serious complications such as severe liver damage, severe respiratory symptoms, worsening of the disease, and death.
Follow public health recommendations like wearing a mask in public and getting vaccinated. Early detection and getting appropriate treatment can reduce your risk of complications and help you live a longer and healthier life.
Calm before the Storm (2022)
Masks and Respirators | Centers for Disease Control and Prevention
WHO Coronavirus (COVID-19) Dashboard | World Health Organization
United States of America: WHO Coronavirus Disease (COVID-19) Dashboard With Vaccination Data | World Health Organization
13 Ways to a Healthy Liver (2023)