ALT/AST Elevation Associated With Increased Risk of Adverse COVID-19-Related Outcomes

torso with liver highlighted in red
3D Illustration of Human Body Organs Anatomy (Liver with nervous system)
Investigators analyzed the liver biochemistries of patients infected with different human coronaviruses.

Elevations of alanine aminotransferase (ALT)/aspartate aminotransferase (AST) associated with acute liver injury and the use of lopinavir–ritonavir may increase the risk of adverse clinical outcomes in patients with the novel coronavirus disease 2019 (COVID-19), a study in Gut suggests.

This retrospective cohort study included 1040 patients with COVID-19 (mean age, 38 years), 1670 patients infected by severe acute respiratory syndrome (SARS) (mean age, 44 years), and 675 patients infected by other human coronaviruses (HCoVs) (mean age, 20 years) included in a Hong Kong territory-wide database.

Researchers assessed ALT/AST elevations, defined as ALT/AST levels reaching ≥2 times the upper limit of normal. The composite primary endpoint included intensive care unit (ICU) admission, use of invasive mechanical ventilation, and/or death.

Elevations in ALT/AST were found in 50.3% of patients with SARS, 22.5% of patients with COVID-19, and 36.0% of patients with other HCoVs. In the COVID-19 cohort, approximately 5.1% (n=53) of patients were admitted to the ICU, 2.1% (n=22) of patients received invasive mechanical ventilation, and 0.4% (n=4) died.

Elevation in ALT/AST was significantly and independently associated with the primary composite endpoint in an analysis adjusted for albumin, diabetes, and hypertension (adjusted odds ratio [aOR], 7.92; 95% CI, 4.14-15.14; P <.001).

The use of lopinavir–ritonavir with or without ribavirin and interferon beta was independently associated with ALT/AST elevation in patients with COVID-19 (aOR, 1.94; 95% CI, 1.20-3.13; P =.006). The use of corticosteroids was also associated with ALT/ AST elevation in these patients (aOR, 3.92; 95% CI, 2.14-7.16; P <.001).

Limitations of this study included its retrospective design, which may have resulted in missing laboratory measurements, as well as the reliance on diagnostic coding for identifying patients with COVID-19, SARS, and other HCoVs.

The researchers note that physicians should perform careful monitoring of liver biochemistries and to carefully prescribe medications with the least hepatotoxicity. They add that this may ultimately minimize liver injury in patients with COVID-19.

The investigators concluded that “in case of progressive liver injury, thorough review of medical history and detailed investigation for concomitant liver diseases are crucial to improve patient outcomes.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Yip TC, Lui GC, Wong VW, et al. Liver injury is independently associated with adverse clinical outcomes in patients with COVID-19. Gut. 2021;70(4):733-742. doi: 10.1136/gutjnl-2020-321726