COVID-19 Curbside Consults

Hepatic manifestations of COVID-19

Sara El Ouali, MD, Carlos Romero-Marrero, MD and Miguel Regueiro, MD
Cleveland Clinic Journal of Medicine August 2020, DOI: https://doi.org/10.3949/ccjm.87a.ccc061

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Tables

  • TABLE 1

    Approach to elevated liver enzymes in patients with COVID-19

    Elevated liver enzyme levels: general principles

    • Consider etiologies unrelated to COVID-19, including Hepatitis A, B, and C

    • Avoid imaging of the liver unless it is likely to change management, as in the case of suspected venous thrombosis or biliary obstruction

    • Therapies for COVID-19 (including remdesivir or hydroxychloroquine) may increase liver enzymes but are not contra-indicated in patients with baseline abnormal liver tests

    • Regularly monitor liver enzymes in patients hospitalized with COVID-19

    Elevated liver enzyme levels in liver transplant recipients or auto-immune hepatitis

    • Acute cellular rejection or disease flare should not be assumed without biopsy confirmation

    Elevated liver enzyme levels in children

    • Because abnormal liver enzymes are uncommon in children with COVID-19, underlying liver disease or infection should be ruled out

    • Based on information from Fix, et al.1

  • TABLE 2

    Recommendations for outpatient management of patients with decompensated cirrhosis, for liver transplant evaluations, and on a transplant waiting list during the COVID-19 pandemic

    Clinic visits and consultations

    • Continue to prioritize in-person transplant evaluations for patients with hepatocellular carcinoma or severe disease and high MELD scores, who are likely to benefit from immediate liver transplant listing

      • Consider telemedicine or virtual alternatives for less urgent patients

      • Consider developing online education programs and avoid group sessions for patient education

    • Consider using a “COVID-19-free” path through the hospital for transplantation candidates

    Laboratory testing and imaging

    • Obtain labs and imaging only if clinically necessary and do not update labs or imaging simply to update MELD score

    • Obtain SARS-CoV-2 testing for patients with new onset hepatic decompensation

    Medications

    • Ensure refills are available for essential medications

    • Prescribe 90-day supplies instead of 30-day supplies

    SARS-CoV-2 positive patients

    • Have a low threshold for hospitalizing patients on the transplant waiting list who develop COVID-19

    General recommendations

    • Advise patients to avoid in-person community support group meetings and provide virtual alternatives

    • Advise patients to avoid travel during the pandemic

    • MELD = model for end-stage liver disease

    • Based on information from Fix, et al.1

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