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World J Gastroenterol. Apr 28, 2023; 29(16): 2397-2432
Published online Apr 28, 2023. doi: 10.3748/wjg.v29.i16.2397
SARS-CoV-2 induced liver injury: Incidence, risk factors, impact on COVID-19 severity and prognosis in different population groups
George D Liatsos
George D Liatsos, Department of Internal Medicine, Hippokration General Hospital, Athens 11527, Attiki, Greece
Author contributions: George D Liatsos wrote, edited, and revised the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: Https://
Corresponding author: George D Liatsos, MD, PhD, Chief Doctor, Department of Internal Medicine, Hippokration General Hospital, Vassilisis Sofias 114, TK 11527, Athens 11527, Attiki, Greece.
Received: October 31, 2022
Peer-review started: October 31, 2022
First decision: February 2, 2023
Revised: February 17, 2023
Accepted: April 7, 2023
Article in press: April 7, 2023
Published online: April 28, 2023
Core Tip

Core Tip: Following respiratory system, liver is the second most involved organ in coronavirus disease 2019 (COVID-19). Besides the well-observed cholangiocyte tropism, typical severe acute respiratory distress syndrome corona virus-2 (SARS-CoV-2) Lesions indicated by ultrastructural and histological evidence, identification of replicating SARS-CoV-2, S and nucleocapsid proteins RNAs within hepatocytes, as well as intrahepatic virus observation by electron microscopy and in-situ hybridization, converge to the conclusion that SARS-CoV-2 may also be hepatotropic. Most prevalent mechanisms of COVID-19-related liver injury are hypercytokinemia with “bystander hepatitis”, cytokine storm syndrome with subsequent oxidative stress, endotheliopathy and immuno-thromboinflammation. Depending on the grade of their abnormalities, increased serum aspartate aminotransferase, (mostly peak) alanine aminotransferase, alkaline phosphatase, total bilirubin, inflammatory markers (C-reactive protein, ferritin, interleukin-6, -10) and decreased albumin levels are independent discriminators of COVID-19 severity and mortality. Age, male gender, chronic liver disease, liver cirrhosis, obesity, diabetes, and non-alcoholic fatty liver disease are independent prognostic factors of unfavorable COVID-19 outcomes.