Coronavirus disease 2019 (COVID-19) has been associated with acute liver injury manifested by increased liver enzymes in reports worldwide. Prevalence of liver injury and associated clinical characteristics are not well-defined. We aim to identify the prevalence of and risk factors for development of COVID-19 associated acute liver injury in a large cohort in the United States.
In this retrospective cohort study, all patients who underwent SARS-CoV-2 testing at three hospitals in the NewYork-Presbyterian network were assessed. Of 3381 patients, 2273 tested positive and had higher initial and peak ALT than those who tested negative. Acute liver injury was categorized as mild if alanine aminotransferase (ALT) was > upper limit of normal (ULN) but five times ULN. Among patients who tested positive, 45% had mild, 21% moderate, and 6.4% severe liver injury. In multivariable analysis, severe acute liver injury was significantly associated with elevated inflammatory markers including ferritin (OR 2.40, p<0.001) and IL-6 (OR 1.45, p=0.009). Patients with severe liver injury had a more severe clinical course, including higher rates of ICU admission (69%), intubation (65%), renal replacement therapy (33%), and mortality (42%). In multivariable analysis, peak ALT was significantly associated with death or discharge to hospice (OR 1.14, p=0.044), controlling for age, body mass index, diabetes, hypertension, intubation, and renal replacement therapy.
Acute liver injury is common in patients who test positive for SARS-CoV-2, but is most often mild. However, among the 6.4% of patients with severe liver injury, a severe disease course should be anticipated.

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