Long Covid, Uncertain Liver Recovery

By Karina Zaragoza
Article Published: September 10, 2021

Long COVID-19 might pose as long and uncertain threat to the recovery of liver damage. 

A new medical condition has surfaced out of the pandemic which is becoming more prevalent in some COVID-19 survivors.  These patients are traversing through a post-COVID recovery that appears to be a range of new, returning, or ongoing health problems for weeks or months after being infected with the virus. According to the CDC, these post-COVID conditions are also known as long COVID, long-haul COVID, post-acute COVID-19, long-term effects of COVID, or chronic COVID.

The COVID-19 virus has been shown to affect multiple organs and systems such as the heart, kidneys, liver, nervous system, and blood system. Given that the liver is a target of the COVID-19 virus, there is great interest in patients with NAFLD to see if they experience a higher risk of severe conditions and mortality rate.  In general, these patients also have other systemic diseases (kidney disease, diabetes, vascular, for example) which could also contribute to more severe COVID-19 infections.

A main concern with people with pre-existing health issues, including liver disease, is that they are thought to be more vulnerable to the virus and may be more likely to have a serious infection. The true impact of the virus is not fully known, and data is being studied to help understand post-COVID recovery. It is important to understand that one published study does not necessarily validate any finding, as it is just one data point.  To validate a finding into a theory is to have multiple studies pointing in the same direction.  

Given this is a new pandemic, it will take more time and more science to have a complete understanding of the post recovery impact.  In one study in the Int J Med Sci. (An, Y, et al., 2021), scientists looked at discharged COVID-19 patients and followed them for more than two months.  These 253 discharged COVID-19 patients were recruited from the Shenzhen Samii Medical Center in Shenzhen City, China. As controls 152 healthy people that have never been infected underwent the same liver function tests during their follow-ups.  Liver injury during hospitalization was characterized by abnormalities in ALT and AST levels, as well as serum hepatic function indicators.

The scientists did a thorough analysis of the post-COVID patients and overall found that chronic liver disease, especially fatty liver, may increase the risk of severe COVID-19 disease.  The link to the published article is below, for more details on the study.   The patients had their ALT, GGT and ALP levels significantly higher than the control group.  Additionally, their levels of TP, ALB, A/G and AST/ALT in patients were significantly lower than those of the control group.  The initial result showed that the liver function had not been restored within approximately 1 week (7.5 ± 3.5 days) from the time of discharge. 

To understand the longer-term clinical affects, 46 of the 253 patients with COVID-19 underwent further testing from 14 days to 2 months. It took some patients around 40 days to recover some of the biomarker ratios, however continued intervention and medical treatment were necessary. The increased levels of liver enzymes — such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST) means a person’s liver is, at least, temporarily damaged during their illness. Depending on the severity of pre-existing liver disease (chronic liver disease, cirrhosis, or related complications), those who were hospitalized [in this study] with COVID-19 were at higher risk of death than people without pre-existing liver disease. 


Another study by Forlano, et al., looked at consecutive adult patients admitted and diagnosed with COVID-19 at Imperial College Healthcare NHS Trust (London, United Kingdom) between the 25th February 2020 and the 5th April 2020. The study was retrospective and NAFLD was diagnosed based on imaging or past medical history.  This was an interesting paper since it reported that the presence of NAFLD per se was not associated with adverse outcomes in their cohort of hospitalized COVID-19 positive patients, and the presence of advanced liver disease was not associated with adverse outcomes in the NAFLD population.

Regardless of the number of metabolic risk factors (type-2 diabetes, hypertension and dyslipidaemia) there was no difference between NAFLD and non-NAFLD patients in terms of clinical observations, including admissions to ICU and in-hospital mortality. In this patient cohort the main risk of sever outcomes leading to death was respiratory failure due to COVID-19 induced pneumonia. 

Interestingly, most of the NAFLD patients who died had an enhanced inflammatory response.  These patients were male and presented higher inflammatory markers (ferritin, PT and LDH) compared to NAFLD patients who survived. The author did report that there was no difference in terms of liver function tests between the two groups, suggesting that liver injury was not a discriminant factor in this population.

Since COVID-19 is still a new illness, there is much to learn about it. These are just two studies which are looking into the connection of NAFLD and COVID-19.  Further studies will need to explore much more data and clinical observations to determine predictors of outcome in NAFLD patients hospitalized with COVID-19.  Our strongest recommendation is to avoid the virus, as much as possible and not become one of these statistics.  The best way to do so is to follow our health professional’s advice of getting vaccinated, wearing a mask in public spaces, and distancing as much as possible. 




An, Ya-Wen, et al., Liver function recovery of COVID-19 patients after discharge, a follow-up study. Int J Med Sci. 2021; 18(1): 176–186.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738966/

Forlano R., et al., In-hospital mortality is associated with inflammatory response in NAFLD patients admitted for COVID-19. PLoS ONE 15(10): e0240400. https://doi.org/10.1371/journal.pone.0240400

Sachdeva S., NAFLD and COVID-19: a Pooled Analysis. SN Compr Clin Med. 2020 Nov 6 : 1–4. doi: 10.1007/s42399-020-00631-3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646222/

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