COVID-19-induced liver injury in infants, children, and adolescents

Abstract

Coronavirus disease 2019 (COVID-19) typically presents with fever and respiratory symptoms in children. Most children develop an asymptomatic and mild illness, with a minority requiring specialist medical care. Gastrointestinal manifestations and liver injury can also occur in children following infection. The mechanisms of liver injury may include infection following direct viral hepatic tissue invasion, immune response, or medication effects. Affected children might develop mild liver dysfunction which has a benign course in most children with no pre-existing liver disease. However, the presence of non-alcoholic fatty liver disease or other pre-existing chronic liver disorders is associated with a higher risk of developing severe COVID-19 illness with poor outcomes. On the other hand, the presence of liver manifestations is associated with the severity of COVID-19 disease and is considered an independent prognostic factor. Respiratory, hemodynamic, and nutritional supportive therapies are the mainstay of management. Vaccination of children at increased risk of developing severe COVID-19 disease is indicated. This review describes the liver manifestations in children with COVID-19, detailing its epidemiology, basic mechanisms, clinical expression, management, and prognosis in those with and without pre-existing liver disease and also children who have had earlier liver transplantation.

Keywords: Child; COVID-19; Gastroenterology; Hepatic dysfunction; Infection; Liver diseases; SARS-CoV-2; Liver injury; Liver transplant

Core Tip: Liver injury presenting with elevated levels of alanine aminotransferase and aspartate aminotransferase is common in children infected with the coronavirus disease 2019 (COVID-19) virus. The mechanism of liver injury is not fully understood and is likely secondary to the viral invasion of the liver, hepato-toxic medications, and the patient’s own immune-mediated response. Liver injury in children is generally mild and resolves spontaneously but is usually seen in children with more severe illnesses. In addition, children with underlying non-alcoholic fatty liver disease or another chronic liver disease may have a higher risk of severe COVID-19 illness. Management of liver injury after COVID infection is supportive. Proactive vaccination may reduce the transmission of infection and the severity of the disease.