Study findings updated . AI-assisted evidence summary, not individual medical advice or a clinician endorsement.
THE SHORT VERSION
What’s worth knowing.
The key findings, what they mean, and the context that matters.
THE HEADLINE TAKEAWAY17.4 vs 13.4 expected2021 death rate per 100,000 with alcohol-related liver disease, vs predicted
Deaths with alcohol-related liver disease soared above trend during the pandemic.
Deaths among people with alcohol-related liver disease were rising 3.5% a year in 2010-2019, then 17.6% a year in 2020-2021. By 2021 the age-adjusted death rate was 17.42 per 100,000, against 13.41 predicted from the earlier trend. The steepest climb hit adults aged 25-44: 34.6% a year.
It means the pandemic hurt livers in ways beyond the virus itself, and the sharpest rise came among young adults, a group with many years of life at stake. Observational analysis of US death records through 2021; the authors say much of the rise was not directly due to COVID infection, and the data cannot show why deaths rose.
See the evidence
An analysis of 626,090 liver-disease-related deaths in national US death records from 2010 to 2021, comparing pandemic years with the earlier trend.
From the study: “Age-standardised mortality rates (ASMRs) for ALD dramatically increased between 2010-2019 and 2020-2021 (annual percentage change [APC] 3.5% to 17.6%, p <0.01)”
17.4 vs 13.4 expected
Gao X et al. Impact of the COVID-19 pandemic on liver disease-related mortality rates in the United States. Journal of hepatology. 2023.
From the study: “The ASMR rise for ALD was particularly severe for the 25-44 age group (APC: 34.6%, vs. 13.7% and 12.6% for 45-64 and ≥65, all p <0.01)”
17.4 vs 13.4 expected
Gao X et al. Impact of the COVID-19 pandemic on liver disease-related mortality rates in the United States. Journal of hepatology. 2023.
Cirrhosis patients testing COVID-positive died more often within a month.
8.9% vs 3.9% diedDeaths within 30 days in cirrhosis: tested positive vs negative for the COVID virus
Among people with cirrhosis (severe liver scarring), 8.9% of those who tested positive for the COVID virus died within 30 days, vs 3.9% of those who tested negative. After adjustment, a positive test was linked to 2.38 times the hazard (moment-to-moment risk) of death. Among infected people with liver disease, cirrhosis itself was linked to 3.31 times the hazard.
For someone with cirrhosis, catching COVID was tied to a sharply higher chance of dying within weeks, compared with similar patients who did not catch it. It marks people with scarred livers as a group to protect. Observational US health-records study through July 2021 (hazard ratios); the authors note the test-negative comparison group was likely sicker than typical cirrhosis patients.
See the evidence
A study of 220,727 adults with chronic liver disease tested for COVID in a national US health-records collaborative, with data through mid-2021.
From the study: “Thirty-day all-cause mortality rates were 3.9% in cirrhosis/negative and 8.9% in cirrhosis/positive patients.”
8.9% vs 3.9% died
Ge J et al. Outcomes of SARS-CoV-2 Infection in Patients With Chronic Liver Disease and Cirrhosis: A National COVID Cohort Collaborative Study. Gastroenterology. 2021.
From the study: “Compared to cirrhosis/negative patients, cirrhosis/positive patients had 2.38 times adjusted hazard of death at 30 days.”
8.9% vs 3.9% died
Ge J et al. Outcomes of SARS-CoV-2 Infection in Patients With Chronic Liver Disease and Cirrhosis: A National COVID Cohort Collaborative Study. Gastroenterology. 2021.
From the study: “Compared to noncirrhosis/positive patients, cirrhosis/positive patients had 3.31 times adjusted hazard of death at 30 days.”
8.9% vs 3.9% died
Ge J et al. Outcomes of SARS-CoV-2 Infection in Patients With Chronic Liver Disease and Cirrhosis: A National COVID Cohort Collaborative Study. Gastroenterology. 2021.
Vaccinated cirrhosis patients had 100% protection from COVID hospitalization or death.
100% protectionAgainst COVID hospitalization or death, 28+ days after one mRNA dose
People with cirrhosis given an mRNA vaccine were compared with matched unvaccinated patients. Infections were similar for the first 28 days after dose one. After that, one dose was linked to 64.8% fewer infections and 100% protection against COVID hospitalization or death; two doses, to 78.6% fewer infections. Infection protection was weaker in more advanced cirrhosis.
Vaccines worked where it counted most for people with scarred livers: keeping them out of the hospital and alive. The catch was a slow start, with weeks of little protection after the first shot. Observational study of US veterans (97% men, median age 69) vaccinated December 2020 to March 2021; it cannot prove the vaccines caused the difference.
See the evidence
A Veterans Health Administration records study matching 20,037 vaccinated patients with cirrhosis to 20,037 similar unvaccinated patients.
From the study: “After 28 days, receipt of 1 dose of an mRNA vaccine was associated with a 64.8% reduction in COVID-19 infections and 100% protection against hospitalization or death due to COVID-19 infection.”
100% protection
John BV et al. Association of BNT162b2 mRNA and mRNA-1273 Vaccines With COVID-19 Infection and Hospitalization Among Patients With Cirrhosis. JAMA internal medicine. 2021.
From the study: “Receipt of a second dose was associated with a 78.6% reduction in COVID-19 infections and 100% reduction in COVID-19-related hospitalization or death after 7 days.”
100% protection
John BV et al. Association of BNT162b2 mRNA and mRNA-1273 Vaccines With COVID-19 Infection and Hospitalization Among Patients With Cirrhosis. JAMA internal medicine. 2021.
From the study: “The number of COVID-19 infections in the vaccine recipients was similar to the control group in days 0 to 7, 7 to 14, 14 to 21, and 21 to 28 after the first dose.”
100% protection
John BV et al. Association of BNT162b2 mRNA and mRNA-1273 Vaccines With COVID-19 Infection and Hospitalization Among Patients With Cirrhosis. JAMA internal medicine. 2021.
AAV2, not the COVID virus, turned up in children with mystery hepatitis.
93% vs 3.5%Mystery-hepatitis children carrying AAV2 virus in blood vs comparison patients
In young children with severe hepatitis of unknown cause, a virus called AAV2 (adeno-associated virus 2) was found in the blood of 93% of cases (13 of 14), vs 3.5% of 113 comparison patients. The COVID virus was not detected in blood from cases or comparison patients. The authors suspect more than 2 years of school and childcare closures left children with less immunity to common viruses.
It suggests the 2022 scare was not COVID attacking children's livers directly but a pile-up of other viral infections, which the authors tie to the pandemic only indirectly, through missed exposure to everyday germs. A small case-control study of 14 tested cases, all positive for adenovirus; it shows an association, not proof AAV2 caused the illness, and the closures idea is untested.
See the evidence
A genetic search for viruses in blood and liver samples from 16 US children with unexplained severe hepatitis (October 2021 to May 2022), compared with 113 controls.
From the study: “In blood from 14 cases, adeno-associated virus type 2 (AAV2) sequences were detected in 93% (13 of 14), compared to 4 (3.5%) of 113 controls (P < 0.001)”
93% vs 3.5%
Servellita V et al. Adeno-associated virus type 2 in US children with acute severe hepatitis. Nature. 2023.
From the study: “We postulate that the COVID-19 pandemic and more than 2 years of school and childcare closures and decreased social interactions with other children may have generated a vulnerable population”
93% vs 3.5%
Servellita V et al. Adeno-associated virus type 2 in US children with acute severe hepatitis. Nature. 2023.
Most COVID liver injury had cleared about two months after discharge.
77% back to normalSevere-injury patients with normal liver tests ~2 months post-discharge; 82% if mild
Among hospitalized COVID patients whose liver enzyme ALT rose (a sign of liver injury), most had not recovered by discharge: only 17.1% of severe and 33.5% of mild cases had. But of those who returned for tests about 2 months later, 76.7% of severe and 82.4% of mild cases had fully normal results.
Abnormal liver tests during a COVID hospital stay usually seem to be temporary. But since most patients still had abnormal results when they went home, a later recheck is how doctors can tell who has healed. One Bronx health system, 2020-2021, excluding people with prior liver disease; only 20.3% to 23.7% of injured patients returned for tests, so results may not reflect everyone.
See the evidence
A records study of 7,595 COVID patients hospitalized in the Montefiore Health System in New York from March 2020 to June 2021.
From the study: “Of those returned, 82.4% of mLI and 76.7% of sLI patients post discharge showed complete recovery”
77% back to normal
Lu JY et al. Clinical predictors of recovery of COVID-19 associated-abnormal liver function test 2 months after hospital discharge. Scientific reports. 2022.
From the study: “Most ALI patients (76.7-82.4%) recovered completely ~ 2 months post-discharge.”
77% back to normal
Lu JY et al. Clinical predictors of recovery of COVID-19 associated-abnormal liver function test 2 months after hospital discharge. Scientific reports. 2022.
From the study: “Only 33.5% of mLI and 17.1% of sLI patients (survivors) recovered completely at hospital discharge.”
77% back to normal
Lu JY et al. Clinical predictors of recovery of COVID-19 associated-abnormal liver function test 2 months after hospital discharge. Scientific reports. 2022.
Hepatitis C testing and treatment plunged in the pandemic's early months.
38% fewer prescriptionsHepatitis C treatment prescriptions, July 2020 vs 2018-2019; down 43% in May
Compared with the same months of 2018 and 2019, hepatitis C antibody tests fell 59% in April 2020 and were back to 6% below normal by July. But prescriptions for hepatitis C treatment fell 43% in May and were still 38% lower in July, and confirmed active infections found stayed 39% below baseline.
Hepatitis C can be cured, but only once it is found. Every missed test or delayed prescription can leave an infection quietly damaging the liver and able to spread to others. National US lab and pharmacy data covering January to July 2020; it counts tests and prescriptions, not later illness in the people who missed care.
See the evidence
An analysis of over 12 million hepatitis C test results from a large national US laboratory, plus national prescription estimates, 2018 to 2020.
From the study: “hepatitis C virus antibody testing volume decreased 59% during April 2020 and rebounded to a 6% reduction in July 2020.”
38% fewer prescriptions
Kaufman HW et al. Decreases in Hepatitis C Testing and Treatment During the COVID-19 Pandemic. American journal of preventive medicine. 2021.
From the study: “For hepatitis C virus treatment, prescriptions decreased 43% in May, 37% in June, and 38% in July relative to the corresponding months in 2018 and 2019.”
38% fewer prescriptions
Kaufman HW et al. Decreases in Hepatitis C Testing and Treatment During the COVID-19 Pandemic. American journal of preventive medicine. 2021.
Liver transplant recipients showed no increase in COVID death risk after adjustment.
No increase in deathsLiver transplant recipients vs non-transplant patients with COVID, after matching
Among adults with a liver transplant who caught COVID, 19% died, vs 27% of patients without a transplant, who were much older. After matching for age and other health factors, the transplant itself showed no increase in death risk. But recipients went to intensive care more often (28% vs 8%) and needed a breathing machine more often (20% vs 5%).
Transplant recipients take immune-dampening drugs, raising fears COVID would hit them hardest. This suggests their age and other illnesses mattered more than the transplant, though they still often landed in intensive care. Doctor-reported registry of 151 recipients from 18 countries, March to June 2020, compared with patients at one UK hospital group; observational, cannot rule out hidden differences.
See the evidence
An international registry study of 151 adult liver transplant recipients with COVID, compared with 627 non-transplant patients, March to June 2020.
From the study: “liver transplantation did not significantly increase the risk of death in patients with SARS-CoV-2 infection”
No increase in deaths
Webb GJ et al. Outcomes following SARS-CoV-2 infection in liver transplant recipients: an international registry study. The lancet. Gastroenterology & hepatology. 2020.
From the study: “28 (19%) patients in the liver transplant cohort died, compared with 167 (27%) in the comparison cohort”
No increase in deaths
Webb GJ et al. Outcomes following SARS-CoV-2 infection in liver transplant recipients: an international registry study. The lancet. Gastroenterology & hepatology. 2020.
From the study: “However, ICU admission (43 [28%] vs 52 [8%], p<0·0001) and invasive ventilation (30 [20%] vs 32 [5%], p<0·0001) were more frequent in the liver transplant cohort.”
No increase in deaths
Webb GJ et al. Outcomes following SARS-CoV-2 infection in liver transplant recipients: an international registry study. The lancet. Gastroenterology & hepatology. 2020.
Off-patent liver drug UDCA lowered the virus's entry door in human tissue.
No randomized trials yetUDCA (ursodiol) lowered the virus's entry protein in lab tissue and human noses
Ursodeoxycholic acid (UDCA, also called ursodiol), an off-patent liver drug, lowered ACE2, the protein the COVID virus uses to enter cells. That cut infection in lab-grown tissue, animals, and human lungs and livers kept working outside the body. It also lowered ACE2 in volunteers' noses, and taking it was linked to better COVID outcomes in registry data.
An existing pill that narrows the virus's way into cells could someday add to vaccines. For now it is a promising idea that still needs clinical trials, not a proven way to prevent COVID. Mostly lab and animal experiments plus a registry analysis the authors say may carry selection bias; no randomized trial has tested it yet.
See the evidence
A lab study using organoids, hamsters and human organs kept alive outside the body, plus small volunteer and patient-registry analyses, published in Nature in 2023.
From the study: “We show that the UDCA-mediated downregulation of ACE2 reduces susceptibility to SARS-CoV-2 infection in vitro, in vivo and in human lungs and livers perfused ex situ.”
No randomized trials yet
Brevini T et al. FXR inhibition may protect from SARS-CoV-2 infection by reducing ACE2. Nature. 2023.
From the study: “Finally, we identify a correlation between UDCA treatment and positive clinical outcomes after SARS-CoV-2 infection using retrospective registry data”
No randomized trials yet
Brevini T et al. FXR inhibition may protect from SARS-CoV-2 infection by reducing ACE2. Nature. 2023.
No clear liver-stiffness change at three-year follow-up
No clear difference
Ultrasound liver stiffness showed no statistically significant change from 3–6 months after COVID-19 to three-year follow-up.
The COVID-19 research group included 90 patients at baseline; 58 had follow-up. This group-level null does not prove absent fibrosis or rule out individual liver injury.
Study details & original results
Radzina, Maija et al.. Multiparametric Ultrasound Assessment of Long-Term Liver Damage in COVID-19: Results of a Three-Year Follow-Up Study.. Medicina. 2026.
SWE liver-stiffness change in the COVID-19 research group (90 patients at baseline; 58 had follow-up), from the assessment 3–6 months after COVID-19 to three-year follow-up in a longitudinal prospective study.
No statistically significant change in SWE liver stiffness (p > 0.05)
The reported result does not establish a difference; it does not prove equivalence.
Dates show when findings were added here, not when papers were published. Study populations and comparisons differ.
WHEN YOU WANT TO GO DEEPERSee all 1 findingsOriginal results, comparisons and study details.
1 of 1 source groupsFindings stay together with their study.
SOURCE 011 finding
Radzina, Maija et al.. Multiparametric Ultrasound Assessment of Long-Term Liver Damage in COVID-19: Results of a Three-Year Follow-Up Study.. Medicina. 2026.
SWE liver-stiffness change in the COVID-19 research group (90 patients at baseline; 58 had follow-up), from the assessment 3–6 months after COVID-19 to three-year follow-up in a longitudinal prospective study.
Added
No statistically significant change in SWE liver stiffness (p > 0.05)Source [1]
Browse the 9 original sourcesThe complete bibliography behind this monitor.
[1]
Radzina, Maija et al.. Multiparametric Ultrasound Assessment of Long-Term Liver Damage in COVID-19: Results of a Three-Year Follow-Up Study.. Medicina. 2026.
Ge J et al. Outcomes of SARS-CoV-2 Infection in Patients With Chronic Liver Disease and Cirrhosis: A National COVID Cohort Collaborative Study. Gastroenterology. 2021.
John BV et al. Association of BNT162b2 mRNA and mRNA-1273 Vaccines With COVID-19 Infection and Hospitalization Among Patients With Cirrhosis. JAMA internal medicine. 2021.
Lu JY et al. Clinical predictors of recovery of COVID-19 associated-abnormal liver function test 2 months after hospital discharge. Scientific reports. 2022.
Webb GJ et al. Outcomes following SARS-CoV-2 infection in liver transplant recipients: an international registry study. The lancet. Gastroenterology & hepatology. 2020.
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