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Liver Injury After SARS-CoV-2 Vaccination: Role of Corticosteroid Therapy and Outcome
TAKE-HOME MESSAGE
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The authors evaluated 87 cases of liver injury that occurred after SARS-CoV-2 vaccination. The majority (59%) of the cases were attributed to the Pfizer-BioNTech vaccine. Liver injury occurred a median of 15 days after vaccination and was primarily hepatocellular in most cases, with 57% of patients showing features of immune-mediated hepatitis. Corticosteroids were more likely to be given in cases of more severe liver injury (grade 3–4) and to patients with immune-mediated hepatitis. Most patients who received corticosteroids had complete resolution, with only 1 patient requiring liver transplantation for acute liver failure.
- SARS-CoV-2 vaccination may be associated with liver injury. Corticosteroid therapy can be beneficial for patients with severe hepatitis or immune-mediated hepatitis.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND AND AIMS
A few case reports of autoimmune hepatitis-like liver injury have been reported after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. We evaluated clinical features, treatment response and outcomes of liver injury following SARS-CoV-2 vaccination in a large case series.
APPROACH AND RESULTS
We collected data from cases in 18 countries. The type of liver injury was assessed with the R-value. The study population was categorized according to features of immune-mediated hepatitis (positive autoantibodies and elevated immunoglobulin G levels) and corticosteroid therapy for the liver injury. We identified 87 patients (63%, female), median age 48 (range: 18-79) years at presentation. Liver injury was diagnosed a median 15 (range: 3-65) days after vaccination. Fifty-one cases (59%) were attributed to the Pfizer-BioNTech (BNT162b2) vaccine, 20 (23%) cases to the Oxford-AstraZeneca (ChAdOX1 nCoV-19) vaccine and 16 (18%) cases to the Moderna (mRNA-1273) vaccine. The liver injury was predominantly hepatocellular (84%) and 57% of patients showed features of immune-mediated hepatitis. Corticosteroids were given to 46 (53%) patients, more often for grade 3-4 liver injury than for grade 1-2 liver injury (88.9% vs. 43.5%, p = 0.001) and more often for patients with than without immune-mediated hepatitis (71.1% vs. 38.2%, p = 0.003). All patients showed resolution of liver injury except for one man (1.1%) who developed liver failure and underwent liver transplantation. Steroid therapy was withdrawn during the observation period in 12 (26%) patients after complete biochemical resolution. None had a relapse during follow-up.
CONCLUSIONS
SARS-CoV-2 vaccination can be associated with liver injury. Corticosteroid therapy may be beneficial in those with immune-mediated features or severe hepatitis. Outcome was generally favorable, but vaccine-associated liver injury led to fulminant liver failure in one patient.
Additional Info
Disclosure statements are available on the authors' profiles:
Liver injury after SARS-CoV-2 vaccination: Features of immune-mediated hepatitis, role of corticosteroid therapy and outcome
Hepatology 2022 Dec 01;76(6)1576-1586, C Efe, AV Kulkarni, B Terziroli Beretta-Piccoli, B Magro, A Stättermayer, M Cengiz, D Clayton-Chubb, C Lammert, C Bernsmeier, Ö Gül, FH la Tijera, M Anders, E Lytvyak, M Akın, T Purnak, R Liberal, M Peralta, B Ebik, S Duman, N Demir, Y Balaban, Á Urzua, F Contreras, MG Venturelli, Y Bilgiç, A Medina, M Girala, F Günşar, MC Londoño, T Androutsakos, A Kisch, A Yurci, F Güzelbulut, YF Çağın, E Avcı, M Akyıldız, EK Dindar-Demiray, M Harputluoğlu, R Kumar, SK Satapathy, M Mendizabal, M Silva, S Fagiuoli, SK Roberts, NK Soylu, R Idilman, EM Yoshida, AJ Montano-Loza, GN Dalekos, E Ridruejo, TD Schiano, S WahlinFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
This paper nicely illustrates the largest series of liver injury developing after COVID-19 vaccination. It encompasses 87 cases from 18 countries and details clinical presentations, treatment, and outcomes. Only a minority of patients (14%) had pre-existing liver diseases, and out of the 87 cases, 57% showed an immune-mediated phenotype. Corticosteroids were used in 46 (53%) patients, more often in patients with immune-mediated hepatitis and in those with grade 3-4 liver injury. While 11 patients were nonresponsive to corticosteroids, 10 of those were responsive to other treatments including azathioprine, mycophenolate mofetil, plasma exchange, and intravenous immunoglobulins. Further, 1 patient, nonresponsive to corticosteroids and plasma exchange, required a liver transplant. Thus, vaccine-induced immune-mediated hepatitis is an extremely rare event that can occur with any COVID-19 vaccine, and most cases resolve without long-term complications.
This paper reported COVID-19 vaccination–induced liver injury and offers a framework to safely manage affected patients. The majority of patients do very well without treatment, but those with severe disease will likely respond to steroids. Once liver tests normalize, with limited follow-up, immunosuppression can be safely tapered with no documented cases of recurrent disease. The article most importantly emphasizes that during a pandemic, such as COVID-19, the rare cases of vaccine-induced immune-mediated hepatitis should not discourage vaccination. Rather, this paper raises awareness of this rare potential complication and provides prudent guidelines for treatment.