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BackgroundUsing a large dataset, we evaluated prevalence and severity of alterations in liver enzymes in COVID-19 and association with patient-centred outcomes. MethodsWe included hospitalized patients with confirmed or suspected SARS-CoV-2 infection from the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) database. Key exposure was baseline liver enzymes (AST, ALT, bilirubin). Patients were assigned Liver Injury Classification score based on 3 components of enzymes at admission Normal; Stage I) Liver injury any component between 1-3x upper limit of normal (ULN); Stage II) Severe liver injury any component >= 3x ULN. Outcomes were hospital mortality, utilization of selected resources, complications, and durations of hospital and ICU stay. Analyses used logistic regression with associations expressed as adjusted odds ratios (OR) with 95% confidence intervals (CI). ResultsOf 17,531 included patients, 46.2% (8099) and 8.2% (1430) of patients had stage 1 and 2 liver injury respectively. Compared to normal, stages 1 and 2 were associated with higher odds of mortality (OR 1.53 [1.37-1.71]; OR 2.50 [2.10-2.96]), ICU admission (OR 1.63 [1.48-1.79]; OR 1.90 [1.62-2.23]) and invasive mechanical ventilation (OR 1.43 [1.27-1.70]; OR 1.95 (1.55-2.45).Stages 1 and 2 were also associated with higher odds of developing sepsis (OR 1.38 [1.27-1.50]; OR 1.46 [1.25-1.70]), acute kidney injury (OR 1.13 [1.00-1.27]; OR 1.59 [1.32-1.91]), and acute respiratory distress syndrome (OR 1.38 [1.22-1.55]; OR 1.80 [1.49-2.17]). ConclusionsLiver enzyme abnormalities are common among COVID-19 patients and associated with worse outcomes. Study HighlightsO_ST_ABSWhat is known?C_ST_ABSO_LIAbnormalities in liver enzymes in hospitalized patients with COVID-19 have been described in small, predominantly single-centre studies. C_LIO_LIImpact of such derangements on clinical outcomes are unclear. C_LI What is new here?O_LIIn this large international study, we found that close to 50% of hospitalized patients with COVID-19 have abnormal liver enzymes at admission. C_LIO_LISuch derangements in liver enzymes are associated with worse clinical outcomes (survival, Intensive Care Unit admission and need for invasive mechanical ventilation). C_LIO_LIThey are also associated with the development of complications such as Acute Kidney Injury, Sepsis and Acute Respiratory Distress Syndrome. C_LI