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Qi X, Wang J, Li X, et al. Clinical course of COVID-19 in patients with pre-existing decompensated cirrhosis: initial report from China. Hepatol Int. 2020;2020:1–5. https://doi.org/10.1007/s12072-020-10051-z. Article Google Scholar Zhang C, Shi L, Wang FS. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol. 2020;5(5):428–30. https://doi.org/10.1016/S2468-1253(20)30057-1. Article PubMed PubMed Central Google Scholar Garrido I, Liberal R, Macedo G. COVID-19 and liver disease-what we know on 1st May 2020. Aliment Pharmacol Ther. 2020. https://doi.org/10.1111/apt.15813. Article PubMed PubMed Central Google Scholar Grace JA, Herath CB, Mak KY, Burrell LM, Angus PW. Update on new aspects of the renin-angiotensin system in liver disease: clinical implications and new therapeutic options. Clin Sci (Lond). 2012;123(4):225–39. https://doi.org/10.1042/CS20120030. Article Google Scholar Haga S, Yamamoto N, Nakai-Murakami C, et al. Modulation of TNF-alpha-converting enzyme by the spike protein of SARS-CoV and ACE2 induces TNF-alpha production and facilitates viral entry. Proc Natl Acad Sci USA. 2008;105(22):7809–14. https://doi.org/10.1073/pnas.0711241105. Article PubMed Google Scholar Sparks MA, South A, Welling P, et al. Sound science before quick judgement regarding RAS blockade in COVID-19. Clin J Am Soc Nephrol. 2020;15(5):714–6. https://doi.org/10.2215/CJN.03530320. Article PubMed Google Scholar Liu Y, Yang Y, Zhang C, et al. Clinical and biochemical indexes from 2019-nCoV infected patients linked to viral loads and lung injury. Sci China Life Sci. 2020;63(3):364–74. https://doi.org/10.1007/s11427-020-1643-8. Article PubMed PubMed Central Google Scholar Casey S, Schierwagen R, Mak KY, et al. Activation of the alternate renin-angiotensin system correlates with the clinical status in human cirrhosis and corrects post liver transplantation. J Clin Med. 2019;8(4):419. https://doi.org/10.3390/jcm8040419. Article PubMed Central Google Scholar Paizis G, Tikellis C, Cooper ME, et al. Chronic liver injury in rats and humans upregulates the novel enzyme angiotensin converting enzyme 2. Gut. 2005;54(12):1790–6. https://doi.org/10.1136/gut.2004.062398. Article PubMed PubMed Central Google Scholar Flacco ME, Martellucci CA, Bravi F, et al. Treatment with ACE inhibitors or ARBs and risk of severe/lethal COVID-19: a meta-analysis. Heart. 2020. https://doi.org/10.1136/heartjnl-2020-317336. Article PubMed PubMed Central Google Scholar Download references Department of Gastroenterology and Hepatology, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia Josephine A. Grace, Stephen Casey & Peter W. Angus Department of Medicine and Cardiology, University of Melbourne, Austin Health, Heidelberg, Australia Josephine A. Grace, Stephen Casey, Louise M. Burrell & Peter W. Angus You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar Correspondence to Josephine A. Grace. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions Grace, J.A., Casey, S., Burrell, L.M. et al. Proposed mechanism for increased COVID-19 mortality in patients with decompensated cirrhosis. Hepatol Int (2020). https://doi.org/10.1007/s12072-020-10084-4 Download citation Received: 24 June 2020 Accepted: 17 August 2020 Published: 04 September 2020 DOI: https://doi.org/10.1007/s12072-020-10084-4