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LETTER TO EDITOR
COVID-19 and Liver Transplantation: Early Reports and Recommendations

Dear Editor:

Respiratory viral infections are common in transplant recipients as a result of long-term immunosuppression and comorbidities.1,2 Notably, transplant patients have comorbidities that predispose those with the novel coronavirus disease (COVID-19), the disease caused by the SARS-CoV-2 virus, to severe disease.3,4 Transplant recipients with COVID-19 disease have high rates of hospitalization, intensive care unit admission, and adverse events.4,5

Emerging reports have investigated the effects of COVID-19 in liver transplantation, but the data are still scarce. De Barros Machado and Ianhez6 reported a COVID-19 case in a 69-year-old man with sequential liver-kidney transplant under triple immunosuppression (tacrolimus, mycophenolate, and prednisone) and recent hospital discharge after laparoscopic appendectomy. The patient presented with low-grade fever and pneumonia findings on chest computed tomography, and the immunosup­pression regimen was modified (decreased tacro­limus, mycophenolate cessation, and increased prednisone) with good outcomes (discharged at 12 days).6 Atypical presentation has also been reported in a 50-year-old male liver transplant recipient, manifesting with symptoms similar to influenza pneumonia; this case reported that immunosup­pression withdrawal and systemic low-dose steroids resulted in resolution of symptoms.7 In a recent report by Hong and associates,8 a 57-year-old woman received a liver graft from her 28-year-old daughter who had unknown COVID-19 status at liver transplant and was later (day 3 after donation) confirmed to be COVID-19 positive. The recipient was initially treated with prophylactic lopinavir/ritonavir and was then switched to hydroxychloroquine (due to drug interaction between tacrolimus and antivirals) and remained SARS-CoV-2 negative at 2 months posttransplant. A high clinical suspicion is required, as the risk of misdiagnosis is high as a result of false negative tests.9 In the current issue of Transplant Infectious Disease and in contrast to previous reports, Gao and associates10 reported 3 cases of liver transplant with initially mild disease that progressed to severe COVID-19 (fever > 39 °C), with 1 patient who was infected during the perioperative period. The role of immunosuppression and the disease course in liver transplant recipients remain to be elucidated.

Liver Transplant Recommendations in the Era of COVID-19
In general, liver disease societies recommend the use of telehealth approaches (100%), continued immuno­suppressive therapy (93%), cessation of nonurgent visits (86%), and minimization of consultations and limited number of people accompanying the patient (57%).11 Strict measures should be applied to ensure prevention of transmission, as in the case of first organ donation in a 68-year-old female recipient after the reopening of Wuhan, China. In this case, a comatose 61-year-old male donor was quarantined and meticulously investigated (history investigation through contact with the family, repeated SARS-CoV-2 polymerase chain reaction in oropharyngeal swab specimens, antibody tests); in the report, the authors suggested an interval of more than 7 days between donor admission and donation.12

The American Society of Transplantation (AST) suggests that all nonurgent transplant procedures should be suspended and that organ donors who may have been exposed (high-risk areas, close contacts with suspected/confirmed COVID-19) should not be considered for donation for an interval of 2 to 4 weeks.13,14 In addition, the Transplant Infectious Disease Section of the Transplantation Society recommends against the procurement of organs from donors with unspecified respiratory failure.15 The detrimental effects of COVID-19 on deceased donor liver transplant availability (11% decrease) and on the number of adult deceased donor liver transplant procedures (24.7%) have been demonstrated by Agopian and colleagues16 who analyzed data from the OPTN/UNOS database. Similarly, in the Netherlands, the number of transplant procedures in children with end-stage organ failure has significantly decreased, with a concomitant decrease in organ donations among all organ transplant services.17

This situation gives rise to ethical dilemmas, where the benefits of a life-saving nonurgent procedure must be balanced against the risk of COVID-19 transmission to the patient and the community. Both health care workers and patients must adhere to the proposed safety measures to prevent transmission and to ensure that transplant programs can continue to operate, without placing the patients or the community at risk. However, transplant organizations must frequently update their recommendations to counteract the detrimental effects of the pandemic on the transplantation community.


References:

  1. Manuel O, Estabrook M, American Society of Transplantation Infectious Diseases Community of P. RNA respiratory viral infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019;33(9):e13511. doi:10.1111/ctr.13511
    CrossRef - PubMed
  2. Arslan H, Musabak U, Ayvazoglu Soy EH, et al. Incidence and immunologic analysis of coronavirus disease (COVID-19) in hemodialysis patients: a single-center experience. Exp Clin Transplant. 2020;18(3):275-283. doi:10.6002/ect.2020.0194
    CrossRef - PubMed
  3. Akdur A, Karakaya E, Ayvazoglu Soy EH, et al. Coronavirus disease (COVID-19) in kidney and liver transplant patients: a single-center experience. Exp Clin Transplant. 2020;18(3):270-274. doi:10.6002/ect.2020.0193
    CrossRef - PubMed
  4. Esagian SM, Ziogas IA, Giannis D, Hayat MH, Elias N, Tsoulfas G. Challenges in abdominal organ transplantation during the COVID-19 pandemic. Front Med (Lausanne). 2020;7:287. doi:10.3389/fmed.2020.00287
    CrossRef - PubMed
  5. Fernandez-Ruiz M, Andres A, Loinaz C, et al. COVID-19 in solid organ transplant recipients: A single-center case series from Spain. Am J Transplant. 2020;20(7):1849-1858. doi:10.1111/ajt.15929
    CrossRef - PubMed
  6. Machado DJB, Ianhez LE. COVID-19 pneumonia in kidney transplant recipients-Where we are? Transpl Infect Dis. 2020;10.1111/tid.13306:e13306. doi:10.1111/tid.13306
    CrossRef - PubMed
  7. Liu B, Wang Y, Zhao Y, Shi H, Zeng F, Chen Z. Successful treatment of severe COVID-19 pneumonia in a liver transplant recipient. Am J Transplant. 2020;20(7):1891-1895. doi:10.1111/ajt.15901
    CrossRef - PubMed
  8. Hong HL, Kim SH, Choi DL, Kwon HH. A case of coronavirus disease 2019-infected liver transplant donor. Am J Transplant. 2020;10.1111/ajt.15997. doi:10.1111/ajt.15997
    CrossRef - PubMed
  9. Ning L, Liu L, Li W, et al. Novel coronavirus (SARS-CoV-2) infection in a renal transplant recipient: Case report. Am J Transplant. 2020;20(7):1864-1868. doi:10.1111/ajt.15897
    CrossRef - PubMed
  10. Gao F, Zheng KI, Gu JY, George J, Zheng MH. COVID-19 and liver transplantation: Lessons learned from three reported cases. Transpl Infect Dis. 2020;22(4):e13335. doi:10.1111/tid.13335
    CrossRef - PubMed
  11. Perazzo H, Piedade J, Castro R, et al. COVID-19: An overview of worldwide recommendations for management of patients with liver diseases or liver transplantation. Clin Gastroenterol Hepatol. 2020;18(10):2381-2384 e2310. doi:10.1016/j.cgh.2020.04.074
    CrossRef - PubMed
  12. Shi H, Xu J, Li X, et al. First organ donation in Wuhan after ending of the coronavirus lockdown. Transpl Int. 2020;10.1111/tri.13658. doi:10.1111/tri.13658
    CrossRef - PubMed
  13. American Society of Transplantation (AST). Coronavirus disease 2019 (COVID-19): Frequently asked questions from transplant candidates and recipients. https://www.myast.org/coronavirus-disease-2019-covid-19-frequently-asked-questions-transplant-candidates-and-recipients

  14. Moris D, Shaw BI, Dimitrokallis N, Barbas AS. Organ donation during the coronavirus pandemic: an evolving saga in uncharted waters. Transpl Int. 2020;33(7):826-827. doi:10.1111/tri.13614
    CrossRef - PubMed
  15. Transplant Infectious Disease Section of the Transplantation Society. Guidance on coronavirus disease 2019 (COVID-19) for transplant clinicians. https://tts.org/tid-about/tid-presidents-message/23-tid/tid-news/657-tid-update-and-guidance-on-2019-novel-coronavirus-2019-ncov-for-transplant-id-clinician

  16. Agopian V, Verna E, Goldberg D. Changes in liver transplant center practice in response to coronavirus disease 2019: unmasking dramatic center-level variability. Liver Transplantation. 2020;26(8):1052-1055. doi:10.1002/lt.25789
    CrossRef - PubMed
  17. de Vries APJ, Alwayn IPJ, Hoek RAS, et al. Immediate impact of COVID-19 on transplant activity in the Netherlands. Transpl Immunol. 2020;61:101304. doi:10.1016/j.trim.2020.101304
    CrossRef - PubMed


DOI : 10.6002/ect.2020.0229


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From the 1Institute of Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA; and 2Duke Surgery, Duke University Medical Center, Durham, North Carolina, USA
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no further declarations of potential conflicts of interest.
Corresponding author: Dimitrios Giannis, Institute of Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, 600 Community Drive - 4th Floor, Manhasset, NY 11030, USA
Phone: +1 516 225 6397
E-mail: dgiannis@northwell.edu