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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 195-199

Liver transplant during COVID-19 pandemic: A tertiary care center retrospective study


1 Department of Liver Transplant Anaesthesia, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
2 Department of Liver Transplant and Hepatobiliary Surgery, Asian Institute of Gastroenterology, Hyderabad, Telangana, India

Date of Submission08-May-2021
Date of Acceptance01-Sep-2021
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. Anuhya Rambhatla
L Block 1806, Rainbow VIstas @ Rock Garden, Green Hills Road, Moosapet, Hyderabad - 500 018, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_45_21

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  Abstract 


Introduction: Novel coronavirus affects different individuals in different ways, with most people recovering with mild to moderate illness not requiring hospitalization. Liver transplant for end-stage liver disease is a lifesaving procedure, and though living donor liver transplant (LDLT) is a well-planned elective surgery, it was considered a semi-emergency owing to the decompensation of the recipient posing a challenge to the transplant team owing to the situation of the pandemic. The availability of liver grafts from cadaveric donors in India was 0.65 per million population until 2019 as per the National Organ and Tissue Transplant Organization statistics which was sparse and further accentuated, leaving LDLT as the only option during the pandemic. Aim: This study aims to describe our experience and testing protocol for COVID-19 disease for the patients undergoing liver transplant during the pandemic at our hospital, which is a tertiary care referral hospital. Materials and Methods: This was a retrospective study done at AIG Hospitals, Hyderabad, India. Fifty adult patients who underwent LDLT and deceased donor liver transplant from May 2020 to December 2020 were included in the study. Exclusion Criteria: All recipients and donors with reverse transcription polymerase chain reaction (RT-PCR) positive for SARS CoV2; and COVID-19 disease reporting and data system (CO-RADS) score of 4 or 5 on high-resolution computed tomography (HRCT) chest. Results: The mean age of the recipients was 46 years, and the donors was 36 years; the most common indication being acute-on-chronic liver failure with failed medical therapies and the second common being hepatocellular carcinoma. All the 50 recipients were RT-PCR negative for SARS CoV2; 8 out of whom had a CO-RADS score of 3; and 4 out of the 8 were post-COVID-19 infection who had IgG positive and IgM negative; and the other 4 were both IgG and IgM negative, similarly 4 out of 8 donors were IgG positive. Intraoperative and postoperative period was uneventful. None of the donors or recipients were infected with COVID-19 disease during the hospital stay and up to 1 month postoperative. One patient died within 1 month due to sudden cardiac arrest. Conclusion: In our experience, with meticulous testing and proper care, there is a favorable outcome for liver transplant even during the pandemic.

Keywords: COVID-19, COVID-19 antibodies, liver transplant


How to cite this article:
Rambhatla A, Kumar G V, Swaroop S, Kumar N S, Ramachandra S, Reddy R, Kumaraswamy P, Chaitanya K, Menon B. Liver transplant during COVID-19 pandemic: A tertiary care center retrospective study. Indian J Transplant 2022;16:195-9

How to cite this URL:
Rambhatla A, Kumar G V, Swaroop S, Kumar N S, Ramachandra S, Reddy R, Kumaraswamy P, Chaitanya K, Menon B. Liver transplant during COVID-19 pandemic: A tertiary care center retrospective study. Indian J Transplant [serial online] 2022 [cited 2022 Aug 15];16:195-9. Available from: https://www.ijtonline.in/text.asp?2022/16/2/195/349354




  Introduction Top


After the scourge of Spanish flu in the early 20th century, no other disease has affected the human lives the way COVID-19 did. Novel coronavirus affects different individuals in different ways, with most people recovering with mild-to-moderate illness not requiring hospitalization. The advent of vaccines has shed a ray of hope about the ongoing pandemic, but there was a steep surge in the number of cases between April 2021 and June 2021(same dates) resulting in what is called as a “second wave,” pushing us back into a dilemma.

Liver transplant for end-stage liver disease is a life-saving procedure for decompensated patients which are mostly done electively with few exceptions such as acute liver failure, acute-on-chronic liver failure, and hepatocellular carcinoma (HCC) which warrant an urgent transplant.[1]

Although living donor liver transplant (LDLT) is a well-planned elective surgery, it was considered as a semi-emergency owing to the decompensation of the recipients, posing a challenge to the transplant team owing to the current pandemic.

The availability of a liver graft from cadaveric donations in India which was 0.65 per million population until 2019 as per the National Organ and Tissue Transplant Organization (NOTTO) statistics, was sparse and further accentuated and leaving LDLT as the only option during the pandemic.

Decompensated cirrhosis are at a greater risk for morbidity and mortality due to higher viral load of COVID-19 disease, but data on liver transplant patients is limited;[2],[3] hence, COVID-19 disease should be carefully evaluated before transplant.

There is a risk of transmission of the virus to the recipients either from a deceased graft or from a living donor graft,[3],[4] hence, we adopted a meticulous testing protocol to rule out COVID-19 disease prior to the transplant in both living donor and deceased donors as well as the recipients.

Posttransplant due to the immunosuppression the infected patients may have prolonged viral shedding, putting the others including health care workers at risk for getting infected with COVID-19 disease.[3]

We have done 50 liver transplants from May 2020 to December 2020, all our donors and recipients were screened 2 days prior to surgery with SARS CoV2 reverse transcription-polymerase chain reaction (RT-PCR), and those who were reported negative were further subjected to high-resolution computed tomography (HRCT) and those with report with COVID-19 disease reporting and data system (CO-RADS) 3 were tested for COVID-19 antibodies as per our institute protocol. All the precautions and the revised guidelines given by the NOTTO and Liver Transplant Society of India (LTSI) were followed for both deceased donor liver transplant (DDLT) and LDLT along with our institutional protocol.[3]

Aim

This study aims to describe our experience and testing protocol for COVID-19 disease for the patients undergoing liver transplant at our hospital, which is a tertiary care referral hospital.


  Materials and Methods Top


Inclusion criteria

This was a retrospective study done at our institute. Fifty adult patients who underwent LDLT and DDLT from May 2020 to December 2020 were included in this study.

Exclusion criteria

All recipients and donors with RT-PCR positive for SARS CoV2 and CO-RADS score of 4 or 5 on HRCT were excluded.

Clinical data were retrieved from electronic medical record and included the patient history, investigations for COVID-19 screening, operation and anesthesia details, and postoperative recovery. The data were collected on a standard pro forma.

Statistical analysis

Descriptive statistics were used, and data were analyzed using Microsoft excel.

Declaration of patient consent

The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.

Ethics statement

The Ethics Committee Approval was waived off because it was a retrospective study. IRB: AIG/IEC/Post BH& R-EXP47/05.2020-01. Principles of Declaration of Helsinki were followed. The study was performed according to the guidelines in Declaration of Helsinki.


  Results Top


We retrieved the data of 50 liver transplant patients which were conducted from May 2020 to December 2020; 2 out of the 50 were DDLT, and the remaining 48 were LDLT.

Of the 50 recipients, 12% (n = 6) were females and 88% (n = 44) were males and the mean age was 46 years, and body mass index was 26.4.

Forty-eight voluntary liver donors donated the Right lobe without middle hepatic vein graft, their mean age being 36 years; out of the 48 donors, 60% (n = 28) were female and 40% (n = 20) were male.

The average body mass index of the donors was 24.8 32% (16 out of the 50) recipients were diabetic, 26% (13 out of 50) were controlled hypertensives, 7 recipients had mild coronary artery disease which was an incidental finding during the recipient workup; 2 recipients were hypothyroid, and 5 were asthmatics. [Table 1] shows the comorbidities of the recipients and donors. Three and 4 out of the 48 donors were controlled diabetic and hypertensive, respectively, and 3 were hypothyroid.

The indications for the 48 LDLT are mentioned in [Table 2].
Table 1: Comorbidities of donor and recipeint

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Table 2: Indications for transplant

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[Table 3]-lists the etiology of end-stage liver disease, most common being alcohol-related liver disease, followed by nonalcoholic steatohepatitis and cryptogenic liver failure.
Table 3: Etiology

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The flowchart summarizes our testing protocol of COVID-19 disease before transplant.

All the donor and recipient underwent testing protocol for COVID-19 as shown in the [Flowchart 1].



[Table 4] summarizes the CO-RADS scoring of both the donors and recipients.
Table 4: Corad scoring

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Out of the 50 recipients 50% (n = 25) were having a score CO-RADS 1 and 32% (n = 16) were CO-RADS 2, 16% (n = 8) were having a score of CO-RADS 3. Similarly, out of 48 donors 52% (n = 25) were having a score of CO-RADS 1, 31% (n = 15) with CO-RADS 2, and 16% (n = 16) with CO-RADS scoring of 3.

The details of the antibody results for COVID-19 disease of both donor and recipient are listed in [Table 5]; 4 out of the 8 of both donor and recipients with a CO-RADS score of 3 were IgG + and IgM negative and the rest were both IgG and IgM negative.
Table 5: Antibodies

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Four out of the 50 recipients were RT-PCR positive for SARS CoV2 during the workup and 4 out of the 48 donors were COVID-19 positive too; the recipient was deferred surgery for 2 weeks and donor for 4 weeks. They were again tested by the same protocol and had undergone transplant subsequently.

All donors and recipients were subjected to general anesthesia with controlled ventilation with the American Society of Anesthesiologists standard monitoring along with invasive hemodynamic and cardiac output monitoring (central venous pressure, invasive blood pressure, FLOWTRAC) with minimal staff in the operating room during intubation and extubation of the trachea, with the senior anesthetist securing the airway.

All recipients received intra-operative immunosuppression with methylprednisolone intravenous at 10 mg/kg body weight before reperfusion of the graft.

The intraoperative period was uneventful for both donors and recipients.

The average duration of recipient surgery was 527 min, and donor surgery was 497 min.

All the donors were extubated on the operating table, and 70% (35 out of the 50) recipients were extubated on the operating table, and the rest were extubated later in the posttransplant intensive care unit (ICU).

All the recipients received triple regimen immunosuppression with a steroid, tacrolimus, and mycophenolate mofetil according to our institutional protocol, and they received clexane 20 mg subcutaneously twice a day for the 1st week.

There was no alteration in the immunosuppression regimen among the recipients till discharge.

All the patients were in single room in posttransplant ward and were given barrier nursing, and the visitors were limited to once a day.

Average length of ICU stay was 4 days, and hospital stay was 16 days for the recipient.

The median length of hospital stay for donor was 5 days.

Repeat RT-PCR for SARS CoV2 was not done for any of the donors or recipients in the postoperative period nor at the time of discharge.

None of the recipients or donors manifested with COVID-19 disease during the hospital stay and up to 1 month posttransplant.

One recipient died of sudden cardiac arrest on postoperative day 30 due to an unknown cause.


  Discussion Top


RT-PCR is a simple and specific qualitative method to detect SARS-CoV 2[5],[6],[7] virus. However, there is risk of eliciting false-negative and false-positive results with it. Thus, a negative result does not exclude the possibility of COVID-19 infection and should not be used as the only criterion for exclusion of the disease.

Studies showed that HRCT had a low rate of missed diagnosis of COVID-19 disease and is a useful method for the diagnosis of the same.[8] Combining these two tests along with clinical screening increases the sensitivity as well as the specificity of detection of the COVID-19 disease which forms the rationale for our testing protocol with both RT-PCR for SARC CoV2 virus and a HRCT.[2],[9]

The indications for transplant among our recipients were acute on chronic liver failure with failed medical therapy, HCC, and acute liver failure with high MELD Na scores as per the LTSI guidelines which states to postpone the elective transplants whenever possible.

We further tested the COVID-19 disease antibodies which helped us to rule out the disease in recipients and donors with a CO-RADS 3 scores on the HRCT. Since CO-RADS 4 and 5 scores indicate a high suspicion of COVID-19 disease, we deferred transplant in them.

Eight out the 50 recipients had a CO-RADS score of 3; and 4 out of them were post-COVID-19 infection 4–6 weeks before the transplant and had negative IgM antibodies and had uneventful postoperative period. Similarly, donors with CO-RADS scoring 3 also had an uneventful postoperative course.

Soin et al. compared the mortality and morbidity in the liver transplant recipients during the COVID and the non-COVID times. There is no significant mortality or morbidity in the recipients even during the pandemic, provided the testing and the postoperative care being meticulous. In our institute, we have not experienced any mortality due to COVID-19 disease in our recipients, similar to the above study.[10]

Few centers reported early postoperative infection of the recipients with COVID-19; however, we did not experience any immediate postoperative infection or within 1 month follow-up at our hospital in any recipient.

Soin et al. had reported one recipient with COVID-19 disease in the early postoperative recovery which was uneventful.[11] Similarly, Maggi et al. have reported two cases (of 17 LT) of COVID-19 disease in the early posttransplant period, of which one died and the other recovered.[11]

Periodic testing of our health care workers with RT-PCR for SARS CoV2 has been done; we made sure our staff who were in contact with COVID-19 disease positive person or had any early symptoms of the disease were not part of the transplant team.

The ELITA COVID-19 registry showed a mortality of 16% in the recipients with it being highest in the older age group. In our study, the mean age group of the recipients was 46 years maybe giving us a favorable outcome in spite of the severity of the liver disease.[12]

Limitations

It is a single centre study and data cannot be generalized.


  Conclusion Top


In our experience, with meticulous testing and proper care, there is a favorable outcome for liver transplant even during the pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Boettler T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Cornberg M, et al. Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper. JHEP Rep 2020;2:100.113.  Back to cited text no. 1
    
2.
Mayank J, Joy V, Kumar KC, Vijaya S, Jayanthi V. Incidence and risk factors for mortality in patients with cirrhosis awaiting liver transplantation. Indian J Transplant 2019;13:210-5.  Back to cited text no. 2
    
3.
Saigal S, Gupta S, Sudhindran S, Goyal N, Rastogi A, Jacob M, et al. Liver transplantation and COVID-19 (Coronavirus) infection: Guidelines of the liver transplant Society of India (LTSI). Hepatol Int 2020;14:429-31.  Back to cited text no. 3
    
4.
Sahin TT, Akbulut S, Yilmaz S. COVID-19 pandemic: Its impact on liver disease and liver transplantation. World J Gastroenterol 2020;26:2987-99.  Back to cited text no. 4
    
5.
Fung M, Babik JM. COVID-19 in immunocompromised hosts: What we know so far. Clin Infect Dis 2021;72:340-50.  Back to cited text no. 5
    
6.
Ji D, Zhang D, Yang T, Mu J, Zhao P, Xu J, et al. Effect of COVID-19 on patients with compensated chronic liver diseases. Hepatol Int 2020;14:701-10.  Back to cited text no. 6
    
7.
Alqahtani SA, Larson AM. Adult liver transplantation in the USA. Curr Opin Gastroenterol 2011;27:240-7.  Back to cited text no. 7
    
8.
Foreman MG, Mannino DM, Moss M. Cirrhosis as a risk factor for sepsis and death: Analysis of the National Hospital Discharge Survey. Chest 2003;124:1016-20.  Back to cited text no. 8
    
9.
Arvaniti V, D'Amico G, Fede G, Manousou P, Tsochatzis E, Pleguezuelo M, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010;139:1246-56.e12565.  Back to cited text no. 9
    
10.
Soin AS, Choudhary NS, Yadav SK, Saigal S, Saraf N, Rastogi A, et al. Restructuring living donor liver transplantation at a high volume center during the COVID-19 pandemic. J Clin Exp Hepatol 2020;11:418-23.  Back to cited text no. 10
    
11.
Maggi U, De Carlis L, Yiu D, Colledan M, Regalia E, Rossi G, et al. The impact of the COVID-19 outbreak on liver transplantation programs in Northern Italy. Am J Transplant 2020;20:1840-8.  Back to cited text no. 11
    
12.
Belli LS, Duvoux C, Karam V, Adam R, Cuervas-Mons V, Pasulo L, et al. COVID-19 in liver transplant recipients: Preliminary data from the ELITA/ELTR registry. Lancet Gastroenterol Hepatol 2020;5:724-5.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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