Liver transplant recipients infected with SARS‐CoV‐2 in the early postoperative period: Lessons from a single center in the epicenter of the pandemic

Abstract

The impact of coronavirus disease‐19 (COVID‐19) in liver recipients remains largely unknown. Most data derive from small retrospective series of patients transplanted years ago. We aimed to report a single‐center case series of five consecutive patients in the early postoperative period of deceased‐donor liver transplantation who developed nosocomial COVID‐19. Two patients presented important respiratory discomfort and eventually died. One was 69 years old and had severe coronary disease. She rapidly worsened after COVID‐19 diagnosis on 9th postoperative day. The other was 67 years old with non‐alcoholic steatohepatitis, who experienced prolonged postoperative course, complicated with cytomegalovirus infection and kidney failure. He was diagnosed on 36th postoperative day and remained on mechanical ventilation for 20 days, ultimately succumbing of secondary bacterial infection. The third, fourth, and fifth patients were diagnosed on 10th, 11th, and 18th postoperative day, respectively, and presented satisfactory clinical evolution. These last two patients were severely immunosuppressed, since one underwent steroid bolus for acute cellular rejection and another also used anti‐thymocyte globulin for treating steroid‐resistant rejection. Our novel experience highlights that COVID‐19 may negatively impact the postoperative course, especially in elder and obese patients with comorbidities, and draws attention to COVID‐19 nosocomial spread in the early postoperative period.

Impact of COVID-19 in solid organ transplant recipients

“…Among 36 patients, 2 of 10 patients who died were early transplant recipients with T cell depleting agents received within the previous 5 weeks 83 . Similarly, two of five recent liver transplant patients died after nosocomial infection diagnosed 9 and 36 days after transplantation 154 . Finally, among three kidney and one liver transplant recipients who contracted SARS‐CoV‐2 infection from an asymptomatic surgeon between 7 and 10 days after transplantation, one kidney recipient died after rapid clinical deterioration 155 .…”

“…Based on the recognition of this higher risk, multiple transplant organizations have released recommendations regarding protecting newly transplanted patients from acquiring SARS‐CoV‐2 41,45 . Potential reasons for COVID‐19 in the peri‐transplant period include asymptomatic infection of the recipient at or around the time of transplantation, donor‐derived infections, community acquired infections by family members or social contacts, or nosocomial transmission by health care workers and/or patients in health care facilities 154‐156 . Screening of recipients and donors to exclude infection at the time of surgery seems mandatory as any type of surgery in a SARS‐CoV‐2 infected patient has been associated with significant postoperative pulmonary complications and high mortality.…”

Abnormal Liver Biochemistry Tests and Acute Liver Injury in COVID-19 Patients: Current Evidence and Potential Pathogenesis

“…There is also evidence that liver transplant recipients who contracted SARS-CoV-2, older and presented with co-morbidities such as obesity may have worse clinical outcomes [ 26 ]. In a small single-center retrospective case series of five long-term liver transplant recipients with COVID-19, two of the patients died while the other three others, one of whom had renal failure and the fourth and fifth immunosuppressed subsequently recovered from the respiratory illness [ 150 ]. Finally, a prospective study performed in Spain comprising 111 liver transplant recipients diagnosed with COVID-19 showed greater risk of SARS-CoV-2 infection with a mortality rate of 18%, and 31.5% of the patients had severe disease [ 151 ].…”

Abnormal Liver Biochemistry Tests and Acute Liver Injury in COVID-19 Patients: Current Evidence and Potential Pathogenesis

“…There is also evidence that liver transplant recipients who contracted SARS-CoV-2, older and presented with co-morbidities such as obesity may have worse clinical outcomes [52]. In a small single-center retrospective case series of five long-term liver transplant recipients with COVID-19, two of the patients died while the other three others, one of whom had renal failure and the fourth and fifth immunosuppressed subsequently recovered from the respiratory illness [176]. Finally, a prospective study performed in Spain comprising 111 liver transplant recipients diagnosed with COVID-19 showed greater risk of SARS-CoV-2 infection with a mortality rate of 18%, and 31.5% of the patients had severe disease [177].…”