Liver transplantation for post-COVID-19 sclerosing cholangitis

Abstract

Since identified in December 2019, COVID-19 has remained a pandemic across the globe. Although primarily a respiratory illness, the impact of COVID-19 on other end organs has been increasingly identified. The effect of COVID-19 on the liver has yet to be completely understood. We describe a case of COVID-19 leading to end-stage cholangiopathy and deceased donor liver transplantation (LT). A 64-year-old man with no underlying respiratory or liver disease presented with acute respiratory distress secondary to COVID-19 pneumonia requiring intubation. Several months after resolution of his respiratory symptoms, he developed transaminitis, worsening jaundice, abdominal pain and dark-coloured urine. Hepatic function remained severely impaired warranting LT 259 days following his initial COVID-19 diagnosis. Explant pathology demonstrated diffuse hepatic injury, onion skinning of the bile ducts and bile duct loss in scattered portal tracts. As more patients develop COVID-19-related complications, we suggest LT as an option for COVID-19-related end-stage liver disease.

Severe acute respiratory syndrome coronavirus-2-associated cholangiopathies

“…Prognosis remained severe, requiring liver transplantation in many patients [24,26]. In a case series of 12 patients, 4 of 12 died, 5 of 12 were listed for OLT, 1 of 12 was rejected from OLT list because of ineligibility.…”

“…Six of 12 patients repeated MRI after 6 months from the first one and 4 of 6 showed a rapid disease progression [8 & ]. Even if only some case reports are available, the transplanted patients showed on average a good survival rate with complete recovery of liver function and wellness lasting at least 6 -8 months after OLT [5, 24,42].…”

“…& ,9,16 & ,22,[24][25][26]. This is a rare complication affecting patients who have been long time hospitalized in the ICU for different causes, needing for mechanical ventilation[30].…”

Covid‐19 and Liver Injury: Role of Inflammatory Endotheliopathy, Platelet Dysfunction, and Thrombosis

“…Interestingly, however, two reports of cholestasis following COVID‐19 infection suggest a possible role for endotheliopathy, noting hepatic artery branches in the portal tract with endothelial swelling with luminal narrowing, portal vein endophlebitis (inflammation of the intima area of a vein), and endothelialitis (leukocyte attachment to the vascular wall) and thrombotic material in portal vein branches. ( 103,105 ) COVID‐19 cholestasis has been reported as a long‐term complication of infection, ( 105 ) leading to the need for liver transplantation ( 106 ) and highlighting its importance for further mechanistic study.…”

“…Abbreviations: CXCL, chemokine (C-X-C motif ) ligand 1; NET, neutrophil extracellular trap; TF, tissue factor; Xa, active factor X. attachment to the vascular wall) and thrombotic material in portal vein branches. (103,105) COVID-19 cholestasis has been reported as a long-term complication of infection, (105) leading to the need for liver transplantation (106) and highlighting its importance for further mechanistic study.…”