The Impact of Severe Acute Respiratory Syndrome Coronavirus Type 2 on Children With Liver Diseases

Abstract

Children are seldom affected by severe forms of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV2) infection; however, the impact of comorbidities in the clinical presentation and outcome of SARS-CoV2 in children is poorly characterized including that of chronic liver disease (CLD) and those taking immunosuppressive medications for autoimmune liver disease or following liver transplantation (LT). Although not the main target organ, a spectrum of liver involvement has been described in children infected with SARS-CoV2 and those presenting with Multisystem Inflammatory Syndrome in Children (MIS-C). The Hepatology Committee of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the Society of Pediatric Liver Transplantation (SPLIT) present an evidence-based position paper on liver involvement in children with SARS-CoV2 infection and its impact on those with CLD as well as LT recipients. All children may exhibit acute liver injury from SARS-CoV2 infection, and those with CLD and may experience hepatic decompensation. Preventative and therapeutic measures are discussed.

SARS-CoV-2 Antibodies in Children with Chronic Disease from a Pediatric Gastroenterology Outpatient Clinic

“…According to the European Society for Paediatric Gastroenterology, Hepatology and Nutrition committee, children with CLD are at a higher risk of developing severe COVID-19 and may experience decompensation of end-stage liver disease during SARS-CoV-2 infection. Children with CLD associated with suspected or documented non-alcoholic fatty liver disease or autoimmune hepatitis may have a higher risk of developing severe COVID-19 [ 13 ]. Kehar et al [ 14 ] compared children with CLD with liver transplant recipients and found that children with CLD required more intensive care unit management and had higher mortality than liver transplant recipients.…”

The impact of COVID-19 on the pediatric solid organ transplant population

“… 9 , 10 , 11 , 12 , 13 However, over the past two years it has become apparent that this is not the case. 14 , 15 In a multicenter international observational registry including 180 pediatric liver transplant recipients with laboratory confirmed SARS-CoV-2 infection, none of the transplant recipients required mechanical ventilation or died. 15 , 16 In another multicenter observational registry through the Pediatric Heart Transplant Society Registry, of 866 pediatric heart transplant recipients with COVID-19, only 14% required hospitalization, 5% required intensive care unit (ICU) admission, 1% required ventilation and less than 1% died.…”

“…7 , 18 As a result, being on chronic immunosuppressive medications may be protective against severe COVID-19. 14 , 15 , 16 , 19 , 20 Calcineurin inhibitors may specifically help to inhibit Coronavirus replication. 21 In a European observational registry including 243 adult liver transplant recipients with laboratory confirmed SARS-CoV-2, tacrolimus use had a positive independent effect on survival (HR, 0.55; 95% CI, 0.31-0.99).…”

“… 24 Therefore, at this time there is no evidence to support reduction or elimination of immunosuppression solely due to COVID-19. 14 …”

“…26 Based on these guidance documents and the reported epidemiology in SOT to date, organizations such as the Society for Pediatric Liver Transplantation and the American Society of Transplantation (AST), have extrapolated therapy recommendations to SOT recipients including the use of antivirals, glucocorticoids and monoclonal antibody preparations as locally available. 14 , 34 Monoclonal antibodies, given with early symptoms to prevent progression to severe disease requiring hospitalization, have evolved with different preparations providing coverage depending on the circulating COVID-19 variant. For example, both bamlanivimab/etesevimab (Eli Lilly and Company, Indianapolis, IN) and casirivimab/imdevimab (REGEN-COV, Regeneron Pharmaceuticals Inc, Tarrytown, NY) exhibited less activity against the Omicron variants BA.1 and BA.2, and sotrovimab (GlaxoSmithKline LLC, Philadelphia, PA) exhibited reduced activity against Omicron variant BA.2; leading to the current recommendation for use of bebtelovirmab (Eli Lilly and Company, Indianapolis, IN) while BA.2 is circulating.…”