Liver transplantation in the era of COVID-19
COVID-19 and liver transplantation
Based on previous observations for SARS and other related viruses, a theoretical risk of liver damage exists with COVID-19 infection. However, available data only reported hepatic dysfunction in the form of abnormal levels of liver aminotransferases and slightly elevated bilirubin levels, mainly in critically ill patients. On the other hand, reports during an influenza outbreak in Germany in winter 2017/2018 showed increased organ failure scores of patients with liver cirrhosis where 5 out of 11 patients with liver cirrhosis developed acute liver failure during influenza infection. No data available on the impact of COVID-19 on decompensated liver disease patients awaiting LTX, but because of the known immunocompromised state of these patients, adequate protective measures should be maintained. Although healthcare facilities are overwhelmed with the management of COVID-19 patients & health resources are being rapidly consumed, the American Association for the Study of Liver Diseases (AASLD), recommended against postponing transplantation. Moreover, they advised each program to consider its capability regarding intensive care unit (ICU) beds, ventilators availability, and blood donation. Prioritization of transplant candidates is another problem that may face clinicians due to limited resources during the pandemic, as well as the exclusion of donors infected with COVID-19. Immunosuppression in the post-transplant recipients may be protective against cytokine storm induced by COVID-19, which is responsible for the severe illness on the one hand. However, and on the other hand, recipients on immunosuppression may have more intense and prolonged shedding of the virus, increasing the risk of transmission to contacts, including healthcare workers . This could emphasize the crucial role of implementing infection control measures to avoid losing candidates on the LTX waiting list because of the closed transplantation centers.
Surgical considerations during operating COVID-19 patient:
International societies like World Health Organization (WHO) and the Centre for Disease Control and Prevention (CDC) are always confirming the necessity to use Personal Protection Equipment (PPE) in addition to the restriction of outpatient and elective procedures as preventive measures against COVID-19. Limitations of aerosol-generating procedures like suction, endotracheal intubation, and advanced endoscopy are of major concern due to the fear of the possibility of disease transmission. Further restrictions to prevent other routes of infections like feco-oral transmission, included colorectal surgeries and colonoscopies. Currently, many interventional surgical societies, anesthesia, endoscopy, radiology, and intensive care have placed their statements, guidelines, and
recommendations to adjust their practice to the current epidemic. Different reasons rationalized the delay or even cancellation of non-emergency procedures as they would consume PPE tools which are currently running short supply worldwide. The second reason that such elective procedures are postponed or canceled is
to prevent unnecessary infections to medical staff and caregivers, which may be transmitted from asymptomatic COVID-19 patients or their companions. Also, they consider such procedures a further burden and workload on an already exhausted medical system. Finally, occupying the operative theatres with such cases would
warranty the need for mechanical ventilators that might be more beneficial and valuable if they are directed to rescue a COVID-19 patient’s life. Meticulous evaluation should be done before deciding for the priority of the procedure through detailed history taking, one by one consultation, temperature measurement, hand hygiene, and reporting of any suspected case of COVID-19 (even if afebrile), and finally cleaning and disinfection protocols of premises. Repeated physical examination and temperature measurement along with the revision of chest imaging like a computed tomography scan or a chest radiograph, and if COVID-19 is suspected or confirmed, all non-emergency procedures would be delayed or canceled.
Indications of liver transplantations in the COVID-19 era
Because of the rapidly changing situation of COVID-19 infection worldwide, indications of LTX will need to be updated according to the emerging data. Bearing in mind that any liver transplant related activity not only involves the donor and the recipient, but it involves many individuals, including doctors, paramedical staff, nurses, and health care workers. Taking into consideration that there is a risk of the donor to recipient transmission of COVID19, from both deceased donors and living donors. The risk of donor-derived infection would depend upon donor exposure, infectivity in the incubation period, degree and duration of viremia, and viability of the virus within blood or specific organ compartments. Traditionally, The AASLD/AST guidelines outline four major types of indications for LTX in the United States: Acute liver failure, complicated cirrhosis, metabolic liver diseases, and systemic complications of chronic liver disease. Acute liver failure is the most important indication for emergency LTX. Common causes of acute liver failure include acetaminophen overdose, acute viral hepatitis, drug-induced liver injury, mushroom poisoning, autoimmune hepatitis, Wilson’s disease, acute ischemic hepatitis (shock liver), and acute fatty liver of pregnancy. Similarly, patients with cirrhosis and type 1 hepatorenal syndrome have a median survival of fewer than two weeks and should be urgently referred to a transplant center for expedited transplant evaluation, as should patients with other evidence for rapid hepatic decompensation. Precautions for preparation of patients before liver transplantation
The emergence of the COVID-19 pandemic has posed extensive threats and problems to all the healthcare facilities, including LTX centers. These effects are not only confined to donor or recipient issues but also extends to involve many other problems in the availability of healthcare resources. We are faced with enormous challenges owing to the high communicability and virulence of the virus, the risk of introducing immunosuppressive therapies during this pandemic, and our utmost need for all the health care utilities. On the other hand, we do have a very long list of miserable patients waiting for LTX, which is the only available treatment option for this difficult to treat a group of patients, so judicious decisions and strict precautions became now mandatory. Streptococcal pneumonia and influenza vaccines are strongly recommended to all recipients prior to LTX, together with strict prophylaxis against complications of cirrhosis to reduce the number of hospital admissions. It is also recommended to test for COVID-19 in patients with acute decompensation or Acute on top of chronic liver failure (ACLF). For those on LTX lists, it is recommended to test both donors and recipients for COVID-19 before LTX, putting into consideration that negative results do not totally exclude the infection. Alternatively, computed tomography (CT) of the chest can be considered. Pre-procedure consent should include the potential hazard for the acquisition of nosocomial COVID-19infection. Accepting only grafts with a low risk of delayed graft function to reduce complications and minimize the length of postoperative stay is also recommended. Diminishing exposure of health care workers as much as possible, through using online clinics and phone calls as a substitute to primary clinics can prevent unnecessary risk of infection. Doctors may also talk to all patients by phone before their visits to rule out any possibility of COVID-19 infection. Deferring optional visits and restricting it only to urgent ones also help to prevent nosocomial infections. Modifications of the outpatient transplant clinics by widening the patients’ waiting areas and following strict infection control precautions are of utmost importance.
Author: Mohamed El Kassas, Mohamed Alboraie, Amira Al Balakosy, Nermeen Abdeen, Shimaa Afify, Mohammad Abdalgaber, Ahmed F. Sherief, Ahmad Madkour, Mohamed Abdellah Ahmed, Mohamed Eltabbakh, Mohamed Salaheldin, Mohamed-Naguib Wifi