Challenges for Liver Transplantation During Recovery From the COVID-19 Pandemic: Insights and Recommendations

Abstract

The coronavirus disease 2019 (COVID-19) pandemic is placing an increasing burden on liver transplant (LT) services worldwide. At the peak of the pandemic, many LT services worldwide reduced or halted their activities. With the gradual easing of lockdowns, LT teams face new challenges when restarting activities. The numbers of LTs are likely to drop in the immediate post-COVID era. Prolonged and intermittent lockdowns are likely to lead to a shortage of supplies, especially in poor resource settings. Special attention is needed to avoid nosocomial COVID-19 infection among cirrhotic patients awaiting transplant, post-transplant patients, and members of transplant teams. LT programs may have to revise existing strategies in selecting donors and recipients for transplants. Redesigning service provision, restructuring outpatient care, carefully screening and selecting donors and recipients, and performing LT with limited resources will have to be initiated in the post-COVID era if long-term recovery of LT services is to be expected. Costs involved with LT are likely to increase, considering the change in protocols of testing, quarantining, and interstate traveling. This paper discusses the different elements affecting and the widespread impact of the COVID-19 pandemic on LT and strategies to minimize the impact of these factors and to adapt so LT services can meet the health care needs during this pandemic and beyond.

Impact of the COVID-19 pandemic on liver donation and transplantation: A review of the literature

“…For this reason, some centers have temporarily suspended treating aging patients with comorbidities and surgical complexities to minimize the chance of complications[ 10 , 13 , 14 ]. Likewise, different centers have reduced the use of marginal grafts and those from donation after circulatory death for both fear of poor transplant outcomes and heavier commitment on ICU personnel[ 3 , 15 , 16 ].…”

“…Donor and recipient testing can significantly extend the timing and complicate the logistics of transplantation. In this context, many local medical centers are now beginning to obtain consistent access to rapid reverse transcription-polymerase chain reaction (RT-PCR) diagnostics[ 3 , 15 ]. Moreover, machine perfusion has been used to extend preservation times of the liver graft while awaiting SARS-CoV-2 test results to be available[ 26 ].…”

“…Staff members contracting the disease or in quarantine can result in the shutdown of a program for weeks. Organ recovery teams moving across centers and regions are exposed to the risk of transmission, and they must take appropriate respiratory and contact precautions throughout the procedure, even if the donor tested negative[ 15 , 20 ]. To reduce the exposure of recovery teams, many transplant centers have started relying on local teams and information sharing between centers via secure digital platforms[ 3 ].…”

“…Rabiee et al [ 45 ] recently reported a liver injury rate of 34.6% among COVID-19-positive LT recipients, which was higher than that of the general population but lower than that of nontransplant patients with chronic liver disease. Likewise, mortality among LT recipients testing positive for COVID-19 varies between 0%-23% in most studies (Table 3 ) and seems higher than that in the general population but lower than that in cirrhotic patients, where it was estimated to be between 34%-40%[ 15 , 41 , 46 ]. Male sex, advanced age, and metabolic comorbidities, which are known to increase COVID-19 severity, are more frequent among LT recipients than among the general population and could account for this difference[ 2 , 47 ].…”

COVID-19 Minisymposium: Toward a Strategic Roadmap

“…Clinical roadmaps for transplant patients during the COVID-19 pandemic are described in this issue: Management of personnel as described by Thiessen et al [ 3 ]; identification of potential recipients by Virmani et al [ 4 ]; alterations of patterns of patient care as described by Binda et al [ 5 ]; Niriella et al [ 6 ], and Monaco et al [ 7 ]; including detection of allograft injury by Garg et al [ 8 ]. Quite reassuring has been the physical and psychological resilience of transplant recipients, reported by Zgoura et al [ 9 ] and Lupi et al [ 10 ].…”