Impact of COVID-19 on Liver Transplant Activity in the USA: Variation by Etiology and Cirrhosis Complications

Abstract

Background and Aims:The COVID-19 pandemic has impacted the care of patients with liver disease. We examined impact of COVID-19 on liver transplant (LT) activity in the USA. Methods: LT listings in the United Network for Organ Sharing (UNOS) database (April 2018-May 2021) were analyzed to examine the impact of COVID-19 pandemic on the LT activity based on etiology: hepatitis C virus (HCV), alcohol-associated liver disease (ALD), alcoholic hepatitis (AH), and nonalcoholic steatohepatitis (NASH) complications: hepatocellular carcinoma (HCC) and acute-on-chronic liver failure (ACLF) grade 2 or 3) and Model for End-Stage Liver Disease (MELD) score. Joinpoint regression models assessed time trend changes on a log scale. Results: Of 23,871 recipients (8,995 in the COV-ID era, April 2018-February 2020), mean age 52 years, 62% men, 61% Caucasian, 32% ALD, 15% HCC, 30% ACLF grades 2-3, and mean MELD score 20.5), monthly LT changes were a decrease of 3.4% for overall LTs and 22% for HCC after September 2020, and increase of 4.5% for ALD since 11/2020 and 17% since 03/2021 for ACLF grade 2-3. Monthly MELD scores increased by 0.7 and 0.36 after June 2020 for HCV and HCC respectively. Conclusions: The COVID-19 pandemic has impacted LT activity, with a decrease of LTs especially for HCC, and an increase of LTs for ALD and severe ACLF. Strategies are needed to reorganize cirrhosis patients to overcome the aftereffects of COVID-19 pandemic.

COVID-19 and Liver Transplantation: Challenges and Opportunities

“…Several papers have evaluated the effect of the COVID-19 pandemic on LT, and frequently there were differences regarding increased or decreased frequency of LT seen because of different time points, different populations and also the evolving nature of the pandemic and the response to it. [6][7][8] The importance of the paper by Kuo et al 5 is that they are able, at least in this specific population, to start identifying the finer differences as to how the pandemic affected LTs of different etiology and to what extent.…”

“…Regarding the MELD score, the main effect was seen with HCV-related LTs, where there was an increase in the average monthly MELD score by 0.7, again indicating the increased challenges for these patients. When Kuo et al 5 evaluated the effect of the COVID-19 pandemic on the frequency of LT performed for HCC and ACLF grade 2-3, the analysis found that for HCC there was a 22% monthly decrease on a log scale of LTs performed during the COVID-19 era, with recipients having higher MELD scores, an increase of 0.36% per month, and being more likely to have ALD-related ACLF, as well as receive a poorer quality graft. As far as ACLF grade 2-3 is concerned although there was a 17% monthly increase in the LTs performed in the COVID-19 era, the recipients had a higher MELD score, and the grafts were of poorer quality.…”

“…1,2 An effort by several transplant associations and the Centers for Medicare and Medicaid led to issuing guidance and recommendations regarding transplantation surgery during COVID-19. 3,4 In the paper "Impact of COVID-19 on Liver Transplant Activity in the USA: Variation by Etiology and Cirrhosis Complications" by Kuo et al, 5 the authors provide us with a thorough evaluation of the impact of the COVID-19 pandemic on LT activity based on etiology in the USA, by analysing data from the United Network of Organ Sharing (UNOS) database (2018-2021). The authors looked at two different time periods, one in the pre-COVID era between April 2018 and February 2020, and one in the COVID era between March 2020 and May 2021).…”

“…It should be noted that overall survival (96% at 3 months post LT) was stable in both periods, showing that quality was maintained. As far as the etiology of LT is concerned, Kuo et al 5 showed a 4.5% monthly increase in the percentage of LTs performed for alcoholic liver disease (ALD) in the period between November 2020 and May 2021, the COVID-19 era. What was even more important was the fact that these LTs were more likely to use a poorer quality organ, to have autoimmune hepatitis and ACLF grade 2-3, and a poor performance status, which is critical in these patients.…”

“…Overall, Kuo et al 5 through their comparison of the preand COVID-19 eras and their statistical analysis of the UNOS database, found that there was an overall decrease in the number of LTs for HCC, in addition to the need for a higher MELD score for these patients, similar to HCV, to receive an LT. On the other hand, there was a proportional increase in the LTs for ALD and ACLF grade 2-3. The findings reveal the effect of the COVID-19 pandemic on LT, which was a decrease in the activity because of a diversion of resources needed, decreased outpatient visits and follow-up, as well as increased ALD prevalence because of the effect of the quarantine and the overall stressors.…”