ABSTRACT
Background: As the world recovers from the aftermath of devastating waves of an outbreak, the ongoing Coronavirus disease 2019 pandemic has presented a unique perspective to the transplantation community of ''organ utilisation'' in liver transplantation, a poorly defined term and ongoing hurdle in this field. To this end, we report the key metrics of transplantation activity from a high-volume liver transplantation centre in the United Kingdom over the past two years. Method(s): Between March 2019 and February 2021, details of donor liver offers received by our centre from National Health Service Blood & Transplant, and of transplantation were reviewed. Differences in the activity before and after the outbreak of the pandemic, including short term post-transplant survival, have been reported. Result(s): The pandemic year at our centre witnessed a higher utilisation of Donation after Cardiac Death livers (80.4% vs. 58.3%, p = 0.016) with preserved United Kingdom donor liver indices and median donor age (2.12 vs. 2.02, p = 0.638;55 vs. 57 years, p = 0.541) when compared to the pre-pandemic year. The 1- year patient survival rates for recipients in both the periods were comparable. The pandemic year, that was associated with increased utilisation of Donation after Cardiac Death livers, had an ischaemic cholangiopathy rate of 6%. Conclusion(s): The pressures imposed by the pandemic led to increased utilisation of specific donor livers to meet patient needs and minimise the risk of death on the waiting list, with apparently preserved early post-transplant survival. Optimum organ utilisation is a balancing act between risk and benefit for the potential recipient, and technologies like machine perfusion may allow surgeons to increase utilisation without compromising patient outcomes.Copyright © 2022
ABSTRACT
Introduction The UK has been severely affected by the COVID-19 pandemic. The impact on the adult population has been disproportionately higher when compared to children with consequent challenges to organ donation and liver transplantation (LT). Across the three UK paediatric liver centres there has only been a very small number of patients who tested positive for COVID-19 and all made a speedy and full recovery. We report here the response during the pandemic across the 3 paediatric LT centres. Methods A series of nationally agreed policy changes affecting the liver procurement, listing and transplant process were agreed during regular meetings with LT centre directors and NHSE. Actions at a local and national level were agreed to protect and maintain the paediatric LT programmes. Data were collected from 27/03/20 until 26/11/20 and compared with same time period for the years 2016-19. Results During the study period, there was a significant reduction in the adult population in the mean number of weekly liver offers, donors and LTs compared to before the pandemic with signs of recovery between the 1st and 2nd UK lockdown periods (figure 1). More specifically the number of livers offered nationally was reduced from an average 30-40/week to only <10/week during the 1st wave in the March-April period. The number of children on the LT list during the study period across all 3 centres was 74 in total with 17 (23%) super-urgent and 57(77%) electives, which was comparable to previous years. Overall, 65-80 paediatric LTs are performed annually across the UK's 3 paediatric centres. From March-November 2020 there were 58(82%) elective and 13(18%) super urgent (acute liver failure & hepatoblastoma) paediatric LTs performed. Donor Brain Dead (DBD) and Donor Cardiac Dead (DCDC) LTs were 54(76%) and 3(4%), respectively. Living related LT (LRLT) programme was sustained comprising 20% of LTs performed. The number of paediatric LTs performed during the pandemic was comparable to those performed yearly since 2016. The number of LT per paediatric centre for King's College Hospital (KCH), Birmingham Children's Hospital (BCH) and Leeds Liver Unit were 40 (56%), 15(21%) and 16(23%), respectively with excellent outcome. A 15-year-old girl from KCH diagnosed with Wilson disease presented with liver failure and became COVID-19 positive whilst listed. She underwent LT soon after becoming COVID-19 negative. No perioperative mortality was reported with excellent outcome so far in all. Conclusion The current COVID-19 pandemic had a significant impact on the UK adult LT programme. The paediatric programme LT was preserved despite a decrease in organ offering and retrieval nationally plus limitations on adult intensive care resources at a regional level. Overall, paediatric LT outcome remained very good.
ABSTRACT
Introduction In April 2020 weekly teleconferences were established involving adult and paediatric representation from all 7 UK liver transplant (LT) centres and NHS England to discuss and maintain a national LT service during the COVID19 pandemic. Objective criteria to prioritise adult patients of high clinical urgency for prioritised access to LT were established. In lieu of such criteria for paediatric patients all three paediatric centres agreed to prioritise individual paediatric patients with chronic liver disease who were clinically deteriorating by consensus. A process to formally nationally prioritise clinically deteriorating paediatric patients was successfully introduced in October 2020. We report on the utilisation of the tier and outcome of these patients at a national level. Methods Patients from all 3 paediatric LT centres registered on the newly established national prioritised paediatric registration tier from October 2020-October 2021 were included. Demographic, clinical and laboratory data were collected and analysed. Results Since the introduction of the prioritization tier for children there were eight UK elective applications and all approved registrations. Mean age of patients registered was 5 years (range, 0-15). All patients were listed for LT prior to (Table Presented) prioritisation except patient 5 who was listed for liver-small bowel transplant before being prioritised for isolated LT. Indications for prioritization were hepatocellular carcinoma (1), acute decompensation due to portal hypertension (2), encephalopathy (3), sepsis (1), acute kidney injury (1). At time of prioritisation median values and range of alanine aminotransferase, albumin, total bilirubin, INR and platelets were 95 IU/ L (23-453), 25 g/L (16-39), 196 micromol/L (10-553), 1.6 (0.97-2.27) and 75 x109 (41-188), respectively. Median waiting time to transplant after prioritisation was 10 days (range, 3-37). All patients received a graft from a DBD donor and are all well at home. Median length of post-transplant ICU stay was 9 days (3-62) and total length of hospital stay was 56 days (27-85). Data on demographics and LT are listed on table 1. Conclusion The national paediatric prioritisation tier, introduced during the COVID19 pandemic, has been a pivotal initiative for the UK paediatric LT program, showcasing national collaboration. All patients underwent a LT successfully within a short time from prioritisation with 100% patient and graft survival. The intention is to maintain this prioritised paediatric tier following the pandemic.
ABSTRACT
Background: The COVID 19 Pandemic has been an unprecedented global health crisis. We undertook a retrospective observational study to evaluate its impact on the management of hepatocellular cancer (HCC) in a large tertiary referral service in the UK offering all treatment modalities: liver transplantation and resection through to locoregional, systemic therapy and specialist palliative care. HCC in adults is often diagnosed in advanced stages as symptoms are only apparent later in the disease, and recent reviews have highlighted more patients presenting later with decompensation and a backlog of deferred care1. This study reviews outcomes pre and post the first wave of the Pandemic, including disease presentation, time to treatment and loss to follow up. Methods: Retrospective study of consecutive new referrals to a tertiary treatment centre. These included patients discussed between Dec 2019-Feb 2020 ('pre-COVID';total referrals n=98 with 66 newly diagnosed HCC), and July-Sept 2020 ('post 1st wave COVID';total referrals n=81 with 51 newly diagnosed HCC). NHS Providers had been asked to maintain access to essential cancer treatment throughout the Pandemic with easing of lockdown on 11 May 2020. Patients were longitudinally followed up and analysed using electronic medical records. Descriptive results were expressed as median with IQR for continuous data and as frequency (%) for categorical data. Baseline characteristics of patients were compared between the two cohorts using the Mann-Whitney U test for continuous data, and χ2 test for qualitative data. Results: As shown in Table 1, post 1st wave there has been a reduction in total number of referrals. Median age, sex and aetiology were similar between groups. Differences were noted in patient characteristics of the 'post 1st wave' cohort with a greater proportion presenting with Child Pugh C (19% vs 4%, p=0.037) and BCLC stage D (25.5% vs 12% p=0.019). Among the group of patients presenting during the Pandemic none had a diagnosis of COVID 19 infection. While there were no significant differences in loss to follow up or the decision to treatment time interval (excluding transplant) between 2019 & 2020 (p=0.672), 3 patients in 2020 had treatment cancellations due to capacity. Conclusion: After the 1st wave there has been a reduction in external referrals and an increase in number of patients presenting with advanced chronic liver disease and untreatable HCC. Whilst these are likely to represent the effects of major service reconfiguration during the Pandemic at both a 1° and 2° care level our study suggests we need to better understand medium to longterm impact. We note local efforts to preserve cancer care avoided treatment delays post 1st wave but further analysis is underway to assess impact of the second wave on quality of care received and mortality.