The positive impact of the COVID 19 pandemic on organ utilisation in liver transplantation

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

Operating a medical intensive liver unit during a pandemic

Background: The novel COVID-19 pandemic created an unprecedented strain on healthcare systems, particularly on intensive care services. Balancing demand for intensive care unit beds with increased patient acuity challenged facility's abilities to provide access to care for patients with advanced liver disease. We report the development of unique practices designed to maintain clinical operations of our Medical Intensive Liver Unit (MILU). Methods: Consecutive patients admitted to the MILU at a United States quaternary care LT center between 08/27/2018 and 12/31/2020 were enrolled in a prospective registry and followed from admission to hospital discharge, LT or death. In March 2020, the MILU was geographically relocated to accommodate the COVID-19 pandemic surge and to protect the at-risk patients with liver disease. To facilitate this transition, new protocols were developed to rapidly train nursing and support staff and to adjust ICU throughput. Procedures were implemented to facilitate virtual models of clinical care and communication. Clinical working groups were assembled to re-design protocols encompassing acute liver failure, acute kidney injury, nutrition optimization, sepsis pathways, and perioperative management. Results: In 2020, 373 patients were admitted to the MILU, accounting for 408 hospital admissions and 472 MILU admissions. Of these patients, 124 patients (30.3%) died in-hospital. 279 patients (74.5%) were cirrhotic, and 26 patients (6.9%) were admitted for acute liver failure. The most common etiology of liver disease in patients with cirrhosis was alcohol-related liver disease (42.6%), increased from 2019 (33.3%). Average MELD-Na score was 30.1, increased from 2019 (27.2). 48 (12.9%) of these patients underwent LT in 2020, 35 (72.9%) of whom were transplanted during the same hospitalization as their MILU admission, and 22 (45.8%) directly from MILU. Conclusion: Data previously presented supports the MILU as a promising sub-specialty model for the improved intensive care of patients with advanced liver disease. The COVID-19 pandemic presented both logistical and clinical challenges for the delivery of care to this vulnerable patient population. Our experience mirrors national trends in increased severity of illness for hospitalized hepatology patients during the pandemic. Collaborative efforts in ensuring adherence to novel protocols and maintained communication within a multi-disciplinary team resulted in successful optimization strategies for bridging higher acuity patients to LT.

Tocilizumab therapy in 5 solid and composite tissue transplant recipients with early ARDS due to SARS-CoV-2.

There are emerging data depicting the clinical presentation of coronavirus disease 19 (COVID-19) in solid organ transplant recipients but negligible data-driven guidance on clinical management. A biphasic course has been described in some infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), beginning with a flu-like illness followed by an intense inflammatory response characterized by elevated c-reactive protein (CRP), interleukin 6 (IL-6), and acute respiratory distress syndrome (ARDS) associated with high mortality. The exuberant and possibly dysregulated immune response has prompted interest in therapeutic agents that target the cytokines involved, particularly IL-6. Tocilizumab is an IL-6 receptor antagonist with a record of use for a variety of rheumatologic conditions and cytokine release syndrome due to chimeric antigen receptor T-cell therapy but experience in solid organ and composite tissue transplant recipients (SOT/CTTRs) with SARS-CoV-2-related ARDS has not been previously reported in detail. We present the clinical course of 5 SOT/CTTRs with SARS-CoV-2-related ARDS that received tocilizumab with favorable short-term outcomes in 4. Responses were characterized by reductions in CRP, discontinuation of vasopressors, improved oxygenation and respiratory mechanics, and variable duration of ventilator support. Four bacterial infections occurred within 2 weeks of tocilizumab administration. We discuss safety concerns and the need for randomized comparative trials to delineate tocilizumab's clinical utility in this population.

Successful orthotopic liver transplantation in a patient with a positive SARS-CoV2 test and acute liver failure secondary to acetaminophen overdose.

SARS-CoV2, first described in December 2019, was declared a pandemic by the World Health Organization in March 2020. Various surgical and medical societies promptly published guidelines, based on expert opinion, on managing patients with COVID-19, with a consensus to postpone elective surgeries and procedures. We describe the case of an orthotopic liver transplantation (OLT) in a young female who presented with acute liver failure secondary to acetaminophen toxicity to manage abdominal pain and in the setting of a positive SARS-CoV2 test. Despite a positive test, she had no respiratory symptoms at time of presentation. The positive test was thought to be residual viral load. The patient had a very favorable outcome, likely related to multiple factors including her young age, lack of respiratory COVID-19 manifestations and plasma exchange peri-operatively. We recommend a full work-up for OLT in COVID-19 patients with uncomplicated disease according to standard of care, with careful interpretation of COVID-19 testing in patients presenting with conditions requiring urgent or emergent surgery as well as repeat testing even a few days after initial testing, as this could alter management.

Coronavirus disease 2019 in an orthotopic liver transplant recipient living with human immunodeficiency virus.

Coronavirus disease 2019 (COVID-19), mediated by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can manifest with flu-like illness and severe pneumonia with acute respiratory distress syndrome (ARDS). Immunocompromised patients merit particular attention as altered host immunity may influence both disease severity and duration of viral shedding as is described with several other ribonucleic acid respiratory viruses. Yet immunocompromised status alone, in the absence of other comorbidities, may not necessarily predict severe illness presentations and poorer clinical outcomes as indicated by recent reports of COVID-19-infected solid organ transplant recipients and people living with human immunodeficiency virus (HIV). Such patients may even be spared the robust inflammatory response that precipitates ARDS associated with COVID-19, complicating the management of iatrogenic immunosuppression in this setting. We present a case of an orthotopic liver transplant recipient with well-controlled HIV who successfully recovered from a mild, flu-like illness attributed to SARS-CoV-2.