Liver transplantation for COVID-19-associated cholangiopathy

Purpose: The hallmark viral pneumonia of coronavirus-19-disease (COVID-19) is often accompanied by important extra-pulmonary manifestations. Liver dysfunction occurs in up to 45% of COVID-19 patients, predominantly as moderate transaminitis whereas a cholestatic pattern is rare. Additionally, it is often described as inconsequential with negligible clinical impact. We describe the cases of 4 patients with COVID-19 who developed cholestatic liver injury that progressed towards a destructive cholangiopathy requiring liver transplantation in 2 patients. Methods: Cases of all patients with COVID-19 admitted to our intensive care unit (ICU) between March and June 2020 were retrospectively reviewed for proven cholestatic injury. Additionally, patients referred to our liver transplant unit with a history of COVID-19 were also considered. Results: Three out of 114 COVID-19 patients admitted to our ICU and one externally referred patient were considered for this case series. All patients suffered severe COVID-19 with need for mechanical ventilation, proning and extracorporeal membrane oxygenation. These patients all developed moderate to severe cholestatic liver injury after resolution of acute respiratory distress syndrome (Figure 1). The clinical presentation, cholangiogram, and histological findings were all typical of the critical care-associated condition 'secondary sclerosing cholangitis in critically ill patients' (SSC-CIP). Two patients ultimately required liver transplantation for refractory cholangitis. Conclusions: The high incidence of this otherwise rare disease suggests that patients surviving severe COVID-19 are at increased risk of developing SSC-CIP. Several disease-and/or treatment-specific features may predispose to biliary ischemia and damage, while a direct pathogenic role of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) via cholangiocyte angiotensin-converting-enzyme-2 (ACE2) receptors is under investigation. We aim to raise awareness about the potential higher risk for SSC-CIP in patients recovering from severe COVID-19, and encourage early diagnosis and timely consideration of liver transplantation as the sole therapeutic option. (Figure Presented).

COVID-19 outcome in an isolated intestinal transplant recipient

Introduction: Age and co-morbidity (including immunosuppression (IS)) are risk factors for severe coronavirus disease 2019 (COVID-19). Due to exposure to heavy IS, intestinal transplant (ITx) recipients may be at particular high risk for severe COVID-19. COVID-19 and its potential gastroenterological manifestations have not been reported after isolated ITx. Case Description: A 41-year-old female ITx recipient was hospitalized because of dehydration and electrolyte disturbances during the second European COVID-19 wave in November 2020. One year earlier, she had undergone an intestinal re-transplantation for chronic allograft enteropathy, 14 years after first ITx for chronic intestinal pseudo-obstruction. IS consisted of Tacrolimus, Azathioprine, and low-dose corticosteroids. On admission, her COVID-19 PCR was negative. Six days after admission, she tested positive on a screening COVID-19 nasopharyngeal PCR swab. At that time, she was asymptomatic and had normal inflammatory markers and a normal chest X-ray. Azathioprine was temporarily halted, and Tacrolimus slightly raised. Prophylactic low-molecular weight heparin (LMWH) was administered because of elevated D-dimers. One week after the positive test, she developed anosmia, mild dyspnea and a mild increase in CRP (25mg/L) was seen. Remdesivir was started at 200mg and continued at 100mg/day for 5 days. She presented a high stomal output 2 days in a row. An ileoscopy and biopsy showed no signs of infection or rejection. She was discharged after 4 weeks and remains in good health since then. Discussion: Despite presenting a mild form of COVID-19 infection, we preventively treated our ITx patient with LMWH and Remdesivir. Like for other solid organ Tx, azathioprine was temporarily halted/reduced. A transient increase in stomal output was observed but without proven rejection or infection. Conclusion: This is a first report of COVID-19 after isolated ITx. The disease was mild and the treatment similar to other organ transplant recipients. Registry data are needed to determine the real incidence and severity of COVD-19 after ITx and its potential gastrointestinal manifestations.

Liver transplantation during the COVID-19 epidemic : recommendations from the Belgian Liver Intestine Transplant Committee (BeLIAC).

Since January 2020, the Novel Coronavirus Disease 2019 (COVID-19) pandemic has dramatically impacted the world. In March 2020, the COVID-19 epidemic reached Belgium creating uncertainty towards all aspects of life. There has been an impressive capacity and solidarity of all healthcare professionals to acutely reconvert facilities to treat these patients. In the context of liver transplantation (LTx), concerns are raised about organ donation shortage and safety, the ethics of using limited healthcare resources for LTx, selection criteria for LTx during the epidemic and the risk of de novo COVID-19 infection on the waiting list and after LTx. BeLIAC makes several recommendations to try to mitigate the deleterious effect that this epidemic has/will have on donation and LTx, taking into account the available resources, and trying to maximize patients and healthcare professionals' safety.