Trinational Study Exploring the Early Impact of the COVID-19 Pandemic on Organ Donation and Liver Transplantation at National and Unit Levels

Post COVID Condition and Long-Term COVID-19 Impact on Hepatic Decompensation and Survival in Cirrhosis: A Propensity Matched Observational Study

Aims

Patients with cirrhosis are susceptible to decompensation events, including ascites, variceal bleeding (VB), hepatic encephalopathy, or death after COVID-19 infection. Patients may experience post-COVID condition (PCC) with multisystem involvement that persists for at least 2 months.

Methods

Hospitalized patients with cirrhosis and COVID-19 between January 2021 and January 2023 were assessed for decompensation events and mortality and compared to a propensity-matched cohort of cirrhosis and non-COVID-19 sepsis. Both groups were followed for outcomes over 1 year.

Results

Of 252 patients with Cirrhosis+ COVID-19 (73% men, aged 48.9 ± 13.7 years, 31%-diabetes, 44%-hypertension, 35%-alcohol-associated, 34.5%-metabolic dysfunction-associated steatotic liver disease; MASLD), 72 (28.6%) died in hospital and 180 (71.4%) recovered, similar to Cirrhosis+ non-COVID-sepsis (58/214, 27.1%). Finally,60 (33.3%) met criteria for PCC, 19 (10.5%) had no post COVID-19 sequelae and 101 (56.1%) patients died (N = 45) or were lost to follow up (N = 56). Late Mortality was higher in Cirrhosis+ COVID-19 than non-COVID-sepsis (56.1% vs. 35.3%, p = 0.026). Patients with PCC were aged 47.6 years, 63.3%-men, Charlson Comorbidity Index > 4 (51.7%), 45%-diabetes, 56.7%-hypertension, with 33.3%, 23.3%, and 43.3% in Child-Turcotte-Pugh class A, B and C, respectively. PCC symptoms included persistent dyspnea (34, 43%), cognitive impairment (20, 25.3%), and anxiety (47, 59.4%). On multivariable analysis, predictors of the development of PCC were baseline MELDNa (HR 1.12, 95% CI: 1.05-1.17, p < 0.001) and age (HR 0.9, 95% CI: 0.91-0.99, p = 0.012). Predictors of mortality following COVID-19 recovery were MELDNa (HR 1.03, 95% CI: 1.01-1.05, p = 0.008), age (HR 1.2, 95% CI: 1.1-1.5, p = 0.002) and hypertension (HR 1.63, 95% CI: 1.07-2.49, p = 0.025).

Conclusion

COVID-19 is associated with long-term mortality in cirrhosis even after recovery from respiratory infection. Long COVID is seen in a third of COVID-19 survivors in patients with cirrhosis.

The toll of COVID-19 on organ donation and kidney transplantation in Europe: Do legislative defaults matter?

This study investigates the cascading effects of COVID-19 pandemic on organ donation and transplantation in Europe. We also check whether legislative defaults for organ donation have a role in these outcomes. For this purpose, we used data from 32 European countries, between 2010 and 2021, and estimated pooled OLS regressions. We find that COVID-19 pandemic reduced deceased organ donation rates by 23.4%, deceased kidney transplantation rates by 27.9% and live kidney transplantation rates by 31.1% after accounting for health system capacity indicators. While our study finds that presumed consent legislation under normal circumstances leads to notable benefits in terms of deceased kidney transplantation and organ donation rates, the legislative defaults did not have a significant impact during the pandemic. Additionally, our findings indicate a trade-off between living and deceased transplantation that is influenced by the legislative default.

Successful liver transplantation from deceased donors with active COVID-19 infections with undetectable SARS-CoV-2 in donor liver and aorta

BACKGROUND

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has had unprecedented effects on society and modern healthcare. In liver transplantation, uncertainty regarding the safety of performing transplants during the early stage of the pandemic resulted in increased waitlist mortality. Additionally, concerns about disease transmission led to avoidance of deceased donors with COVID-19 infections. Several successful case reports describing incidental transplant of organs from donors with COVID-19 infections or intentional transplant of such donors into recipients with current or prior COVID-19 infections prompted the transplant community to re-evaluate that position. While excellent short-term results have been published, little is known about use of donors with active infections and the extent of COVID-19 organ involvement, which may affect long term outcomes.

METHODS

We report the successful transplantation of three livers from deceased donors with active COVID-19 infections. Donor liver and aortic tissues were evaluated by sensitive molecular testing for SARS-CoV-2 RNA via in situ hybridization and real-time quantitative reverse transcription PCR.

RESULTS

Postoperatively, all patients had excellent allograft function, without clinical or molecular evidence of SARS-CoV-2 transmission in donor tissues.

CONCLUSION

This evidence supports the use of liver donors with active COVID-19 infections.

Outcome of Patients Waitlisted for Deceased Donor Liver Transplantation During COVID-19 Pandemic: A Single-Center Experience

Background and aim

COVID-19 pandemic has strained several healthcare resources across the world. While liver transplantation (LT) is the only curative therapy for patients with end-stage liver disease, we aimed to determine the clinical outcome of patients waitlisted for deceased donor liver transplantation (DDLT) during COVID-19 pandemic.

Methods

A retrospective comparative observational study of adult patients waitlisted for DDLT from January 2019 to January 2022 at our liver unit (Dr Rela Institute and Medical Center, Chennai, Tamil Nadu, India) was carried out. Patient demographics, disease etiology, Model for End-Stage Liver Disease - Sodium (MELD-Na) score were calculated for all patients listed during the study period. Clinical event was defined as number of DDLT, death in the absence of transplant, and patients awaiting LT were compared. Statistical analysis was performed with SPSS V24.0.

Results

In total, 310 patients were waitlisted for DDLT, of whom 148, 63, and 99 patients listed during 2019, 2020, and 2021 (till January 2022), respectively; 22 (53.6%), 10 (24.3%), and 9 (21.9%) patients underwent DDLT in the year 2019, 2020, and 2021 (P = 0.000); 137 patients (44.19%) died on the DDLT waitlist of whom 41 (29.9%), 67 (48.9%), and 29 (21.1%) in the year 2019, 2020, and 2021 (P = 0.000), respectively. Waitlist mortality was significantly higher during the COVID first wave.

Conclusion

COVID-19 pandemic has significantly impacted patients waitlisted for DDLT in India. With limited access to healthcare facilities and decreased organ donation rates during the pandemic, there was a considerable reduction in the patients waitlisted for DDLT, lesser number of patients underwent DDLT, and higher waitlist mortality during the pandemic year. Efforts to improve organ donation in India should be strongly implemented.

Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM

There is a wide gap between patients who need transplants and the organs that are available in India. Extending the standard donation criterion is certainly important to address the scarcity of organs for transplantation. Intensivists play a major role in the success of deceased donor organ transplants. Recommendations for deceased donor organ evaluation are not discussed in most intensive care guidelines. The purpose of this position statement is to establish current evidence-based recommendations for multiprofessional critical care staff in the evaluation, assessment, and selection of potential organ donors. These recommendations will give "real-world" criteria that are acceptable in the Indian context. The aim of this set of recommendations is to both increase the number and enhance the quality of transplantable organs.

How to cite this article

Zirpe KG, Tiwari AM, Pandit RA, Govil D, Mishra RC, Samavedam S, et al. Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM. Indian J Crit Care Med 2022;26(S2):S43-S50.

A Narrative Review COVID-19 in Solid-Organ Transplantation: Real-World Evidence From India

Worldwide, India ranks number 2 and 3 for COVID-19 burden and absolute transplant numbers, respectively. Here, we summarized our single and multicenter Indian studies on solid-organ transplant during the COVID-19 pandemic. During the pandemic, solid-organ transplants declined 40% to 50%. The mortality rate in COVID-19-positive kidney transplant recipients (11.6%) was lower in India compared with the developed world during the first wave and lower compared with maintenance hemodialysis patients (13% to 38%) but significantly higher compared with the nonimmunosuppressed general population (1% to 3%) in India. We contributed to National Organ and Tissue Transplant Organization transplant-related guidelines to increase safety and access to solid-organ transplant. We reported the safety and feasibility of remdesivir (n = 57) and convalescent plasma therapy (n = 10) in kidney transplant recipients. We reported 100% patient and graft survival without any complications related to COVID-19 in a large cohort of kidney transplant recipients who recovered from COVID-19 (n = 372) and a large cohort of kidney transplant recipients of living donors (n = 31) who recovered from COVID-19 without any change in induction and maintenance immunosuppression. COVID-19 disease severity and mortality in the second episode (reoccurring infection) was higher (46%) compared with the first episode (11.6%). There was 4.4% incidence of COVID-19-associated mucormycosis in kidney transplant recipients with mortality of 46% in the second wave. We reported COVID-19 vaccine safety with suboptimal efficacy in kidney transplant recipients and dialysis patients compared with the general population. Our report suggested that transplant with carefully selected COVID-19-recovered donors and patients may be feasible and safe, at least over the short term. Continued research is needed on vaccine efficacy, booster doses, and long-term follow up sequelae.

Solid Organ Donation and Transplantation Activity in the Eurotransplant Area During the First Year of COVID-19

BACKGROUND

Transplantation activity during the first wave of the coronavirus disease 2019 (COVID-19) pandemic was severely affected worldwide. This retrospective analysis aimed to assess the impact of COVID-19 on organ donations and transplantations in the Eurotransplant region during the first 12 mo of the pandemic. Specifically, we compared donor and transplantation numbers during both waves to determine whether transplant systems adapted to this new reality.

METHODS

All reported organ donations and transplantations from March 1, 2015, to February 28, 2021, were collected from the Eurotransplant International Foundation registry. The observation period from 2020 to 2021 was divided into three 4-mo periods, which were then compared with the corresponding periods of the preceding 5 y. COVID-19 cases for Eurotransplant countries were retrieved from the OurWorldInData.org database.

RESULTS

Overall, the number of organ donors decreased by 18.3% (P < 0.0001) and the number of organ transplantations by 12.5% (P > 0.0001) compared with previous years. Pancreas transplantation was the most affected, followed by kidney, liver, heart, and lung transplant. In detail, during period 1, the number of organ donors decreased by 26.2% (P < 0.0001) and the number of organ transplantations by 16.5% (P < 0.0001), in period 2 by 5.5% (P < 0.0091) and 4.9% (P < 0.0001), and in period 3 by 23.1% (P < 0.0001) and 16.4% (P < 0.0001), respectively.

CONCLUSIONS

Organ donation and transplantation decreased drastically also during the second wave; however, despite the severity of the second wave, the decline was comparable with that of the first wave.

Utilization of SARS-COV-2 positive donors and recipients for liver transplantation in the pandemic era - An evidence-based review

The current SARS-COV-2 pandemic led to a drastic drop in liver donation and transplantation in DDLT and LDLT settings. Living donations have decreased more than deceased organ donation due to the need to protect the interest of donors. In the SARS-COV-2 pandemic, major professional societies worldwide recommended against the use of organs from donors with acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The basis for these recommendations are; SARS-CoV-2 could be transmitted to the recipient through organ transplantation and can result in severe manifestations; only limited effective targeted therapies are available, risk of transmission to the healthcare professionals, logistical limitations, and ethical concerns. In addition, end-stage liver disease patients on the waiting list represent vulnerable populations and are at higher risk for severe COVID-19 infection. Therefore, deferring life-saving transplants from COVID-positive donors during a pandemic may lead to more collateral damage by causing disease progression, increased death, and dropout from the waitlist. As this SARS-COV-2 pandemic is likely to stay with us for some time, we have to learn to co-exist with it. We believe that utilizing organs from mild/ asymptomatic COVID19 positive donors may expand the organ donor pool and mitigate disruptions in transplantation services during this pandemic.

COVID-19 and Short- and Medium-term Outcomes in Liver Transplant Patients: A Spanish Single-center Case Series

BACKGROUND & AIMS

The evidence suggests that most vulnerable subjects to COVID-19 infection suffer from patients with comorbidities or immunosuppression, including liver transplant recipients. Liver graft dysfunction may be a rare complication. Some patients complain about the post-COVID-19 syndrome. The aim of this study was to assess medium- and short-term outcomes in liver transplant patients.

PATIENTS AND METHODS

A retrospective case series was performed at a tertiary referral center. We screened 845 patients who had liver transplant (LT) in our center. All consecutive LT patients with COVID-19 during the Spanish outbreak from March 2020 to April 2021 were included. Demographics, pre-existing comorbidities, clinical and radiological data of COVID-19 infection, complications, and liver graft function were assessed at diagnosis and 3-month follow-up.

RESULTS

Overall, 20 LT patients were diagnosed with confirmed COVID-19. We included 16 patients that met the inclusion criteria, 8 nonhospitalized (50%) and 8 (50%) hospitalized patients were analyzed. The median follow-up was 5.33 months (IQR 3.06-8.26). One patient died during the follow-up. All patients presented some grade of respiratory or functional symptoms. Dyspnea and fatigue were the most prevalent symptoms during the 3-month follow-up. No liver graft dysfunction were reported despite of partial immunosuppression withdrawal in four patients (25%). One patient had cardiovascular complications.

CONCLUSIONS

Our results suggest the presence of post-COVID-19 syndrome with mild residual physical and psychological dysfunction in this subgroup of patients at 3 months after COVID-19. However, no cases of loss or liver graft dysfunction were reported.

Coronavirus disease 2019 in liver transplant patients: Clinical and therapeutic aspects

The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted liver transplant (LT) activity across the world, with notable decreases in the number of donations and procedures in most Western countries, in particular throughout the first wave. The cumulative incidence of COVID-19 in LT recipients (with estimates ranging from 0.34% to 1.56%) appears to be at least comparable to that observed for the general population. Clinical and radiological features at presentation are also similar to non-transplant patients. The risk of death among LT recipients requiring hospital admission is high (from 12% to 19%), although some authors have suggested that overall mortality may be actually lower compared to the general non-transplant population. It is likely that these poor outcomes may be mainly influenced by the older age and higher comorbidity burden of LT recipients, rather than by the transplant status itself. In fact, it has been hypothesized that post-transplant immunosuppression would exert a protective role, with special focus on tacrolimus-containing regimens. There is scarce evidence to guide the optimal management of post-transplant COVID-19 and the use of antiviral or immunomodulatory therapies, although both clinical practice and guidelines support the dose reduction or withdrawal of anti-proliferative agents such as mofetil mycophenolate. Preliminary reports suggest that the antibody response to messenger RNA vaccines is significantly impaired as compared to non-immunocompromised individuals, in line with other transplant populations. Finally, it is foreseeable that the future will be conditioned by the emerging variants of severe acute respiratory syndrome coronavirus 2 with increased transmissibility among LT recipients.

An overview of SARS-COV-2-related hepatic injury

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative pathogen of coronavirus disease 2019 (COVID-19), is highly contagious and has a variety of clinical manifestations, including liver injury. There have been a few reports indicating acute-on chronic liver failure among COVID-19 patients, however, patients with COVID-19-related liver injury are generally asymptomatic and present with a mild to moderate elevation in serum hepatic enzymes. Severe COVID-19 patients have high rates of liver injury with poorer outcomes. The pattern of abnormalities in liver biochemical indicators may be hepatocellular, cholestatic, or mixed. Although the pathogenesis of hepatic injury is not yet completely understood, causes of liver damage include systemic inflammatory response syndrome, ischemia-reperfusion injury, side effects of medications, and underlying chronic liver disease. While viral RNA has been detected in hepatocytes, it remains unknown if the coronavirus has the capacity to cause cytopathic effects in hepatic tissue. Additionally, it is important to remember that the current upheaval to daily life and access to healthcare caused by the COVID-19 pandemic has had a significant and negative effect on other patients with chronic liver disease. The objective of this review was to summarize the current literature on COVID-19-related hepatic injury with an examination of clinical features, potential pathogenesis, and histopathological findings of this entity.

Liver Disease and Coronavirus Disease 2019: From Pathogenesis to Clinical Care

Infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus that emerged in late 2019, is posing an unprecedented challenge to global health. Coronavirus disease 2019 (COVID-19), the clinical disease caused by SARS-CoV-2, has a variable presentation ranging from asymptomatic infection to life-threatening acute respiratory distress syndrome and multiorgan failure. Liver involvement is common during COVID-19 and exhibits a spectrum of clinical manifestations from asymptomatic elevations of liver function tests to hepatic decompensation. The presence of abnormal liver tests has been associated with a more severe presentation of COVID-19 disease and overall mortality. Although SARS-CoV-2 RNA has been detected in the liver of patients with COVID-19, it remains unclear whether SARS-CoV-2 productively infects and replicates in liver cells and has a direct liver-pathogenic effect. The cause of liver injury in COVID-19 can be attributed to multiple factors, including virus-induced systemic inflammation, hypoxia, hepatic congestion, and drug-induced liver disease. Among patients with cirrhosis, COVID-19 has been associated with hepatic decompensation and liver-related mortality. Additionally, COVID-19's impact on health care resources can adversely affect delivery of care and outcomes of patients with chronic liver disease. Understanding the underlying mechanisms of liver injury during COVID-19 will be important in the management of patients with COVID-19, especially those with advanced liver disease. This review summarizes our current knowledge of SARS-CoV-2 virus-host interactions in the liver as well the clinical impact of liver disease in COVID-19.

Transplant of SARS-CoV-2-infected Living Donor Liver: Case Report

Supplemental Digital Content is available in the text.

Given the high community prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), transplant programs will encounter SARS-CoV-2 infections in living donors or recipients in the perioperative period. There is limited data on SARS-CoV-2 viremia and organotropism beyond the respiratory tract to inform the risk of transplant transmission of SARS-CoV-2. We report a case of a living donor liver transplant recipient who received a right lobe graft from a living donor with symptomatic PCR-confirmed SARS-CoV-2 infection 3 d following donation. The donor was successfully treated with remdesivir, dexamethasone, and coronavirus disease 2019 (COVID-19) convalescent plasma. No viral transmission was identified, and both donor and recipient had excellent postoperative outcomes.

Impact of COVID-19 in Liver Disease Progression

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel coronavirus that causes coronavirus disease 19 (COVID-19), which has infected millions of people worldwide in only a few months. A minority, but significant number, of infected individuals require hospitalization and intensive care. From the start of this new virus pandemic, it was apparent that obese and/or diabetic individuals had a bad prognosis for COVID-19 progression, strongly suggesting an association between liver disease and severe COVID-19. Because chronic liver disease (CLD) is associated with immune dysregulation and inflammation, it is unsurprising that patients with CLD may carry a greater risk of adverse outcomes following SARS-CoV-2 infection. Initial COVID-19 data have also indicated that healthy infected individuals display abnormal liver function tests, suggesting a possible direct implication of SARS-CoV-2 in liver damage. Here we show that COVID-19 affects the liver metabolism and increases the morbidity and mortality of individuals with underlying CLD.

COVID-19 and Solid Organ Transplantation: A Review Article

The coronavirus pandemic has significantly impacted solid organ transplantation (SOT). Early in the outbreak period, transplant societies recommended suspending living kidney transplant programs in communities with widespread transmission to avoid exposing recipients to increased risk of immunosuppression, while recommendations were made to reserve deceased-donor kidney transplantation for likely life-saving indications. SOT recipients may be at high risk from COVID-19 disease due to chronic immunosuppressive treatment and other medical comorbidities. Mortality rates reported between 13 to over 30% in SOT recipients. In addition to high rates of complications and mortality attributable to COVID-19 infections, the pandemic has also led to additional complexities in transplantation including new questions regarding screening of donors and recipients, decision making to accept a patient for kidney transplant or wait after pandemic. The clinical implications of COVID-19 infection may also differ depending on the type of the transplanted organ and recipient comorbidities which further impacts decisions on continuing transplantation during the pandemic. Transplant activity during a pandemic should be tailored with careful selection of both donors and recipients. Furthermore, while tremendous strides have been made in treatment strategies and vaccinations, the impact of these in transplant recipients may be attenuated in the setting of their immunosuppression. In this review, we aim to summarize several aspects of COVID-19 in transplantation, including the immune response to SARS-CoV-2, SARS-CoV-2 diagnostics, clinical outcomes in SOT recipients, and end-stage kidney disease patients, transplant activity during the pandemic, and treatment options for COVID-19 disease.

Summary of International Recommendations for Donation and Transplantation Programs During the Coronavirus Disease Pandemic

BACKGROUND

The COVID-19 pandemic has disrupted all aspects of the international organ donation and transplantation (ODT) system. Multiple organizations have developed guidance, but to date, no comparative summary has emerged to understand differences in existing recommendations.

METHODS

We developed and applied a comparative methodology to a convenience sample of recommendations available on The Transplantation Society website. Document types were classified according to characteristics such as type of organization (eg, governing body or professional society) and geographic region. Recommendations were grouped according to content, and summaries were posted on a public website. This process is ongoing and will be updated as new recommendations become available.

RESULTS

Eighteen documents were extracted in the initial review. All documents were based on expert opinion, and none described a formal literature review or adherence with clinical guideline development processes. Recommendation categories included screening of potential donors, risk assessment of potential recipients, posttransplant risk, living/paired donation, protection of ODT professionals, and ethics/logistics. While many documents included similar recommendations, such as the need to screen and test patients who are potential donors, there was variation on some topics. Type of recommended laboratory testing varied with 64% recommending nasopharyngeal swabs, 43% oropharyngeal, and 24% bronchial aspirates. Updated results are available at https://cdtrp.ca/en/covid-19-international-recommendations-for-odt/.

CONCLUSIONS

The current state of COVID-19 ODT recommendations is limited to expert opinion. Substantial variation exists regarding recommendations, which are based on emerging but currently low-quality evidence. This summary of existing recommendations will serve to inform priorities for evidence-based recommendations.

Trends in Lung Transplantation Practices Across the United States During the COVID-19 Pandemic

BACKGROUND

The purpose of this study is to examine the effects of the coronavirus disease 2019 (COVID-19) pandemic on adult lung transplants and report practice changes in the United States.

METHODS

A retrospective analysis of a public dataset from the United Network for Organ Sharing was performed regarding adult lung transplantation (January 19, 2020-June 30, 2020). Data were stratified into 3 periods: pre-COVID-19 (January 19, 2020-March 14, 2020), first COVID-19 era (March 15, 2020-May 8, 2020), and second COVID-19 era (May 9, 2020-June 30, 2020). Weekly changes in waitlist inactivations (COVID-19 precautions or not), waitlist additions, transplant volume, and donor recovery were examined across eras and changes across era were correlated.

RESULTS

During the first COVID-19 era, 301 patients were added to the waitlist, representing a 40% decrease when compared to the prior 8-week period. This was followed by a significant increase in listing during the second COVID-19 era (t = 2.16, P = 0.032). Waitlist inactivations decreased in the second COVID-19 era from the first COVID-19 era (t = 3.60, P < 0.001). There was no difference in waitlist inactivations between the pre-COVID era and the second COVID-19 era (P = 0.10). Weekly volume was not associated with trends in COVID-19 cases across any era, but was negatively associated with waitlist inactivations due to COVID-19 precautions entering the first COVID-19 era (r = -0.73, P = 0.04) and second COVID-19 era (r = -0.89, P = 0.003).

CONCLUSIONS

Due to the COVID-19 pandemic, the United States experienced a decrease in lung transplant volume. While overall volume has returned to normal, additional studies are needed to identify areas of improvement to better prepare for future pandemics.