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Colmenero J, Rodríguez-Perálvarez M, Salcedo M, Arias-Milla A, Muñoz-Serrano A, Graus J, Nuño J, Gastaca M, Bustamante-Schneider J, Cachero A, Lladó L, Caballero A, Fernández-Yunquera A, Loinaz C, Fernández I, Fondevila C, Navasa M, Iñarrairaegui M, Castells L, Pascual S, Ramírez P, Vinaixa C, González-Dieguez ML, González-Grande R, Hierro L, Nogueras F, Otero A, Álamo JM, Blanco-Fernández G, Fábrega E, García-Pajares F, Montero JL, Tomé S, De la Rosa G, Pons JA. Epidemiological pattern, incidence, and outcomes of COVID-19 in liver transplant patients. J Hepatol 2021; 74:148-155. [PMID: 32750442 PMCID: PMC7395653 DOI: 10.1016/j.jhep.2020.07.040] [Citation(s) in RCA: 234] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The incidence and outcomes of coronavirus disease 2019 (COVID-19) in immunocompromised patients are a matter of debate. METHODS We performed a prospective nationwide study including a consecutive cohort of liver transplant patients with COVID-19 recruited during the Spanish outbreak from 28 February to 7 April, 2020. The primary outcome was severe COVID-19, defined as the need for mechanical ventilation, intensive care, and/or death. Age- and gender-standardised incidence and mortality ratios (SIR and SMR) were calculated using data from the Ministry of Health and the Spanish liver transplant registry. Independent predictors of severe COVID-19 among hospitalised patients were analysed using multivariate Cox regression. RESULTS A total of 111 liver transplant patients were diagnosed with COVID-19 (SIR = 191.2 [95% CI 190.3-192.2]). The epidemiological curve and geographic distribution overlapped widely between the liver transplant and general populations. After a median follow-up of 23 days, 96 patients (86.5%) were admitted to hospital and 22 patients (19.8%) required respiratory support. A total of 12 patients were admitted to the ICU (10.8%). The mortality rate was 18%, which was lower than in the matched general population (SMR = 95.5 [95% CI 94.2-96.8]). Overall, 35 patients (31.5%) met criteria of severe COVID-19. Baseline immunosuppression containing mycophenolate was an independent predictor of severe COVID-19 (relative risk = 3.94; 95% CI 1.59-9.74; p = 0.003), particularly at doses higher than 1,000 mg/day (p = 0.003). This deleterious effect was not observed with calcineurin inhibitors or everolimus and complete immunosuppression withdrawal showed no benefit. CONCLUSIONS Being chronically immunosuppressed, liver transplant patients have an increased risk of acquiring COVID-19 but their mortality rates are lower than the matched general population. Upon hospital admission, mycophenolate dose reduction or withdrawal could help in preventing severe COVID-19. However, complete immunosuppression withdrawal should be discouraged. LAY SUMMARY In liver transplant patients, chronic immunosuppression increases the risk of acquiring COVID-19 but it could reduce disease severity. Complete immunosuppression withdrawal may not be justified. However, mycophenolate withdrawal or temporary conversion to calcineurin inhibitors or everolimus until disease resolution could be beneficial in hospitalised patients.
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Affiliation(s)
- Jordi Colmenero
- Liver Transplant Unit, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Manuel Rodríguez-Perálvarez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, IMIBIC, Cordoba, Spain.
| | - Magdalena Salcedo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Hepatology and Liver Transplantation Unit, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Ana Arias-Milla
- Hepatology and Liver Transplant Unit, Hospital Puerta de Hierro, IDIPHIMSA, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alejandro Muñoz-Serrano
- Hepatology and Liver Transplant Unit, Hospital Puerta de Hierro, IDIPHIMSA, Universidad Autónoma de Madrid, Madrid, Spain
| | - Javier Graus
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Department of Digestive Diseases, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Javier Nuño
- Hepatobiliary and Liver Transplantation Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Mikel Gastaca
- Liver Transplantation Unit, Cruces University Hospital, University of the Basque Country, Biocruces Bizkaia Health Research Institute, Bilbao, Spain
| | - Javier Bustamante-Schneider
- Liver Transplantation Unit, Cruces University Hospital, University of the Basque Country, Biocruces Bizkaia Health Research Institute, Bilbao, Spain
| | - Alba Cachero
- Liver Transplant Unit, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Lladó
- Liver Transplant Unit, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Aránzazu Caballero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Hepatology and Liver Transplantation Unit, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Ainhoa Fernández-Yunquera
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Hepatology and Liver Transplantation Unit, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Carmelo Loinaz
- Department of Hepatology/HPB-surgery/Transplantation, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Inmaculada Fernández
- Department of Hepatology/HPB-surgery/Transplantation, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Constantino Fondevila
- Liver Transplant Unit, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Miquel Navasa
- Liver Transplant Unit, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Mercedes Iñarrairaegui
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Liver Unit, Clínica Universidad de Navarra, IDISNA, Pamplona, Spain
| | - Lluis Castells
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Department of Internal Medicine, Liver Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sonia Pascual
- Liver Unit, Hospital General Universitario de Alicante, Alicante, Spain
| | - Pablo Ramírez
- Liver Transplantation Unit, Liver Unit, Department of Surgery, IMIB, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Carmen Vinaixa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Department of Hepatology and Liver Transplantation, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - María Luisa González-Dieguez
- Liver Unit and Division of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Rocío González-Grande
- Department of Liver Transplantation, Hospital Regional Universitario de Málaga, Malaga, Spain
| | - Loreto Hierro
- Department of Paediatric Hepatology and Liver Transplantation, Hospital Universitario La Paz, Madrid, Spain
| | - Flor Nogueras
- Department of Hepatology and Liver Transplantation, Hospital Virgen de las Nieves, Granada, Spain
| | - Alejandra Otero
- Liver Transplant Unit, Hospital de A Coruña, A Coruña, Spain
| | - José María Álamo
- Liver Transplant Unit, Hospital Virgen del Rocío, Seville, Spain
| | - Gerardo Blanco-Fernández
- Department of HPB surgery and Liver Transplantation, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain
| | - Emilio Fábrega
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Department of Digestive Diseases, IDIVAL, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - José Luis Montero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, IMIBIC, Cordoba, Spain
| | - Santiago Tomé
- Department of Liver Transplantation, Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Gloria De la Rosa
- Registro Español de Trasplante Hepático (RETH) y Organización Nacional de Trasplantes (ONT), Madrid, Spain
| | - José Antonio Pons
- Liver Transplantation Unit, Liver Unit, Department of Surgery, IMIB, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
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Pipa-Muñiz M, Castells L, Pascual S, Fernández-Castroagudín J, Díez-Miranda I, Irurzun J, Díaz-Beveridge R, Senosiaín M, Arenas J, de la Mata M, Turnes J, Monge-Romero MI, Pérez-Enguix D, Bustamante-Schneider J, Otegui N, Molina-Pérez E, Rodríguez-Menéndez JE, Varela M. The ART-SCORE is not an effective tool for optimizing patient selection for DEB-TACE retreatment. A multicentre Spanish study. Gastroenterol Hepatol 2017; 40:515-524. [PMID: 28676199 DOI: 10.1016/j.gastrohep.2017.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 05/08/2017] [Accepted: 05/23/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The appropriate selection of hepatocellular carcinoma (HCC) patients who are eligible for transarterial chemoembolization (TACE) remains a challenge. The ART score has recently been proposed as a method of identifying patients who are eligible or not for a second TACE procedure. OBJECTIVE To assess the validity of the Assessment for Retreatment with TACE (ART) score in a cohort of patients treated with drug-eluting bead TACE (DEB-TACE). SECONDARY OBJECTIVE to identify clinical determinants associated with overall survival (OS). METHOD A retrospective, multicentre study conducted in Spain in patients with HCC having undergone two or more DEB-TACE procedures between January 2009 and December 2014. The clinical characteristics and OS from the day before the second DEB-TACE of patients with a high ART score (ART≥2.5) and a low ART score (ART 0-1) were compared. Risk factors for mortality were identified using Cox's proportional hazards model. RESULTS Of the 102 patients included, 51 scored 0-1.5 and 51 scored ≥2.5. Hepatitis C was more frequent in patients scoring ≥2.5. Median OS from the day before the second DEB-TACE was 21 months (95% CI, 15-28) in the group scoring 0-1.5, and 17 months (95% CI, 10-25) in the group scoring ≥2.5 (P=0.3562). Platelet count and tumour size, but not the ART score, were independent baseline predictors of OS. CONCLUSIONS The ART score is not suitable for guiding DEB-TACE retreatment according to Spanish clinical practice standards.
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Affiliation(s)
- Maria Pipa-Muñiz
- Department of Gastroenterology and Hepatology, Hospital de Cabueñes, Gijón, Asturias, Spain
| | - Lluis Castells
- Liver Unit, Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Sonia Pascual
- Liver Unit, Digestive Department, Ciberehd, Hospital General Universitario de Alicante, Alicante,, Spain
| | | | - Iratxe Díez-Miranda
- Interventional Radiology Service, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Javier Irurzun
- Interventional and Vascular Radiological Unit, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - María Senosiaín
- Digestive Department, Hospital Universitario Cruces, Barakaldo, Vizcaya, Spain
| | - Juan Arenas
- Gastroenterology and Hepatology Department, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
| | - Manuel de la Mata
- Unit of Hepatology and Liver Transplantation, CIBERehd, IMIBIC, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Juan Turnes
- Department of Gastroenterology, Complejo Hospitalario Universitario de Pontevedra, Instituto de Investigación Sanitaria Galicia Sur, Pontevedra, Spain
| | | | - Daniel Pérez-Enguix
- Interventional Radiology, Medical Imaging Clinical Area, Hospital Universitari i Policlínic La Fe, Valencia, Spain
| | | | - Nora Otegui
- Gastroenterology and Hepatology Department, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
| | - Esther Molina-Pérez
- Gastroenterology Department, Hospital Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | | | - Maria Varela
- Liver Unit, Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
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