Resuming post living donor liver transplantation in the COVID-19 pandemic: real-life experience, single-center experience

BACKGROUND

Solid organ transplantation (SOT) service has been disrupted during the current coronavirus disease 2019 (COVID-19) pandemic, which deferred the service in most centers worldwide. As the pandemic persists, there will be an urgency to identify the best and safest practices for resuming activities as areas re-open. Resuming activity is a difficult issue, in particular, the decision of reopening after a period of slowing down or complete cessation of activities.

OBJECTIVES

To share our experience in resuming living donor liver transplantation (LDLT) in the context of the COVID-19 pandemic in the Liver Transplantation Unit of El-Manial Specialized Hospital, Cairo University, Egypt, and to review the obstacles that we have faced.

MATERIAL AND METHODS

This study is a single-center study. We resumed LDLT by the 26th of August 2020 after a period of closure from the 1st of March 2020. We have taken a lot of steps in order to prevent COVID-19 transmission among transplant patients and healthcare workers (HCWs).

RESULTS

In our study, we reported three LDLT recipients, once resuming the transplantation till now. All our recipients and donors tested negative for SARS-CoV-2 by nasopharyngeal RT-PCR a day before the transplantation. Unfortunately, one of them developed COVID-19 infection. We managed rapidly to isolate him in a single room, restricting one team of HCWs to deal with him with strict personal protective measures. Finally, the patient improved and was discharged in a good condition. The second patient ran a smooth course apart from FK neurotoxicity which improved with proper management. The third patient experienced a sharp rise in bilirubin and transaminases on day 14 that was attributed to drug toxicity vs. rejection and managed by discontinuing the offending drugs and pulse steroids. In addition, one of our head nurses tested positive for SARS-CoV-2 that was manageable with self-isolation.

CONCLUSION

Careful patient, donor, personnel screening is mandatory. Adequate supply of personal protective equipments, effective infection control policies, and appropriate administrative modifications are needed for a safe return of LDLT practice.

Tacrolimus-induced posterior reversible encephalopathy syndrome presenting as left upper limb monoplegia, convulsions, and sudden blindness: case report

Background

To report a case of sudden onset left upper limb monoplegia, convulsions, and bilateral blindness in a patient receiving tacrolimus for immunosuppression following living donor liver transplantation (LDLT) consistent with posterior reversible encephalopathy syndrome (PRES).

Case presentation

We report a case of a 64-year-old male patient on tacrolimus treatment following LDLT. On day 11, during his post-operative routine follow-up. The patient developed sudden onset of left upper limb monoplegia associated with attacks of convulsions and sudden bilateral blindness. MRI revealed multiple, bilateral cortical, and subcortical areas of high T2 and FLAIR signal intensity that did not show restricted diffusion. Findings were suggestive of posterior reversible encephalopathy syndrome (PRES). After the cessation of tacrolimus, vision was completely regained and all other neurologic symptoms were resolved, and follow-up MRI was normal. This case represents an uncommon presentation of tacrolimus toxicity.

Conclusion

Tacrolimus toxicity may present with PRES. Neurological deficits may be fully reversible with discontinuation of the drug; therefore, the early recognition and prompt management of this condition are of utmost importance.

Comparative evaluation between two immunoenzymatic techniques (FAST and Phadezym) and the Phadebas RAST in food allergy

The diagnosis of food IgE-dependent hypersensitivity is based on the demonstration of specific IgE, completed by provocation tests. Two immunoenzymatic techniques, the Phadezym and the FAST, are compared with the Phadebas RAST, in 86 sera (23 controls, 28 from patients with a reported food allergy and 35 with a positive RAST to a food allergen). The within-run variation coefficient of class 0-2 sera was 9% for the Phadebas RAST, and higher than 20% for the Phadezym and the FAST. It was in order of 8.7%, 9.4% and of 17.6% respectively for Phadebas RAST, Phadezym and FAST when estimated with class 3-4 sera. The specificity was higher than 95% for the three techniques. The sensitivity was 75% for Phadebas and 43% for Phadezym and FAST. The FAST test is much less sensitive with allergens of vegetal origin than those of animal origin (P less than 0.01). This work indicates the high percentage of false negative results of immunoenzymatic techniques when food extracts are tested. This could be explained either by an enzyme-substrate reaction or by a non-specific inhibition of the enzyme linked to the anti-IgE IgG.