Convalescent plasma therapy and remdesivir duo successfully salvaged an early liver transplant recipient with severe COVID-19 pneumonia

The impact and clinical spectrum of COVID-19 infection in liver transplant recipients/solid organ transplants are being unveiled during this recent pandemic. The clinical experience of use of current antiviral drugs and immunomodulators are sparse in solid organ transplantation. We present the clinical course of a 49-year-old male recipient who underwent living donor liver transplant for recurrent gastrointestinal bleed and contracted severe COVID-19 pneumonia during the third postoperative week. Herein we report the successful management of severe COVID-19 pneumonia using convalescent plasma therapy and remdesivir. Recipient’s clinical deterioration was halted after three consecutive convalescent plasma transfusions with improvement in hypoxia and inflammatory markers (interleukin-6 and C-reactive protein). The use of convalescent plasma therapy along with remdesivir may be an ideal combination in the management of severe COVID-19 pneumonia in solid organ transplant recipients.

Restarting LDLT During COVID-19: Early Results After Restructuring

Introduction

Living-donor liver transplantation (LDLT) has been mostly suspended and deceased-donor living transplantation activity has been considerably reduced because of coronavirus disease 2019 (COVID-19). We modified our protocols and procedures in line with COVID-19 guidelines. Since the restructuring, we have performed 20 LDLTs. Our study reports the outcomes of these cases and demonstrates the feasibility of LDLT during this pandemic.

Materials and Methods

The changes were influenced by experiences and communications from across the globe. A month-long self-imposed moratorium was spent in restructuring the program and implementing new protocols. Twenty LDLTs were performed between April 18 and September 15 using the new protocols. Our experience includes 2 simultaneous liver-kidney transplants, 1 ABO-incompatible LDLT, and 1 pediatric case (age 11 months).

Results

Nineteen patients recovered and 1 patient died. We maintained our postoperative immunosuppression protocol without many changes. Major complications were observed in 30% of recipients but none of the donors. One recipient was infected with COVID-19 during the postoperative period. A donor-recipient couple contracted COVID-19 after discharge from the hospital. All patients recovered from COVID-19 and liver enzymes were unaffected.

Conclusion

This study represents a microcosm of experience in LDLT during the COVID-19 era. Outcomes of LDLT are not affected by COVID-19 per se, provided that we make necessary changes.

Sublingual Administration of Tacrolimus is Safe and Provides Similar Drug Exposure to Per-oral Route in Liver Transplant Recipients During Early Postoperative Period-A Large, Retrospective, Observational Study

Background/Aims

Per-oral (PO) administration of tacrolimus (TAC) results in inadequate trough levels in the early postoperative period in liver-transplant (LT) recipients who undergo Roux-en-Y hepaticojejunostomy for biliary reconstruction. Sublingual administration (SL) of tacrolimus provides an alternative route in such patients.The objectives of this study were to assess the feasibility and safety of SL tacrolimus in adult LT-recipients in the early postoperative period and to compare therapeutic efficacy of SL administration of tacrolimus versus PO route.

Methods

single-center, retrospective, observational study carried out in adult living donor liver transplant (LDLT) recipients between January 2022 and December 2022. Recipients who underwent Roux-en-Y hepaticojejunostomy for biliary reconstruction received tacrolimus through the SL route till postoperative day (POD) 5 as they were kept nil per oral constituted the study group while recipients who underwent duct-to-duct (D-D) anastomosis for biliary reconstruction were allowed orally from POD1 and received PO-tacrolimus were chosen as controls. The feasibility and safety of SL-tacrolimus were assessed in terms of patient acceptance, need to discontinue SL-tacrolimus, incidence of local adverse effects, and systemic adverse events like neurotoxicity and nephrotoxicity. Therapeutic efficacy was evaluated by comparing median trough levels (TAC level) achieved and incidence of graft rejection between two groups.

Results

Two hundred twelve patients underwent LT during the study period, of which 125 were included (58 in the SL-group and 67 in PO-group). Both groups had comparable baseline characteristics. In the SL-group, all patients tolerated SL-Tacrolimus well and no local adverse events were observed. Patients with SL-Tacrolimus administration achieved a higher median TAC level (ng/ml) vs. PO route (5.85 vs. 5 (P = 0.06)) despite receiving similar median cumulative tacrolimus dose before assessing TAC-level. Fifty percent of patients achieved TAC level ≥6 ng/ml in SL-group vs. 35.8% in PO-group (P = 0.14). The incidence of neurotoxicity, nephrotoxicity, and graft rejection during hospital stay were similar in both the groups (P = 0.56, 0.82, and 0.28, respectively).

Conclusion

SL-tacrolimus is safe and provides similar trough levels to PO-tacrolimus and may be considered as a viable alternative whenever inadequate TAC levels are anticipated through the per-oral route.

Impact of Living Donor Liver Transplantation on COVID-19 Clinical Outcomes from a Quaternary Care Centre in Delhi

BACKGROUND AND AIMS

The anticipated fear of serious outcomes in coronavirus infected liver transplant recipients led to disruption of transplant services globally. The aim of our study was to analyze COVID-19 severity in transplant recipients and to compare the difference of COVID-19 clinical outcomes in early (<1 year) vs. late (>1 year) post-transplant period.

METHODS

41 post-living donor liver transplant recipients with COVID-19 infection were studied retrospectively from 1st April 2020 to 28th February 2021.

RESULTS

The median age was 49.00 years with a male preponderance (80.49%). Fifteen patients had infection within 1 year of transplant and 26 were infected after 1 year of transplant. The overall median interval between transplantation and COVID-19 diagnosis was 816.00 days. Fever and malaise were the common presenting symptoms. The most common associated comorbidities were diabetes mellitus (65.85%) and hypertension (46.34%). The severity of illness was mild in 28 (68.29%), moderate in 4 (9.76%), severe in 6 (14.63%) and critical in 3 (7.32%). To identify associated risk factors, we divided our patients into less severe and more severe groups. Except for lymphopenia, there was no worsening of total bilirubin, transaminases, alkaline phosphatase, and gamma-glutamyl transferase in the more severe group. Eight (19.51%) patients required intensive care unit admission and three (7.32%) died, while none suffered graft rejection. In recipients with early vs. late post-transplant COVID-19 infection, there were similar outcomes in terms of severity of COVID-19 illness, intensive care unit care need, requirement of respiratory support, and death.

CONCLUSION

Living donor liver transplantation can be performed during the COVID-19 pandemic without the fear of poor recipient outcome in cases of unfortunate contraction of severe acute respiratory syndrome coronavirus-2.

Management of Incidentally Detected Urinary Tract Calculus in Patients Awaiting Living Donor Liver Transplantation: A Protocol-Based Approach

BACKGROUND

Urinary tract calculi (UTC) in patients awaiting living donor liver transplant (LDLT) requires proper management due to increased risk of infections in the post-liver transplant (LT) period.

MATERIALS AND METHODS

A retrospective analysis of records of LDLT recipients with UTC was conducted between July 2019 and July 2023. No prisoners or paid participants were included.

RESULTS

Thirty patients (25 women and 5 men) with a mean age of 44.45 ± 9.67 years, model of end stage liver disease with sodium (MELD-Na) of 20.5 ± 12.2 were diagnosed to have a UTC during pre-LT evaluation. Twenty-five patients had renal stones, whereas five patients had ureteric calculus (22 were unilateral and 8 were bilateral calculi). Fifteen patients underwent double J (DJ)-stenting prior to LT. The mean stone size in patients who underwent DJ stenting was 13.6 (±9.83) mm vs 4.78 (±5.3) mm in whom stenting was not done. Patients with preoperative DJ stenting had a significantly reduced hospital stay (18.5 ± 2.1 days), lower mortality rates (0%), and lower rates of hematuria (6.66%) vs (23.4 ± 12.8 days, 13.33% and 13.3%, respectively). Patients with preoperative DJ stenting underwent post-transplant definitive procedure for UTC without any complications. Our Protocol for Incidentally Detected Ureteric Stones in LT Recipients: a. Proximal-ureteric calculi: Preoperative DJ stenting (2-3 days prior/ on day of LT) → LT → ESWL/URS 2-3 weeks later → DJ stent removal after 2-3 weeks. b. Distal-ureteric calculi: Preoperative DJ stenting ± URS (2-3 days prior/ day of LT) → LT → DJ stent removal after 2-3 weeks. Our protocol for incidentally detected renal stones in LT recipients: a. Stone size (< 5 mm) and nonobstructive calculi with no active UTI: No surgical intervention → Liver transplant under antibiotics cover → medical management of stone. b. Multiple calculi sized < 5 mm or single stone 5-10 mm: DJ stent placement → LT → ESWL/RIRS after 4-6 weeks → DJ stent removal after 3 weeks. c. Single stone size > 10 mm or multiple calculi > 5 mm: DJ stent placement → LT → RIRS/PCNL after 4-6 weeks→DJ stent removal after 3-4 weeks.

CONCLUSION

A systemic minimally invasive approach is needed for pre-LT management of UTC for better patient outcomes.