Living donor liver transplants for sick recipients during COVID-19 pandemic—An experience from a tertiary center in India

To The Editor,

The recent outbreak of the coronavirus disease 2019 (COVID-19) has brought elective surgeries including liver transplantation to a standstill. The concerns in living donor liver transplant (LDLT) were that immunosuppressed recipients and healthy donors would be exposed to nosocomial severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection.¹ However, as patients began to suffer and die, Liver Transplant Society of India revised its guidelines² and allowed LDLT for those who were very sick, or had just recovered from a life-threatening decompensation (high Model for End-Stage Liver Disease/Child-Turcotte-Pugh [MELD/CTP] score) or had malignancy. More than 90% of transplants in India are from live donors because we have a very low donation rate. Our center is the largest LDLT center in India and performs an average of 250 adults/pediatric transplants per year. In the ongoing pandemic, most Western centers have stopped LDLT and therefore our experience in this pandemic may allay some of the concerns.

Nine blood group–compatible LDLTs were performed during March 24 to April 29, 2020 and 1 case could not be done because the asymptomatic donor tested positive and her recipient continues to be in our ICU as the transplant was deferred. LDLT was carried out when 2 tests for SARS-CoV-2 were negative (1 test was done immediately before the transplant). All team members were also tested for SARS-CoV-2 before reinitiation of LDLT, and only those who were negative were part of the operating room (OR) team. In the OR, all hospital-directed precautions were taken during aerosol-generating procedures.³ Postoperatively, similar precautions were taken in the ICU and throughout the stay at the hospital. No alteration was made in the immunosuppressive protocol and all patients received a standard 3-drug regimen ( Table 1).

TABLE 1.

Baseline demographic of recipients/donors who underwent LDLT during COVID-19 pandemic

Serial number	Age (y)	Sex	Cause	Reasons for transplant	MELD/PELD score/CTP	Date of transplant	IS regimen	Complications	Status	Donor age/sex	Relation to recipient
Case 1	55	F	HCV with HCC	Malignancy with recent AV embolization	24/10 C	24.3.2020	CNI + MMF+steroid	None	Discharge	31/M	Son
Case 2	15	M	ALF	Acute liver failure	31/14 C	2.4.2020	CNI + MMF+steroid	HAT	In patient	41/F	Mother
Case 3	54	F	HBV	Early chronic rejection	16/9 B	6.4.2020	CNI + MMF+steroid	None	Discharge	61/M	Husband
Case 4	49	M	NASH	hyperbilirubinemia with recurrent HE	28/12 C	8.4.2020	CNI + MMF+steroid	None	Discharge	44/F	Wife
Case 5	65	M	NASH	Multiple admissions for HE	27/13 C	10.4.2020	CNI + MMF+steroid	None	Discharge	35/M	Son
Case 6	56	M	HBV + ethanol	Intractable pruritus	26/10 C	13.4.2020	CNI + MMF+steroid	None	Discharge	28/F	Daughter
Case 7	1.5	M	Hepatoblastoma	Malignancy	30/5 A	22.4.2020	CNI + MMF+Steroid	None	In patient	30/F	Mother
Case 8	2	M	Biliary atresia	Hyperbilirubinemia/recurrent cholangitis	18/10 C	24.4.2020	CNI + MMF+steroid	None	In patient	37/M	Uncle
Case 9	0.9	F	Biliary atresia	Hyperbilirubinemia/UGI bleed	19/11 C	29.4.2020	CNI + MMF+steroid	None	In patient	30/F	Mother

Abbreviations: ALF, acute liver failure; AV, arteriovenous; CNI, calcineurin inhibitors; COVID-19, coronavirus disease 2019; CTP, Child-Turcotte-Pugh; HAT, hepatic artery thrombosis; HBV, hepatitis B virus; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; HE, hepatic encephalopathy; IS, immunosuppressive regimen; LDLT, living donor liver transplant; MELD, Model for End-Stage Liver Disease; MMF, mycophenolate mofetil; NASH, nonalcoholic steatohepatitis; PELD, Pediatric End-Stage Liver Disease; UGI, upper gastrointestinal.

The basic demographic and clinical details and reasons for transplant are given in Table 1. The median ± interquartile range MELD/Pediatric End-Stage Liver Disease (PELD) score at the time of admission was 21 ± 8 and CTP score was 10 ± 2. LDLT was carried out on 3 ± 3 days after admission. The pretransplant total bilirubin was 8.9 ± 18.7 mg/dL and international normalized ratio was 1.5 ± 0.9. None of the recipients/donors had any intraoperative complication. The immediate posttransplant course for all patients was uneventful and followed a normal course. Case 2 developed late hepatic artery thrombosis and underwent surgical revision but continues to have a bile leak. Five of 9 patients were discharged on average 17 ± 3 days while the remaining 4 are awaiting discharge. All donors recovered well. No one developed COVID-related symptoms posttransplant, in keeping with the low rate of infection in our hospital. Over ten thousand tests have been done at our center, and the positivity rate was <1% in asymptomatic cases.

In countries such as ours where LDLT is the predominant form of transplant, once the donor workup has been completed, the recipient undergoes transplant within 6 weeks. During this period, 21 patients have had their transplant deferred and remain on medical therapy. In summary, LDLT can be carried out safely with extra precaution during this pandemic.