Coronavirus Disease 2019 in the Early Postoperative Period of Liver Transplantation: Is the Outcome Really So Positive?

Abstract

Potential conflict of interest: Nothing to report. TO THE EDITOR: We read with interest the article by Massoumi et al.(1) regarding 5 patients who developed coronavirus disease 2019 (COVID‐19) in the early postoperative period of liver transplantation (LT). None of them exhibited severe disease, and they all fully recovered, suggesting that COVID‐19 in the early postoperative period of LT might not be associated with unfavorable outcomes. Here, we share our experience with 7 cases that was not so promising. Between March 24 and July 1, 2020, we performed 28 deceased donor LTs, and 7 patients were diagnosed with COVID‐19 in the early posttransplant period, ranging from 9 to 39 days (Table 1). Because there is no clear definition for early COVID‐19 after LT, we assumed it to be until postoperative day (POD) 60, irrespective of whether the patient had been discharged home or remained hospitalized. TABLE 1 - Patients Who Developed COVID‐19 in the Early Postoperative Period of LT Case Age (Years) and Sex Liver Disease Comorbidities COVID‐19 Severity LT to COVID‐19 Interval (Days) Outcome Tacrolimus Level on COVID‐19 Diagnosis (ng/mL) C‐Reactive Protein (mg/L) D‐Dimer (ng/mL) Ferritin (ng/mL) Platelets (×103/mm3) 1 69, female Cirrhosis: Hepatitis C virus infection (MELD 15, Child‐Pugh A6), down‐staged HCC Systemic hypertension Severe 9 Death on POD 13 10.8 146.1 8477 NA 248 Coronary artery disease Pulmonary hypertension Obesity Postoperative hemodialysis 2 67, male Cirrhosis: NASH and α1‐antripsin deficiency (MELD 13, Child‐Pugh B7), hepatic encephalopathy Systemic hypertension Severe 36 Death on POD 56 13.1 226 19,534 2896 98 Obesity Postoperative hemodialysis DM 3 69, male Alcohol‐related cirrhosis (MELD 13, Child‐Pugh A6), HCC Systemic hypertension Moderate 10 Discharged home on POD 27 13.3 96.3 4626 NA 148 DM 4 59, male Cryptogenic cirrhosis (MELD 10, Child‐Pugh B7), ascites hepatic encephalopathy Hepatosplenic schistosomiasis Moderate 11 Discharged home on POD 27 13.4 50.5 2253 NA 346 Postoperative hemodialysis 5 34, male Cirrhosis: sclerosing primary cholangitis (MELD 35, Child‐Pugh B7) None Mild 18 Discharged home on POD 41 13.7 82.2 6489 1558 311 6 61, male Alcohol‐related cirrhosis (MELD 14, Child‐Pugh B8), hepatic encephalopathy Systemic hypertension Mild 39 Discharged home after 8 days of hospitalization 3.3 144 14,750 771 193 DM 7 70, male Cirrhosis: Hepatitis C virus infection (MELD 12, Child‐Pugh A5), down‐staged HCC Systemic hypertension Severe 23 Still remains hospitalized after having been under invasive mechanical ventilation for 42 days 4.7 140.5 2730 347 137 DM Coronary artery disease Unlike the series by Massoumi et al.,(1) we experienced 3 cases of severe disease (patients 1, 2, and 7), with 2 deaths related to COVID‐19. This difference in outcomes may be associated with some distinct features between the 2 series. First, our patients were older and had more comorbidities. Patient 1 was obese, had triple‐vessel coronary disease and pulmonary hypertension, and was started on renal replacement therapy shortly after LT. Patient 2 was obese, had diabetes mellitus (DM), and remained hospitalized for a long time as a result of renal replacement therapy and cytomegalovirus infection. Patient 7 also had DM and triple‐vessel coronary disease. On the other hand, patients 4 and 5, who presented moderate/mild disease, were heavily immunosuppressed because they had acute cellular rejection and had undergone pulse methylprednisolone therapy. Patient 5 also received anti‐thymocyte globulin. These data suggest that in the early postoperative period, the prognosis of recipients diagnosed with COVID‐19 is more determined by the patients’ medical comorbidities and clinical status than immunosuppression, as observed in long‐term transplant recipients.(2) Second, 4 of our patients were in their index hospitalization when COVID‐19 was diagnosed (cases 1, 2, 4, and 5). Moreover, 2 patients were diagnosed 10 and 11 days after LT (cases 3 and 7). In contrast, in the series by Massoumi et al.,(1) only 1 patient was diagnosed during index hospitalization. The other 4 patients developed symptoms after discharge, possibly infected in the community, and 2 presented with the infection rather late at 67 days after LT. These patients were probably in a better clinical condition than immediately after LT or if they had remained hospitalized as a result of complications. In conclusion, our experience indicates that older patients with comorbidities may evolve unfavorably in the early postoperative course of LT, mainly if the infection is acquired during the posttransplant hospitalization period. It is paramount, however, to carefully interpret our data because this is a small case series from a single institution that may be subjected to selection bias, and thus our findings may not be generalizable.