Living Donor Hepatectomy After Proven SARS-CoV-2 Infection: First Report of 9 Cases From 3 Centers

Abstract

We read the report by Kute et al1 published in Transplantation regarding the safety of live kidney donation in 31 individuals with previous severe acute respiratory syndrome coronovirus-2 (SARS-CoV-2) infection. Liver transplantation (LT) has been severely restricted during the coronavirus disease 2019 (COVID-19) pandemic due to concerns of perioperative SARS-CoV-2 infection in donors and recipients.2,3 Unlike kidney transplantation that can be postponed for an extended duration, there is an element of urgency for patients awaiting LT. While there is general consensus that individuals with symptomatic SARS-CoV-2 infections should not proceed with living donor hepatectomy (LDH), there are no clear recommendations regarding the safety of LDH in individuals with recent asymptomatic infection. We had several instances of asymptomatic donors testing positive on preoperative screening. We set up a protocol of reassessing these donors for LDH if they satisfied the following 4 criteria: asymptomatic infection without abnormal inflammatory markers or liver function tests, have completed 2-wk isolation period, 2 negative real-time polymerase chain reaction (RT-PCR) tests 48 h apart—the second within 48 h of LDLT, and normal preoperative chest computed tomography scan. SARS-nCoV2 antibody levels were not routinely measured. Donors and recipients were managed in a COVID-19 free unit. All donors received perioperative deep venous thrombosis prophylaxis. Postdischarge follow-up visits were minimized and donors were followed by e-consultation with home blood sample collection.4 This is a retrospective report of living donors who tested positive for SARS-nCoV2 infection on routine RT-PCR screening. All clinical procedures were performed in accordance with the principles of the Istanbul Declaration. The study was exempt from ethics board approval as it was a retrospective review of deidentified data. Between July and December 2020, 9 potential living donors tested positive for SARS-nCoV2 infection on routine RT-PCR screening at 3 LT centers in India. There were 3 male and 6 female donors donating to 5 adult and 4 pediatric recipients (Table 1). Six tested positive during donor evaluation, while 3 tested positive during preoperative testing. None had computed tomography chest findings suggestive of SAR-nCoV2 infection. Two potential recipients also had positive testing with no symptoms. LT was postponed in all cases and donors and recipients were managed with strict home isolation for 2 wk. Repeat testing was performed after 2 wk, and donors proceeded with LDH once previously mentioned criteria were satisfied. TABLE 1. - Details of 9 donors who underwent LDH after asymptomatic SARS-CoV-2 infection Center number Donor age/sex Recipient age/sex Cause/MELD (PELD) Donor-patient relationship Graft type Time interval between first positive test and LDH (d) Total RT-PCR tests performed Peak postop serum bilirubin (mg%) Perioperative morbidity Hospital stay (d) Current status of donor Follow-up duration (mo) 1.1 24/M 41/M ALD/12 Uncle LL 92 4 2.1 Nil 7 Good 2.5 1.2 34/F 9/F Wilson’s/11 Mother LL 72 3 1.9 Ileus, NG 5 Good 1 1.3 35/F 47/M ALD/31 Spouse RL 64 3 3.4 Nil 6 Good 2 1.4 29/F 2/F EHBA/18 Mother LLS 53 3 1.6 Nil 6 Good 1 2.1 43/F 48/M ALD/24 Spouse RL 27 5 1.8 Pleural effusion 7 Good 4 2.2 33/F 8/F Wilson’s ACLF/28 Mother LL 15 3 1.3 Nil 7 Good 1 3.1 32/M 12/F BCS with HCC/20 Cousin RL 49 3 3.3 Nil 7 Good 1.5 3.2 30/F 35/M Cryptogenic CLD/22 Spouse RL 22 6 1.7 Nil 8 Good 1 3.3 46/M 3/M Abernathy syndrome Father LLS 87 4 1.0 Nil 7 Good 1 ACLF, acute on chronic liver failure; ALD, alcoholic liver disease; BCS, Budd-Chiari syndrome; CLD, chronic liver disease; EHBA, extrahepatic biliary atresia; F, female, HCC, hepatocellular carcinoma; LDH, living donor hepatectomy; LL, left lobe; LLS, left lateral segment graft; M, male; MELD, Model for End-stage Liver Disease; NG, nasogastric tube; PELD, pediatric end-stage liver disease; RL, right lobe; RT-PCR, real-time polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronovirus-2. Median interval between the first positive RT-PCR and LDH was 53 d. Three donors had positive RT-PCR tests even 3 wk after the initial positive test necessitating further delays in surgery until 2 consecutive negative tests were obtained. There were no major complications in any of the donors. One recipient needed reoperation for sepsis and developed early allograft dysfunction leading to prolonged hospital stay. All donors and recipients were discharged in stable condition. There were no COVID-19-related complications among the donors or recipients during the perioperative and follow-up period. Our report provides initial evidence for the safety of LDH after previous asymptomatic SARS-nCOV2 infection. Clarity is needed regarding the significance of repeat positive tests beyond 3 wk, role of antibody testing, and the benefit of preoperative vaccination for potential donors with previous asymptomatic SARS-nCOV2 infection.