S2740 A Case Report in Managing COVID-19 in a Liver Transplant Recipient

Abstract

INTRODUCTION: Coronavirus Disease 2019 (COVID-19) is a pandemic impacting the entire globe, with over 5.3 million cases worldwide and 1.6 million US cases. Given the scarcity of information on COVID-19 infections in liver transplant patients, this case explores a patient 7 months post-liver transplant on immunosuppression who presented with COVID-19. CASE DESCRIPTION/METHODS: The patient was a 67-year-old female with a past medical history of alpha-1-antitrypsin cirrhosis status post orthotopic liver transplant (OLT) in October 2019, COPD, hypertension, CKD, and insulin-dependent diabetes. She was asymptomatic but tested positive at her nursing home on routine testing. Then lab work showed elevated liver function tests (LFTs)—AST 258, ALT 423, AP 210 from a normal baseline—which prompted the decision to bring her to the hospital. We held her Cellcept and continued her normal tacrolimus and prednisone dosing, 2 mg twice a day and 2.5 mg daily, respectively. We also continued her Mepron and Valcyte prophylaxis. During her 9-day course the only complications she had were fevers day 2–3 and profuse diarrhea day 3–6. Though low suspicion, we treated her empirically for a community-acquired pneumonia and possible C diff. We considered the administration of convalescent plasma but did not since she never became hypoxic. Her transaminitis—a phenomenon seen in 14.8–53% of COVID cases—persistently down-trended thus liver biopsy was not pursued. DISCUSSION: This patient was considered high-risk for decompensation given her age, medical history, and immunosuppression, however her clinical course was mild. Per AASLD guidelines we stopped her Cellcept and continued her tacrolimus and prednisone. We were concerned since kidney transplant patients tended to have poorer outcomes than the general population. The only literature on COVID in OLT patients was a case series from Italy with 6 patients which showed that short-term OLT recipients (<2 years) had better survival rates than long-term recipients (>10 years). The short-term group tended to have significantly higher rates of full immunosuppression, but had lower rates of comorbidities such as diabetes, hypertension, and kidney disease. Although our patient was a short-term recipient on immunosuppression, she was unique in that she had significant comorbidities. Her case demonstrates that OLT patient with a new transaminitis should be considered for COVID-19, and that their immunosuppressive agents may have a protective role against the infection.Table 1.: This table shows the trend of the patient’s LFTs from 1 month prior to admission determined to be her baseline on routine lab work, her admission LFTs (which was her peak), and her LFTs on discharge.