key: cord-0730507-mi7dqzv4 authors: Varghese, Joy; Malleeswaran, Selvakumar; Patcha, Rajanikanth V.; Appusamy, Ellango; Karnan, Perumal; Kapoor, Dharmesh; Kota, Venugopal; Kedarisetty, Chandhan Kumar; Singh, Balbir; Rao, Prashantha S.; Yalakanti, Raghavendra Babu; Mohanka, Ravi; Shrimal, Anurag; Nikam, Vinayak; Kumar, Karan; Shenvi, Sunil D.; Pillai, Venugopal Bhaskaran; Heaton, Nigel D. title: A Multicentric Experience on Living Donor Liver Transplantation in COVID‐19 Hotspots in India date: 2020-11-30 journal: Liver Transpl DOI: 10.1002/lt.25957 sha: 50dd9ad8d4b3e847504f31cb0626e35c4dd81d4a doc_id: 730507 cord_uid: mi7dqzv4 As of August 2020, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has affected more than 213 countries, leading to more than 18 million cases and 690,000 deaths. India is the second most affected country, with the majority of cases in metropolitan cities, such as Mumbai, New Delhi, Chennai, and Bengaluru. There is limited literature on the outcomes and safety of performing living donor liver transplantation (LDLT) in coronavirus disease 2019 (COVID‐19) epicenters. This article is protected by copyright. All rights reserved As of August 2020, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected more than 213 countries, leading to more than 18 million cases and 690,000 deaths. India is the second most affected country, with the majority of cases in metropolitan cities, such as Mumbai, New Delhi, Chennai, and Bengaluru. There is limited literature on the outcomes and safety of performing living donor liver transplantation (LDLT) in coronavirus disease 2019 epicenters. We conducted a multicenter prospective cohort study recruiting consecutive LDLT recipients from four major transplant centers in Mumbai, Chennai, Hyderabad, and Bengaluru. The coordinating center was Gleneagles Global Health City in Chennai. This study conformed to the Declaration of Helsinki and was approved by the institutional ethics committee. Written informed consent was obtained from all patients. Both adult and pediatric recipients undergoing LDLT between April and July 2020 were included in the study. Recipient and donor data including demographic, perioperative clinical & laboratory parameters and postoperative outcome variables were recorded. Overall survival at the end of 1-month post-LT was recorded and analyzed. COVID-19 safety measures for LDLT were divided into three standard operating protocols (SOPs): patient related, staff related, and environment/equipment related. Emphasis was given to make the protocols safe and sustainable. A COVID-19-free transplant pathway was designed ( Fig. 1 ). During the liver transplant ICU stay, donors and recipients were allowed to talk to their attenders through video calling. Caregivers underwent SARS-CoV-2 polymerase chain reaction This article is protected by copyright. All rights reserved (PCR) screening before coming into the liver unit. Home collection of blood samples and video consultations with the LT team were the primary modalities of follow-up. If needed, patients came back to the dedicated liver unit, where all the emergency/elective queries were directed. Descriptive statistics were expressed as median (interquartile range) or number (%). Comparison of continuous variables was done by Wilcoxon rank sum test, and categorical variables were compared by Fisher's exact test or Pearson's chi-square test. One-way and two-way tables were computed. A P value of less than 0.05 was considered significant. Data were analyzed from Excel Sheets using MedCalc statistical software. A total of 31 LDLTs were conducted during the study period. Of these, 21 (67.7%) were adults and 10 (32.2%) were children. The demographic characteristics of donors and recipients and their clinical details are included in Table 1 . . In adults, ethanol related chronic liver disease was the predominant etiology followed by metabolic dysfunction-associated fatty liver disease (MAFLD) . Of the children, 2 had progressive familial intrahepatic cholestasis presenting as secondary biliary cirrhosis and 3 underwent LDLT for hepatoblastoma. Notably, 1 child presented with acute liver failure. The median postoperative ICU stay was 7 days in adults compared to 5 days in children (P = 0.02). Of the adults, 2 patients expired due to bacterial sepsis. Of the 7 adult recipients with postoperative morbidity, 4 had septicemia. The remaining 3 had bile leak, hepatic artery thrombosis and PTFE graft thrombosis, which were managed successfully. 1 pediatric recipient had acute cellular rejection, which was managed by pulse steroid therapy. 1 adult recipient was This article is protected by copyright. All rights reserved diagnosed with COVID-19 infection after discharge from the hospital, 46 days after surgery. The patient presented with fever and hypoxemia and had deranged transaminases. Chest computed tomography (CT) showed ground glass opacities with COVID-19 Reporting and Data System (CO-RADS) 4 grading, and nasopharyngeal swab for COVID-19 PCR was positive. Mycophenolate mofetil was discontinued, and the doses of steroid and tacrolimus were optimized. Antivirals were avoided due to hepatitis. The patient is currently in the hospital and recovering without ventilatory support. Notably, none of the donors, recipients, or transplant team members acquired nosocomial COVID-19 infection. Timely LT in a patient with progressively decompensating cirrhosis or a critically ill acute-onchronic liver failure (ACLF) patient is potentially curative, with good long-term survival. However, the COVID-19 pandemic has raised many unanswered questions, including the risk and severity of perioperative COVID-19 in transplant recipients, the safety of the donors, and the safety of the LT team. In a large online cross-sectional survey (1) from 109 European transplant centers, the overall incidence of symptomatic COVID-19 and the crude death rate in transplant waitlist candidates vs LT recipients, were 1.05% vs. 0.3% and 18% vs 15% respectively. The data from Mount Sinai Medical Center, New York, also showed similar results in 38 recipients infected with COVID-19, with overall mortality of 18% and in-hospital mortality of 29%. (2) Therefore, if we select patients who need urgent transplant and would be at higher risk of dying from liver failure rather than COVID-19, LT could be safely performed with appropriate precautions. This article is protected by copyright. All rights reserved During the study period, the average monthly incidence of COVID-19 in the four cities ranged between 955 to 2274 new cases per million population. The average hospital admission for COVID-19 in the four study centers ranged between 16 to 38% of the total available beds in each hospital. Inspite of this, due to stringent precautionary measures followed by the donor, recipient, and their accompanying caregivers; strict mitigation of the primary LT surgical, anesthesia, and supporting staff from other duties to avoid unnecessary exposure; and the segregation of the donors and recipients in the LTICU, the chain of any possible transmission in the hospital was broken and therefore nosocomial acquired COVID-19 cases were avoided. Only those patients with urgent indications, such as high MELD scores, ALF, ACLF, primary hepatic malignancies, etc were considered for timely LDLT after explaining the risks of COVID-19 and ensuring strict compliance to prevention protocols. Unfortunately, 1 adult recipient acquired COVID-19 infection from the community after discharge but is recovering. Similar encouraging results have also been reported from centers in India (3) and Korea. (4) The possible limitation in the study is the small size of the study group. Further studies with longterm follow-up of these patients and donors can give us more information about the risk and severity of COVID-19 infections compared to the general population. In conclusion, this is the first multicentric study highlighting the perioperative safety and good outcomes in carefully timed LDLT, even in COVID-19 hotspots, with stringent preventive protocols in place. This article is protected by copyright. All rights reserved Impact of COVID-19 on liver transplantation in Europe: alert from an early survey of European Liver and Intestine Transplantation Association (ELITA) and European Liver Transplant Registry (ELTR) COVID-19 in liver transplant recipients: an initial experience from the US epicenter Living donor liver transplants for sick recipients during COVID-19 pandemic: an experience from a tertiary center in India Effect of COVID-19 on liver transplantation in Korea Wilson's disease (3, 30%) Post-Kasai (1, 10%) 30%) Progressive familial intrahepatic cholestasis (2, 20%) Cholesteryl esterase deficiency (1, 10%) Indication for LT ALF (1, 10%) ACLF (6, 60%) Hepatoblastoma (3, 30%) NA Diabetes mellitus (4, 19%) Hypertension (2, 9.5%) Ischemic heart disease (1, 4.7%) Diabetes, hypertension We thank Prof. Vijaya Srinivasan, senior consultant epidemiologist, for This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved Mortality (n, %) 2 (9.5%) 0