key: cord-0734065-af37vs4x authors: Altunisik Toplu, Sibel; Bayindir, Yasar; Yilmaz, Sezai; Yalçınsoy, Murat; Otlu, Baris; Kose, Adem; Sahin, Tevfik Tolga; Akbulut, Sami; Isik, Burak; Başkiran, Adil; Koc, Cemalettin title: Short‐term experiences of a liver transplant centre before and after the COVID‐19 pandemic date: 2021-08-05 journal: Int J Clin Pract DOI: 10.1111/ijcp.14668 sha: 6514dda0339e2bcb5f5d39542e5b7c80e286ddd6 doc_id: 734065 cord_uid: af37vs4x BACKGROUND/AIM: With the COVID‐19 pandemic, managing the process of solid organ transplantation has become a significant matter for transplant centres. In this study, we report our experiences on evaluating the effects of COVID‐19 in patients with recent liver transplants. MATERIALS AND METHODS: We evaluated patients who received liver transplants during three close consecutive periods of time. For transplants conducted between October 1 and December 31, 2019, January 1 and March 10, 2020 and March 11 and June 22, 2020, the lung tomographies of patients were inspected for radiological signs of viral pneumonia. For patients after March 11, 2020, the hospital's electronic database system was scanned for preoperative and postoperative SARS‐CoV‐2 testing from Real‐time Polymerase Chain Reaction (RT‐PCR) of the respiratory tract samples. RESULTS: A total of 149 patients over the age of 18 who received liver transplants at our centre between October 1, 2019 and June 22, 2020 were evaluated. During this time span, our centre conducted liver transplants on patients from 34 different provinces and also abroad. Within this time period, a total of nine patients had respiratory samples with a positive SARS‐CoV‐2 RT‐PCR test. PCR of respiratory tract samples was performed in 21 (14%) patients to identify the other potential infective agents in the respiratory tracts; Rhinovirus and Influenza A were detected in two and respiratory syncytial virus (RSV) was detected in one patient. During the transplant periods, 99 (67.1%) patients were evaluated with computed tomography (CT). The CT findings of 18 (12%) patients were consistent with viral pneumonia. There was a statistically significant difference between the groups only in terms of air bronchogram findings (P = .012). CONCLUSION: The clinical status of our short‐term liver transplant patients was far better than we originally anticipated, but it remains obvious that the necessary precautions should continue to be taken. On December 31, 2019, the World Health Organisation's China Office reported pneumonia cases of unknown ethology in the Chinese city of Wuhan in Hubei province. On January 7, 2020, the causative agent was identified as a novel coronavirus (2019 nCoV) that was not previously detected in humans. 1 The virus was subsequently termed as SARS-CoV-2. The infectious disease caused by SARS-CoV-2 (COVID-19) has rapidly spread worldwide and has affected life in an unimaginable way. With the COVID-19 pandemic, managing the process of solid organ transplantation has become a significant matter for transplant centres. Since COVID-19 is a contagious disease, it is important to evaluate the donor and potential recipient during the transplantation process, and follow-up on the recipient, who will be receiving immunosuppressive medication. The World Health Organisation declared a pandemic on March 11, the same day our country reported its first case. 2 In this study, we report our experiences on evaluating the effects of COVID-19 in patients with recent liver transplants, and believe that it can contribute to the literature during this ongoing pandemic. In this study, we evaluated patients who received liver transplants during three close consecutive periods of time at the Organ Transplant Institute of Turgot Ozal Medical Center, Inonu University, Faculty of Medicine. The three time periods were as follows: October 1, 2019-December 31, 2019 being the pre-pandemic period or period I; January 1, 2020-March 10, 2020 being the temporary period or period II (March 10 being the date that the WHO declared a pandemic and the first reported case in Turkey) and March 11-June being the pandemic period or period III. For patients after March 11, 2020, the hospital's electronic database system was scanned for preoperative and postoperative SARS-CoV-2 testing from RT-PCR of nasopharyngeal smear, oropharyngeal smear and/ or bronchoalveolar lavage (BAL) samples; positive cases were noted. Patients positive for COVID-19 were retrospectively evaluated for their treatment and follow-up results from electronic case report forms. Retrospective evaluation of post-transplant SARS-CoV-2 RT-PCR control was conducted for 3 months after the evaluation of the last patient. The immunosuppressive medication that patients are receiving was noted. The immunosuppressive treatment protocol includes corticosteroids, 5-10 mg/d methyl prednisolone in patients with autoimmune hepatitis, tacrolimus for patients with normal kidney functions and mycophenolate mofetil, basiliximab or tacrolimus in patients with abnormal kidney functions. Everolimus was given to patients with renal dysfunction and as a combination therapy to reduce the side effects of calcineurin inhibitors (CNI) such as tacrolimus. In addition, for transplants conducted in our centre between October 1, 2019 and December 31, 2019 and January 1, 2020 and March 10, 2020, we retrospectively evaluated the viral agents that were detected (through molecular analysis) in the respiratory tract samples of liver recipients. Likewise, the lung tomographies of patients were inspected for radiological signs of viral pneumonia. Findings from all three time periods were evaluated for statistically significant differences. The statistical analyses of the data were performed through SPSS (Statistical Package for Social Sciences) for Windows 22.0 software. Data for qualitative variables were presented as number and percentage, and data for quantitative variables, as mean ± SD. • It is not clear whether solid organ transplant recipients are at higher risk of undertaking SARS-CoV-2 infection than the general population. • In liver transplant patients, chronic immunosuppression and frequent contact with the health system support the risk of getting COVID-19. • Life-saving transplantation should continue to be carried out. • All recipients and donors candidates should be screened for COVID-19. • It is critical that recipients within the pandemic period be followed up and consistently evaluated before and following transplantation. • The clinics of almost all of our COVID-19 cases, who were short-term liver transplant patients, were mild to moderate. with SARS-CoV-2 continued their immunosuppressive treatments without irregularity. • Thoracic tomographs of patients who underwent liver transplantation in consecutive recent periods, including before the COVID-19 pandemic announcement, were not different in terms of viral pneumonia findings. Kruskal-Wallis test was used to compare independent samples. A value of P < .05 was accepted as statistically significant. The present study was approved by The Inonu University Medical Faculty non-interventional Ethical Committee (approval no: 2020/868) and Republic of Turkey Ministry of Health, Labor Council for Scientific Research (form no: 2020-06-15T22_12_38). Table 3 displays the CT findings consistent with viral pneumonia with respect to time period. The patients' thorax CT images were evaluated for groundglass opacity, consolidation, air bronchogram, crazy paving pattern, septal thickening, vascular dilatation, bronchial changes, pleural effusion and cavitation findings. There was a statistically significant difference between the groups in terms of air bronchogram findings (P = .012). The difference was due to patients in the period III. There was no statistical difference with respect to the other findings (Table 4 ). therefore, it will be influential to determine the optimal management of COVID-19 using data from recent transplant patients. and three (7.5%) short-term LT recipients were positive for SARS-CoV-2, but had survived the disease. 9 In our study, we evaluated 149 adult patients who received a transplant during three different time periods including the pre-pandemic period, temporary period and pandemic period. All of them were in short time period after transplantation ( Table 1) It is critical that recipients within the pandemic period be followed The EASL-ESCMID report emphasises the importance of drug-drug interactions and antiviral treatment protocols while adjusting immunosuppressive drug dosage. 17 The possibility of clinical deterioration after transplantation for a recipient with an undiagnosed COVID-19 disease proves to be a matter of concern. Lagana et al reported that a 6-month-old baby with biliary atresia developed COVID-19 and severe pneumonia after receiving a LDLT from her COVID-19-positive mother. 18 The While it has almost been an entire year since the breakout of SARS-CoV-2 (November of 2019), 22 speculations as to when it could end remain uncertain. The period in which our study was conducted included the first period in which the number of daily cases was most common with the onset of the pandemic in our country. 23 11 April 2020 daily number of cases became 5138. 24 During these periods, the number of COVID-19 cases is shown in Table 5 in our province where our institute is located. Like the rest of the world, our medical facility must label specific routes that must be taken for solid organ (primarily liver) transplantations. While taking necessary precautions; limiting the number of patients in our polyclinic, providing all of our healthcare and other personnel with protective equipment, limiting the number and duration of patient interactions and through selective operations based on urgency, we provided LT for patients whose conditions were critical. 25 In our study, SARS-CoV-2 RT-PCR test was positive in respiratory samples of 9 of 149 patients who had recently undergone liver transplantation. The clinics of almost all of our COVID-19 cases, who were short-term liver transplant patients, were mild to moderate. One patient, was being monitored for chronic rejection, died 45 days after diagnosis of COVID-19. The patient's cause of death was not associated with COVID-19. Even, mortality rates in liver transplant recipients are reported lower than in the matched general population. 26 On the other hand, as Bhoori et al reported, those with short-time liver recipients may have an advantage over long-term recipients for COVID-19. 9 The clinical status of our LT patients were far better than we originally anticipated, but it remains obvious that the necessary precautions should continue to be taken. transition No conflict of interest was declared by the authors. The author declared that this study has not received financial support. Sibel Altunisik Toplu https://orcid.org/0000-0002-2915-4666 Adem Kose https://orcid.org/0000-0002-1853-1243 Director-General's opening remarks at the media briefing on COVID19-11 Changing epidemiology of respiratory viral infections in hematopoietic cell transplant recipients and solid organ transplant recipients The COVID-19 pandemic: a community approach Early description of coronavirus 2019 disease in kidney transplant recipients in New York COVID-19 in solid organ transplant recipients: Initial report from the US epicenter Coronaviruses and immunosuppressed patients: the facts during the third epidemic COVID-19 in longterm liver transplant patients: preliminary experience from an Italian transplant centre in Lombardy Low prevalence and disease severity of COVID-19 in post-liver transplant recipients-a single centre experience Coronavirus disease (COVID-19) in kidney and liver transplant patients: a single-center experience COVID-19 in solid organ transplant recipients: a single-center case series from Spain Clinical outcome in solid organ transplant recipients with COVID-19: a single-center experience COVID-19 in solid organ transplant recipients: a single-center case series from Spain COVID-19 and African Americans Management of COVID-19 in patients after liver transplantation: Beijing working party for liver transplantation Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper COVID-19 associated hepatitis complicating recent living donor liver transplantation American Society of Transplantation. 2019-n-CoV (Coronavirus): FAQs for Organ Donation and Transplantation Bouza E; on behalf of the PISOT study group. Pneumonia in solid organ transplant recipients: a prospective multicenter study The presence of SARS-CoV-2 RNA in human sewage Turkey: WHO Coronavirus Disease (COVID-19) Dashboard. Accessed COVID-19 pandemic: Its impact on liver disease and liver transplantation Epidemiological pattern, incidence and outcomes of COVID-19 in liver transplant patients Short-term experiences of a liver transplant centre before and after the COVID-19 pandemic