key: cord-0766926-me7s5upv
authors: Barros, Nicolas; Ermel, Aaron; Mihaylov, Plamen; Lacerda, Marco; Fridell, Jonathan; Kubal, Chandrashekhar
title: Deceased donor liver transplantation from a SARS‐CoV‐2 positive donor to a SARS‐CoV‐2 positive recipient
date: 2021-08-05
journal: Liver Transpl
DOI: 10.1002/lt.26253
sha: 1a939ebf9a4b48ce3701e2098b0c40270e85fe05
doc_id: 766926
cord_uid: me7s5upv

Liver grafts from deceased donors with active SARS‐CoV‐2 infection carry an unknown risk of transmission. Recently, the OPTN Ad Hoc DTAC summary stated that the decision to recover organs from donors with active COVID‐19 should consider the recipient’s risk of mortality by delaying the transplantation while waiting for a suitable donor and the potential risk of donor‐derived SARS‐CoV‐2 (1). With the high likelihood of persistent community transmission, many deceased donor livers from SARS‐CoV‐2 infected donors will not be transplanted (2).

Dear Editor, Liver grafts from deceased donors with active SARS-CoV-2 infection carry an unknown risk of transmission. Recently, the OPTN Ad Hoc DTAC summary stated that the decision to recover organs from donors with active COVID-19 should consider the recipient's risk of mortality by delaying the transplantation while waiting for a suitable donor and the potential risk of donor-derived SARS-CoV-2

(1). With the high likelihood of persistent community transmission, many deceased donor livers from SARS-CoV-2 infected donors will not be transplanted (2). While the precise rate of discarded organs due to COVID-19 is not available, there was a 1.7% excess rate of discarded organs during the first 3 months of 2020 compared to the rest of the year (3). As of now, SARS-CoV-2 donor-derived transmission has not been reported outside of lung transplantation (3) . Here, we present a case of successful transplantation of a liver from a SARS-CoV-2 positive deceased donor to a SARS-CoV-2 positive recipient.

A 48-year-old male with end-stage alcoholic cirrhosis, complicated with coagulopathy, hepatic encephalopathy, diuretic refractory ascites, esophageal varices and hypervolemic hyponatremia was found to have SARS-CoV-2 by PCR on nasopharyngeal swab (cycling threshold: 26). Upon detection of SARS-CoV-2, he was made inactive. Ten days later, his condition deteriorated with worsening encephalopathy and coagulopathy with spontaneous bleeding. His Model for End-stage Liver Disease (MELD) score was 35. He had asymptomatic COVID-19, and his chest CT was unremarkable. He did not require any SARS-CoV-2 therapy and SARS-CoV-2 antibody was positive.

Due to his worsening medical condition, he was made active on the list. There were no suitable organ offers for more than 24 hours. At that point, an offer was made of a deceased 17-year-old male donor who had SARS-CoV-2 detected by PCR from nasopharyngeal swab (cycling threshold: 12). CT of the chest showed minimal ground glass opacities. The cause of death was anoxia from hanging. Given the rapid decline of our recipient's condition, the organ offer was accepted. On the day of transplant, the recipient's SARS-CoV-2 PCR remained positive (cycling threshold: 31).

Standard transplantation was performed with 4.5 hours of cold and 17 minutes of warm ischemia times. Due to the coagulopathy and generalized oozing, packing of the upper abdomen fascial Accepted Article closure was delayed to the next day. The recipient received induction with methylprednisolone 500 mg IV daily for 3 doses, and maintenance with mycophenolate mofetil 500 mg BID and Tacrolimus with target trough levels of 8-10 ng/dL. On post-operative day 1, the fascia was closed and he was extubated. His liver function improved, and he was discharged on day 10. Blood samples from the donor and recipient, and liver graft biopsies before and 1 day after transplantation were negative for SARS-CoV-2 by RT-PCR. Two weeks post-transplantation, his repeat SARS-CoV-2 PCR was negative. Four months later he remains clinically well with good graft function.

The cycling threshold refers to the number of cycles required to exceed the established threshold to call a result positive (4). Low cycling thresholds represent higher viral loads. Higher viral loads may be associated with increased disease severity and mortality (5) . While the cycling threshold of the donor suggested a high viral load, there is no evidence that this correlates with a higher risk of transmission through non-lung organ donations. Furthermore, cycling thresholds vary widely between different platforms rendering their interpretation challenging. For this reason, we decided to accept the offer despite a low cycling threshold.

To the best of our knowledge, this is the first intentional deceased donor liver transplant in the Korea in 2020 (6) . Subsequently 3 LDLTs with positive SARS-CoV-2 tests in donors as well as recipients were reported from India. All were at least 14 days from the time of diagnosis and were asymptomatic at time of transplantation (7). We recognize that there is small risk of transmission of SARS-CoV-2 through extra-pulmonary solid organ transplantation. SARS-CoV-2 enters human cells by engaging with the cell surface receptor protein, angiotensin-converting enzyme 2 (ACE2), which has ubiquitous distribution in vascular endothelium and bile ducts. SARS-CoV-2 RNA has been isolated from the postmortem liver tissue in patients who succumbed to severe COVID-19 (8) .

Though, relative to other organs such as the kidney, its detection is less frequent in livers (9) . We felt that the possibility of presence of SARS-CoV-2 in the liver from an asymptomatic donor should be extremely low, and perhaps without significant consequences in a recipient who has antibodies against SARS-CoV-2.

This article is protected by copyright. All rights reserved Several reports of liver transplants in patients that have recently recovered from COVID-19 have been published. However, due to high mortality associated with end stage liver disease, patients with decompensated liver failure may not have the option of waiting until the viral shedding has resolved as the PCR can remain positive for long periods of time. Prior studies have shown that prolonged viral shedding beyond 8-10 days is not associated with prolonged infectivity (10) . Hence, detection of SARS-CoV-2 by PCR following resolution of symptoms should not discourage the transplant team from considering transplantation. Given our patient's rapid deterioration, we believed that this was his only opportunity to be transplanted and without it his chances of long-term survival were negligible.

Our case exemplifies that judicious use of extra-pulmonary organs from SARS-CoV-2 positive donors for transplantation in recipients with active or recovered SARS-CoV-2 infection may be considered if a recipient candidate's risk of mortality or further complications by delaying transplantation is high. However, larger experience is needed to allow changes in practice or policy.

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