key: cord-0789312-6l4rv1hg
authors: Verma, Sapana; aleen Agarwal, Shaleen; Chikkala, Bhargav Ram; Dey, Rajesh; Singh, Shekhar; Varma, Sharat; Yadav, Vivek; Das, Divyajyoti; Goyal, Sumit; Pandey, Vijay Kanth; Nasa, Vaibhav; Madan, Kaushal; Shweta, Singh; Tarai, Bansidhar; Gupta, Subhash
title: Living donor liver transplants for sick recipients during COVID‐19 pandemic‐ An experience from a tertiary center in India
date: 2020-06-07
journal: Am J Transplant
DOI: 10.1111/ajt.16102
sha: 97fe8d982bc58bb3a606ee22f85e798822d2833d
doc_id: 789312
cord_uid: 6l4rv1hg

The recent outbreak of COVID‐19 has brought elective surgeries including liver transplantation to a standstill. The concerns in Living Donor Liver Transplant (LDLT) were that immunosuppressed recipients and healthy donors would be exposed to nosocomial SARS‐ CoV‐2 infection.(1) However, as patients began to suffer and die, Liver Transplant Society of India (LTSI) revised its guidelines (2) and allowed LDLT for those who were very sick, or had just recovered from a life threatening decompensation (high MELD/ CTP score) or had malignancy. Over 90 % of transplants in India are from live donors as we have a very low donation rate.

The recent outbreak of COVID-19 has brought elective surgeries including liver transplantation to a standstill. The concerns in Living Donor Liver Transplant (LDLT) were that immunosuppressed recipients and healthy donors would be exposed to nosocomial SARS-CoV-2 infection. 1 However, as patients began to suffer and die, Liver Transplant Society of India (LTSI) revised its guidelines 2 and allowed LDLT for those who were very sick, or had just recovered from a life threatening decompensation (high MELD/ CTP score) or had malignancy. Over 90 % of transplants in India are from live donors as we have a very low donation rate. Our center is the largest LDLT center in India and performs an average of 250 adults/pediatric transplants per year. In the ongoing pandemic, most Western centers have stopped LDLT and therefore our experience in this pandemic may allay some of the concerns.

Nine blood group compatible LDLT were performed during 24 th March -29 th April 2020 and one case could not be done as the asymptomatic donor tested positive and her recipient continues to be in our ICU as the transplant was deferred. LDLT was carried out when two tests for SARS-CoV-2 were negative (one test was done immediately before the transplant). All team members were also tested for SARS-CoV-2 before reinitiation of LDLT and only those who were negative were part of the OR team. In the OR, all hospital directed precautions were taken during aerosol generating procedures. 3 Post operatively similar precaution were taken in ICU and throughout the stay of the hospital. No alteration was made in the immunosuppressive (IS) protocol and all patient received standard three drug regimen. (Table 1) The basic demographic and clinical details and reasons for transplant are given in Table 1 . The median ± IQR MELD /PELD score at the time of admission was 21± 8 and CTP score was 10 ± 2.

This article is protected by copyright. All rights reserved LDLT was carried out on 3± 3 days after admission. The pre transplant Total Bilirubin was 8.9 ± 18.7 mg/dL and INR was 1.5 ± 0.9. None of the recipients/donors had any intraoperative complication.

The immediate post-transplant course for all patients were uneventful and followed a normal course.

Case 2 developed late hepatic artery thrombosis (HAT) and underwent surgical revision but continues to have a bile leak. Five of eight patients were discharged on an average of 17 ± 3 days while the remaining four are awaiting discharge. All donors recovered well. No one developed COVID-related symptoms post-transplant in keeping with the low rate of infection in our hospital. Over ten thousand tests have been done at our center, and the positivity rate was < 1 % in asymptomatic cases.

In countries such as ours where LDLT is the predominant form of transplant, once the donor workup has been completed, the recipient undergoes transplant within 6 weeks. During this period, 21 patients have had their transplanted deferred and remain on medical therapy. In summary, LDLT can be carried out safely with extra precaution during this pandemic.

COVID-19: a global transplant perspective on successfully navigating a pandemic

Liver transplantation and COVID-19 (Coronavirus) infection: guidelines of the liver transplant Society of India (LTSI)

COVID Operation Theatre-Advisory and Position Statement of Indian Society of Anaesthesiologists (ISA National)

The authors of this manuscript have no conflicts to disclose as described by the American Journal of Transplantation.