key: cord-0898894-06j1jlc6
authors: Gao, Feng; Zheng, Kenneth I.; Gu, Jin‐Yang; George, Jacob; Zheng, Ming‐Hua
title: COVID‐19 and liver transplantation: Lessons learned from three reported cases
date: 2020-06-02
journal: Transpl Infect Dis
DOI: 10.1111/tid.13335
sha: e10775a41139cb9259350f83946ff70b3acbfe1d
doc_id: 898894
cord_uid: 06j1jlc6

During the COVID-19 pandemic, transplant recipients have been recognized as more susceptible to infection, to have greater severity of disease, and prolonged shedding of this highly transmissible virus.1 However, there is limited information on the impact of COVID-19 in liver transplant (LT) recipients. We reviewed three reported cases with detailed treatment information from China to better understand the features and associated therapeutic strategies used in transplant recipients with COVID-19.2-4.

To the Editor, During the COVID-19 pandemic, transplant recipients have been recognized as more susceptible to infection, to have greater severity of disease, and prolonged shedding of this highly transmissible virus. 1 However, there is limited information on the impact of COVID-19 in liver transplant (LT) recipients. We reviewed three reported cases with detailed treatment information from China to better understand the features and associated therapeutic strategies used in transplant recipients with COVID-19. [2] [3] [4] As summarized in Table 1 , three patients all received immunosuppressive therapy after transplantation and were initially diagnosed as having mild disease and then progressed to severe illness. High fever (ie, >39°C) was common in the patients, which differed from previous reports that organ transplant recipients present with only lowgrade or no fever. Similar to the general population, lymphopenia was common, while multiple peripheral pulmonary ground-glass opacities were the typical radiological findings during progressive infection.

Two patients (cases 1 and 2) of similar age with post-transplant infections had opposite outcomes. The first patient (case 1) was infected by his wife. 2 During hospitalization, immunosuppressive therapy with maintained with tacrolimus and mycophenolate.

He also received standard methylprednisolone therapy. Despite antibacterial treatment, he succumbed to secondary bacterial and fungal infection. The second patient (case 2) was suspected of having opportunistic infections; treatment was subsequently changed to discontinuation of tacrolimus and addition of cefoperazone. 3 After a month of treatment, he successfully recovered and was discharged. Unlike these two patients, the third (case 3) was infected with COVID-19 during the perioperative period. 4 Antimicrobial agents were started immediately following transplantation because of persistent fever. When COVID-19 was confirmed, tacrolimus and glucocorticoids were titrated to lower doses. After 60 days of hospitalization, he was successfully discharged.

Current data suggest that an exaggerated innate immune response is important in instigating severe illness in patients with COVID-19. In this context, the immunocompromised host may be protected by a weaker innate response against severe COVID-19.

However, this ignores the fact that recipients are more likely to develop secondary bacterial or fungal infections, which was found in all three of the cases. 

The authors have no conflict of interest to declare.

Feng Gao and Ming-Hua Zheng conceived and designed the study.

Gao and Kenneth I. Zheng drafted the manuscript. Jacob George critically revised the manuscript for important intellectual content.

Ming-Hua Zheng supervised the study. All authors contributed to the manuscript for important intellectual contents and approved the submission. 

Novel Coronavirus-19 (COVID-19) in the immunocompromised transplant recipient: #Flatteningthecurve

Zheng Ming-Hua. Fatal outcome in a liver transplant recipient with COVID-19

Successful treatment of severe COVID-19 pneumonia in a liver transplant recipient

Perioperative Presentation of COVID-19 Disease in a Liver Transplant Recipient

Coronaviruses and Immunosuppressed Patients: The Facts During the Third Epidemic

Alive and discharged on day 60Note: The first day of hospital admission was assumed as day 1 (d1).