Liver transplants and COVID-19

Liver specialists in New York report a high frequency of severe COVID-19 cases in organ transplant recipients who became infected with SARS-CoV-2, while Italian specialists report that 15 of 17 patients who underwent liver transplants in northern Italy since early February remain free of SARS-CoV-2. These early reports on the impact of COVID-19 on organ transplants have been published in the American Journal of Transplantation.

People undergoing organ transplants are at higher risk of SARS-CoV-2 infection owing to hospitalisation. They may also be at risk of more severe COVID-19 outcomes after infection due to immunosuppression, although data are lacking to answer this question.

But transplants cannot be postponed so more information is needed about what happens if people who have recently undergone transplants become infected with SARS-CoV-2 and what proportion of patients are becoming infected.

Information is also lacking on what happens to long-term transplant recipients who acquire SARS-CoV-2.

Transplant doctors at Columbia University and Weill Cornell Medical College in New York reported on their experience in the first three weeks of the outbreak in the city. They identified 90 cases of COVID-19, confirmed by PCR testing, in people who had received a solid organ transplant at their clinics. They do not state the overall number of transplant recipients receiving care through their clinics.

Thirteen out of 90 were liver transplant recipients.

People diagnosed with COVID-19 had undergone transplantation a median of six years ago; only three were in the immediate post-transplant period (< 1 month) and 13 had undergone transplantation less than a year before diagnosis with COVID-19.

Twenty-seven out of 90 were classed as severe cases requiring mechanical ventilation and intensive care, the remainder were mild (outpatient) or moderate (inpatient, non-ventilation care) cases.

Severe cases were significantly more likely to have hypertension (78% vs 60%, p = 0.001) and to be aged 60 or over (70% vs 30%), in line with other studies which also show a high prevalence of these risk factors in severe cases.

Compared to Chinese cohorts of hospitalised patients, the investigators say that the proportion of transplant patients with severe disease appeared higher. One in four transplant patients admitted to hospital with COVID-19 died (16 patients) and 18% of all transplant patients presenting with COVID-19 died.

The investigators say that because of the high death rate in transplant patients, there is an urgent need to identify the most effective treatment strategies for this patient group.

The use of immunosuppressive drugs might prolong viraemia in COVID-19 patients and lead to more severe illness, but reducing immunosuppressive treatment might lead to graft rejection, the investigators say. Doses of antimetabolite immunosuppressive drugs were reduced or held in 88% of patients (42 of 48) but steroid doses were reduced in only 3 of 43 patients and calcineurin inhibitors in 10 of 56 patients. No cases of rejection were detected during the 20-day observation period.

Fatty liver disease may increase risk of severe COVID-19 disease

A preliminary analysis of people admitted to hospital in China with COVID-19 symptoms shows that people with non-alcoholic fatty liver disease (NAFLD) were six times more likely to progress to severe COVID-19 illness than people without NAFLD and remained potentially infectious for longer, Chinese researchers report in the Journal of Hepatology.

Researchers reported on 202 people admitted to hospital with COVID-19. Thirty-seven per cent met diagnostic criteria for NAFLD using a combination of hepatic steatosis index, body mass index and abdominal ultrasound. Thirty-nine people subsequently progressed to severe illness requiring intensive care including ventilation.

Multivariate analysis showed that people with NAFLD were at least six times more likely to progress (odds ratio 6.4, 95% CI 1.5-31.2) and underlying co-morbidity was associated with a similar increase in risk (OR 6.3, 95% CI 2.3-18.8). Male sex (OR 3.1, 95% CI 1.1-9.4) and age over 60 years (OR 4.8, 95% CI 1.5-16.2) were also associated with progression.

NAFLD was also associated with a higher frequency of liver injury (abnormal liver function during hospitalisation) (70% vs 11%), although liver enzyme increases were mild to moderate.

Although the obesity and metabolic syndrome that accompany NAFLD are known risk factors for more severe COVID-19 illness, the study authors say that NAFLD itself may promote a pro-inflammatory environment in the liver, impairing innate immunity and leading to more severe COVID-19 illness.

New resources on liver disease and COVID-19

AASLD's Clinical Insights for Hepatology and Liver Transplant Providers During the COVID-19 Pandemic

This document provides data on what is known about COVID-19, and how it may impact hepatologists and liver transplant providers and their patients. The document will continue to evolve and be reviewed by the authors and AASLD Governing Board, and be revised and updated as needed in response to the COVID-19 pandemic.

AASLD COVID-19 and the liver webinar series

On 16 April, AASLD hosted a webinar that highlighted information from the 16 April update to the Clinical Insights for Hepatology and Liver Transplant Providers During the COVID-19 Pandemic paper. It also:

  • Provides short synopses on several research articles.
  • Presents a few cases submitted in advance by attendees. The experts discuss the next best steps to be taken in that patient’s care.

EASL-ESCMID Position Paper: Patients with advanced liver disease and transplant recipients require specific care during COVID-19

The European Association for the Study of the Liver (EASL) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) have issued a Position Paper, providing recommendations for clinicians caring for patients with liver diseases during the current pandemic.

EASL COVID-19 resource page

Includes links to archived EASL webcasts on COVID-19.

World Hepatitis Alliance resource page on COVID-19 and hepatitis

This page is being updated regularly with the latest information on COVID-19 for people living with viral hepatitis. The page was last updated on 28 April 2020.

Directly observed treatment for hepatitis C highly effective in people who inject drugs

Directly observed treatment for hepatitis C achieved a very high cure rate in people who inject drugs, an Austrian study carried out in pharmacies and drugs projects offering opioid substitution therapy has reported.

The study findings, published in the journal PLOS ONE, showed that daily directly observed treatment with the fixed-dose direct-acting antiviral regimen glecaprevir/pibrentasvir cured 94% of people.

The study investigators say that directly observed treatment "may represent a key measure in order to contribute to the hepatitis C virus elimination target" in people who inject drugs who are accessing opioid substitution therapy. The study also underlines the importance of making opioid substitution therapy available through community pharmacies and the potential value of these services as access points for hepatitis C treatment.

Hepatitis C transmission in men who have sex with men

Gay and bisexual men who acquire hepatitis C infection while using pre-exposure prophylaxis (PrEP) for HIV prevention are part of the same sexual networks and have the same risk factors as HIV-positive men who acquire hepatitis C, a study of men in London reports in the Journal of Viral Hepatitis. These risk factors include:

  • High prevalence of sexually transmitted infections diagnosed at the same time as hepatitis C
  • High prevalence of injecting drug use
  • Low awareness of having sex with partners who had hepatitis C.

The study investigators conclude that awareness of hepatitis C transmission routes should be promoted among gay and bisexual men, through PrEP clinics, social networking apps and sex on premises venues. Three-monthly testing using an antigen test or hepatitis C virus (HCV) RNA test is essential, as antibodies may take longer than three months to emerge. Development of a home test for HCV may also improve diagnosis.

Clinics providing PrEP and HIV treatment clinics should ensure that they are talking about drug injecting during sex and harm reduction with gay and bisexual men, as well as supplying sterile injecting equipment, the study investigators recommend. Harm reduction and behaviour change are likely to be essential for achieving microelimination of hepatitis C among gay and bisexual men, even if very high levels of treatment coverage can be achieved, they say.

Another study on sexual transmission of hepatitis C showed that hepatitis C is spreading rapidly among HIV-positive men who have sex with men (MSM) in Bangkok and is associated with use of crystal methamphetamine. A second study identified a large HCV transmission cluster among MSM that involved a different strain of HCV to the one predominating among injecting drug users in Thailand.

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