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Liver transplants and COVID-19

Keith Alcorn
28 April 2020

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, in early reports on the impact of COVID-19 on organ transplants 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. The remainder were kidney (46), lung (17) and heart (9) recipients, and five multiple organ 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.

The average age of the patients was 57 years, 22% were black and 68 out of 90 were admitted to hospital. 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%).

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 and 18% of all transplant patients presenting with COVID-19 died.

Immunosuppression was not associated with disease severity in this population and there was no difference in outcome between lung transplant recipients and other organ recipients.

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.

Liver transplant outcomes in Italy

Italian researchers in Lombardy, the region worst affected by COVID-19, reported on the outcomes of 17 liver transplants carried out between 23 February and 10 April 2020. Two patients have been diagnosed with SARS-CoV-2 post-transplant and one patient died of COVID-19, 30 days after transplantation. All other patients are alive and ten have already been discharged from hospital.

Donors were screened for SARS-CoV-2 using bronchealveolar lavage (BAL) to obtain sputum samples. Recipients were also screened for SARS-CoV-2, in advance of Italian guidelines issued in mid-March, and the investigators suggest that BAL should be used as an additional sampling method to screen recipients.

Key lessons learned from operating a liver transplant service during the COVID-19 outbreak include:

  • Reserve liver transplantation for patients with very poor prognosis or advanced hepatocellular carcinoma
  • Perform BAL for SARS-CoV-2 testing in all donors and a chest CT scan if available.
  • Avoid sending organ procurement teams to local hospitals; try to get local hospitals to carry out organ retrieval
  • Test recipients using nasopharyngeal swab at arrival and BAL at intubation
  • During the in-patient post-op follow-up, limit transport of the patients to other units such as Radiology or Endoscopy. No family/visitors allowed at bedside.
  • After discharge, minimise patients coming to hospitals for outpatient follow-up, unless strictly necessary.


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. The paper includes advice on managing patients after liver transplantation.


Pereira M et al. COVID-19 in solid organ transplant recipients: report from the US epicentre. American Journal of Transplantation, online publication, 24 April 2020

Maggi U et al. The impact of the COVID-19 programme on liver transplantation programmes in northern Italy. American Journal of Transplantation, online publication, 24 April 2020