Living Donor Liver Transplantation During the COVID-19 Pandemic: A Serendipitous Silver Lining!

The impact of COVID-19 on liver transplantation (LT) has been widely reported and numerous changes have been introduced at national, regional, and center levels to facilitate safe LT.^1,2 Our hospital based in Chennai, a COVID-19 hotspot has a busy LDLT program performing around 200 LDLT annually. After a brief suspension of LT activity during the initial phase of the pandemic, our program was cautiously restarted. During this period, we made extensive changes to our clinical practice to reduce the risk of SARS-CoV-2 transmission and enable safe performance of LDLT (Table 1). Healthcare-associated infections (HCAI) are common in developing countries and adversely impact posttransplant outcomes.^3,4 Antibiotics are fast becoming ineffective and there is increasing recognition of the importance of basic infection control practices such as handwashing, aseptic technique, and use of appropriate PPE to reduce HCAI.⁵ We hypothesized that changes to clinical practice made in response to the COVID pandemic may have the additional benefit of reduced post-LT infections leading to better outcomes.

TABLE 1. - List of major changes in practice implemented during the COVID-19 pandemic and feasibility of continuing them in the post-COVID-era

Modification of practices in the transplant unit due to COVID-19 pandemic	Can it be continued post-COVID?
Preoperative evaluation
Replace direct hospital visits with e-consultations whenever possible	Yes
Enhanced PPE usage during clinic appointments	Possible
Prevent crowding in key areas of hospital	Yes
Streamline recipient and donor evaluation to restrict patient and donor movement around the hospital	Possible
Pretransplant counseling regarding handwashing and use of face mask for the patient and his/her family	Yes
Social distancing advice for 2 wk before LDLT	No
Two COVID-19 PCR tests for both recipient, donor –72 h apart, second test within 48 h of LDLT	No
Isolating the “transplant pair” at home or in-campus after the COVID-19 PCR test	No
Preoperative chest CT to screen for COVID-19 infection for recipient and donor	No
COVID testing for key transplant staff involved in the patient’s care	No
Operating room practice	Yes
Limit waiting time during transfer from ward to operating room	Yes
Restrict theater personnel movement during the procedure and avoid nonessential staff in the operating room	Yes
Induction and intubation by senior anesthesist	Yes
Use of WHO Guidelines/Checklists for Anesthesia & Surgery on COVID-19 patients	No
Time start of recipient surgery to match progress in the donor operation	Yes
Procedures performed by senior staff, reduced in-theater mentored training	Possible
Postoperative care
No change in antibiotic and immunosuppressive protocols	Yes
ICU/HDU manned by experienced nursing staff-reduce excess shift changes	Possible
ICU/HDU rounds by 1 or 2 senior clinicians, minimize teaching rounds	Possible
No patient-visits by relatives, daily updates to family by phone	Possible
Video calls by patients to family members to maintain contact	Yes
Enhanced PPE usage by medical and nursing staff during bedside procedures	Yes
Patients nursed in the ICU/HDU facility until discharge	No
Detailed patient education at discharge regarding infection prevention	Yes

Patients who underwent LDLT at our center between March 1, 2020, and August 20, 2020, were compared with LDLT performed during the same 6-month period in 2019. This period was chosen to coincide with the time when the number of COVID-19 cases started increasing in South India. Patient demographics, perioperative details, and postoperative outcomes were compared with particular reference to postoperative infection episodes.

One hundred eleven and 46 LDLT were performed during the 6-month periods in 2019 and 2020, respectively (58.5% reduction in activity). Reduction in activity was greater for adults (72%) as compared to children (27%). There was no difference in patient demographics, MELD at LT, need for pre-LT organ support and intraoperative variables in adult, and pediatric cohorts between the 2 study periods (Table S1, SDC, http://links.lww.com/TP/C88). Adult 2020 cohort had significantly lesser major complications (22.7% versus 48.7%; P = 0.03), fewer postoperative infection episodes (9.1% versus 32.1%; P = 0.032), shorter hospital stay (13 d versus 18 d; P = 0.006) but similar 30-day survival (100% versus 91%) as compared to the 2019 cohort. Pediatric 2020 cohort showed statistically insignificant reduction in postoperative infections (16.7% versus 39.4%; P = 0.078), duration of hospital stay (16 d versus 19 d; P = 0.057) and early survival (100% versus 90.9%) compared with 2019 cohort. None of the recipients or donors had COVID infection in the immediate postoperative period.

The most prominent finding in this study was the significant reduction in postoperative infections during the COVID-19 era. We believe that this is multifactorial including mandated preoperative social distancing measures, increased stress on handwashing, universal usage of face mask, reduced footfall within hospital environment, and enhanced use of PPE in ICU and wards. Our results provide 3 important learning points. LDLT can be safely performed during the COVID-19 pandemic after taking effective measures to limit infection risk. Strict implementation of these measures can achieve similar or even better outcomes in the COVID-era. Finally, many of these simple-yet-effective changes can be continued in the post-COVID-era to ensure better LT outcomes.