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

Menon, Jagadeesh DM1; Hakeem, Abdul R. FRCS1; Rammohan, Ashwin FRCS1; Sundaramoorthy, Subha MD1; Kanagavelu, Rathnavel G. FRCA1; Reddy, Mettu S. FRCS1; Rela, Mohamed FRCS1

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doi: 10.1097/TP.0000000000003574
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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.

REFERENCES

1. Di Maira T, Berenguer M. COVID-19 and liver transplantation. Nat Rev Gastroenterol Hepatol. 2020; 17:526–528
2. Reddy MS, Hakeem AR, Klair T, et al. Trinational study exploring the early impact of the COVID-19 pandemic on organ donation and liver transplantation at national and unit levels. Transplantation. 2020; 104:2234–2243
3. Allegranzi B, Bagheri Nejad S, Combescure C, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet. 2011; 377:228–241
4. Gopalakrishnan V, Agarwal SK, Aggarwal S, et al. Infection is the chief cause of mortality and non-death censored graft loss in the first year after renal transplantation in a resource limited population: a single centre study. Nephrology (Carlton). 2019; 24:456–463
5. Loftus RW, Dexter F, Goodheart MJ, et al. The effect of improving basic preventive measures in the perioperative arena on Staphylococcus aureus transmission and surgical site infections: a randomized clinical trial. JAMA Netw Open. 2020; 3:e201934

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