Coronavirus disease 2019: Implications of emerging infections for transplantation

Use of chronic medications and risk of death due to COVID-19 in hospitalised patients

OBJECTIVES

To evaluate the potential association between chronic exposure to medication and death related to COVID-19.

METHODS

This is a retrospective cross-sectional study that included all patients hospitalised due to COVID-19 from 11 March to 4 June 2020 in our centre. Chronic patient medication was classified by the Anatomical Therapeutic Chemical (ATC) classification; demographic and clinical data were analysed. Multivariate logistic regression models were used to estimate the adjusted odds ratios (aOR) of death for each drug exposure; each aOR represents an independent model adjusted by clinical factors related to COVID-19 mortality.

RESULTS

The study included 978 patients with a mean (SD) age of 64.5 (17.7) years who were predominantly male (531, 54.3%). Of all 978 patients, 182 (18.61%) died during the follow-up of the study. The most common Charlson Comorbidity Index (CCI) was 0, 4.2% were smokers, 16.7% were obese, 47.4% had hypertension, and 19.4% were diabetic. Most patients (70.8%) were prescribed at least one treatment, 32.5% used >5 treatments, and 8.6% >10. Our data suggest that COVID-19 hospitalised patients taking trimethoprim and analogues, leukotriene receptor antagonists, calcineurin inhibitors, aldosterone antagonists, selective immunosuppressants, propulsives, insulins and analogues, and benzodiazepine derivatives have a higher risk of death.

CONCLUSIONS

This study investigated the association between chronic exposure to drugs and the risk of death in COVID-19 patients. Our results have shed some light on the impact of chronic drug exposure on the risk of severe COVID-19; however, further research is needed to increase the understanding about its relevance.

Single-center Outcomes After Liver Transplantation With SARS-CoV-2-Positive Donors: An Argument for Increased Utilization

Background

The COVID-19 pandemic has led to an increase in SARS-CoV-2-test positive potential organ donors. The benefits of life-saving liver transplantation (LT) must be balanced against the potential risk of donor-derived viral transmission. Although emerging evidence suggests that the use of COVID-19-positive donor organs may be safe, granular series thoroughly evaluating safety are still needed. Results of 29 consecutive LTs from COVID-19-positive donors at a single center are presented here.

Methods

A retrospective cohort study of LT recipients between April 2020 and December 2022 was conducted. Differences between recipients of COVID-19-positive (n = 29 total; 25 index, 4 redo) and COVID-19-negative (n = 472 total; 454 index, 18 redo) deceased donor liver grafts were compared.

Results

COVID-19-positive donors were significantly younger (P = 0.04) and had lower kidney donor profile indices (P = 0.04) than COVID-19-negative donors. Recipients of COVID-19-positive donor grafts were older (P = 0.04) but otherwise similar to recipients of negative donors. Donor SARS-CoV-2 infection status was not associated with a overall survival of recipients (hazard ratio, 1.11; 95% confidence interval, 0.24-5.04; P = 0.89). There were 3 deaths among recipients of liver grafts from COVID-19-positive donors. No death seemed virally mediated because there was no qualitative association with peri-LT antispike antibody titers, post-LT prophylaxis, or SARS-CoV-2 variants.

Conclusions

The utilization of liver grafts from COVID-19-positive donors was not associated with a decreased overall survival of recipients. There was no suggestion of viral transmission from donor to recipient. The results from this large single-center study suggest that COVID-19-positive donors may be used safely to expand the deceased donor pool.

COVID-19 and Nutrition: Focus on Chronic Kidney Disease

Some chronic diseases, including chronic kidney disease (CKD), may be associated with poor outcomes, including a high rate of hospitalization and death after COVID-19 infection. In addition to the vaccination program, diet intervention is essential for boosting immunity and preventing complications. A healthy diet containing bioactive compounds may help mitigate inflammatory responses and oxidative stress caused by COVID-19. In this review, we discuss dietary interventions for mitigating COVID-19 complications, including in persons with CKD, which can worsen COVID-19 symptoms and its clinical outcomes, while diet may help patients with CKD to resist the ravages of COVID-19 by improving the immune system, modulating gut dysbiosis, mitigating COVID-19 complications, and reducing hospitalization and mortality. The concept of food as medicine, also known as culinary medicine, for patients with CKD can be extrapolated to COVID-19 infection because healthy foods and nutraceuticals have the potential to exert an important antiviral, anti-inflammatory, and antioxidant role.

Minimizing the Risk of Donor-Derived Events and Maximizing Organ Utilization Through Education and Policy Development

Herein, we review the current knowledge of donor-derived disease and current US Organ Procurement and Transplantation Network policies to minimize the risk. During the process, we also consider actions to further mitigate the risk of donor-derived disease. The overarching goal is to provide an infectious disease perspective on the complex decision of organ acceptance for transplant programs and candidates.

SARS-CoV-2 induced liver injury: Incidence, risk factors, impact on COVID-19 severity and prognosis in different population groups

Liver is unlikely the key organ driving mortality in coronavirus disease 2019 (COVID-19) however, liver function tests (LFTs) abnormalities are widely observed mostly in moderate and severe cases. According to this review, the overall prevalence of abnormal LFTs in COVID-19 patients ranges from 2.5% to 96.8% worldwide. The geographical variability in the prevalence of underlying diseases is the determinant for the observed discrepancies between East and West. Multifactorial mechanisms are implicated in COVID-19-induced liver injury. Among them, hypercytokinemia with "bystander hepatitis", cytokine storm syndrome with subsequent oxidative stress and endotheliopathy, hypercoagulable state and immuno-thromboinflammation are the most determinant mechanisms leading to tissue injury. Liver hypoxia may also contribute under specific conditions, while direct hepatocyte injury is an emerging mechanism. Except for initially observed severe acute respiratory distress syndrome corona virus-2 (SARS-CoV-2) tropism for cholangiocytes, more recent cumulative data show SARS-CoV-2 virions within hepatocytes and sinusoidal endothelial cells using electron microscopy (EM). The best evidence for hepatocellular invasion by the virus is the identification of replicating SARS-CoV-2 RNA, S protein RNA and viral nucleocapsid protein within hepatocytes using in-situ hybridization and immunostaining with observed intrahepatic presence of SARS-CoV-2 by EM and by in-situ hybridization. New data mostly derived from imaging findings indicate possible long-term sequelae for the liver months after recovery, suggesting a post-COVID-19 persistent live injury.

Transplant of organs from donors with positive SARS-CoV-2 nucleic acid testing: A report from the organ procurement and transplantation network ad hoc disease transmission advisory committee

BACKGROUND

Decisions to transplant organs from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid test-positive (NAT+) donors must balance risk of donor-derived transmission events (DDTE) with the scarcity of available organs.

METHODS

Organ Procurement and Transplantation Network (OPTN) data were used to compare organ utilization and recipient outcomes between SARS-CoV-2 NAT+ and NAT- donors. NAT+ was defined by either a positive upper or lower respiratory tract (LRT) sample within 21 days of procurement. Potential DDTE were adjudicated by OPTN Disease Transmission Advisory Committee.

RESULTS

From May 27, 2021 (date of OTPN policy for required LRT testing of lung donors) to January 31, 2022, organs were recovered from 617 NAT+ donors from all OPTN regions and 53 of 57 (93%) organ procurement organizations. NAT+ donors were younger and had higher organ quality scores for kidney and liver. Organ utilization was lower for NAT+ donors compared to NAT- donors. A total of 1241 organs (776 kidneys, 316 livers, 106 hearts, 22 lungs, and 21 other) were transplanted from 514 NAT+ donors compared to 21 946 organs from 8853 NAT- donors. Medical urgency was lower for recipients of NAT+ liver and heart transplants. The median waitlist time was longer for liver recipients of NAT+ donors. The match run sequence number for final acceptor was higher for NAT+ donors for all organ types. Outcomes for hospital length of stay, 30-day mortality, and 30-day graft loss were similar for all organ types. No SARS-CoV-2 DDTE occurred in this interval.

CONCLUSIONS

Transplantation of SARS-CoV-2 NAT+ donor organs appears safe for short-term outcomes of death and graft loss and ameliorates the organ shortage. Further study is required to assure comparable longer term outcomes.

Severe Acute Respiratory Syndrome Coronavirus Type 2: Insight Into Challenges for Cell Therapy

Coronavirus disease 2019 has affected more than 4 million people throughout the world since December 2019. It seems this infection has been the most insidious virus of the coronavirus family. This virus causes severe respiratory failure and symptoms in patients and can result in death. Designing a restrict protocol to deal with infections from severe acute respiratory syndrome coronavirus type 2 is critical in cell therapy institutes. In this review, we present the important aspects related to this virus in cell therapy protocols.

Hepatic Disorders and COVID-19: From Pathophysiology to Treatment Strategy

Following the SARS-CoV-2 outbreak and the subsequent development of the COVID-19 pandemic, organs such as the lungs, kidneys, liver, heart, and brain have been identified as priority organs. Liver diseases are considered a risk factor for high mortality from the COVID-19 pandemic. Besides, liver damage has been demonstrated in a substantial proportion of patients with COVID-19, especially those with severe clinical symptoms. Furthermore, antiviral medications, immunosuppressive drugs after liver transplantation, pre-existing hepatic diseases, and chronic liver diseases such as cirrhosis have also been implicated in SARS-CoV-2-induced liver injury. As a result, some precautions have been taken to prevent, monitor the virus, and avoid immunocompromised and susceptible individuals, such as liver and kidney transplant recipients, from being infected with SARS-CoV-2, thereby avoiding an increase in mortality. The purpose of this review was to examine the impairment caused by SARS-CoV-2 infection and the impact of drugs used during the pandemic on the mortality range and therefore the possibility of preventive measures in patients with liver disease.

Organ transplantation using COVID-19-positive deceased donors

The COVID-19 pandemic has influenced organ transplantation decision making. Opinions regarding the utilization of coronavirus disease-2019 (COVID-19) donors are mixed. We hypothesize that COVID-19 infection of deceased solid organ transplant donors does not affect recipient survival. All deceased solid organ transplant donors with COVID-19 testing results from March 15, 2020 to September 30, 2021 were identified in the OPTN database. Donors were matched to recipients and stratified by the COVID-19 test result. Outcomes were assessed between groups. COVID-19 test results were available for 17 694 donors; 150 were positive. A total of 269 organs were transplanted from these donors, including 187 kidneys, 57 livers, 18 hearts, 5 kidney-pancreases, and 2 lungs. The median time from COVID-19 testing to organ recovery was 4 days for positive and 3 days for negative donors. Of these, there were 8 graft failures (3.0%) and 5 deaths (1.9%). Survival of patients receiving grafts from COVID-19-positive donors is equivalent to those receiving grafts from COVID-19-negative donors (30-day patient survival = 99.2% COVID-19 positive; 98.6% COVID-19 negative). Solid organ transplantation using deceased donors with positive COVID-19 results does not negatively affect early patient survival, though little information regarding donor COVID-19 organ involvement is known. While transplantation is feasible, more information regarding COVID-19-positive donor selection is needed.

Risk of Severe Acute Respiratory Syndrome Coronavirus 2 Transmission Through Solid Organ Transplantation and Outcomes of Coronavirus Disease 2019 Among Recent Transplant Recipients

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmissible through lung transplantation, and outcomes among infected organ recipients may be severe. Transmission risk to extrapulmonary organ recipients and recent (within 30 days of transplantation) SARS-CoV-2-infected recipient outcomes are unclear.

METHODS

During March 2020-March 2021, potential SARS-CoV-2 transmissions through solid organ transplantation were investigated. Assessments included SARS-CoV-2 testing, medical record review, determination of likely transmission route, and recent recipient outcomes.

RESULTS

During March 2020-March 2021, approximately 42 740 organs were transplanted in the United States. Forty donors, who donated 140 organs to 125 recipients, were investigated. Nine (23%) donors and 25 (20%) recipients were SARS-CoV-2 positive by nucleic acid amplification test (NAAT). Most (22/25 [88%]) SARS-CoV-2-infected recipients had healthcare or community exposures. Nine SARS-CoV-2-infected donors donated 21 organs to 19 recipients. Of these, 3 lung recipients acquired SARS-CoV-2 infections from donors with negative SARS-CoV-2 testing of pretransplant upper respiratory tract specimens but from whom posttransplant lower respiratory tract (LRT) specimens were SARS-CoV-2 positive. Sixteen recipients of extrapulmonary organs from SARS-CoV-2-infected donors had no evidence of posttransplant COVID-19. All-cause mortality within 45 days after transplantation was 6-fold higher among SARS-CoV-2-infected recipients (9/25 [36%]) than those without (6/100 [6%]).

CONCLUSIONS

Transplant-transmission of SARS-CoV-2 is uncommon. Pretransplant NAAT of lung donor LRT specimens may prevent transmission of SARS-CoV-2 through transplantation. Extrapulmonary organs from SARS-CoV-2-infected donors may be safely usable, although further study is needed. Reducing recent recipient exposures to SARS-CoV-2 should remain a focus of prevention.

Outcomes of Anesthesiologist-Led Care of Patients Following Liver Transplantation During the COVID-19 Pandemic

Background

During the COVID-19 pandemic, anesthesiologists were redeployed as transplant ICU intensivists and a postanesthesia care unit was converted to a novel transplant ICU. This study compared the outcomes of patients undergoing liver transplantation under the new model with the prepandemic model.

Methods

Adult patients who underwent liver transplantation at an urban tertiary care center in the United States from December 28, 2015, through May 1, 2020, were identified and grouped according to date of procedure. Peri-COVID cases included transplants that were performed after March 3, 2020. Transplants performed before March 3, 2020, served as pre-COVID controls.

Results

A total of 523 liver transplant patients (30 study cases, 493 controls) were included. Kaplan-Meier survival analysis showed no significant difference in novel transplant ICU length of stay (N-TLOS) (median LOS 3.8 vs. 4.5 days, log-rank p = 0.60) and hospital length of stay (HLOS) (median LOS 14.2 vs. 14.5 days, log-rank p = 0.66). Cox proportional hazards regression with inverse probability of treatment weighting showed no difference in N-TLOS (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.67–1.23, p = 0.55) or HLOS (HR 0.90, 95% CI 0.65–1.25, p = 0.52). In addition, there were no significant differences (pre-COVID vs. COVID) in time to extubation (median [interquartile range] 28.7 [20.6–50.7] vs. 26.8 [17.4–40.8] hours, p = 0.35), one-year patient survival (12.0% vs. 6.7%, p = 0.055), one-year graft survival (13.4% vs. 6.7%, p = 0.43), and readmission to the ICU (15.0% vs. 20.0%, p = 0.68).

Conclusion

Care provided by non-intensivist anesthesiologists to patients undergoing orthotopic liver transplantation during a pandemic emergency resulted in outcomes similar to those of care provided by intensivists.

Evolution of Clinical Care in COVID-Infected Solid Organ Transplant Recipients

Purpose of Review

In this review, we aim to summarize the evolution of care for the solid organ transplant recipient (SOTR) with COVID-19 disease, based on the current published guidelines and our center’s experience.

Recent Findings

Oral antiviral medications and monoclonal antibodies are now used with the goal to prevent severe disease. Immunomodulating drugs in addition to antivirals have been used in the treatment of severe COVID-19.

Summary

With the ongoing pandemic and unique challenges posed by the SOTR, understanding the risk and advancing management and treatment of COVID-19 infections are imperative to the successful care of a transplant recipient. There are many ongoing clinical trials being conducted in hopes of developing novel therapeutics towards COVID-19.

COVID-19 and liver diseases, what we know so far

Coronavirus disease 2019 (COVID-19) pneumonia outbreak started in December 2019. On March 12, 2020, the World Health Organization (WHO) declared that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) constitutes a pandemic, and as of May 2021, SARS-CoV-2 has infected over 167.3 million patients, including 3.4 million deaths, reported to WHO. In this review, we will focus on the relationship between SARS-CoV-2 infection and the liver. We will discuss how chronic liver diseases affect the COVID-19 disease course and outcomes. We will also discuss the SARS-CoV-2 effects on the liver, mechanisms of acute liver injury, and potential management plans.

Management of the Potential Lung Donor

The use of donor management protocols has significantly improved recovery rates; however, the inherent instability of lungs after death results in low utilization rates of potential donor lungs. Donor lungs are susceptible to direct trauma, aspiration, neurogenic edema, ventilator-associated barotrauma, and ventilator-associated pneumonia. After irreversible brain injury and determination of futility of care, the goal of medical management of the donor shifts to maintaining hemodynamic stability and maximizing the likelihood of successful organ recovery.

Incidencia de infección por SARS-CoV-2 en pacientes con un trasplante renal funcionante de un hospital terciario de la Comunidad de Madrid

En diciembre de 2019, apareció un nuevo coronavirus que ha dado lugar a una pandemia. Dadas las características del paciente trasplantado, se hace necesario conocer cuál ha sido la repercusión respecto a la infección por SARS-CoV-2, planteándonos como objetivo describir la incidencia de SARS-CoV-2 en pacientes con un trasplante renal.Se llevó a cabo un estudio observacional de cohorte retrospectiva de pacientes con un trasplante renal y que están en seguimiento por la consulta de trasplantes de un hospital terciario, durante el periodo comprendido entre el 1 de marzo de 2020 y el 1 de marzo de 2021. Se incluyeron 604 individuos, con una edad media de 61,6±12,8 años. Un 62,3% (n=376) fueron hombres.La incidencia por SARS-CoV-2 fue 14,9% (n=90). La mortalidad por SARS-CoV-2 fue 3,8% (n=23) lo que supone una letalidad del 25,5%. Al comparar si han pasado la infección en función del sexo no se encontraron diferencias significativas. Tampoco al comparar en función de la edad media, que fue de 60,9±11,8 años en los infectados y de 61,7±12,9 años en los no infectados. Se encontraron diferencias significativas (p=0,005) al comparar la media de años transcurridos desde el trasplante; que fue de 8,7±5,6 años en los infectados y de 11±7,3 años en los no infectados.La incidencia de infección por SARS-CoV-2 encontrada en personas con TR fue muy superior a la descrita para la población general. La letalidad y la mortalidad también fueron mayores que en la población general, pero acordes con otras poblaciones de individuos con TR.

COVID-19 in liver transplant recipients: incidence, hospitalization and outcome in an Italian prospective double-centre study

Liver transplant (LT) recipients are vulnerable to SARS-CoV-2-infection (COVID-19), due to immunosuppression and comorbidities. This study aimed to evaluate the impact of COVID-19 on LT recipients compared to general population in the Campania region. In this prospective double-centre study, we enrolled all consecutive adult LT recipients with confirmed SARS-CoV-2-infection. Data were collected at diagnosis of COVID-19 and during follow-up and compared with the regional population. Thirty LT recipients (3.28%) developed SARS-CoV-2-infection (76.66% male, median age 62.61 years). Sixteen (53.33%) were symptomatic. Common symptoms were fever, cough, fatigue, and anosmia. Twenty-five (83.33%) were outpatients, 5 (16.66%) required hospitalization (6.66% admitted to Intensive Care Unit, 6.62% developed Acute Respiratory Distress Syndrome and 6.66% died). Immunosuppressors were in 3 (10%) patients. Incidence rate of COVID-19 was similar between LT patients and general population (3.28% vs 4.37%, p = 0.142) with higher rate of symptoms in LT patients (53.33% vs 15.87%, p < 0.000). At univariate analysis, hospitalization and case fatality rates were higher in LT patients compared to general population (16.66% vs 4.54%, p = 0.001; and 6.66% vs 1.76%, p = 0.041, respectively). At multivariable logistic regression analysis, LT patients with COVID-19 were more frequently symptomatic (OR 5.447 [95% CI 2.437–12.177], p < 0.000), whereas hospitalization and death for COVID-19 were not significatively associated with LT condition (p = 0.724 and p = 0.462, respectively) and were comparable with general population. LT is not a risk factor for acquiring COVID-19. Nonetheless, LT patients are more frequently symptomatic, although comparable to the general population for hospitalization rate and mortality.

Patterns of liver profile disturbance in patients with COVID-19

Fever and cough are the most common clinical symptoms of coronavirus disease 2019 (COVID-19), but complications (such as pneumonia, respiratory distress syndrome, and multiorgan failure) can occur in people with additional comorbidities. COVID-19 may be a new cause of liver disease, as liver profile disturbance is one of the most common findings among patients. The molecular mechanism underlying this phenomenon, however, is still unknown. In this paper, we review the most current research on the patterns of change in liver profile among patients with COVID-19, the possible explanation for these findings, and the relation to pre-existing liver disease in these patients.

A Case Report of COVID-19 in a Living Kidney Transplant Recipient: A Challenging Case with Complete Rehabilitation

Adjustment of immunosuppressive and COVID-19 treatment in terms of drug interactions is still challenging. Herein, we report a 45-year-old woman with end-stage renal disease due to autosomal dominant polycystic diseases (ADPKD) with COVID-19 and pulmonary involvement following kidney transplantation. The patient was properly treated by discontinuation of immunosuppressive drugs, bronchoscopy, and high volume of blood transfusions. The fact that we quickly used early intubation and a new treatment regimen that suppressed immune systems may help physicians develop optimal treatment strategies for similar severe cases. However, this treatment method requires more detailed evaluations due to the contradictory results in reviewing other studies.

Global Effects of SARS-CoV-2 Era on Kidney Transplantation Activities: Analysis of WHO Data

Background

Uncertainty raises questions in kidney transplant during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic regarding the recipient, the donor, and health care professionals. The pandemic not only has disrupted kidney transplanted patients but also has influenced transplant systems, donation chains, and timely and safe transplant surgeries. In the present study, we aimed to explore the global effects of the SARS-CoV-2 pandemic on kidney transplant.

Methods

We collected transplantation statistics and SARS-CoV-2 pandemic data from the World Health Organization website on June 15, 2021. Spearman correlation analysis was applied to assess the strength of a monotonic relationship among quantitative variables. We also demonstrated the clinical characteristics of our kidney recipients with SARS-CoV-2 infection.

Results

Comparison of the mean of global kidney transplantation statistics between 2010 and 2019 with 2020 statistics showed a significant decrease in kidney transplant from living donors (P < .001). From the beginning of the pandemic to June 15, 2021, 1 of the 43 kidney transplant patients we treated in our clinic died of SARS-CoV-2 infection after discharge. Two of the patients we transplanted and saw in follow-up before the pandemic died of SARS-CoV-2 infection.

Conclusion

While the overall kidney transplant numbers have increased in the year to date, kidney transplants decreased drastically at the onset of the pandemic.

A systematic review and meta-analysis of COVID-19 in kidney transplant recipients: Lessons to be learned

Kidney transplant recipients (KTR) may be at increased risk of adverse COVID-19 outcomes, due to prevalent comorbidities and immunosuppressed status. Given the global differences in COVID-19 policies and treatments, a robust assessment of all evidence is necessary to evaluate the clinical course of COVID-19 in KTR. Studies on mortality and acute kidney injury (AKI) in KTR in the World Health Organization COVID-19 database were systematically reviewed. We selected studies published between March 2020 and January 18th 2021, including at least five KTR with COVID-19. Random-effects meta-analyses were performed to calculate overall proportions, including 95% confidence intervals (95% CI). Subgroup analyses were performed on time of submission, geographical region, sex, age, time after transplantation, comorbidities, and treatments. We included 74 studies with 5559 KTR with COVID-19 (64.0% males, mean age 58.2 years, mean 73 months after transplantation) in total. The risk of mortality, 23% (95% CI: 21%-27%), and AKI, 50% (95% CI: 44%-56%), is high among KTR with COVID-19, regardless of sex, age and comorbidities, underlining the call to accelerate vaccination programs for KTR. Given the suboptimal reporting across the identified studies, we urge researchers to consistently report anthropometrics, kidney function at baseline and discharge, (changes in) immunosuppressive therapy, AKI, and renal outcome among KTR.

The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2020 Part I - Lung Transplantation

This special article focuses on the highlights in cardiothoracic transplantation literature in the year 2020. Part I encompasses the recent literature on lung transplantation, including the advances in preoperative assessment and optimization, donor management, including the use of ex-vivo lung perfusion, recipient management, including those who have been infected with coronavirus disease 2019, updates on the perioperative management, including the use of extracorporeal membrane oxygenation, and long-term outcomes.

Immunosuppressant Management in Renal Transplant Patients with COVID-19

The coronavirus disease 2019 (COVID-19) pandemic poses a special risk for both immunosuppressed patients, especially transplant recipients. Although the knowledge about this infection is growing, many uncertainties remain, particularly regarding the kidney. Kidney transplant recipients (KDRs) should be considered immunocompromised hosts since a potential risk for infection, comorbidity, and immunosuppression exposure exists. Additionally, the management of immunosuppressive agents in KDRs remains challenging. Potential drug interactions with immunosuppressive treatment escalated the risk of unwanted side effects. In this review, we aimed to attain an augmented awareness and improved management immunosuppressant for COVID-19 KDRs.

Impact of the COVID-19 Pandemic on Keratoplasty and Corneal Eye Banking

PURPOSE

The purpose of this study was to assess the impact of COVID-19 guidelines for corneal donor tissue screening and the utility of routine postmortem COVID-19 testing of donors intended for surgical use at a single eye bank.

METHODS

A retrospective analysis of referrals to and eligible donors from an eye bank between March 1, 2020, and June 30, 2020, was performed, with the same time period in 2019 as a control. Referrals who were not procured because of Eye Bank Association of America COVID-19 guidelines and eye bank-specific restrictions were noted. The results of 1 month of routine postmortem testing performed by the eye bank were examined. Analysis of variance tests were performed to assess the change between donors from 2019 to 2020.

RESULTS

There was a significant reduction in both the number of total referrals to the eye bank (P = 0.044) and donors eligible for surgical transplantation (P = 0.031). Eye Bank Association of America COVID-19 guidelines reduced the number of referrals over this period by 4% to 14%. Of the 266 surgically eligible donors who received postmortem COVID-19 testing in June by the eye bank, 13 resulted positive (4.9%).

CONCLUSIONS

Despite a reduction in referrals and eligible corneal transplant donors at a single eye bank, there was a surplus of surgically suitable corneal tissue during the first wave of the COVID-19 pandemic. Eye banks should consider routine postmortem COVID-19 testing to identify asymptomatic infected donors although the risk of transmission of COVID-19 from infected donors is unknown.

Periprocedural complications in patients with SARS-CoV-2 infection compared to those without infection: A nationwide propensity-matched analysis

BACKGROUND

Reports on emergency surgery performed soon after a COVID-19 infection that are not controlled for premorbid risk-factors show increased 30-day mortality and pulmonary complications. This contributed to a virtual cessation of elective surgery during the pandemic surge. To inform evidence-based guidance on the decisions for surgery during the recovery phase of the pandemic, we compare 30-day outcomes in patients testing positive for COVID-19 before their operation, to contemporary propensity-matched COVID-19 negative patients undergoing the same procedures.

METHODS

This prospective multicentre study included all patients undergoing surgery at 170 Veterans Health Administration (VA) hospitals across the United States. COVID-19 positive patients were propensity matched to COVID-19 negative patients on demographic and procedural factors. We compared 30-day outcomes between COVID-19 positive and negative patients, and the effect of time from testing positive to the date of procedure (≤10 days, 11-30 days and >30 days) on outcomes.

RESULTS

Between March 1 and August 15, 2020, 449 COVID-19 positive and 51,238 negative patients met inclusion criteria. Propensity matching yielded 432 COVID-19 positive and 1256 negative patients among whom half underwent elective surgery. Infected patients had longer hospital stays (median seven days), higher rates of pneumonia (20.6%), ventilator requirement (7.6%), acute respiratory distress syndrome (ARDS, 17.1%), septic shock (13.7%), and ischemic stroke (5.8%), while mortality, reoperations and readmissions were not significantly different. Higher odds for ventilation and stroke persisted even when surgery was delayed 11-30 days, and for pneumonia, ARDS, and septic shock >30 days after a positive test.

DISCUSSION

30-day pulmonary, septic, and ischaemic complications are increased in COVID-19 positive, compared to propensity score matched negative patients. Odds for several complications persist despite a delay beyond ten days after testing positive. Individualized risk-stratification by pulmonary and atherosclerotic comorbidities should be considered when making decisions for delaying surgery in infected patients.

COVID-19 reinfection or reactivation in a renal transplant patient

Recurrences of COVID-19 infection may occur in immunocompromised patients. Reinfection or reactivation of COVID-19 virus is a challenging issue in these patients.

Gastrointestinal and hepatic diseases during the COVID-19 pandemic: Manifestations, mechanism and management

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is considered the causative pathogen of coronavirus disease 2019 (COVID-19) and has become an international danger to human health. Although respiratory transmission and symptoms are still the essential manifestations of COVID-19, the digestive system could be an unconventional or supplementary route for COVID-19 to be transmitted and manifested, most likely due to the presence of angiotensin-converting enzyme 2 (ACE2) in the gastrointestinal tract. In addition, SARS-CoV-2 can trigger hepatic injury via direct binding to the ACE2 receptor in cholangiocytes, antibody-dependent enhancement of infection, systemic inflammatory response syndrome, inflammatory cytokine storms, ischemia/reperfusion injury, and adverse events of treatment drugs. Gastrointestinal symptoms, including anorexia, nausea, vomiting, and diarrhea, which are unusual in patients with COVID-19, and some digestive signs may occur without other respiratory symptoms. Furthermore, SARS-CoV-2 can be found in infected patients' stool, demonstrating the likelihood of transmission through the fecal-oral route. In addition, liver function should be monitored during COVID-19, particularly in more severe cases. This review summarizes the evidence for extra-pulmonary manifestations, mechanisms, and management of COVID-19, particularly those related to the gastrointestinal tract and liver.

Incidence and outcome of SARS-CoV-2 infection on solid organ transplantation recipients: A nationwide population-based study

Since February 21 2020, when the Italian National Institute of Health (Istituto Superiore di Sanità-ISS) reported the first autochthonous case of infection, a dedicated surveillance system for SARS-CoV-2-positive (COVID+) cases has been created in Italy. These data were cross-referenced with those inside the Information Transplant System in order to assess the cumulative incidence (CI) and the outcome of SARS-COV-2 infection in solid organ transplant recipients (SOTRs) who are assumed to be most at risk. We compared our results with those of COVID+ nontransplanted patients (Non-SOTRs) with follow-up through September 30, 2020. The CI of SARS-CoV-2 infection in SOTRs was 1.02%, higher than in COVID+ Non-SOTRs (0.4%, p < .05) with a greater risk in the Lombardy region (2.89%). The CI by type of organ transplant was higher for heart (CI 1.57%, incidence rate ratio [IRR] 1.36) and lower for liver (CI 0.63%, IRR 0.54). The 60-day CI of mortality was 30.6%, twice as much that of COVID+ Non-SOTRs (15.4%) with a 60-day gender and age adjusted odds ratio (adjusted-OR) of 3.83 for COVID+ SOTRs (95% confidence interval [3.03-4.85]). The lowest 60-day adjusted-OR was observed in liver SOTRs (OR 0.46, 95% confidence interval [0.25-0.86]). More detailed studies on disease management and evolution will be necessary in these patients at greater risk of COVID-19.

Single-center experience of organ transplant practice during the COVID-19 epidemic

In order to safely carry out organ donation transplants during the outbreak of coronavirus disease 2019 (COVID-19), we have formulated strict procedures in place for organ donation and transplantation. We retrospectively analyzed our transplantation work from January 20 to May 5, 2020, to discuss whether organ transplantation can be carried out safely during the epidemic period. From January 20 to May 5, 43 cases of donation were carried out in our hospital, and the utilization rate of liver, kidney, heart, lung, and pancreas donations was more than 90%. Forty-one cases of liver transplantation and 84 cases of kidney transplantation were performed. No graft loss or recipient death occurred within one month after kidney transplantation, and one patient (2.4%) died after liver transplantation. There was no significant difference in the length of hospital stay compared with that during the same period in the previous three years. More importantly, COVID-19 infection did not occur among healthcare providers, donors, patients, or their accompanying families in our center. Under the premise of correct protection, it is safe and feasible to carry out organ transplantation during the epidemic period. Our experience during the outbreak might provide a clinical reference for countries facing COVID-19 worldwide.

Liver transplantation in acute liver failure: Dilemmas and challenges

Acute liver failure (ALF) refers to a state of severe hepatic injury that leads to altered coagulation and sensorium in the absence of pre-existing liver disease. ALF has different causes, but the clinical characteristics are strikingly similar. In clinical practice, however, inconsistency in the definition of ALF worldwide and confusion regarding the existence of pre-existing liver disease raise diagnostic dilemmas. ALF mortality rates used to be over 80% in the past; however, survival rates on medical treatment have significantly improved in recent years due to a greater understanding of pathophysiology and advances in critical care management. The survival rates in acetaminophen-associated ALF have become close to the post-transplant survival rates. Given that liver transplantation (LT) is an expensive treatment that involves a major surgical operation in critically ill patients and lifelong immunosuppression, it is very important to select accurate patients who may benefit from it. Still, emergency LT remains a lifesaving procedure for many ALF patients. However, there is a lack of consistency in current prognostic models that hampers the selection of transplant candidates in a timely and precise manner. The other problems associated with LT in ALF are the shortage of graft, development of contraindications on the waiting list, vaguely defined delisting criteria, time constraints for pre-transplant evaluation, ethical concerns, and comparatively poor post-transplant outcomes in ALF. Therefore, there is a desperate need to establish accurate prognostic models and explore the roles of evolving adjunctive and alternative therapies, such as liver support systems, plasma exchange, stem cells, auxiliary LT, and so on, to enhance transplant-free survival and to fill the void created by the graft shortage

Framework for Solid-Organ Transplantation During COVID-19 Pandemic in Europe

Introduction

Since the effect of the COVID-19 pandemic on solid-organ transplantation (SOT) is unclear, an online survey on the specific framework of leading European transplant centers (n=155) in 31 European countries was conducted between April 24 and May 15, 2020.

Methods

A questionnaire was designed to collect information on restrictions on SOT, protective measures,(non)governmental information policies, and individual opinions on how to deal with SOT during COVID-19.

Results

The response rate was 37.4% (58 of 155). Overall, 84.5% reported an effect of COVID-19 on SOT in Europe. In 49% of these, limited capacity was mentioned, and in 51% the reason for restricted resources was strategic preparedness. As a result, SOT was totally or partially suspended for several weeks. In sum, 93.1% of centers implemented protective measures against COVID-19. Nongovernmental information policies were felt to be adequate in 90%. Continuation of transplant activities was desired by 97% of centers.

Conclusion

The results of this survey suggested a need for more ICU capacity during COVID-19, in order to guarantee adequate and timely treatment of other patient cohorts in surveyed countries.

Navigating the COVID-19 pandemic: Initial impacts and responses of the Organ Procurement and Transplantation Network in the United States

COVID-19 has been sweeping the globe, hitting the United States particularly hard with a state of emergency declared on March 13, 2020. Transplant hospitals have taken various precautions to protect patients from potential exposure. OPTN donor, candidate, and transplant data were analyzed from January 5, 2020 to September 5, 2020. The number of new waiting list registrations decreased, with the Northeast seeing over a 50% decrease from the week of 3/8 versus the week of 4/5. The national transplant system saw near cessation of living donor transplantation (-90%) from the week of 3/8 to the week of 4/5. Similarly, deceased donor kidney transplant volume dropped from 367 to 202 (-45%), and other organs saw similar decreases: lung (-70%), heart (-43%), and liver (-37%). Deceased donors recovered dropped from 260 to 163 (-45%) from 3/8 compared to 4/5, including a 67% decrease for lungs recovered. The magnitude of this decrease varied by geographic area, with the largest percent change (-67%) in the Northeast. Despite the pandemic, discard rates across organ has remained stable. Although the COVID-19 pandemic continues to evolve, OPTN data show recent evidence of stabilization, an indication that an early recovery of the number of living and deceased donors and transplants has ensued.

Outcomes of COVID-19 in solid organ transplant recipients: A matched cohort study

Whether solid organ transplant (SOT) recipients are at increased risk of poor outcomes due to COVID‐19 in comparison to the general population remains uncertain. In this study, we compared outcomes of SOT recipients and non‐SOT patients hospitalized with COVID‐19 in a propensity score matched analysis based on age, race, ethnicity, BMI, diabetes, and hypertension. After propensity matching, 117 SOT recipients and 350 non‐SOT patients were evaluated. The median age of SOT recipients was 61 years, with a median time from transplant of 5.68 years. The most common transplanted organs were kidney (48%), followed by lung (21%), heart (19%), and liver (10%). Overall, SOT recipients were more likely to receive COVID‐19 specific therapies and to require ICU admission. However, mortality (23.08% in SOT recipients vs. 23.14% in controls, P = .21) and highest level of supplemental oxygen (P = .32) required during hospitalization did not significantly differ between groups. In this propensity matched cohort study, SOT recipients hospitalized with COVID‐19 had similar overall outcomes as non‐SOT recipients, suggesting that chronic immunosuppression may not be an independent risk factor for poor outcomes in COVID‐19.

COVID-19 in transplant recipients: The Spanish experience

We report the nationwide experience with solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients diagnosed with coronavirus disease 2019 (COVID-19) in Spain until 13 July 2020. We compiled information for 778 (423 kidney, 113 HSCT, 110 liver, 69 heart, 54 lung, 8 pancreas, 1 multivisceral) recipients. Median age at diagnosis was 61 years (interquartile range [IQR]: 52-70), and 66% were male. The incidence of COVID-19 in SOT recipients was two-fold higher compared to the Spanish general population. The median interval from transplantation was 59 months (IQR: 18-131). Infection was hospital-acquired in 13% of cases. No donor-derived COVID-19 was suspected. Most patients (89%) were admitted to the hospital. Therapies included hydroxychloroquine (84%), azithromycin (53%), protease inhibitors (37%), and interferon-β (5%), whereas immunomodulation was based on corticosteroids (41%) and tocilizumab (21%). Adjustment of immunosuppression was performed in 85% of patients. At the time of analysis, complete follow-up was available from 652 patients. Acute respiratory distress syndrome occurred in 35% of patients. Ultimately, 174 (27%) patients died. In univariate analysis, risk factors for death were lung transplantation (odds ratio [OR]: 2.5; 95% CI: 1.4-4.6), age >60 years (OR: 3.7; 95% CI: 2.5-5.5), and hospital-acquired COVID-19 (OR: 3.0; 95% CI: 1.9-4.9).

Liver transplantation in the United States during the COVID-19 pandemic: National and center-level responses

COVID-19 has profoundly affected the American health care system; its effect on the liver transplant (LT) waitlist based on COVID-19 incidence has not been characterized. Using SRTR data, we compared observed LT waitlist registrations, waitlist mortality, deceased donor LTs (DDLT), and living donor LTs (LDLT) 3/15/2020-8/31/2020 to expected values based on historical trends 1/2016-1/2020, stratified by statewide COVID-19 incidence. Overall, from 3/15 to 4/30, new listings were 11% fewer than expected (IRR = 0.84 0.890.93 ), LDLTs were 49% fewer (IRR = 0.37 0.510.72 ), and DDLTs were 9% fewer (IRR = 0.85 0.910.97 ). In May, new listings were 21% fewer (IRR = 0.74 0.790.84 ), LDLTs were 42% fewer (IRR = 0.39 0.580.85 ) and DDLTs were 13% more (IRR = 1.07 1.151.23 ). Centers in states with the highest incidence 3/15-4/30 had 59% more waitlist deaths (IRR = 1.09 1.592.32 ) and 34% fewer DDLTs (IRR = 0.50 0.660.86 ). By August, waitlist outcomes were occurring at expected rates, except for DDLT (13% more across all incidences). While the early COVID-affected states endured major transplant practice changes, later in the pandemic the newly COVID-affected areas were not impacted to the same extent. These results speak to the adaptability of the transplant community in addressing the pandemic and applying new knowledge to patient care.

Designing a Liver Transplant Patient and Family Decision Support Tool for Organ Offer Decisions

BACKGROUND

For liver transplant candidates on the waiting list, deciding to accept a donor organ with known or potential risk factors can be stressful and can lead to declined offers. Current education for patients and family often takes place during transplant evaluations and can be overwhelming and result in low retention and poor understanding of donor quality.

METHODS

In the first phase, we sought to understand provider experiences when counseling patients about donor risks and donor offers. We conducted interviews and focus groups with liver transplant providers at 1 local center and at a national clinician conference. Twenty providers participated: 15 hepatologists and 5 surgeons. The provider feedback was used to create an initial outline of content that is consistent with decision support frameworks. In a second phase, graphic design collaborators created mockups of a patient-friendly tool. We reviewed mockups with 4 transplant coordinators and 9 liver transplant candidates for feedback on clarity and utility to prepare for an organ offer. Patient responses allowed a comparison of perceived readiness to receive an offer call before and after viewing mockups.

RESULTS

We identified themes relating to the offer process, repetition and timing of education, and standardization and tailoring of content. The results indicated a gap in available education after the evaluation session, and information specific to offer decisions is needed. Patient feedback emphasized the need to review the offer process before a real offer.

CONCLUSIONS

Patients and providers responded favorably to a patient tool addressing existing gaps in education while waiting for a donor offer. Additional patient, family, and provider feedback will guide the development of an interactive tool to prepare patients and families for an offer decision.

Predicting the outcome of COVID-19 infection in kidney transplant recipients

BACKGROUND

We aimed to present the demographic characteristics, clinical presentation, and outcomes of our multicenter cohort of adult KTx recipients with COVID-19.

METHODS

We conducted a multicenter, retrospective study using data of patients hospitalized for COVID-19 collected from 34 centers in Turkey. Demographic characteristics, clinical findings, laboratory parameters (hemogram, CRP, AST, ALT, LDH, and ferritin) at admission and follow-up, and treatment strategies were reviewed. Predictors of poor clinical outcomes were analyzed. The primary outcomes were in-hospital mortality and the need for ICU admission. The secondary outcome was composite in-hospital mortality and/or ICU admission.

RESULTS

One hundred nine patients (male/female: 63/46, mean age: 48.4 ± 12.4 years) were included in the study. Acute kidney injury (AKI) developed in 46 (42.2%) patients, and 4 (3.7%) of the patients required renal replacement therapy (RRT). A total of 22 (20.2%) patients were admitted in the ICU, and 19 (17.4%) patients required invasive mechanical ventilation. 14 (12.8%) of the patients died. Patients who were admitted in the ICU were significantly older (age over 60 years) (38.1% vs 14.9%, p = 0.016). 23 (21.1%) patients reached to composite outcome and these patients were significantly older (age over 60 years) (39.1% vs. 13.9%; p = 0.004), and had lower serum albumin (3.4 g/dl [2.9-3.8] vs. 3.8 g/dl [3.5-4.1], p = 0.002), higher serum ferritin (679 μg/L [184-2260] vs. 331 μg/L [128-839], p = 0.048), and lower lymphocyte counts (700/μl [460-950] vs. 860 /μl [545-1385], p = 0.018). Multivariable analysis identified presence of ischemic heart disease and initial serum creatinine levels as independent risk factors for mortality, whereas age over 60 years and initial serum creatinine levels were independently associated with ICU admission. On analysis for predicting secondary outcome, age above 60 and initial lymphocyte count were found to be independent variables in multivariable analysis.

CONCLUSION

Over the age of 60, ischemic heart disease, lymphopenia, poor graft function were independent risk factors for severe COVID-19 in this patient group. Whereas presence of ischemic heart disease and poor graft function were independently associated with mortality.

Liver Transplantation for T2 Hepatocellular Carcinoma during the COVID-19 Pandemic: A Novel Model Balancing Individual Benefit against Healthcare Resources

Simple Summary

Using Italian national data from more than 8000 patients, we proposed a novel model calculating the net benefit of liver transplantation (individual benefit minus harm to others on the waiting list) in T2 hepatocellular carcinoma (HCC) patients in different scenarios of transplant activity reduction. Our results show that the transplant net benefit is closely related to the decrease in the number of organs, but it is also higher in T2 HCC patients than in non-HCC patients with the same model for end-stage liver disease (MELD) scores. Our model supports liver transplantation for T2 HCC with the highest net benefit also during crises such as COVID-19.

Abstract

The COVID-19 pandemic caused temporary drops in the supply of organs for transplantation, leading to renewed debate about whether T2 hepatocellular carcinoma (HCC) patients should receive priority during these times. The aim of this study was to provide a quantitative model to aid decision-making in liver transplantation for T2 HCC. We proposed a novel ethical framework where the individual transplant benefit for a T2 HCC patient should outweigh the harm to others on the waiting list, determining a “net benefit”, to define appropriate organ allocation. This ethical framework was then translated into a quantitative Markov model including Italian averages for waiting list characteristics, donor resources, mortality, and transplant rates obtained from a national prospective database (n = 8567 patients). The net benefit of transplantation in a T2 HCC patient in a usual situation varied from 0 life months with a model for end-stage liver disease (MELD) score of 15, to 34 life months with a MELD score of 40, while it progressively decreased with acute organ shortage during a pandemic (i.e., with a 50% decrease in organs, the net benefit varied from 0 life months with MELD 30, to 12 life months with MELD 40). Our study supports the continuation of transplantation for T2 HCC patients during crises such as COVID-19; however, the focus needs to be on those T2 HCC patients with the highest net survival benefit.

The association between perceived stress with sleep quality, insomnia, anxiety and depression in kidney transplant recipients during Covid-19 pandemic

Background

The psychological distress and sleep problems caused by current Covid-19 outbreak is not well known in kidney transplant recipients. In this study, we aimed to investigate the association between perceived stress with sleep quality, insomnia, anxiety, depression and kidney function in kidney transplant recipients during the Covid-19 pandemic.

Material and methods

A hundred-six kidney transplant recipients were enrolled. Questionnaire of "Socio-demographics", "Perceived Stress Scale (PSS)", "Pittsburgh Sleep Quality Index (PSQI)", "Insomnia Severity Index (ISI)" and “Hospital Anxiety Depression Scale (HADS)” are performed. The laboratory data is recorded. The perceived stress related to Covid-19 pandemic and its associations were investigated.

Results

The mean age of patients was 44.2±13.3 years, and 65 of the patients (61.3%) were men. Forty-nine (46.2%) of the patients had high-perceived stress; 51 (48.1%) of the patients had poor sleep quality, 40 (37.7%) of the patients had insomnia, 25 (23.6%) of the patients had anxiety and 47 (44.3%) of the patients had depression. The patients having a history of Covid-19 infection in own or closed relatives (9.09±4.17 vs 6.49±4.16, p:0.014) and the patients who have a rejection episode any of time (8.24±5.16 vs 6.37±3.57, p:0.033) have had significantly higher anxiety scores, when they compared to others. The high PSS were positively correlated with PSQI, ISI, HAD-A and HAD-D. Regression analyses revealed that high-perceived stress is an independent predictor of anxiety and depression. There was not significant difference between kidney function with PSS, PSQI, ISI, HAD-A and HAD-D.

Conclusions

High PSS is positively correlated with poor sleep quality and insomnia and also an independent predictor of anxiety and depression in kidney transplant recipients during the outbreak of Covid-19. As the pandemic is still spreading worldwide quickly early identification and intervention of sleep disturbances and psychiatric disorders are essential to protect graft function with high compliance to treatment in transplantation patients.

Thoracic surgery and COVID-19: changes and managements during the pandemic

Background

Several articles have been published about the reorganization of surgical activity during the coronavirus disease 2019 (COVID-19) pandemic but little is known about the operative volume, distribution of cases, or capacity of The Department of Thoracic Surgery to deliver surgical services in the time of COVID-19.

Methods

A retrospective operative logbook review was completed in department of thoracic in a designated COVID-19 hospital. We reviewed and analyzed the operative logbook and discussed our countermeasures during the outbreak. A prediction model was established to discuss the time consuming about delayed surgeries during the pandemic.

Results

One thousand two hundred and seventy-five operation records were collected. The thoracic surgeries of this year has decreased (43.4%) during the Wuhan lockdown. From Jan 23^rd to Apr 8^th in 2020, there were 461 surgeries performed in The Department of Thoracic in our hospital with 0 cases of nosocomial COVID-19 infection. Prediction model showed that it will take 6 weeks to solve the backlog if department can reach the 85% of maximum of operations per week.

Conclusions

An understanding of operative case volume and distribution is essential in facilitating targeted interventions to strengthen surgical capacity in the time of COVID-19. A proper guideline is imperative to ensure access to safe, timely surgical care. By developing a scientific and effective management of hospital, it is possible to ensure optimal surgical safety during this crisis. Regular updates and a further study include multicenter is required.

Clinical trial registry number

ChiCTR2000034346.

Cardiovascular implications and complications of the coronavirus disease-2019 pandemic: a world upside down

PURPOSE OF REVIEW

The new pandemic of coronavirus disease-2019 (COVID-19) has produced a global tumult and has overburdened national health systems. We herein discuss the cardiovascular implications and complications of this pandemic analyzing the most recent data clustered over the last several months.

RECENT FINDINGS

COVID-19 afflicts the cardiovascular system producing acute cardiac injury in 10-20% of cases with mild disease but in greater than 50-60% in severe cases, contributing to patients' demise. Other cardiovascular complications include arrhythmias, heart failure, pulmonary embolism and shock. Off-label therapies are being trialed with their own inherent cardiovascular risks, while supportive therapies currently dominate, until more specific and effective antiviral therapies and vaccinations become available. A controversial issue relates to the safety of drugs blocking the renin--angiotensin system as an angiotensin-converting enzyme (ACE) homologue, ACE2, serves as the receptor for viral entry into host cells. However, to-date, no harm has been proven for these drugs.

SUMMARY

In the cardiovascular system, COVID-19 can induce acute cardiac injury, arrhythmias, heart failure, pulmonary embolism, shock and death, whereas anti-COVID therapies also confer serious cardiovascular side-effects. Ongoing extensive efforts focus on specific vaccines and antivirals. Meanwhile, cardiovascular risk factors and diseases should be jointly controlled according to current evidence-based guidelines.

2020 Clinical Update in Liver Transplantation

The gold standard treatment of end-stage liver disease continues to be liver transplantation (LT). The challenges of LT require skilled anesthesiologists to anticipate physiologic changes associated with end-stage liver disease and surgical considerations that affect multiple organ systems. While on the waiting list, patients may be placed on new anticoagulation medications that can confound already complex coagulopathy in LT patients. Pain management often is an afterthought for such a complex procedure, but appropriate medications can help control pain while limiting opioid medications. Surgical stress and medications for immunosuppression can affect perioperative glucose management in ways that have implications for patient and graft survival. The coronavirus disease 2019 pandemic in 2020 provided a new challenge for anesthesiologists. The uncertainty of the novel respiratory virus challenged providers beyond just LT patients.

COVID 19 and liver: An A-Z literature review

The coronavirus pandemic has changed the priorities of the whole medical society. During the clinical course of COVID-19, it has been observed that hepatic injury occurs in a significant proportion of patients, particularly in those with severe or critical illness. In this literature review, we summarize the most recent studies, which covered the pathophysiology of COVID-19 induced liver injury including; hepatic pathological findings, therapy related liver damage, and the effects of the viral infection on pre-existing liver diseasesin context of the most recent recommendations. Conclusions: This review sheds light on the impact of COVID-19 infection on the liver, as well as the prognostic effect of liver laboratory markers on disease outcome. Temporal variations in liver parameters during disease course as well as different patterns of derangement are depicted. More intensive surveillance and individualized therapeutic approaches should be tailored for immunocompromised patients with advanced liver disease, hepatocellular carcinoma, and liver transplant patients. Despite the limited studies on COVID-19 infected patients with preexisting liver disease, this comprehensive overview provides a perspective on the management of liver disease during COVID-19.

Experiences and Short-Term Outcomes of Kidney Transplantation During the Coronavirus Disease 2019 Pandemic From a Medium-Volume Transplantation and Superregional Coronavirus Disease 2019 Treatment Center

Introduction

The coronavirus, which first appeared in 2019, developed into a pandemic during 2020. It remains unclear to what extent the pandemic endangers the safety of kidney transplantation programs. In this study, we evaluated the short-term outcomes of our patients receiving a kidney transplant during the first phase and compared them with patients who received a kidney transplant immediately before the coronavirus pandemic.

Materials and Methods

Our retrospective study includes 34 kidney transplant recipients between October 1, 2019, and April 30, 2020. Nineteen patients from the phase immediately prior to the first coronavirus wave (pre-corona group), and 15 patients from the phase of the first coronavirus wave (corona group) were studied. We retrospectively evaluated demographic data, postoperative short-term outcomes and complications, immunosuppression regime, coronavirus infection status, and behavior during the first phase of the pandemic.

Results

There were no differences between the 2 groups regarding short-term outcomes and postoperative complications or in immunosuppressive medication. After the introduction of intensified hygienic conditions and routine swabs prior to transplantation, no nosocomial SARS-CoV-2 infections occurred. In the outpatient setting, none of the patients developed a SARS-CoV-2 infection. The majority of patients performed voluntary quarantine.

Conclusions

The short-term outcomes after kidney transplantation during the first phase of the coronavirus pandemic were comparable to pre-pandemic patients, and no SARS-CoV-2-associated death or transplant failure occurred in our small cohort. We considered patient compliance with hygiene and self-isolation measures very high. Nevertheless, in further phases of the pandemic, the continuation of the living kidney donation program must be critically evaluated.

COVID-19 management in heart transplanted recipients: registry of Almazov National Medical Research Centre

Aim      This study presents the experience of managing patients with COVID-19 after cardiac transplantation (CT).Material and methods  Infectious complications (IC) following CT are a leading cause for morbidity and mortality. A prolonged incubation period, atypical IC symptoms, and originally altered results of laboratory and instrumental diagnosis are characteristic of recipients due to immunosuppression. In 2020, the coronavirus infection (COVID-19) rapidly spread worldwide, and timely diagnosis and searching for effective treatments for this disease became a major challenge. From January 2010 through July 2020, 148 patients received orthotopic heart transplants at the V.A. Almazov National Medical Research Center; 34 of these patients died by the present time and were excluded from this analysis. 114 patients were included into the retrospective evaluation of results. These patients had been a part of the group followed up at the Center for more than a month.Results From March through July 2020, 12 (10.5 %) of 114 CT recipients were infected with the virus SARS-CoV-2. In 75 % (n=9) of the sick patients, the COVID-19 infection developed after more than one year after CT. From the first day of clinical symptoms, mycophenolic acid/everolimus were temporarily suspended. The outpatient treatment was started on the first day and included an antiviral therapy (oseltamivir), mucolytics (bromhexine), vitamin C, and anticoagulants. If the disease onset was associated with pyretic fever the empiric antibacterial levofloxacin treatment was administered due to a high risk of mixed infection. Hospitalized patients with moderately severe COVID-19 (n=3) were treated with oxygen inhalation through nasal cannula and prone position with a positive effect.Conclusion      Remote counseling of patients after CT and consistency of the outpatient treatment with recommendations of managing transplant physicians provided timely diagnosis of IC, early administration of treatment, and the absence of COVID-19 complications. Reducing the regimen of immunosuppressive therapy (antiproliferative agents) for up to 14 days facilitated infection control and was not associated with acute rejection crisis and/or impairment of the transplant function.