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World J Hepatol. Oct 27, 2021; 13(10): 1299-1315
Published online Oct 27, 2021. doi: 10.4254/wjh.v13.i10.1299
Coronavirus disease 2019 in liver transplant patients: Clinical and therapeutic aspects
Carmelo Loinaz-Segurola, Alberto Marcacuzco-Quinto, Mario Fernández-Ruiz
Carmelo Loinaz-Segurola, Alberto Marcacuzco-Quinto, HBP and Transplant Surgery Unit. Department of General Surgery, Digestive Tract and Abdominal Organ Transplantation, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Universidad Complutense, Madrid 28041, Spain
Mario Fernández-Ruiz, Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Universidad Complutense, Madrid 28041, Spain
Author contributions: Loinaz-Segurola C and Marcacuzco-Quinto A performed the literature review on the clinical aspects and wrote the related text; Fernández-Ruiz M reviewed mainly the therapeutics issues and wrote the related text; All the authors reviewed the paper and approve the final manuscript.
Conflict-of-interest statement: The authors declare that there are no any conflicts of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Carmelo Loinaz-Segurola, FACS, MD, PhD, Associate Professor, HBP and Transplant Surgery Unit. Department of General Surgery, Digestive Tract and Abdominal Organ Transplantation, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Universidad Complutense, Avenida de Cordoba s/n, Madrid 28041, Spain. cloinaz@ucm.es
Received: February 21, 2021
Peer-review started: February 21, 2021
First decision: June 4, 2021
Revised: June 17, 2021
Accepted: August 23, 2021
Article in press: August 23, 2021
Published online: October 27, 2021
Processing time: 242 Days and 19.7 Hours
Abstract

The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted liver transplant (LT) activity across the world, with notable decreases in the number of donations and procedures in most Western countries, in particular throughout the first wave. The cumulative incidence of COVID-19 in LT recipients (with estimates ranging from 0.34% to 1.56%) appears to be at least comparable to that observed for the general population. Clinical and radiological features at presentation are also similar to non-transplant patients. The risk of death among LT recipients requiring hospital admission is high (from 12% to 19%), although some authors have suggested that overall mortality may be actually lower compared to the general non-transplant population. It is likely that these poor outcomes may be mainly influenced by the older age and higher comorbidity burden of LT recipients, rather than by the transplant status itself. In fact, it has been hypothesized that post-transplant immunosuppression would exert a protective role, with special focus on tacrolimus-containing regimens. There is scarce evidence to guide the optimal management of post-transplant COVID-19 and the use of antiviral or immunomodulatory therapies, although both clinical practice and guidelines support the dose reduction or withdrawal of anti-proliferative agents such as mofetil mycophenolate. Preliminary reports suggest that the antibody response to messenger RNA vaccines is significantly impaired as compared to non-immunocompromised individuals, in line with other transplant populations. Finally, it is foreseeable that the future will be conditioned by the emerging variants of severe acute respiratory syndrome coronavirus 2 with increased transmissibility among LT recipients.

Keywords: COVID-19; Liver transplantation; Clinical features; Therapy; Immunosuppression; SARS-CoV-2

Core Tip: Coronavirus disease 2019 incidence and clinical and radiological features are similar in liver transplant recipients and the general population. Reported mortality in hospitalized patients is 12%-19%. Risk factors are older age and comorbidity. Tacrolimus could be protective, but anti-proliferative agents such as mycophenolate mofetil should be avoided.