Publication: Epidemiological pattern, incidence, and outcomes of COVID-19 in
liver transplant patients
Authors
Pons, JA
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Publisher
Elsevier
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DOI
https://doi.org/10.1016/j.jhep.2020.07.040
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info:eu-repo/semantics/article
Description
Abstract
Background & Aims: The incidence and outcomes of coronavirus
disease 2019 (COVID-19) in immunocompromised patients
are a matter of debate.
Methods: We performed a prospective nationwide study
including a consecutive cohort of liver transplant patients with
COVID-19 recruited during the Spanish outbreak from 28
February to 7 April, 2020. The primary outcome was severe
COVID-19, defined as the need for mechanical ventilation,
intensive care, and/or death. Age- and gender-standardised
incidence and mortality ratios (SIR and SMR) were calculated
using data from the Ministry of Health and the Spanish liver
transplant registry. Independent predictors of severe COVID-19
among hospitalised patients were analysed using multivariate
Cox regression.
Results: A total of 111 liver transplant patients were diagnosed
with COVID-19 (SIR = 191.2 [95% CI 190.3–192.2]). The epidemiological
curve and geographic distribution overlapped widely
between the liver transplant and general populations. After a
median follow-up of 23 days, 96 patients (86.5%) were admitted
to hospital and 22 patients (19.8%) required respiratory support.
A total of 12 patients were admitted to the ICU (10.8%). The
mortality rate was 18%, which was lower than in the matched
general population (SMR = 95.5 [95% CI 94.2–96.8]). Overall, 35
patients (31.5%) met criteria of severe COVID-19. Baseline
immunosuppression containing mycophenolate was anindependent predictor of severe COVID-19 (relative risk = 3.94;
95% CI 1.59–9.74; p = 0.003), particularly at doses higher than
1,000 mg/day (p = 0.003). This deleterious effect was not
observed with calcineurin inhibitors or everolimus and complete
immunosuppression withdrawal showed no benefit.
Conclusions: Being chronically immunosuppressed, liver transplant
patients have an increased risk of acquiring COVID-19 but
their mortality rates are lower than the matched general population.
Upon hospital admission, mycophenolate dose reduction
or withdrawal could help in preventing severe COVID-19. However,
complete immunosuppression withdrawal should be
discouraged.
Lay summary: In liver transplant patients, chronic immunosuppression
increases the risk of acquiring COVID-19 but it could
reduce disease severity. Complete immunosuppression withdrawal
may not be justified. However, mycophenolate withdrawal
or temporary conversion to calcineurin inhibitors or
everolimus until disease resolution could be beneficial in hospitalised
patients.
Citation
Journal of hepatology 2021 74:148-155
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