Impact of the COVID-19 pandemic on liver donation and transplantation: A review of the literature

Table 1 Reduction in LT activity around the world during the pandemic

Ref.	Country	Reduction in organ donations	Reduction in LT activity	Period
Putzer et al[9], 2020	Europe1	N/A	-29%	mid-March – mid-June, 2020 vs 2015 – 2019
Agopian et al[18], 2020	United States	N/A	-24%	February – March, 2020 vs 2019
Turco et al[19], 2020	France	-28%	-22%	January 1 – May 31, 2020 vs 2019
Domínguez-Gil et al[4], 2020	Spain	N/A	-75.8% LT/wk	March 13 – April 23 vs weekly mean 2019
Angelico et al[8], 2020	Italy	-30% (North)-9% (South)	-17%	February 24 – March 22, 2020 vs 2015-2019
Lee et al[20], 2020	South Korea	No difference	No difference	January – March, 2020 vs 2000-2019

¹Eurotransplant data. N/A: Not applicable; LT: Liver transplantation.

Table 2 Recommendations of international societies

	AASLD[58]	EASL[51]	APASL[32]
Donor screening	RT-PCR for SARS-CoV-2. Screen for exposure and clinical symptoms/fever compatible with COVID-19. Additionally, consider chest X-ray	RT-PCR for SARS-CoV-2	SARS-COV-2 RNA on NPS or BAL. Exclude any evidence of COVID-19 infection on chest CT scan
Recipient testing	Screen for exposure and clinical symptoms/fever compatible with COVID-19. RT-PCR for SARS-CoV-2	Evaluation of clinical history, chest radiology, and SARS-CoV-2 testing. Screening before admission	Assess recipients for COVID-19 infection, particularly in the presence of symptoms or contact with a known COVID-19 case
Liver allocation policy	High MELD scores. HCC based on their risk of drop-out and disease progression	Acute liver failure. ACLF. High MELD score. HCC at the upper limits of the Milan criteria	Acute liver failure. High MELD. High risk of HCC progression
Living donation	Consider suspending, except for pediatric patients with acute liver failure	Should be considered on a case-by-case basis	Not specified (avoid if evidence of COVID-19 infection)
Immunosuppression in COVID-19 positive recipients	Standard immunosuppression protocol. Reduction of immunosuppression may be considered in the setting of lymphopenia, fever, or worsening pulmonary status	Standard immunosuppression protocol. Reduction should only be considered under special circumstances	Standard immunosuppression protocol. Reduction of immunosuppression may be considered in patients diagnosed with moderate COVID-19 infection

AASLD: American Association for the Study of Liver Diseases; ACLF: Acute on chronic liver failure; APASL: Asian-Pacific Association for the Study of the Liver; BAL: Bronchoalveolar lavage; CT: Computerized tomography; EASL: European Association for the Study of the Liver; HCC: Hepatocellular carcinoma; MELD: Model for end stage liver disease; NAT: Nucleic acid test; RT-PCR: Reverse transcription-polymerase chain reaction; SARS-CoV-2: Severe acute respiratory syndrome coronavirus type 2; COVID-19: Coronavirus disease 2019.

Table 3 Mortality, hospitalization, intensive care unit admission, and risk factors among liver transplantation recipients

Ref.	Registry	n	Mortality (%)	Hospital admission (%)	ICU admission (%)1	Major correlations with mortality
Polak et al[2], 2020	ELTR	272	15	N/A	14	sexage
Rabiee et al[45], 2020	COLD	112	22.3	72.3	26.8	N/A
Colmenero et al[44], 2020	SETH	111	18	86.5	10.8	Charlson comorbidity index; Male sex; Dyspnea at diagnosis; Immunosuppression with mycophenolate
Bhoori et al[49], 2020	–	111 (long term); 40 (short term)	30	N/A	N/A	N/A
Belli et al[48], 2020	ELTR/ELITA	103	16	66	15	N/A
Becchetti et al[43], 2020	–	57	12	72	7	N/A
Webb et al[42], 2020	COVID-hep and SECURE-cirrhosis	39	23	N/A	N/A	N/A
Patrono et al[41], 2020	–	10	10	N/A	N/A	N/A

¹Calculated as proportion of the total cohort. N/A: Not applicable; COLD: Consortium of investigators to study COVID-19 in chronic liver disease; ELITA: European Liver and Intestine Transplantation Association; ELTR: European Liver Transplant Registry; SETH: Spanish Society of Liver Transplantation; COVID: Coronavirus disease.