key: cord-0965248-k0b2u23l authors: Martini, Silvia; Patrono, Damiano; Pittaluga, Fabrizia; Brunetto, Maurizia Rossana; Lupo, Francesco; Amoroso, Antonio; Cavallo, Rossana; Balagna, Roberto; Romagnoli, Renato title: Urgent liver transplantation soon after recovery from COVID‐19 in a patient with decompensated liver cirrhosis date: 2020-07-14 journal: Hepatol Commun DOI: 10.1002/hep4.1580 sha: 8bbfb88da2751c60d7f9afbd3e81299e9b4bca0e doc_id: 965248 cord_uid: k0b2u23l Italy has been the first Western nation facing COVID‐19 outbreak. Despite the emergency situation, all efforts have been done to preserve liver transplant (LT) activity and to minimize the impact of current scenario on transplant waiting list time and mortality. Little is known about COVID‐19 consequences in transplant candidates, especially those with limited life expectancy due to the severity of their baseline disease. We report here the case of a young patient requiring inpatient care due to severe decompensated liver disease (MELD 24), justifying her referral from her local hospital to our high‐volume LT unit, despite the unfavourable COVID‐19 epidemiology in our Region. She was quickly listed for liver transplant (MELD 26), but 5 days later she was incidentally diagnosed with COVID‐19 in the setting of our surveillance program for very sick patients and, despite her underlying condition, had an indolent course of the viral disease. Concerns about potential COVID‐19 consequences in a LT candidate were overruled by the severity of liver disease (MELD 36), forcing our team to proceed with an urgent successful LT as soon as 9 days after the COVID‐19 diagnosis, 2 days after the first negative SARS‐CoV‐2 RNA by a nasopharyngeal swab and 1 day after the confirmation of its negativity on bronchoalveolar lavage. The patient was discharged on day 9 after LT. In conclusion, to the best of our knowledge, this is the first report of a LT candidate recovering from a mild form of COVID19 and undergoing a successful LT shortly after. Aggressive care should be maintained in SARS‐CoV‐2‐positive patients with decompensated cirrhosis in order to overcome viral infection and to proceed as soon as possible with life‐saving treatment. Italy has been the first Western nation facing COVID-19 outbreak. Despite the emergency situation, all efforts have been done to preserve liver transplant (LT) activity and to minimize the impact of current scenario on transplant waiting list time and mortality. Little is known about COVID-19 consequences in transplant candidates, especially those with limited life expectancy due to the severity of their baseline disease. We report here the case of a young patient requiring inpatient care due to severe decompensated liver disease (MELD 24), justifying her referral from her local hospital to our high-volume LT unit, despite the unfavourable COVID-19 epidemiology in our Region. She was quickly listed for liver transplant (MELD 26), but 5 days later she was incidentally diagnosed with COVID-19 in the setting of our surveillance program for very sick patients and, despite her underlying condition, had an indolent course of the viral disease. Concerns about potential COVID-19 consequences in a LT candidate were overruled by the severity of liver disease (MELD 36), forcing our team to proceed with an urgent successful LT as soon as 9 days after the COVID-19 diagnosis, 2 days after the first negative SARS-CoV-2 RNA by a nasopharyngeal swab and 1 day after the confirmation of its negativity on bronchoalveolar lavage. The patient was discharged on day 9 after LT. In conclusion, to the best of our knowledge, this is the first report of a LT candidate recovering from a mild form of COVID19 and undergoing a successful LT shortly after. Aggressive care should be maintained in SARS-CoV-2-positive patients with decompensated cirrhosis in order to overcome viral infection and to proceed as soon as possible with life-saving treatment. Dear Editor, Italy has been the first Western nation facing COVID-19 outbreak and all efforts have been done to preserve liver transplant (LT) activity. Nevertheless, a 25% reduction of procured organs has already been observed during the first 4 weeks of the epidemic (1). Little is known about COVID-19 consequences in transplant candidates. This article is protected by copyright. All rights reserved On March 21 th , 2020, a 39-year-old lady was admitted to our liver unit for decompensated autoimmune cirrhosis (MELD 24). She had no co-morbidities and was not a smoker. On March 25 th she was listed for LT (MELD 26) with normal chest computed tomography (CT). On March 30 th , in the setting of persistent fever, without respiratory symptoms and with normal chest CT, she tested positive for SARS-CoV-2 RNA on nasopharyngeal swab (NPS) (DiaSorin Molecular Simplexa™ COVID-19 Direct assay system). She was moved to a COVID-19 ward and started on hydroxychloroquine for 7 days. In the following days, she developed mild lymphopenia and profound coagulopathy ( Figure 1 ). On April 2 nd her saturation dropped to 85% with a PaO2/FiO2 ratio=138 and she required non-invasive ventilation; 24 hours after, her blood gases markedly improved and she was transferred back to COVID-19 ward, with oxygen by nasal cannula at 2 L/min. On April 6 th and 7 th , two consecutive SARS-CoV-2 RNA NPSs tested negative, allowing her to be transferred back to our liver unit. On April 7 th , negative SARS-CoV-2 RT-PCR was confirmed on bronchoalveolar lavage (BAL) fluid and a new chest CT was again negative. Thus, she was reactivated on the LT waiting list (MELD 36). The day after an ABO-identical liver from a 46-year-old deceased donor became available and she underwent LT. Immunosuppression consisted of basiliximab, steroids, tacrolimus and mycophenolate. She made an uneventful recovery and was discharged home on postoperative day (POD) 9. A second SARS-CoV-2 RT-PCR on BAL performed on POD 2 tested negative again. Serology for SARS-CoV-2 infection was performed by testing anti-Spike S1 total antibodies and IgM on the day of LT and on POD 7: both samples tested negative, which can be explained by early testing after symptoms onset, interference of immunosuppressive treatment on the development of a full humoral response and hemodilution effect by multiple transfusions. In our case, LT appeared as the only way forward, and we felt that the expected benefit of a timely LT outweighing the risks linked to recent COVID-19 infection. The favorable outcome suggests that LT soon after recovery from COVID-19 should be considered as a viable option in candidates with severely compromised liver function. In conclusion, to the best of our knowledge, this is the first report of a LT candidate recovering from a mild form of COVID-19 and undergoing successful LT shortly after. The COVID-19 outbreak in Italy: Initial implications for organ transplantation programs Aggressive care should be maintained in SARS-CoV-2-positive patients with decompensated cirrhosis in order to overcome viral infection and to proceed as soon as possible with life-saving treatment.