key: cord-1027031-tjjo73ff
authors: Terrabuio, Débora Raquel Benedita; Haddad, Luciana; Ducatti, Liliana; Gouveia, Larissa; Rocha‐Santos, Vinicius; Ferreira, Renee Mignolo Tanaka; Darce, George Felipe; Cardoso, Ana Julia Andrade; Carrilho, Flair José; Andraus, Wellington; Abdala, Edson; D´Albuquerque, Luiz Augusto Carneiro
title: Insights in the approach of long‐term liver transplant recipients with COVID‐19
date: 2020-07-23
journal: Transpl Infect Dis
DOI: 10.1111/tid.13424
sha: 3489c575c8d1675a7a0426740aae33041cc7335c
doc_id: 1027031
cord_uid: tjjo73ff

Despite the great number of cases of COVID‐19 around the world, data in liver transplant (LT) recipients are still settling down. We share our experience after the first four cases of long‐term LT recipients admitted for hospitalization and the measures for suspicion and diagnostic investigation adopted after these cases. The mean time of initial symptoms at hospitalization was 8 days; only one case had the classical respiratory symptoms.

To the Editor, Despite the great number of cases of COVID-19 around the world, data in liver transplant (LT) recipients are still settling down. We share our experience after the first four cases of long-term LT recipients admitted for hospitalization and the measures for suspicion and diagnostic investigation adopted after these cases. The mean time of initial symptoms at hospitalization was 8 days; only one case had the classical respiratory symptoms (table 1). The most reported symptoms were diarrhea, fever, headache and asthenia. This finding is in line with a series of 18 transplant recipients 1 , as well as a series 2 with kidney transplant recipients in which 22% of them referred diarrhea as a prominent symptom, compared to less than 10% in general population 3 . A recent series only with LT recipients reported 42% of gastrointestinal symptoms 4 . Maybe immunosuppression alters the clinical presentation and course of the disease, making them more susceptible to gastrointestinal symptoms. After these cases, we considered that we should be alert to search for the virus even in the absence of respiratory complaints. We changed our policy of outpatient screening for SARS-CoV-2 infection, and included diarrhea, besides respiratory symptoms, as a feature for proceeding with precautions measures and diagnostic investigation.

Other important finding was that 2 out of 4 cases were initially discharged and returned 48h later due to worsening symptoms, and one case presented desaturation even after 13 days of symptoms (case 2), which led us to adopt more careful criteria for follow up, hospitalization and discharge.

All patients had lymphopenia, which is common in COVID-19, related to severity and mortality and this finding reinforces the recommendations of American Association for Study of Liver Diseases (AASLD) to withdrawal antimetabolite during hospitalization for COVID-19 5 . All patients had elevated C-RP and LDH at admission with a progressive drop in both of them and increase of lymphocyte count, coincidental with clinical improvement. The patient who required oxygen supplementation had one of the greatest levels of C-RP and D-dimer and drop in platelet count, with clinical improvement after increasing the dose of enoxaparin and switching prednisone to methylprednisolone. Disease severity has been linked to markers of coagulation disturbances, including thrombocytopenia and elevated D-dimer and fibrin degradation products and autopsy

This article is protected by copyright. All rights reserved findings shows relation between thromboembolic phenomena and clinical outcomes 6 . The use of heparin in therapeutic doses tailored to clinical severity resulted in significant increase in PaO 2 /FiO 2 ratio in a series of 27 cases, which allowed us to adopt this measure to deal with this patient 7 .

Despite the presence of risk factors for severe disease, all patients were discharged without ICU admission and only one patient required oxygen supplementation. Our series of cases demonstrates that long-term LT recipients may have an atypical initial clinical presentation and disease progression. It appears that immunosuppression has no protective effect and age and comorbidities could worsen the prognosis of disease, such as in general population. It is important to closely monitor these patients if one proposes an outpatient follow up.

This article is protected by copyright. All rights reserved C-RP: C-reactive protein (< 5mg/L); D-dimer normal value < 500ng/mL; LDH: lactate dehydrogenase (<214 U/l); LMWH: low molecular weight heparin (40mg/d); HCQ: hydroxychloroquine sulfate; MPD: methylprednisolone 1 Cases 2 and 3 were discharged by the Emergency Room assistant team and readmitted 48h latter due to worsening symptoms. None of the patients presented significant liver enzymes elevation or loss of graft function. 6 All patients tested negative for influenza virus. 3s None of the patients was admitted to

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