All healthcare delivery services were significantly disrupted by the global pandemic of COVID-19 [6]. Surely, SOT patients are the most vulnerable group subjected to severe infection, morbidity, and mortality. They also require a high level of care through pre-transplant evaluation, transplant surgery, and post-transplant management [6, 7].
Most of the organ transplantation centers worldwide have postponed all elective organ transplantation, and now we are in the process of resuming SOT. COVID-19 pandemic has created unprecedented circumstances and unique challenges for resuming SOT worldwide. Being a highly dynamic pandemic, our understanding continues to evolve. It remains difficult to provide strong unique recommendations given the paucity of robust data to inform guidance.
Being on immunosuppressive medications, the post-transplant patients are considered at high risk for COVID-19 infection, therefore with reopening care, every effort should be taken to protect them from exposure to the virus [6].
In order to prevent possible patient-to-patient and patient-to-personnel transmission, several aspects should be systematically taken into account. Overcrowding should be always avoided and an adequate air change per hour should be maintained [8].
Many transplant centers worldwide developed a COVID-19 donor and recipient clinical screening programs such as Canada, Switzerland, Italy, and Spain. Accordingly, the Japanese Society for Transplantation established a recommendation to screen donors for significant exposure to COVID-19, travel history to high-risk countries, and symptoms including fever and respiratory symptoms together with home or hospital isolation for 14 days prior to intervention in order to avoid COVID-19 exposure for both lung and liver living donors, in cases where transplantation can be postponed for 14 days. Also, the Korean Society for Transplantation published their recommendation on March 13, 2020, for testing both living and deceased donors for SARS-CoV-2 by a nasopharyngeal swab prior to appointment. However, there is still variation in approach to donation between different countries according to the burden of COVID-19 infection and availability of service resources [9].
Preventative strategies and social distancing measures should be reinforced in living donors, especially within 14 days prior to organ donation. Moreover, a high-risk living donor is either because of COVID-19 symptoms or exposure, postponement of organ donation for at least 28 days is a must. American Society of Transplantation recommends delaying the transplant for at least 14 days if the donor is of intermediate risk for COVID-19 such as those with exposure but no symptoms [10], the donor with resolved symptoms more than 28 days prior to organ donation, and with negative testing repeatedly with at least 24 h apart [10].
The aim of this article was to share our experience in resuming the LDLT program in the context of the COVID-19 pandemic and to report the obstacles that faced us.
In our study we reported three LDLT recipients once resuming the transplantation; unfortunately, one of them developed COVID-19 infection. We managed by isolating him in a single room, restricting one team of HCWs to deal with him with full PPE supplies. Finally, the patient improved and was discharged in a reasonable condition. The second patient ran a smooth course apart from FK neurotoxicity that was managed properly. The third patient experienced a sharp rise in bilirubin and transaminases on day 14 that was attributed to drug toxicity vs. rejection and managed by discontinuing the offending drugs and pulse steroids.
Unfortunately, we were unable to trace the source of COVID-19 infection in our first case, due to the lack of accessibility of performing the test to all HCWs. As for most centers, we are also facing the problem of the increased financial burden of transplantation including and the shortage of PPE.
There are no best practices in a pandemic; therefore, managing best practices in a pandemic requires bold decisions and frequent reassessment of rationales [11].
In Wuhan, the COVID-19 pandemic greatly slowed and then stopped organ donation and transplantation, but the decrease in the number of infections has allowed hospitals in Wuhan to carefully resume deceased donor organ donation and transplantation [12].
COVID-19 infection was reported in a 55-month-old girl, 5 months after undergoing liver transplantation; she recovered completely despite the high level of received immunosuppression [13]. Another case report, records living liver donation from a COVID-19 infected donor, the donor was apparently healthy with mild symptoms; lopinavir plus ritonavir were started to the recipient then shifted to hydroxychloroquine due to drug-drug interaction. Fortunately, the result of the serial COVID-19 RT-PCR test via both nasopharyngeal swab and serum was negative. Further information on the pathogenesis and transmissibility of COVID-19 in organ transplantation is still required [14].
Hyo-Lim Hong et al. [14] and Stephen Lagana et al. [15] have reported 2 cases of donor-derived transmission of COVID-19; therefore, a strategy is needed to prevent donor-derived transmission from all potential asymptomatic carriers.
In Italy, out of 17 liver transplanted patients, 2 developed COVID-19 on postoperative days 9 and 22 [16]. On the contrary, a center in China, among six liver transplants performed during COVID-19, no complications were reported [17].
It is still confusing whether the infection source is nosocomial, donor-derived, or just delayed diagnosis of asymptomatic recipients.
Hence, the recommendations for transplantation from donors diagnosed with COVID-19 are prudent, so it is of utmost importance to screen donors for COVID-19 by epidemiological investigations and clinical history for suspected COVID-19 as well as PCR within 3 days of procurement and CT, when feasible [18].
Currently, many SOT centers across the world recommend using CT to screen asymptomatic living donors for COVID-19 in the preoperative evaluation process; however, the American Society of Transplantation is against this issue [6].
For the exclusion of asymptomatic infection in donors, most of the centers have already adopted real-time-PCR and CT scan screening along with serology. However, without complete isolation of the transplant process from cross-contamination and the capability for identification of all asymptomatic COVID-19 patients, the levels of transplantation will not reach their baseline level as it was in the pre-COVID-19 era [6].
Indeed, all the reopening measures should be considered in the context of the pandemic where the possibility of a second peak or even further peaks is still possible.
Furthermore, every effort should be made to maintain one full set of transplant armamentaria in a COVID-19 area, when still in place, in order to perform all SOT in an isolated clean environment with minimization of the risk of COVID-19 transmission.
Finally, strategic planning and coordination will be needed to ensure the robust enrolment of SOT patients in ongoing clinical trials once routine care in the COVID-19 era is reopened.
