COVID-19 and Liver Transplantation: Challenges and Opportunities (J Clin Transl Hepatol 2023)
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A Hot Topic Commentary by Georgios Tsoulfas of the Department of Transplantation Surgery, Aristotle University School of Medicine, Thessaloniki, Greece, COVID-19 and Liver Transplantation: Challenges and Opportunities, in the Journal of Clinical and Translational Hepatology 2023 vol. 11(3), pages 521–522, published online 20 January 2023. It discusses liver transplantation during the COVID-19 era, citing a study that counted 15,312 liver transplants before the pandemic and 8,995 in the COVID-19 era. It states that overall survival, at 96% at 3 months after transplantation, was stable in both periods, showing that quality was maintained.
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“COVID-19 and Liver Transplantation: Challenges and Opportunities (J Clin Transl Hepatol 2023).”
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Journal of Clinical and Translational Hepatology 2023 vol. 11(3) | 521–522
DOI: 10.14218/JCTH.2022.00038
Hot Topic Commentary
COVID-19 and Liver Transplantation: Challenges and
Opportunities
Georgios Tsoulfas*
Department of Transplantation Surgery, Aristotle University School of Medicine, Thessaloniki, Greece
Received: 27 September 2022 | Revised: 28 December 2022 | Accepted: 10 January 2023 | Published online: 20 January 2023
Citation of this article: Tsoulfas G. COVID-19 and Liver formed during the COVID-19 era, with 15,312 LTs performed
Transplantation: Challenges and Opportunities. J Clin Transl prior to the pandemic and 8,995 in the COVID-19 era. It
Hepatol 2023;11(3)521–522. doi: 10.14218/JCTH.2022.00 should be noted that overall survival (96% at 3 months post
038. LT) was stable in both periods, showing that quality was
maintained. As far as the etiology of LT is concerned, Kuo
et al.5 showed a 4.5% monthly increase in the percentage
Coronavirus disease 2019 (COVID-19) has presented hu-
of LTs performed for alcoholic liver disease (ALD) in the pe-
manity with a significant global challenge that has neces-
riod between November 2020 and May 2021, the COVID-19
sitated changes and adaptations at all levels. Liver transplant
era. What was even more important was the fact that these
(LT) activity could not have been an exception, as it was
LTs were more likely to use a poorer quality organ, to have
impacted both by changes in the urgency of the use of medi-
autoimmune hepatitis and ACLF grade 2–3, and a poor per-
cal resources, including shortage of hospital and intensive
formance status, which is critical in these patients. Regarding
care unit beds, problems in outpatient follow-up, redefining
the MELD score, the main effect was seen with HCV-related
the urgency of a LT among others. In addition to the fact that
LTs, where there was an increase in the average monthly
the quarantines placed and the resulting emotional isolation
MELD score by 0.7, again indicating the increased challenges
have led to increased alcohol use and abuse.1,2 An effort by
for these patients. When Kuo et al.5 evaluated the effect of
several transplant associations and the Centers for Medicare
the COVID-19 pandemic on the frequency of LT performed
and Medicaid led to issuing guidance and recommendations
for HCC and ACLF grade 2–3, the analysis found that for
regarding transplantation surgery during COVID-19.3,4 In the
HCC there was a 22% monthly decrease on a log scale of
paper “Impact of COVID-19 on Liver Transplant Activity in
LTs performed during the COVID-19 era, with recipients hav-
the USA: Variation by Etiology and Cirrhosis Complications”
ing higher MELD scores, an increase of 0.36% per month,
by Kuo et al.,5 the authors provide us with a thorough evalu-
and being more likely to have ALD-related ACLF, as well as
ation of the impact of the COVID-19 pandemic on LT activity
receive a poorer quality graft. As far as ACLF grade 2–3 is
based on etiology in the USA, by analysing data from the
concerned although there was a 17% monthly increase in
United Network of Organ Sharing (UNOS) database (2018–
the LTs performed in the COVID-19 era, the recipients had
2021). The authors looked at two different time periods, one
a higher MELD score, and the grafts were of poorer quality.
in the pre-COVID era between April 2018 and February 2020,
In both these cases of HCC and ACLF grade 2–3, we can see
and one in the COVID era between March 2020 and May
that the pandemic made it harder for LTs with, what could
2021). They evaluated the effect of COVID-19 examined LT
be considered, less of an urgent etiology harder to proceed
frequency, variation in liver disease etiology, Model for End-
and with lower quality grafts. Thankfully, there was no effect
stage Liver Disease (MELD) score, and complications of cir-
in the case of patients with acute liver failure needing an LT.
rhosis, with an emphasis on hepatocellular carcinoma (HCC)
Overall, Kuo et al.5 through their comparison of the pre-
and acute on chronic liver failure (ACLF). The pre-COVID era
and COVID-19 eras and their statistical analysis of the UNOS
was purposefully chosen to be 22 months long to include
database, found that there was an overall decrease in the
trends that developed prior to COVID-19, such as the de-
number of LTs for HCC, in addition to the need for a higher
crease in the incidence of hepatitis C virus (HCV) in terms
MELD score for these patients, similar to HCV, to receive an
of etiology for LT and the increase in non-alcoholic steato-
LT. On the other hand, there was a proportional increase in
hepatitis (NASH). In terms of methodology, the authors used
the LTs for ALD and ACLF grade 2–3. The findings reveal
monthly statistics and joinpoint regression models.
the effect of the COVID-19 pandemic on LT, which was a
The results, as far as the LT frequency is concerned,
decrease in the activity because of a diversion of resources
showed a 3.4% monthly decrease in the number of LTs per-
needed, decreased outpatient visits and follow-up, as well as
increased ALD prevalence because of the effect of the quar-
antine and the overall stressors. The study had the advantage
Abbreviations: ACLF, acute on chronic liver failure; ALD, alcoholic liver disease;
COVID-19, coronavirus disease 2019; HCC, hepatocellular carcinoma; HCV, hep- of comparing long time periods and using joinpoints to find
atitis C virus; LT, liver transplant; MELD, model for end-stage liver disease. the best fitting log linear regression model. Also, the use of a
*Correspondence to: Georgios Tsoulfas, Department of Transplantation Sur-
large database, such as the UNOS one, has the advantage of
gery, Aristotle University School of Medicine, Thessaloniki, Greece. ORCID:
https://orcid.org/0000-0001-5043-7962. Tel: +30-6971895190, Fax: +30- a wealth of patients and data, but there is an inherent chal-
2310332022, E-mail: tsoulfasg@auth.gr lenge in all these databases of identifying fine differences.
Copyright: © 2023 The Author(s). This article has been published under the terms of Creative Commons Attribution-Noncommercial 4.0 International License
(CC BY-NC 4.0), which permits noncommercial unrestricted use, distribution, and reproduction in any medium, provided that the following statement is provided.
“This article has been published in Journal of Clinical and Translational Hepatology at https://doi.org/10.14218/JCTH.2022.00038 and can also be viewed
on the Journal’s website at http://www.jcthnet.com”.
Tsoulfas G: COVID-19 and liver transplantation
Additionally, this was necessarily a retrospective study, and the role of the transplant infectious disease teams, the need
given the continuously evolving nature of organ allocation, for an organized approach by transplant societies and asso-
the changes in February 2020 with capping of MELD excep- ciations and of course the existence of regional and national
tion points for HCC listings, may have played a role in the de- variations. For all the reasons and challenges mentioned
crease in HCC-related LTs. Several papers have evaluated the above we have to acknowledge the importance of papers
effect of the COVID-19 pandemic on LT, and frequently there such as the one by Kuo et al.,5 which provide us with the
were differences regarding increased or decreased frequency necessary data to start making the necessary adjustments.
of LT seen because of different time points, different popula- We need to understand that we do not have the full picture
tions and also the evolving nature of the pandemic and the yet; the only thing that we have is the opportunity to gain
response to it.6–8 The importance of the paper by Kuo et al.5 from the lessons we learn from addressing the pandemic.
is that they are able, at least in this specific population, to
start identifying the finer differences as to how the pandemic
affected LTs of different etiology and to what extent. Funding
However, there are more lessons to be learned here. None to declare.
First we have to acknowledge the facts that (1) COVID-19
is a reality of our times, albeit more manageable with the
advent of the vaccines, and (2) LT is and should continue Conflict of interest
to be a social priority, not only because it has to do with a GT has been an editorial board member of Journal of Clinical
life-saving procedure, but also because we need to honor and Translational Hepatology since 2020.
the noble decision that families make during a difficult time
to donate the organs of their loved ones. The points raised
above mean that as a society and as a health care system, References
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522 Journal of Clinical and Translational Hepatology 2023 vol. 11(3) | 521–522
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