Chronic immunosuppression increases the risk of acquiring COVID-19 in liver transplant patients, however, it could reduce severity of disease. Although whole immunosuppression withdrawal may not be justified, mycophenolate withdrawal or temporary conversion to calcineurin inhibitors or everolimus until disease resolution could be advantageous in hospitalised patients. The study is aimed at evaluating the incidence and outcomes of coronavirus disease 2019 (COVID-19) in immunocompromised patients.

The authors of the nationwide prospective study included a consecutive cohort of liver transplant patients with COVID-19 during the Spanish outbreak from 28 February to 7 April, 2020. The primary outcome was severe COVID-19, typified as the need for mechanical ventilation, intensive care, and/or death. Age- and gender-standardised incidence and mortality ratios (SIR and SMR) were measured using data from the Ministry of Health and the Spanish liver transplant registry. Multivariate Cox regression was used to evaluate independent predictors of severe COVID-19 among hospitalised patients.

The outcome suggested that a total of 111 liver transplant patients were diagnosed with COVID-19 (SIR = 191.2 [95% CI 190.3-192.2]). An extensive overlapping of epidemiological curve and geographic distribution was found between the liver transplant and general populations. A total of 96 patients (86.5%) were admitted to hospital and 22 patients (19.8%) required respiratory support, after a median follow-up of 23 days. A total of 12 patients were admitted to the ICU (10.8%). The mortality rate was 18% that was lower than in the matched general population (SMR = 95.5 [95% CI 94.2-96.8]). Overall, 35 patients (31.5%) met criteria of severe COVID-19. Baseline immunosuppression containing mycophenolate was an independent predictor of severe COVID-19 (relative risk = 3.94; 95% CI 1.59-9.74), especially at doses higher than 1,000 mg/day. On the contrary, this harmful effect was not observed with calcineurin inhibitors or everolimus and complete immunosuppression withdrawal has no beneficial effect.

The study thus, concluded that Being, liver transplant patients, owing to their chronically immunosuppressed state are at a higher risk of acquiring COVID-19, however, their mortality rates are lower in comparison to the matched general population. Although, mycophenolate dose reduction or withdrawal upon hospital admission, can aid in preventing severe COVID-19, complete immunosuppression withdrawal should be discouraged.

Source: Epidemiological pattern, incidence, and outcomes of COVID-19 in liver transplant patients. J Hepatol. 2021 Jan;74(1):148-155.