Epidemiological pattern, incidence and outcomes of COVID-19 in liver transplant patients
Jordi Colmenero 1 , Manuel Rodríguez-Perálvarez 2 , Magdalena Salcedo 3 , Ana Arias-Milla 4 , Alejandro Muñoz-Serrano 4 , Javier Graus 5 , Javier Nuño 6 , Mikel Gastaca 7 , Javier Bustamante-Schneider 7 , Alba Cachero 8 , Laura Lladó 8 , Aránzazu Caballero 3 , Ainhoa Fernández-Yunquera 3 , Carmelo Loinaz 9 , Inmaculada Fernández 9 , Constantino Fondevilla 10 , Miquel Navasa 1 , Mercedes Iñarrairaegui 11 , Lluis Castells 12 , Sonia Pascual 13 , Pablo Ramírez 14 , Carmen Vinaixa 15 , María Luisa González-Dieguez 16 , Rocío González-Grande 17 , Loreto Hierro 18 , Flor Nogueras 19 , Alejandra Otero 20 , José María Álamo 21 , Gerardo Blanco-Fernández 22 , Emilio Fábrega 23 , Fernando García-Pajares 24 , José Luis Montero 25 , Santiago Tomé 26 , Gloria De la Rosa 27 , José Antonio Pons 28
Background & aims: The incidence and outcomes of coronavirus disease 2019 (Covid-19) in immunocompromised patients are a matter of debate.
Methods: Prospective nationwide study including a consecutive cohort of liver transplant patients with Covid-19 recruited during the Spanish outbreak from February 28th to April 7th, 2020. The primary outcome was severe Covid-19, defined as the need for mechanical ventilation, intensive care, and/or death.
Age- and gender-standardized incidence and mortality ratios (SIR and SMR) were calculated using data from the Ministry of Health and the Spanish liver transplant registry. Independent predictors of severe Covid-19 among hospitalized patients were analyzed using multivariate Cox regression.
Results: A total of 111 liver transplant patients were diagnosed with Covid-19 (SIR=191.2 [95%CI 190.3-192.2]). The epidemiological curve and geographic distribution overlapped widely between liver transplant and general populations.
After a median follow-up of 23 days, 96 patients (86.5%) were admitted to hospital and 22 patients (19.8%) required respiratory support. Twelve patients were admitted to the ICU (10.8%). The mortality rate was 18%, being lower compared to the matched general population (SMR=95.5 [95%CI 94.2-96.8]). Thirty-five patients (31.5%) met criteria of severe Covid-19.
Baseline immunosuppression containing mycophenolate was an independent predictor of severe Covid-19 (RR=3.94; 95%CI 1.59-9.74; p=0.003), particularly at doses higher than 1,000 mg/day (p=0.003). This deleterious effect was not observed with calcineurin inhibitors or everolimus and complete immunosuppression withdrawal showed no benefit.
Conclusions: Being chronically immunosuppressed, liver transplant patients have an increased risk of acquiring Covid-19 but their mortality rates are lower than matched general population.
Upon hospital admission, mycophenolate dose reduction or withdrawal could help in preventing severe Covid-19. However, complete immunosuppression withdrawal should be discouraged.
CITA DEL ARTÍCULO J Hepatol. 2020 Aug 1;S0168-8278(20)30521-3.