(197) Successful COVID-19 + Liver Transplant in an Unvaccinated Patient: A Case Report and Review of the Literature

Abstract: Already grappling with scarce organs, the transplant community mobilized quickly in the COVID-19 pandemic to evaluate the safety of transplanting COVID+ organs (1). Early case reports helped shape preliminary guidelines, including a strong recommendation for recipient vaccination. There remains a paucity of literature surrounding COVID+ organ transplantation in unvaccinated individuals. We present a case of successful transplantation of a COVID+ liver in an unvaccinated patient with life-threatening fulminant hepatic failure following acetaminophen overdose.

VB is a 25 year old previously healthy female who presented following a suicide attempt by acetaminophen overdose. She was in severe hepatic encephalopathy. Laboratory results showed high transaminitis, coagulation abnormalities and hyperammonemia. N-acetylcysteine was initiated on admission. Her condition progressed quickly with global cerebral edema and cerebellar tonsillar herniation requiring neuro-ICU care. The decision to proceed with liver transplantation with a COVID+ liver was made in careful consideration with family as the surrogate medical-decision makers and support from Ethics and CL psychiatry teams. We detail the post-op course, serial COVID testing, prophylaxis with monoclonal antibodies and later supportive treatment including management of immunosuppressants after the patient seroconverted to COVID+. The patient was extubated on POD 10 and discharged to acute rehabilitation on POD 16. She is stable medically and psychiatrically 5 months later.

CL psychiatrists are called upon to evaluate a patient’s candidacy for liver transplantation after an intentional overdose causes acute terminal liver failure. We also support the family in this fraught decision. It behooves us to have a solid understanding of the nuances of risks and outcomes. Prior to the COVID-19 pandemic, outcomes of emergent liver transplantation after intentional overdose were comparable to those for patients transplanted for acute and chronic liver failure from other causes (2). The literature is limited on the outcomes of using COVID+ organs, and very sparse on the risks in unvaccinated patients (3). We review the existing case literature on COVID+ organ transplantation, current guidelines, and discuss the areas in need of further study.

1. De Carlis, R., Vella, I., Incarbone, N., Centonze, L., Buscemi, V., Lauterio, A., & De Carlis, L. (2021). Impact of the COVID-19 pandemic on liver donation and transplantation: A review of the literature. World journal of gastroenterology, 27(10), 928–938.
2. Karvellas, C.J., Safinia, N., Auzinger, G., Heaton, N., Muiesan, P., O'Grady, J., Wendon, J. and Bernal, W. (2010), Medical and psychiatric outcomes for patients transplanted for acetaminophen-induced acute liver failure: a case–control study. Liver International, 30: 826-833.
3. Eichenberger, E. M., Kaul, D. R., & Wolfe, C. R. (2021). The pandemic provides a pathway: What we know and what we need to know about using COVID positive donors. Transplant infectious disease: an official journal of the Transplantation Society, 23(5), e13727