PATTERNS AND PREDICTORS OF LIVER INJURY IN LIVER TRANSPLANT RECIPIENTS WITH CORONAVIRUS DISEASE 2019 (COVID-19)
Authors: A. Rabiee, N. Adeniji, V. Nguyen, A. Moghe, P. V. Perumalswami, N. L. Latt, S. Kumar, C. Aloman, M. A. Catana, P. P. Bloom, K. D. Chavin, R. M. Carr, W. Dunn, V. Chen, E. S. Aby, J. D. Debes, R. Dhanasekaran
Journal: Hepatology (2020)

Background: Recent reports have revealed that coronavirus disease 2019 (COVID-19) is associated with liver injury The burden of liver injury in liver transplant (LT) recipients remains unknown We conducted a multi-center study to evaluate the prevalence, pattern and predictors of liver injury in LT recipients with COVID-19 and its impact on clinical outcomes Methods: The was carried out by the consortium of investigators to study COVID-19 in chronic liver disease (COLD) (registered Clinicaltrials gov NCT04439084) Inclusion criteria constituted: age > 18 years, laboratory confirmed diagnosis of COVID-19 and history of LT  We collected de-identified data on patients diagnosed before May 30, 2020 For the analysis on liver injury, only patients who had laboratory values for aspartate aminotransferase (AST) and alanine aminotransferase (ALT) prior to- and during COVID-19 infection were included The primary outcome was the presence of acute liver injury The secondary outcome was all-cause mortality within 90 days of diagnosis Logistic regression analyses were used to determine interdependent risk factors of primary outcome Results: We included 112 adult LT recipients from 21 US medical centers with confirmed diagnosis of COVID-19 The median age of the cohort was 61 years (IQR 20), and 54 5% (n = 61) were male There were 39 3% (n = 44) Hispanic, 27 7% (n = 31) non-Hispanic white, and 25 9% (n = 29) non-Hispanic African-American The all-cause mortality was 22 3% (n = 25);72 3% (n = 81) were hospitalized and 26 8% (n = 30) were admitted to the intensive care unit (ICU) 81 patients had data for analysis of liver injury 34 6% of LT patients had liver injury, Mild to moderate liver injury (ALT 2-5x ULN) in 22 2% (n=18) and severe (ALT > 5x ULN) in 12 3% (n = 10)  Younger age (p = 0 009, odds ratio (OR) 2 06 [1 20-3 54]), Hispanic ethnicity (p = 0 011;OR 6 01[1 51-23 9]), metabolic syndrome (p = 0 016;OR 5 87 [1 38-24 99]), receipt of vasopressors (p = 0 018;OR 7 34 [1 39-38 52]) and antibiotic use (p = 0 046;PR 6 93 [1 04-46 26]) were associated with independent risk of liver injury on multivariate logistic regression Immunosuppression was modified in approximately half the patients (49 4%, [n = 40]) Reduction in immunosuppression during COVID-19 was not associated with liver injury (p = 0 156) or risk for mortality (p = 0 084)  Presence of liver injury was significantly and independently associated with higher overall mortality (p = 0 007;OR = 6 91 [95% CI: 1 68-28 48]) in LT recipients Conclusion: Mild to moderate liver injury was common in LT patients diagnosed with COVID-19 Immunosuppression was modified during COVID-19 in half the patients but was not associated with liver injury or mortality Younger age, Hispanic ethnicity, metabolic syndrome, vasopressor and antibiotic use were associated with independent risk of liver injury Lastly, liver injury was associated with higher mortality rate in LT recipients with COVID-19