Epidemiological pattern, incidence and outcomes of COVID-19 in liver transplant patients.

Colmenero, Jordi; Rodríguez-Perálvarez, Manuel; Salcedo, Magdalena; Arias-Milla, Ana; Muñoz-Serrano, Alejandro; Graus, Javier; Nuño, Javier; Gastaca, Mikel; Bustamante-Schneider, Javier; Cachero, Alba; Lladó, Laura; Caballero, Aránzazu; Fernández-Yunquera, Ainhoa; Loinaz, Carmelo; Fernández, Inmaculada; Fondevilla, Constantino; Navasa, Miquel; Iñarrairaegui, Mercedes; Castells, Lluis; Pascual, Sonia; Ramírez, Pablo; Vinaixa, Carmen; González-Dieguez, María Luisa; González-Grande, Rocío; Hierro, Loreto; Nogueras, Flor; Otero, Alejandra; Álamo, José María; Blanco-Fernández, Gerardo; Fábrega, Emilio; García-Pajares, Fernando; Montero, José Luis; Tomé, Santiago; De la Rosa, Gloria; Pons, José Antonio

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 28(th) to April 7(th), 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.