Liver Transplantation Candidates With COVID-19 Have High Risk for Early Death

Researchers investigated the impact of COVID-19 on patients waiting for liver transplants, as well as on the clinical course following transplantation.

Liver transplantation (LT) candidates with COVID-19 have a roughly 33% risk for early mortality, according to a study in Gut.

Researchers collected data from the ELITA/ELTR COVID-19 registry from February 21, 2020, to November 20, 2020, which included 136 adult cases of laboratory-confirmed SARS-CoV-2 infections from 33 centers in 11 European countries. The study authors also included a control group of 91 patients with cirrhosis who were hospitalized for acute decompensation resulting from a bacterial infection between 2016 and 2020.

A total of 113 patients were symptomatic with COVID-19 and were included in the analysis. Of this group, 33 patients (29.2%) received home care, with the other 80 patients (70.8%) requiring hospitalization; 28 (35%) of these patients were admitted to the intensive care unit (ICU). Participants’ median age was 58.0 years (interquartile range [IQR], 53-63 years), and 61.9% were men. Among the cohort, 37 patients (32.7%) died after a median of 18 days (IQR, 10-30 days) from diagnosis, 89.1% of whom had respiratory failure.

From February to June 2020, 51 patients developed COVID-19 in the first wave of the pandemic. From July to November 2020, 62 patients developed COVID-19 in the second wave. The clinical presentation and course were similar in the 2 waves. Between the first and second waves, the 60-day mortality risk was 35.3% (95% CI, 23.9%-50.0%) compared with 26.0% (95% CI, 16.2%-40.2%), respectively, and peaked to 43.9% (95% CI, 30.4%-60.3%) vs 41.7% (95% CI, 26.6%-61.0%), respectively, in those requiring hospitalization, with respiratory failure being the primary cause of death.

Multivariable analysis showed that 3 factors were significantly associated with mortality: dyspnea (hazard ratio [HR], 3.89; 95% CI, 2.02-7.51), Model for End-Stage Liver Disease (MELD) class of 15 to 19 (HR, 5.46; 95% CI, 1.81-16.50), and MELD class of ≥20 (HR, 5.24; 95% CI, 1.77-15.55).

In addition, 26 patients had an LT after a median of 78.5 days (IQR, 44-102 days) from diagnosis. The overall median ICU and hospital stay were 3 days (IQR, 3-6 days) and 11 days (IQR 8-19 days), respectively. The survival rate was 96% after a median follow-up of 118 days (IQR, 31-170 days); 1 patient died from posterior reversible encephalopathy syndrome 82 days after the LT.

The risk for early death for LT candidates with COVID-19 increased to 49.2% in those with decompensated cirrhosis and a Laboratory MELD (Lab-MELD) score of ≥15, a rate that is triple the mortality risk for patients on a waiting list with comparable Lab-MELD scores without COVID-19.

The study authors noted 2 main limitations to their findings. By including symptomatic cases with confirmed positive SARS-CoV-2 polymerase chain reaction tests with test sensitivity less than 80%, some cases may have inadvertently been excluded. Additionally, the impact of the COVID-19 pandemic on access to LT was not assessed.

“LT candidates with [decompensated cirrhosis] should rigorously adopt all the usual measures to prevent SARS-CoV-2 infection and reinforced vaccination programmes should be implemented as the efficacy of standard vaccines is much lower than that reported in the registration studies,” the researchers commented. “The evaluation of Lab-MELD score and dyspnoea at clinical presentation will aid clinicians in their decision-making,” They concluded.


Belli LS, Duvoux C, Cortesi PA, et al. COVID-19 in liver transplant candidates: pretransplant and post-transplant outcomes—an ELITA/ELTR multicentre cohort study. Gut. Published online July 19, 2021. doi: 10.1136/gutjnl-2021-324879.