Abstract

Background: Initial recommendations from scientific societies cautioned against procurement of livers from COVID-19(+) donors. Growing evidence supports the short-term safety of liver transplantation from COVID-19(+) donors. We described usage of liver transplants from COVID-19(+) donors during the COVID-19 pandemic and characterized associated transplant outcomes using data from the United Network for Organ Sharing registry.

Methods: Liver transplant recipients from 7/2020-7/2022 were included in our retrospective cohort study. COVID-19(+) donors were identified by nucleic acid test or antigen positive testing. Trends in procurement of COVID-19(+) livers were compared against incident COVID-19 cases in the United States. Propensity score matching was used to account for differences between patient groups and to generate a 3:1 controls:cases matched cohort. Kaplan-Meier analysis was performed to plot survival distributions between donor COVID-19 status and transplant outcomes in the matched cohort. Fine and Gray competing risks regression (competing event = retransplantation) and standard Cox regression were performed to evaluate the association between donor status and patient and allograft survival, respectively.

Results: The analytic cohort included liver transplants from 13,096 COVID-19(-) and 299 COVID-19(+) donors. Increased utilization of COVID-19(+) organs was observed after peaks in COVID-19 cases in the US (Figure A). COVID-19(+) donors were younger (median age 38 vs 41, p<0.001), more likely to be donors after brain death (94.0% vs 88.8%, p=0.005), and more likely to be in certain UNOS regions (p<0.001). No significant differences in demographic data were observed between recipients of COVID-19(-) vs COVID-19(+) livers. After one year of post-transplant follow-up, no differences in patient survival (log-rank p=0.70; subhazard ratio [sHR]: 1.11, 95% confidence interval [CI]: 0.61-2.00, p=0.74; Figure B) or allograft survival (log-rank p=0.14; hazard ratio [HR]: 1.44, 95% CI: 0.88-2.36, p=0.14; Figure C) were noted between transplant from COVID-19(+) and COVID-19(-) donors.

Conclusion: Patient and allograft survival were similar at one year post-transplant in a large cohort comparing COVID-19(-) and COVID-19(+) donors. Utilization of livers from COVID-19(+) donors paralleled disease incidence in the US and varied across UNOS region. Liver transplant from COVID-19(+) donors has acceptable short-term outcomes and may represent an opportunity to expand organ access.