A Less Restrictive Policy for Liver Transplantation in Coronavirus Disease 2019 Positive Patients, Based Upon Cycle Threshold Values

Abstract

\n The coronavirus disease 2019 drastically impacted solid organ transplantation. Lacking scientific evidence, a very stringent but safer policy was imposed on liver transplant (LT) early in the pandemic. Restrictive transplant guidelines must be reevaluated and adjusted as data become available. Prior to LT, the prevailing policy requires a negative SARS-Cov-2 real-time polymerase chain reaction (RT-PCR) of donors and recipients. Unfortunately, prolonged viral RNA shedding frequently hinders transplantation. Recent data reveal that positive test results for viral genome are frequently due to non-infectious and prolonged convalescent shedding of viral genome. Moreover, studies demonstrated that the cycle threshold of quantitative RT-PCR could be leveraged to inform clinical transplant decision-making. We present an evidence-adjusted significantly less restrictive policy for LT, where risk tolerance is tiered to recipient acuity. In addition, we delineate the pre-transplant clinical decision-making, intra- and postoperative management, and early outcome of two recipients of a liver graft performed while their RT-PCR of airway swabs remained positive. Convalescent positive RT-PCR results are common in the transplant arena, and the proposed policy permits reasonably safe LT in many circumstances.\n