Dr Ramesh Singh Bhandari
The Year 2076 remained very special in the history of transplant program of whole nation. Tribhuvan University Teaching Hospital (TUTH), which is considered as country’s one of the largest tertiary referral center of the country having almost all the medical and surgical specialties besides running the academic courses of all the major disciplines at all levels started the much awaited liver transplantation program. Renal transplant was already a very well established program in TUTH for more than a decade. After years of preparation, the hospital was finally able to start the program.
Liver transplantation is considered as one of the most complicated procedure requiring highest level of dedication and multidisciplinary involvement. Till the beginning of the COVID-19 pandemic, the Liver transplant team at TUTH with the support of Indian Liver Transplant team performed four successful living donor liver transplants. Till date, all four donor and recipients have remained in a state of good health and are in regular follow up. Like other clinical services, liver transplantation has also remained on hold after the beginning of the COVID-19 pandemic. This has badly hit both the kidney and liver transplant programs of teaching hospital, which were going on very smoothly.
Liver transplantation specially has suffered more as it was just in a very infancy state. We were in the process of establishing the liver transplant program in TUTH for which required performing good number of successful liver transplants. Because of the COVID-19, the momentum of ongoing liver transplant program has been affected and it will definitely create difficulties and will need extra efforts again to restart the program in a very smoother way.
Not only in Nepal, the emergence of COVID‐19 pandemic has impacted all transplantation programs worldwide and the impact of this pandemic is not just limited to the issues of the donors and recipients, but also about the utilization of healthcare resources as the intensity of cases is such that it might exceed the available capacity.Whether organ transplantation should be carried out during the COVID-19 epidemic has remained controversial. Due to risks unknown and well defined yet; some experts around the world are suggesting that transplantation should be suspended temporarily. However, some of the recently released guidance from China suggested that liver transplantation surgery is possible after careful risk assessments.Early data is suggesting that the effects of COVID-19 on the liver might be modest and reflect infection severity among patients without pre-existing liver disease but the effects of COVID-19 on those with liver transplants or established liver disease remain unclear.
Worldwide different mitigation strategies are being studied and applied to run the transplant programs in most effective way and at the same time not putting other essential clinical services in jeopardy. Strategies include donor screening, resource planning, and a staged approach to transplant volume considerations as local resource issues demand.Donor screening for SARS- COV-2 is done for stratifying the donor into different risk categories for donations. Most transplantation societies do nucleic acid testing (RT-PCR) from Nasopharyngeal swabs.
Approach to transplantation have been decided by individual transplant programs in terms of ceasing or continuity of the liver transplantation programs as the pandemic can impact the transplant recipients and donor adversely.Individual guidelines are being developed.Before proceeding for transplants, many important issues are taken into considerations like introducing immunosuppression into patients in the midst of a pandemic, the risk vs. benefit ratio of postponing transplant vs. proceeding, and rationing of healthcare resources including both inpatient and outpatient resources. Lack of ventilator capacity is also an extremely important consideration once widespread activity is present. In centers where Liver transplantation is being carried, patients are being stratified based on MELD scoring system and the decision made to only transplant high MELD patients that means patients at very high risk of dying if not transplanted soon.
Much suggested approach by many around the world and for them who are performing transplants in very high volumes is a phased approach to decreasing transplant activity. Elective transplant visits are being postponed and only urgent visits are being seen. Telehealth/telephone calls are utilized as substitution for hospital visits. Transplant patients are being directed to public health transplant‐specific websites for information.At present, there is no recommendation for prophylactic medications or vaccinations for transplant patients. However, newer medications against COVID-19 are likely to be available soon. If transplants are being carried out, safety of transplant team is also a major concern and many of these risks can be mitigated by careful use of personal protection measures, and if needed avoidance of high‐risk situations and following hospital directives regarding in‐person meetings.
In Nepal, almost half a dozen of hospitals which includes both private and government sectors are providing Kidney transplant services although only few of them like TUTH and human Organ Transplant Center (HOTC) are performing regularly and in very high volumes. However, only TUTH and HOTC have started liver transplantation program and some private medical school hospitals have also received the license to start the program but they are yet to start. After the onset of this COVID-19 pandemic and initiation of the lockdown, the transplant programs at these institutions are almost on hold. There have been no published guidelines from any of these hospitals or any formal societies have come up with the strategies for safely conducting the transplants.
We, the liver transplant team at TUTH have well understood the fact that the liver transplant will utilize the massive amount of human resources as well as the logistics which would potentially affect the other very essential, urgent and life saving surgeries. Moreover, the liver transplantation is being carried out with the support from the Indian team members. Thus, requesting them to come and support us seems very impractical at this moment of time. Thus, liver transplant program at TUTH has been put on hold and we expect to resume the program once majority of the other essential hospital activities get back to routine stage. Last year, we had performed four successful living donor liver transplants and all of them are doing well and in regular follow-ups. In regards to this COVID-19 pandemic we have been extremely vigilant to our patients and teaching them all the protective measures to remain uninfected from this highly contagious virus. Till now, none of our donor recipients have reported with any kind possible symptoms of CIVID-19 although the liver transplant recipients specially are extremely vulnerable to any kind of infections due to immunosuppressive therapies.
If the pandemic continues at its present pace, the number of patients requiring the transplants as urgent and semi urgent status will definitely pile up. Therefore, like in other developed countries we shall also have to come with special guidelines and strategies’ but modified to our local setups and resources to start the transplant program in most rational way.
-(Dr Bhandari is Professor of Gastrointestinal Hepatopancreatobiliary and Liver Transplant in TUTH).