The COVID-19 pandemic had a substantial impact on liver transplantation outcomes, with lower graft survival and patient survival at 90 days post-transplant versus a pre-pandemic time period, a researcher said.

Graft survival was significantly lower during the COVID versus pre-COVID period (95.2% vs 96.0%) and there was a significant decline in patient survival (96.0% vs 96.6%, P<0.01 for both) at 90-days post-transplantation, which was more pronounced after 30 days post-transplantation, reported Kenji Okumura, MD, of New York Medical College/Westchester Medical Center in Valhalla, New York.

In addition, patients in the COVID period had significantly higher median model for end-stage liver disease (MELD) scores and increased need for hemodialysis prior to transplant, and a significantly lower waiting list time, he said at a presentation at the American Association for the Study of Liver Diseases (AASLD) virtual meeting.

His group examined data from the United Network for Organ Sharing (UNOS) database on all liver transplant recipients, ages 18 and up, from March 11 to September 11 in 2019 (“pre-COVID period”) and 2020 (“early COVID period”).

Overall, there were 4% fewer liver transplants in the 2020 versus the 2019 time-period, which was most pronounced in March and April, the early months of the pandemic. However, by May and June, the number rebounded.

There were 4,277 liver transplant recipients in the pre-COVID and 4,107 liver transplant recipients in the COVID period. These patients were a median age of 58, and a little less than two-thirds were men. About 70% were white. There was no significant difference in demographics between the two time periods.

However, there were significantly more patients with alcoholic liver disease (ALD) in the COVID versus pre-COVID period, and significantly fewer hepatocellular carcinoma patients. ALD was the most common primary diagnosis (32%).

Donor characteristics were mostly similar between time periods, though donor BMI was significantly higher in the COVID period compared to the pre-COVID period. The donor risk index was also significantly higher (1.65 vs 1.55, P<0.01).

While there was an increase in percentage of patients with multi-organ dysfunction in the COVID period, it was nonsignificant, Okumura said.

He acknowledged a significant potential confounder: the liver and intestine distribution system based on acuity circles, which was implemented by UNOS on Feb. 4, 2020. This replaced “donation service area and regional boundaries … with a system based on distance between donor hospital and transplant hospital.”

The COVID period was also independently associated with 90-day grant survival (HR 1.77, 95% CI 1.45-2.17), Okumura said. Five of 155 liver transplant patients during the COVID period died of COVID-19 (3.2%), he added.

When asked about the higher rejection rate before discharge in the COVID period (4.6% vs 3.4%), he suggested that it might be related to immunosuppressive therapies, as use of antithymocyte globulin (ATG) declined significantly, while use of basiliximab (Simulect) and steroids significantly increased during 2020.

Okumura said “many centers have been changing the practice” of how the types of immunosuppressive therapies they use. AASLD session moderator Norah Terrault, MD, of Keck Medical Center at the University of Southern California in Los Angeles, added that, “we probably need a little more granular data to better understand that.”