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. 2021 Nov:16:100262.
doi: 10.1016/j.lanwpc.2021.100262. Epub 2021 Sep 7.

Impact of COVID-19 on Liver Transplantation in Hong Kong and Singapore: A Modelling Study

Eunice Xiang-Xuan Tan  1   2   3 , Wei Liang Quek  4 , Suryadi  5 , Haroun Chahed  4 , Shridhar Ganpathi Iyer  2   3   6 , Prema Raj Jeyaraj  7   8 , Guan-Huei Lee  1   2   3 , Albert Chan  9 , Stephanie Cheng  8 , Jan Hoe  3 , Ek Khoon Tan  7   8 , Lock Yue Chew  5 , James Fung  10 , Melvin Chen  4 , Mark D Muthiah  1   2   3 , Daniel Q Huang  1   2   3
Affiliations

Impact of COVID-19 on Liver Transplantation in Hong Kong and Singapore: A Modelling Study

Eunice Xiang-Xuan Tan et al. Lancet Reg Health West Pac. 2021 Nov.

Abstract

Background: Liver transplantation (LT) activities during the COVID-19 pandemic have been curtailed in many countries. The impact of various policies restricting LT on outcomes of potential LT candidates is unclear.

Methods: We studied all patients on the nationwide LT waitlists in Hong Kong and Singapore between January 2016 and May 2020. We used continuous time Markov chains to model the effects of different scenarios and varying durations of disruption on LT candidates.

Findings: With complete cessation of LT, the projected 1-year overall survival (OS) decreased by 3•6%, 10•51% and 19•21% for a 1-, 3- and 6-month disruption respectively versus no limitation to LT, while 2-year OS decreased by 4•1%, 12•55%, and 23•43% respectively. When only urgent (acute-on-chronic liver failure [ACLF] or acute liver failure) LT was allowed, the projected 1-year OS decreased by a similar proportion: 3•1%, 8•41% and 15•20% respectively. When deceased donor LT (DDLT) and urgent living donor LT (LDLT) were allowed, 1-year projected OS decreased by 1•2%, 5•1% and 8•85% for a 1-, 3- and 6-month disruption respectively. OS was similar when only DDLT was allowed. Complete cessation of LT activities for 3-months resulted in an increased projected incidence of ACLF and hepatocellular carcinoma (HCC) dropout at 1-year by 49•1% and 107•96% respectively. When only urgent LT was allowed, HCC dropout and ACLF incidence were comparable to the rates seen in the scenario of complete LT cessation.

Interpretation: A short and wide-ranging disruption to LT results in better outcomes compared with a longer duration of partial restrictions.

Funding: None to disclose.

Keywords: COVID-19; Liver transplant; hepatocellular carcinoma; modelling; outcomes; survival.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Simulation of the Transition States where 0-15 represented: 0: decompensated cirrhosis without HCC, 1: HCC without decompensated cirrhosis, 2: acute liver failure or acute on chronic liver failure, 3: decompensated cirrhosis with HCC, 4: decompensated cirrhosis with ACLF but without HCC, 5: decompensated cirrhosis with HCC and ACLF, 6: too sick for transplant in a decompensated cirrhotic, 7: HCC that progressed out of criteria, 8: ALF or ACLF that was deemed too sick for transplant, 9: decompensated cirrhosis with HCC that was too sick for transplant, 10: decompensated cirrhosis with ACLF deemed too sick for transplant with no HCC, 11: decompensated cirrhosis with ACLF and HCC deemed too sick for transplant, 12: recovered without transplant, 13: well following LDLT, 14: well following DDLT and 15: Death• Abbreviations: ALF, acute liver failure; ACLF, acute-on-chronic liver failure; HCC, hepatocellular carcinoma, LDLT, living donor liver transplant; DDLT, deceased donor liver transplant.
Figure 2
Figure 2
Projected survival of waitlisted patients, incidence of ACLF, and proportion of permanent waitlist dropout in HCC patients. The respective scenarios were projected for one-month, three-months, six-months and twelve-months• Figure 2a Projected survival of waitlisted patients, by scenario, plotted by mean ± standard deviation• Figure 2b Projected ACLF development, by scenario, plotted by mean ± standard deviation• Figure 2c Projected rate of HCC progression beyond UCSF criteria, by scenario, plotted by mean ± standard deviation. Abbreviations: ACLF, acute-on-chronic liver failure; UCSF, University of California San Francisco; LT, liver transplant; DDLT, deceased donor liver transplant; LDLT, living donor liver transplant;
Figure 2
Figure 2
Projected survival of waitlisted patients, incidence of ACLF, and proportion of permanent waitlist dropout in HCC patients. The respective scenarios were projected for one-month, three-months, six-months and twelve-months• Figure 2a Projected survival of waitlisted patients, by scenario, plotted by mean ± standard deviation• Figure 2b Projected ACLF development, by scenario, plotted by mean ± standard deviation• Figure 2c Projected rate of HCC progression beyond UCSF criteria, by scenario, plotted by mean ± standard deviation. Abbreviations: ACLF, acute-on-chronic liver failure; UCSF, University of California San Francisco; LT, liver transplant; DDLT, deceased donor liver transplant; LDLT, living donor liver transplant;
Figure 2
Figure 2
Projected survival of waitlisted patients, incidence of ACLF, and proportion of permanent waitlist dropout in HCC patients. The respective scenarios were projected for one-month, three-months, six-months and twelve-months• Figure 2a Projected survival of waitlisted patients, by scenario, plotted by mean ± standard deviation• Figure 2b Projected ACLF development, by scenario, plotted by mean ± standard deviation• Figure 2c Projected rate of HCC progression beyond UCSF criteria, by scenario, plotted by mean ± standard deviation. Abbreviations: ACLF, acute-on-chronic liver failure; UCSF, University of California San Francisco; LT, liver transplant; DDLT, deceased donor liver transplant; LDLT, living donor liver transplant;
Figure 3a
Figure 3a
Percentage change in projected survival in the respective scenarios versus no restriction to LT.Abbreviations: LT, liver transplant; LDLT, living donor liver transplant; DDLT, deceased donor liver transplant
Figure 3b
Figure 3b
Percentage change in ACLF incidence in the respective scenarios versus no restriction to LT. Abbreviations: LT, liver transplant; ACLF, acute-on-chronic liver failure; LDLT, living donor liver transplant; DDLT, deceased donor liver transplant
Figure 3c
Figure 3c
Percentage change in proportion of waitlist dropout among HCC patients in the respective scenarios versus no restriction to LT.Abbreviations: LT: liver transplant, HCC: hepatocellular carcinoma, LDLT: living donor liver transplant, DDLT: deceased donor liver transplant
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