Successful liver transplantation for hepatitis B-related acute liver failure in a patient with active COVID-19

The emergence of coronavirus disease 19 (COVID-19) has significantly disrupted liver transplantation worldwide. Despite significant, collective experience in treating liver transplant recipients with COVID-19, there remains a paucity of data to guide the management of transplant candidates with acute COVID-19 who require urgent transplantation. We present the case of an otherwise well, 39-year-old female presenting for urgent liver transplantation for acute liver failure secondary to hepatitis B, with concomitant acute, mild COVID-19 due to Omicron BA.2. COVID-19 antivirals were not administered pre-transplant as the potential risk of hepatotoxicity precipitating further deterioration of liver function was not felt to outweigh the small, potential benefit of antiviral therapy. No effective SARS-CoV-2 monoclonal antibodies were available; however, the patient was previously vaccinated against SARS-CoV-2 with evidence of anti-spike antibodies at the time of COVID-19. Transplantation surgery and recovery were uncomplicated with no progression of COVID-19 post-transplant, hospital discharge was at day 14. At 30 days post-transplant the patient had recovered, with normal liver function and SARS-CoV-2 was not detectable on nasopharyngeal PCR. While the safety of transplantation of patients with acute COVID-19 cannot be assured by a single case, ours highlights the complex decision-making process undertaken and competing priorities that need to be balanced when assessing patients with acute COVID-19 who require urgent transplantation.