A team at Vancouver General Hospital took a calculated risk that is now saving the lives of patients with acute liver failure.
Sometimes you have to push boundaries to advance medical science.
That is exactly what Dr. Eric Yoshida, a principal investigator with Vancouver Coastal Health Research Institute and the former medical director of the BC Liver Transplant Program, and his team did in 2021 when they successfully completed an orthotopic liver transplant into a young patient with active COVID-19.
It was the first successful instance of such a transplant in Canada and only the second one recorded worldwide.
“We all practice evidence-based medicine, but what if there is no evidence? That is the conundrum because if you wait for evidence to accumulate, your patient will be dead.”
The resulting case report published in the August 2021 edition of Transplant Direct filled a knowledge void for clinicians whose COVID-19-positive patients urgently required transplants. Previously, clinicians would not have attempted transplant surgery in this circumstance due to the lack of published scientific literature on the subject.
Subsequently submitted to the International Liver Transplant Society Meeting in 2021, the case report was not only accepted, but was also the subject of a podium presentation, something unheard of for a single patient snapshot. Since then, it has continued to garner the attention of the national and international transplant community because it highlights exceptions that exist to current guidelines, limiting transplants in COVID-19-positive patients.
Patient’s age a factor in success
The 28-year-old patient at the centre of Yoshida’s case report arrived at Vancouver General Hospital with acute liver failure. Concern was voiced that if COVID-19 was responsible for liver decompensation, potential multisystem failure could result post-transplant.
After determining COVID-19 was not the root cause of liver failure — and after carefully considering the risks and possible adverse outcomes — the team made the decision to proceed with the surgery, knowing the patient would likely die without it.
Tipping the scale in favour of transplant were the facts that the patient was young, had mild COVID-19 symptoms isolated to the upper respiratory tract, and had limited risk factors for adverse outcome from COVID-19 infection. As such, Yoshida and his team believed a positive outcome was possible.
After considering the ethics of allocating a scarce organ resource to a patient with an unknown outcome, the team moved forward to notify liver transplant centres across Canada that a “high status” patient in Vancouver needed a liver urgently.
Bold steps advance medical science
Reflecting on the case today, Yoshida is proud of his team’s decision to push against medical boundaries and existing transplantation guidelines.
“We proved the adage that absence of evidence is not proof that there is no benefit,” he says. “This was a feasible venture and we had to be bold.”
Since last summer, two more case reports with similar outcomes have been published, broadening the body of evidence that says organ transplants in COVID-19-positive patients are, indeed, possible.
“This is changing mindsets and saving lives. There is now a collection of experiences in published literature that surgeons can look at to see if it is applicable to their own circumstance.”
As for the patient, he has recovered and continues to receive post-surgical care from Yoshida and the team. While he may have been the first such patient to receive a liver transplant in the era of COVID-19, he will not be the last.
“There is no longer a fear that transplantation into a patient with COVID-19 is futile,” says Yoshida. “We now know that in certain situations, a COVID-19 infection may not be an absolute contraindication to liver transplantation.”
