Liver transplant in a recently COVID-19 positive child with hepatoblastoma

Background: The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has transformed innumerable aspects of clinical practice, particularly in the field of organ transplantation As outcomes data remain scarce and a definitive treatment has yet to be realized, it is anticipated that transplant of an actively or recently COVID-19 infected patient could result in an adverse outcome Meanwhile, it is important to acknowledge that withholding or delaying transplant can lead to increased morbidity or death in some patients We describe the successful pediatric liver transplant for unresectable hepatoblastoma in a 4-year-old formerly premature male with COVID-19 infection prior to transplant The first negative nasopharyngeal (NP) swab was documented one month after initial diagnosis, when SARS-CoV-2 antibodies were also detected The patient was therefore actively listed for orthotopic liver transplant after completing four blocks of a SIOPEL-4 based regimen due to his PRETEXT IV disease which remained unresectable Following three additional negative NP swabs and resolution of symptoms for four weeks, he underwent a whole-organ pediatric liver transplant Methods: COVID-19 positivity determined via NP swab SARS-CoV-2 real-time RT-PCR (Hologic Aptima SARS-CoV-2 RT-PCR assay) IgG and IgM total SARS-CoV-2 antibodies detected via Ortho Clinical Diagnostics VITROS®nodiagnostics Products Anti- SARS-CoV-2 Test Results: Patient received standard prednisone and tacrolimus-based immunosuppression without induction therapy following transplant Post-transplant course was remarkable for neutropenia and thrombocytopenia, which were closely followed, with discharge home on posttransplant day #11 Prior to discharge, RT-PCR testing was repeated three times and each test did not detect SARSCoV- 2 RNA Additionally, SARS-CoV-2 antibodies persisted at four weeks after transplant Conclusion: We describe one of the earliest, if not the first case of liver transplant following recent recovery from COVID-19 in a pediatric patient with a lethal malignant liver tumor A better understanding of how to balance the risk profile of transplant in the setting of COVID-19 with disease progression if transplant is not performed is needed It remains imperative that we provide life-saving liver transplants to children amid the COVID-19 pandemic while recognizing that transplant with any active viral infection typically portends worse outcomes In addition, the safety of our healthcare team remains a priority To meet these goals, we followed existing guidance to document clearance of the viral infection and resolution of symptoms and only then performed the transplant This case highlights that liver transplant can be safely performed in a child upon documented clearance of active COVID-19 infection with adherence to current guidelines and close follow-up