The_AT0 novel_AJ0 coronavirus_NN1 disease_NN1 2019_CRD (_PUL COVID-19_CRD )_PUR ,_PUN the_AT0 clinical_AJ0 syndrome_NN1 caused_VVN by_PRP the_AT0 severe_AJ0 acute_AJ0 respiratory_AJ0 syndrome_NN1 coronavirus_NN1 2_CRD (_PUL SARS-CoV-2_NP0 )_PUR ,_PUN has_VHZ had_VHN a_AT0 profound_AJ0 impact_NN1 on_PRP all_DT0 aspects_NN2 of_PRF transplantation_NN1 in_PRP the_AT0 United_NP0 States_NP0 and_CJC worldwide_AJ0 ._SENT The_AT0 infection_NN1 continues_VVZ to_TO0 spread_VVI at_PRP an_AT0 alarming_AJ0 rate_NN1 around_PRP the_AT0 world_NN1 ,_PUN having_VHG reached_VVN over_PRP 3.3_CRD million_CRD deaths_NN2 globally_AV0 and_CJC over_PRP 580_CRD ,_PUN 000_CRD deaths_NN2 in_PRP the_AT0 United_NP0 States_NP0 alone_AV0 as_CJS of_PRF May_NP0 2021._CRD Although_CJS mortality_NN1 from_PRP COVID-19_NN1 is_VBZ primarily_AV0 related_VVN to_PRP pulmonary_AJ0 complications_NN2 ,_PUN there_EX0 are_VBB numerous_AJ0 extrapulmonary_AJ0 manifestations_NN2 of_PRF the_AT0 disease_NN1 ,_PUN including_PRP gastrointestinal_AJ0 and_CJC hepatic_AJ0 ._SENT Patients_NN2 with_PRP preexisting_AJ0 medical_AJ0 comorbidities_NN2 including_PRP chronic_AJ0 liver_NN1 disease_NN1 (_PUL CLD_NP0 )_PUR and_CJC cirrhosis_NN1 are_VBB likely_AJ0 to_TO0 be_VBI at_PRP high_AJ0 risk_NN1 of_PRF severe_AJ0 disease_NN1 and_CJC death_NN1 when_CJS compared_VVN with_PRP healthy_AJ0 patients_NN2 and_CJC those_DT0 without_PRP liver_NN1 disease_NN1 ._SENT There_EX0 has_VHZ been_VBN significant_AJ0 interest_NN1 in_PRP the_AT0 outcomes_NN2 of_PRF patients_NN2 with_PRP COVID-19_NN1 among_PRP liver_NN1 transplantation_NN1 candidates_NN2 and_CJC recipients_NN2 ,_PUN as_CJS well_AV0 as_CJS the_AT0 impact_NN1 the_AT0 pandemic_AJ0 has_VHZ had_VHN on_PRP the_AT0 rates_NN2 and_CJC logistics_NN1 of_PRF the_AT0 transplantation_NN1 itself_PNX ._SENT Here_AV0 ,_PUN we_PNP review_VVB what_DTQ we_PNP have_VHB learned_VVN in_PRP the_AT0 first_ORD year_NN1 of_PRF this_DT0 pandemic_AJ0 about_PRP the_AT0 impact_NN1 of_PRF COVID-19_NN1 in_PRP liver_NN1 transplantation_NN1 and_CJC identify_VVB key_AJ0 knowledge_NN1 gaps_NN2 to_TO0 guide_VVI research_NN1 in_PRP this_DT0 area_NN1 ._SENT 
The_AT0 Impact_NN1 of_PRF the_AT0 COVID-19_NN1 Pandemic_AJ0 on_PRP the_AT0 Practice_NN1 of_PRF Liver_NN1 Transplantation_NN1 
Many_DT0 aspects_NN2 of_PRF health_NN1 care_NN1 have_VHB changed_VVN dramatically_AV0 during_PRP the_AT0 pandemic_AJ0 ,_PUN with_PRP practices_NN2 in_PRP liver_NN1 transplantation_NN1 being_VBG no_AT0 exception_NN1 ._SENT Most_DT0 centers_NN2 rapidly_AV0 converted_VVN to_PRP telehealth_NN1 for_PRP the_AT0 majority_NN1 of_PRF their_DPS patient_NN1 visits_NN2 ._SENT In_PRP the_AT0 first_ORD quarter_NN1 of_PRF 2020_CRD ,_PUN there_EX0 was_VBD a_AT0 significant_AJ0 impact_NN1 of_PRF the_AT0 pandemic_AJ0 on_PRP the_AT0 number_NN1 of_PRF liver_NN1 transplantations_NN2 performed_VVN (_PUL Fig._NN1 1_CRD )_PUR ,_PUN number_NN1 of_PRF additions_NN2 to_PRP the_AT0 liver_NN1 transplantation_NN1 waiting_VVG list_NN1 ,_PUN and_CJC number_NN1 of_PRF liver_NN1 transplantation_NN1 waitlist_NN1 inactivations_NN2 as_PRP the_AT0 pandemic_AJ0 evolved_VVN throughout_PRP the_AT0 United_NP0 States_NP0 ._SENT Adding_VVG additional_AJ0 complexity_NN1 ,_PUN these_DT0 data_NN0 must_VM0 be_VBI interpreted_VVN in_PRP the_AT0 context_NN1 of_PRF the_AT0 virtually_AV0 simultaneous_AJ0 change_NN1 in_PRP the_AT0 liver_NN1 allocation_NN1 system_NN1 in_PRP February_NP0 2020._CRD This_DT0 initial_AJ0 decline_NN1 in_PRP transplantation_NN1 activities_NN2 was_VBD likely_AV0 fueled_VVN by_PRP concerns_NN2 about_PRP donor_NN1 and_CJC recipient_NN1 safety_NN1 ,_PUN as_CJS well_AV0 as_CJS the_AT0 safety_NN1 of_PRF the_AT0 transplantation_NN1 teams_NN2 and_CJC unknowns_NN2 about_PRP the_AT0 resources_NN2 available_AJ0 in_PRP transplantation_NN1 centers_NN2 as_PRP the_AT0 virus_NN1 spread_VVD geographically_AV0 and_CJC access_VVB to_PRP viral_AJ0 testing_NN1 was_VBD very_AV0 limited_VVN ._SENT In_PRP addition_NN1 ,_PUN there_EX0 was_VBD a_AT0 notable_AJ0 increase_NN1 in_PRP number_NN1 of_PRF waitlist_AJ0 inactivations_NN2 because_CJS of_PRF COVID-19_AJ0 precautions_NN2 at_PRP this_DT0 same_DT0 time_NN1 ._SENT Between_PRP March_NP0 15_CRD ,_PUN 2020_CRD and_CJC April_NP0 30_CRD ,_PUN 2020_CRD ,_PUN states_NN2 with_PRP the_AT0 highest_AJS incidence_NN1 of_PRF COVID-19_AJ0 cases_NN2 saw_VVD 33_CRD %_NN0 fewer_DT0 new_AJ0 listings_NN2 for_PRP liver_NN1 transplantation_NN1 than_CJS expected_VVN ,_PUN with_PRP 34_CRD %_NN0 fewer_DT0 deceased_AJ0 donor_NN1 liver_NN1 transplantations_NN2 (_PUL DDLTs_NN2 )_PUR ._SENT Over_PRP this_DT0 period_NN1 ,_PUN transplantation_NN1 centers_NN2 in_PRP these_DT0 states_NN2 had_VHD 59_CRD %_NN0 more_AV0 waitlist_AJ0 deaths_NN2 than_CJS expected_VVN ._SENT 
Interestingly_AV0 ,_PUN even_AV0 within_PRP geographic_AJ0 areas_NN2 with_PRP similar_AJ0 COVID-19_AJ0 rates_NN2 ,_PUN there_EX0 were_VBD significant_AJ0 variations_NN2 in_PRP transplantation_NN1 practices_NN2 between_PRP individual_AJ0 centers_NN2 ._SENT When_CJS changes_NN2 in_PRP adult_NN1 DDLT_NN1 in_PRP the_AT0 month_NN1 preceding_VVG and_CJC following_VVG the_AT0 onset_NN1 of_PRF widespread_AJ0 COVID-19_AJ0 infection_NN1 in_PRP the_AT0 United_NP0 States_NP0 were_VBD evaluated_VVN ,_PUN there_EX0 was_VBD an_AT0 11.0_CRD %_NN0 decrease_NN1 in_PRP deceased_AJ0 donors_NN2 from_PRP February_NP0 2020_CRD to_PRP March_NP0 2020_CRD overall_AJ0 ,_PUN with_PRP a_AT0 resultant_AJ0 decrease_NN1 in_PRP adult_NN1 DDLTs_NN2 nationally_AV0 of_PRF 24.7_CRD %_NN0 ._SENT When_CJS region_NN1 and_CJC center_NN1 were_VBD considered_VVN ,_PUN there_EX0 was_VBD much_AV0 greater_AJC variability_NN1 seen_VVN in_PRP 2020_CRD compared_VVN with_PRP 2019_CRD when_CJS looking_VVG at_PRP transplantation_NN1 practices_NN2 within_PRP the_AT0 same_DT0 region_NN1 ,_PUN despite_PRP similar_AJ0 rates_NN2 of_PRF COVID-19_NN1 at_PRP these_DT0 centers_NN2 ._SENT This_DT0 was_VBD observed_VVN among_PRP regions_NN2 with_PRP high_AJ0 and_CJC low_AJ0 rates_NN2 of_PRF COVID-19_NN1 ,_PUN although_CJS notably_AV0 with_PRP some_DT0 of_PRF the_AT0 highest_AJS within-region_AJ0 variability_NN1 seen_VVN in_PRP that_DT0 with_PRP the_AT0 highest_AJS burden_NN1 of_PRF COVID-19_AJ0 cases_NN2 (_PUL such_DT0 as_PRP region_NN1 9_CRD )_PUR ._SENT It_PNP is_VBZ not_XX0 clear_AJ0 what_DTQ accounts_VVZ for_PRP these_DT0 differences_NN2 ,_PUN though_CJS it_PNP is_VBZ possible_AJ0 that_CJT center-specific_AJ0 resources_NN2 ,_PUN COVID-19_AJ0 transmission_NN1 among_PRP transplantation_NN1 team_NN1 members_NN2 ,_PUN and_CJC center_NN1 leadership_NN1 philosophy_NN1 regarding_PRP risk_NN1 may_VM0 have_VHI played_VVN a_AT0 role_NN1 ._SENT 
Despite_PRP the_AT0 risks_NN2 and_CJC unknowns_NN2 ,_PUN these_DT0 early_AJ0 effects_NN2 of_PRF the_AT0 pandemic_AJ0 on_PRP transplantation_NN1 and_CJC waitlist_NN1 rates_NN2 are_VBB largely_AV0 seen_VVN only_AV0 in_PRP the_AT0 first_ORD 2_CRD months_NN2 of_PRF the_AT0 pandemic_AJ0 ._SENT Subsequently_AV0 ,_PUN even_AV0 as_CJS COVID-19_CRD cases_NN2 spread_VVN between_PRP states_NN2 ,_PUN waitlist_AJ0 registrations_NN2 ,_PUN rates_NN2 of_PRF transplantation_NN1 ,_PUN and_CJC waitlist_AJ0 mortality_NN1 were_VBD very_AV0 near_PRP that_DT0 expected_VVN in_PRP new_AJ0 high-incidence_AJ0 areas_NN2 ._SENT Some_DT0 of_PRF this_DT0 restoration_NN1 of_PRF transplantation_NN1 volume_NN1 may_VM0 be_VBI attributed_VVN to_PRP the_AT0 rapid_AJ0 implementation_NN1 of_PRF guidance_NN1 surrounding_VVG COVID-19_NN1 from_PRP the_AT0 United_AJ0 Network_NN1 for_PRP Organ_NN1 Sharing_NN1 (_PUL UNOS_NP0 )_PUR as_CJS well_AV0 as_CJS medical_AJ0 societies_NN2 ._SENT With_PRP the_AT0 adoption_NN1 of_PRF COVID-19_AJ0 testing_NN1 in_PRP donors_NN2 and_CJC recipients_NN2 based_VVN on_PRP society_NN1 guidelines_NN2 ,_PUN increased_AJ0 access_NN1 to_PRP personal_AJ0 protective_AJ0 equipment_NN1 ,_PUN and_CJC especially_AV0 now_AV0 with_PRP health_NN1 care_NN1 workers_NN2 having_VHG been_VBN offered_VVN vaccination_NN1 against_PRP COVID-19_NN1 ,_PUN concerns_VVZ about_PRP risk_NN1 of_PRF transmission_NN1 to_PRP the_AT0 transplantation_NN1 team_NN1 in_PRP the_AT0 perioperative_AJ0 period_NN1 are_VBB diminished_VVN ._SENT Figure_NN1 1_CRD shows_VVZ the_AT0 number_NN1 of_PRF liver_NN1 transplantations_NN2 performed_VVN in_PRP the_AT0 United_NP0 States_NP0 from_PRP January_NP0 2020_CRD to_PRP May_NP0 2021_CRD ,_PUN highlighting_VVG key_AJ0 events_NN2 related_VVN to_PRP COVID-19_NN1 ._SENT 
There_EX0 was_VBD a_AT0 particularly_AV0 sharp_AJ0 initial_AJ0 decline_NN1 in_PRP living_VVG donor_NN1 liver_NN1 transplantation_NN1 early_AJ0 in_PRP the_AT0 pandemic_AJ0 ,_PUN which_DTQ has_VHZ also_AV0 subsequently_AV0 recovered_VVN ._SENT As_CJS reported_VVN also_AV0 in_PRP countries_NN2 where_AVQ living_NN1 donor_NN1 liver_NN1 transplantation_NN1 is_VBZ the_AT0 main_AJ0 source_NN1 of_PRF liver_NN1 allografts_NN2 ,_PUN with_PRP improved_AJ0 safety_NN1 protocols_NN2 and_CJC testing_NN1 ,_PUN these_DT0 operations_NN2 are_VBB likely_AV0 safe_AJ0 if_CJS the_AT0 local_AJ0 hospital_NN1 resources_NN2 are_VBB not_XX0 overwhelmed_VVN ._SENT Overall_AV0 ,_PUN we_PNP believe_VVB living_AJ0 donor_NN1 liver_NN1 transplantation_NN1 evaluation_NN1 and_CJC programming_NN1 should_VM0 continue_VVI ,_PUN especially_AV0 in_PRP the_AT0 context_NN1 of_PRF widespread_AJ0 vaccination_NN1 ,_PUN with_PRP additional_AJ0 precautions_NN2 as_CJS described_VVN here_AV0 for_PRP donor_NN1 testing_NN1 to_TO0 ensure_VVI safety_NN1 of_PRF the_AT0 potential_AJ0 donor_NN1 ,_PUN recipient_NN1 ,_PUN and_CJC transplantation_NN1 team_NN1 ._SENT 
CLD_NP0 ,_PUN Cirrhosis_NP0 ,_PUN and_CJC Liver_NN1 Transplantation_NN1 Candidates_NN2 
Since_CJS the_AT0 early_AJ0 reports_NN2 of_PRF the_AT0 clinical_AJ0 characteristics_NN2 of_PRF COVID-19_NN1 ,_PUN it_PNP has_VHZ been_VBN clear_AJ0 that_CJT liver_NN1 injury_NN1 as_CJS measured_VVN by_PRP both_DT0 elevations_NN2 in_PRP liver_NN1 enzymes_NN2 and_CJC post-mortem_NN1 pathology_NN1 has_VHZ been_VBN common_AJ0 ,_PUN perhaps_AV0 a_AT0 particular_AJ0 threat_NN1 to_PRP patients_NN2 with_PRP decompensated_AJ0 liver_NN1 disease_NN1 ._SENT Liver_NN1 enzyme_NN1 elevations_NN2 have_VHB been_VBN reported_VVN in_PRP up_AVP to_PRP 63.0_CRD %_NN0 of_PRF patients_NN2 hospitalized_VVN with_PRP COVID-19_AJ0 infection_NN1 ,_PUN with_PRP a_AT0 more_AV0 severe_AJ0 disease_NN1 course_NN1 including_PRP higher_AJC rates_NN2 of_PRF intensive_AJ0 care_NN1 unit_NN1 (_PUL ICU_NN1 )_PUR admission_NN1 ,_PUN intubation_NN1 ,_PUN renal_AJ0 replacement_NN1 therapy_NN1 ,_PUN and_CJC mortality_NN1 seen_VVN in_PRP patients_NN2 with_PRP marked_AJ0 elevations_NN2 ._SENT In_PRP addition_NN1 ,_PUN there_EX0 have_VHB been_VBN reports_NN2 of_PRF less_AV0 common_AJ0 but_CJC more_AV0 severe_AJ0 forms_NN2 of_PRF liver_NN1 disease_NN1 in_PRP the_AT0 context_NN1 of_PRF COVID-19_NN1 that_CJT could_VM0 create_VVI additional_AJ0 indications_NN2 for_PRP liver_NN1 transplantation_NN1 ,_PUN including_PRP acute_AJ0 liver_NN1 failure_NN1 as_CJS well_AV0 as_CJS progressive_AJ0 cholangiopathy_NN1 ._SENT 
Patients_NN2 with_PRP CLD_NP0 and_CJC cirrhosis_NN1 have_VHB also_AV0 been_VBN greatly_AV0 affected_VVN by_PRP COVID-19_NN1 (_PUL Table_NN1 1_CRD )_PUR ._SENT While_CJS patients_NN2 with_PRP CLD_NP0 do_VDB not_XX0 appear_VVI to_TO0 be_VBI overrepresented_VVN in_PRP the_AT0 largest_AJS epidemiological_AJ0 cohorts_NN2 ,_PUN it_PNP does_VDZ appear_VVI that_CJT patients_NN2 with_PRP CLD_NP0 overall_AJ0 are_VBB at_PRP increased_AJ0 risk_NN1 of_PRF severe_AJ0 disease_NN1 and_CJC death_NN1 ._SENT This_DT0 has_VHZ been_VBN demonstrated_VVN in_PRP large_AJ0 data_NN0 set_NN1 analyses_NN2 ,_PUN where_CJS CLD_NP0 is_VBZ associated_VVN with_PRP increased_AJ0 rates_NN2 of_PRF hospitalization_NN1 and_CJC a_AT0 significantly_AV0 higher_AJC risk_NN1 of_PRF mortality_NN1 when_CJS compared_VVN with_PRP patients_NN2 without_PRP liver_NN1 disease_NN1 ,_PUN with_PRP the_AT0 greatest_AJS risk_NN1 among_PRP patients_NN2 with_PRP cirrhosis_NN1 ._SENT From_PRP subsequent_AJ0 studies_NN2 with_PRP more_DT0 granular_AJ0 patient_NN1 data_NN0 ,_PUN it_PNP is_VBZ likely_AJ0 that_CJT both_DT0 the_AT0 etiology_NN1 of_PRF CLD_NP0 and_CJC the_AT0 disease_NN1 severity_NN1 impact_NN1 this_DT0 risk_NN1 ,_PUN and_CJC it_PNP is_VBZ possible_AJ0 that_CJT cirrhosis_NN1 is_VBZ underdiagnosed_AJ0 in_PRP these_DT0 larger_AJC data_NN0 sets_VVZ ._SENT 
The_AT0 earliest_AJS multicenter_AJ0 cohorts_NN2 to_TO0 explore_VVI outcomes_NN2 among_PRP patients_NN2 with_PRP cirrhosis_NN1 ,_PUN though_CJS relatively_AV0 small_AJ0 ,_PUN were_VBD from_PRP China_NP0 and_CJC Italy_NP0 ,_PUN the_AT0 first_ORD epicenters_NN2 of_PRF the_AT0 pandemic_AJ0 ._SENT Following_VVG these_DT0 initial_AJ0 reports_NN2 ,_PUN larger_AJC studies_NN2 from_PRP the_AT0 United_NP0 States_NP0 and_CJC multinational_AJ0 cohorts_NN2 have_VHB further_AV0 refined_VVN our_DPS understanding_NN1 of_PRF the_AT0 relationship_NN1 between_PRP CLD_NP0 ,_PUN cirrhosis_NN1 ,_PUN and_CJC COVID-19_AJ0 outcomes_NN2 ._SENT The_AT0 first_ORD of_PRF these_DT0 is_VBZ the_AT0 COVID-19_NN1 in_PRP Chronic_AJ0 Liver_NN1 Disease_NN1 (_PUL COLD_AJ0 )_PUR consortium_NN1 ,_PUN which_DTQ included_VVD 867_CRD patients_NN2 across_PRP 21_CRD US_NP0 centers_NN2 with_PRP CLD_NP0 (_PUL 71.5_CRD %_NN0 with_PRP cirrhosis_NN1 ,_PUN 10.7_CRD %_NN0 with_PRP decompensated_AJ0 cirrhosis_NN1 )_PUR and_CJC confirmed_VVD SARS-CoV-2_AJ0 infection_NN1 ._SENT In_PRP this_DT0 cohort_NN1 ,_PUN decompensated_AJ0 cirrhosis_NN1 was_VBD associated_VVN with_PRP an_AT0 increased_AJ0 risk_NN1 of_PRF severe_AJ0 COVID-19_AJ0 infection_NN1 and_CJC higher_AJC mortality_NN1 ._SENT Higher_AJC mortality_NN1 was_VBD also_AV0 seen_VVN in_PRP alcohol-related_AJ0 liver_NN1 disease_NN1 (_PUL ALD_NN1 )_PUR ,_PUN patients_NN2 with_PRP hepatocellular_AJ0 carcinoma_NN1 (_PUL HCC_NP0 )_PUR ,_PUN and_CJC several_DT0 medical_AJ0 comorbidities_NN2 including_PRP older_AJC age_NN1 ,_PUN diabetes_NN1 mellitus_NN1 ,_PUN hypertension_NN1 ,_PUN chronic_AJ0 obstructive_AJ0 pulmonary_AJ0 disease_NN1 ,_PUN and_CJC current_AJ0 smoking_NN1 ._SENT Similar_AJ0 findings_NN2 were_VBD seen_VVN in_PRP the_AT0 SECURE-Liver_NN1 Registry_NN1 (_PUL formerly_AV0 SECURE-Cirrhosis_NN1 )_PUR and_CJC the_AT0 COVID-Hep_AJ0 registry_NN1 ,_PUN which_DTQ included_VVD 745_CRD patients_NN2 with_PRP CLD_NP0 from_PRP 29_CRD countries_NN2 ._SENT Within_PRP this_DT0 cohort_NN1 ,_PUN patients_NN2 with_PRP cirrhosis_NN1 (_PUL n_ZZ0 =_NN1 386_CRD )_PUR had_VHD a_AT0 mortality_NN1 rate_NN1 of_PRF 32.0_CRD %_NN0 compared_VVN with_PRP only_AV0 8.0_CRD %_NN0 in_PRP patients_NN2 with_PRP CLD_NP0 but_CJC no_AT0 cirrhosis_NN1 ._SENT Among_PRP patients_NN2 with_PRP cirrhosis_NN1 ,_PUN there_EX0 was_VBD a_AT0 stepwise_AJ0 increase_NN1 in_PRP mortality_NN1 with_PRP increasing_AJ0 Child-Turcotte-Pugh_NP0 (_PUL CTP_NP0 )_PUR class_NN1 ._SENT Multivariable_AJ0 analysis_NN1 showed_VVD older_AJC age_NN1 ,_PUN cirrhosis_NN1 (_PUL with_PRP any_DT0 CTP_NP0 class_NN1 )_PUR ,_PUN and_CJC ALD_NN1 to_TO0 be_VBI associated_VVN with_PRP increased_AJ0 risk_NN1 for_PRP mortality_NN1 ._SENT 
However_AV0 ,_PUN it_PNP is_VBZ also_AV0 clear_AJ0 that_CJT this_DT0 literature_NN1 must_VM0 be_VBI interpreted_VVN in_PRP the_AT0 context_NN1 of_PRF carefully_AV0 selected_AJ0 control_NN1 groups_NN2 to_TO0 understand_VVI what_DTQ is_VBZ driving_VVG these_DT0 outcomes_NN2 ._SENT In_PRP a_AT0 US-based_AJ0 multicenter_NN1 study_NN1 comparing_VVG patients_NN2 with_PRP cirrhosis_NN1 and_CJC COVID-19_NN1 with_PRP 2_CRD age-_AJ0 and_CJC sex-matched_AJ0 comparator_NN1 groups_NN2 ,_PUN patients_NN2 with_PRP cirrhosis_NN1 and_CJC COVID-19_NN1 had_VHD higher_AJC mortality_NN1 than_CJS those_DT0 without_PRP cirrhosis_NN1 with_PRP COVID-19_NN1 ,_PUN but_CJC similar_AJ0 mortality_NN1 rates_NN2 when_CJS compared_VVN with_PRP patients_NN2 with_PRP cirrhosis_NN1 without_PRP COVID-19_NN1 ,_PUN perhaps_AV0 indicating_VVG that_CJT cirrhosis_NN1 itself_PNX is_VBZ driving_VVG the_AT0 high_AJ0 inpatient_NN1 mortality_NN1 rates_NN2 ._SENT In_PRP a_AT0 recent_AJ0 international_AJ0 study_NN1 comparing_VVG outcomes_NN2 among_PRP patients_NN2 with_PRP autoimmune_NN1 hepatitis_NN1 (_PUL AIH_NP0 )_PUR and_CJC COVID-19_NN1 with_PRP a_AT0 propensity_NN1 score_NN1 –_PUN matched_AJ0 cohort_NN1 of_PRF patients_NN2 with_PRP other_AJ0 etiologies_NN2 of_PRF CLD_NP0 and_CJC COVID-19_NP0 ,_PUN cirrhosis_NN1 was_VBD again_AV0 identified_VVN as_PRP the_AT0 strongest_AJS predictor_NN1 for_PRP severe_AJ0 COVID-19_NN1 in_PRP patients_NN2 with_PRP AIH_NP0 ._SENT 
Treatment_NN1 of_PRF COVID-19_NN1 in_PRP Transplantation_NN1 Candidates_NN2 
Data_NN0 for_PRP the_AT0 treatment_NN1 of_PRF COVID-19_NN1 specifically_AV0 among_PRP patients_NN2 with_PRP cirrhosis_NN1 and_CJC decompensated_AJ0 cirrhosis_NN1 are_VBB limited_VVN ._SENT There_AV0 remain_VVB concerns_NN2 about_PRP the_AT0 potential_AJ0 hepatotoxicity_NN1 of_PRF several_DT0 SARS-CoV-2_AJ0 therapies_NN2 ,_PUN particularly_AV0 remdesivir_NN1 and_CJC interleukin_NN1 6_CRD (_PUL IL6_CRD )_PUR inhibitors_NN2 such_DT0 as_PRP tocilizumab_NN1 ._SENT Remdesivir_NP0 has_VHZ been_VBN associated_VVN with_PRP elevation_NN1 in_PRP aspartate_NN1 aminotransferase_NN1 and_CJC /_PUN or_CJC alanine_AJ0 aminotransferase_NN1 in_PRP 10.0_CRD %_NN0 -11.0_CRD %_NN0 of_PRF patients_NN2 treated_VVN for_PRP SARS-CoV-2_NP0 in_PRP the_AT0 trials_NN2 to_PRP date_NN1 ,_PUN though_CJS grade_NN1 3-4_CRD elevations_NN2 in_PRP liver_NN1 enzymes_NN2 were_VBD rare_AJ0 and_CJC not_XX0 greater_AJC than_CJS those_DT0 in_PRP the_AT0 control_NN1 populations_NN2 in_PRP the_AT0 phase_NN1 3_CRD trials_NN2 ._SENT However_AV0 ,_PUN remdesivir_NP0 is_VBZ currently_AV0 recommended_VVN to_TO0 be_VBI discontinued_VVN among_PRP patients_NN2 with_PRP liver_NN1 enzyme_NN1 elevation_NN1 over_PRP 10_CRD times_NN2 the_AT0 upper_AJ0 limit_NN1 of_PRF normal_AJ0 or_CJC if_CJS symptomatic_AJ0 liver_NN1 disease_NN1 is_VBZ diagnosed_VVN ._SENT The_AT0 use_NN1 of_PRF remdesivir_NN1 in_PRP patients_NN2 with_PRP CLD_NP0 and_CJC cirrhosis_NN1 has_VHZ not_XX0 been_VBN reported_VVN outside_AV0 of_PRF 1_CRD case_NN1 report_NN1 ,_PUN where_AVQ a_AT0 patient_NN1 with_PRP decompensated_AJ0 cirrhosis_NN1 received_VVD the_AT0 medication_NN1 without_PRP adverse_AJ0 effects_NN2 ._SENT 
There_EX0 are_VBB also_AV0 numerous_AJ0 studies_NN2 regarding_PRP tocilizumab-related_AJ0 hepatotoxicity_NN1 in_PRP the_AT0 rheumatology_NN1 literature_NN1 ,_PUN including_PRP reports_NN2 of_PRF up_AVP to_PRP 71.0_CRD %_NN0 of_PRF patients_NN2 with_PRP liver_NN1 injury_NN1 in_PRP this_DT0 context_NN1 ._SENT In_PRP the_AT0 trials_NN2 currently_AV0 published_VVN of_PRF tocilizumab_NN1 for_PRP the_AT0 treatment_NN1 of_PRF COVID-19_NN1 ,_PUN liver_NN1 enzyme_NN1 elevations_NN2 were_VBD reported_VVN in_PRP over_AV0 15.0_CRD %_NN0 of_PRF patients_NN2 ,_PUN although_CJS these_DT0 reflect_VVB only_AV0 significant_AJ0 enzyme_NN1 elevations_NN2 ._SENT In_PRP other_AJ0 series_NN0 ,_PUN for_PRP example_NN1 ,_PUN liver_NN1 enzyme_NN1 elevations_NN2 were_VBD seen_VVN in_PRP over_AV0 80.0_CRD %_NN0 of_PRF patients_NN2 who_PNQ received_VVD tocilizumab_NN1 during_PRP their_DPS hospitalization_NN1 ._SENT However_AV0 ,_PUN it_PNP is_VBZ challenging_AJ0 to_TO0 understand_VVI whether_CJS there_EX0 is_VBZ a_AT0 direct_AJ0 tocilizumab-related_AJ0 liver_NN1 injury_NN1 in_PRP many_DT0 cases_NN2 given_VVN the_AT0 many_DT0 competing_AJ0 etiologies_NN2 of_PRF acute_AJ0 liver_NN1 injury_NN1 (_PUL ALI_NP0 )_PUR in_PRP this_DT0 population_NN1 ,_PUN especially_AV0 among_PRP hospitalized_AJ0 patients_NN2 ._SENT 
Despite_PRP these_DT0 concerns_NN2 ,_PUN there_EX0 have_VHB been_VBN no_AT0 reports_NN2 to_TO0 suggest_VVI that_DT0 patients_NN2 with_PRP CLD_NP0 and_CJC cirrhosis_NN1 should_VM0 not_XX0 receive_VVI these_DT0 COVID-19-directed_AJ0 therapies_NN2 ._SENT Given_VVN the_AT0 significant_AJ0 mortality_NN1 associated_VVN with_PRP severe_AJ0 COVID-19_NN1 ,_PUN the_AT0 increased_AJ0 risk_NN1 of_PRF severe_AJ0 disease_NN1 in_PRP the_AT0 context_NN1 of_PRF liver_NN1 enzyme_NN1 elevation_NN1 ,_PUN and_CJC the_AT0 limited_AJ0 therapeutic_AJ0 options_NN2 available_AJ0 ,_PUN it_PNP will_VM0 be_VBI important_AJ0 to_TO0 report_VVI outcomes_NN2 among_PRP these_DT0 patients_NN2 who_PNQ receive_VVB these_DT0 agents_NN2 ._SENT 
SARS-CoV-2_AJ0 Testing_NN1 of_PRF Donors_NN2 and_CJC Recipients_NN2 at_PRP Transplantation_NN1 
Screening_NN1 of_PRF donors_NN2 (_PUL both_AV0 deceased_NN1 and_CJC living_NN1 )_PUR and_CJC recipients_NN2 at_PRP the_AT0 time_NN1 of_PRF transplantation_NN1 is_VBZ now_AV0 widely_AV0 performed_VVN ,_PUN although_CJS not_XX0 yet_AV0 standardized_AJ0 outside_NN1 of_PRF society_NN1 consensus_NN1 statements_NN2 ._SENT All_DT0 patients_NN2 who_PNQ present_VVB for_PRP transplantation_NN1 should_VM0 be_VBI tested_VVN for_PRP SARS-CoV-2_NP0 with_PRP a_AT0 nasopharyngeal_AJ0 polymerase_NN1 chain_NN1 reaction_NN1 (_PUL PCR_NP0 )_PUR test_NN1 prior_AJ0 to_PRP undergoing_VVG the_AT0 operation_NN1 ._SENT Current_AJ0 recommendations_NN2 advise_VVB against_PRP transplantation_NN1 in_PRP recipients_NN2 with_PRP active_AJ0 COVID-19_NN1 and_CJC recommend_VVB proceeding_VVG to_PRP transplantation_NN1 ideally_AV0 2-3_CRD weeks_NN2 after_CJS symptoms_NN2 have_VHB resolved_VVN and_CJC only_AV0 if_CJS at_PRP least_AV0 1_CRD nasopharyngeal_AJ0 PCR_NP0 test_NN1 is_VBZ negative_AJ0 ,_PUN with_PRP some_DT0 physicians_NN2 recommending_VVG 2_CRD negative_AJ0 tests_NN2 ._SENT 
All_DT0 donors_NN2 should_VM0 also_AV0 undergo_VVI a_AT0 nasopharyngeal_AJ0 PCR_NP0 test_NN1 prior_AJ0 to_PRP acceptance_NN1 of_PRF the_AT0 organ_NN1 offer_NN1 ._SENT In_PRP lung_NN1 transplantation_NN1 donors_NN2 a_AT0 lower_AJC respiratory_AJ0 specimen_NN1 is_VBZ also_AV0 required_VVN ,_PUN with_PRP this_DT0 policy_NN1 change_NN1 being_VBG implemented_VVN after_PRP a_AT0 case_NN1 of_PRF SARS-CoV-2_AJ0 transmission_NN1 from_PRP a_AT0 lung_NN1 transplantation_NN1 donor_NN1 to_PRP recipient_NN1 was_VBD reported_VVN ._SENT Potential_AJ0 living_AJ0 donors_NN2 with_PRP prior_AJ0 SARS-CoV-2_NN1 infection_NN1 should_VM0 have_VHI at_PRP least_AV0 1_CRD negative_AJ0 SARS-CoV-2_NP0 RNA_NN1 test_NN1 ;_PUN if_CJS repeat_NN1 testing_NN1 remains_VVZ positive_AJ0 ,_PUN proceeding_VVG to_PRP donation_NN1 should_VM0 be_VBI considered_VVN only_AV0 if_CJS they_PNP are_VBB asymptomatic_AJ0 and_CJC the_AT0 infection_NN1 was_VBD between_PRP 21_CRD and_CJC 90_CRD days_NN2 prior_AJ0 to_PRP donor_NN1 evaluation_NN1 ,_PUN as_CJS this_DT0 is_VBZ felt_VVN to_TO0 reflect_VVI viral_AJ0 shedding_NN1 and_CJC not_XX0 new_AJ0 or_CJC active_AJ0 infection_NN1 ._SENT 
One_CRD unique_AJ0 challenge_NN1 in_PRP testing_NN1 is_VBZ the_AT0 prolonged_AJ0 viral_AJ0 shedding_NN1 that_CJT has_VHZ been_VBN observed_VVN in_PRP patients_NN2 with_PRP end-stage_AJ0 liver_NN1 disease_NN1 ,_PUN especially_AV0 among_PRP those_DT0 with_PRP nonalcoholic_AJ0 fatty_AJ0 liver_NN1 disease_NN1 ,_PUN where_AVQ PCR_NP0 testing_NN1 can_VM0 remain_VVI positive_AJ0 beyond_PRP the_AT0 period_NN1 expected_VVN in_PRP the_AT0 general_AJ0 population_NN1 ._SENT 
