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\begin{document}

\title{Does the severity of SARS-CoV-2 infection higher in liver transplant
recipients?: A single-center experience.}



\author[1]{Dilara Turan Gökçe}%
\author[1]{Derya Arı}%
\author[2]{Adalet Aypak}%
\author[1]{Osman Aydın}%
\author[1]{Sabite Kaçar}%
\author[1]{Erdal Bostanci}%
\author[1]{Meral Akdoğan}%
\affil[1]{Ankara City Hospital}%
\affil[2]{University of Health Sciences}%


\vspace{-1em}



  
  \date{May 23, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: Liver transplant (LT) recipients with COVID-19 have been
reported as a high-risk population for severe disease through the
COVID-19 pandemic. Studies have shown that liver transplantation did not
significantly increase the risk of death and severe disease in patients
with SARS-CoV-2 infection. Methods: From September 2020- March 2021, we
collected data and serum anti-SARS-CoV-2 IgM +IgG results for 91 liver
transplant recipients. Study enrolment was performed when patients
presented for scheduled routine follow-up. All participants with serum
anti-SARS-CoV-2 IgM+IgG completed a questionnaire querying information
including clinical symptoms in the last six months. We further collected
91 patients with anti-SARS-CoV-2 IgM + IgG results. Seven patients had a
known history of symptomatic COVID-19 during the previous six months. Of
the 84 participants included in the study, 21 (25 \%) had positive
anti-SARS-Cov-2 IgM + IgG results. In addition, we applied the COVID-19
PCR test to all 21 patients, and all of them were negative. Overall,
only seven patients declared flu-like upper respiratory tract infection
symptoms or diarrhea in detailed inquiry. Conclusion: We documented past
SARS-CoV-2 infection in 25 \% of our outpatient LT recipients, and the
majority were asymptomatic. There was no significant relationship
between symptoms and seropositivity for SARS-COV-2.%
\end{abstract}%



\sloppy


\textbf{Does the severity of SARS-CoV-2 infection higher in liver
transplant recipients?: A single-center experience.~}

\textbf{Background:} ~Liver transplant (LT) recipients with COVID-19
have been reported as a high-risk population for severe disease through
the COVID-19 pandemic. Studies have shown that liver transplantation did
not significantly increase the risk of death and severe disease in
patients with SARS-CoV-2 infection.

\textbf{Methods:} From September 2020- March 2021, we collected data and
serum anti-SARS-CoV-2 IgM +IgG results for 91 liver transplant
recipients. Study enrolment was performed when patients presented for
scheduled routine follow-up. All participants with serum anti-SARS-CoV-2
IgM+IgG completed a questionnaire querying information including
clinical symptoms in the last six months. We further collected 91
patients with anti-SARS-CoV-2 IgM + IgG results. Seven patients had a
known history of symptomatic COVID-19 during the previous six months. Of
the 84 participants included in the study, 21 (25 \%) had positive
anti-SARS-Cov-2 IgM + IgG results. In addition, we applied the COVID-19
PCR test to all 21 patients, and all of them were negative. Overall,
only seven patients declared flu-like upper respiratory tract infection
symptoms or diarrhea in detailed inquiry.

\textbf{Conclusion:} ~We documented past SARS-CoV-2 infection in 25 \%
of our outpatient LT recipients, and the majority were asymptomatic.
There was no significant relationship between symptoms and
seropositivity for SARS-COV-2.

\textbf{Key Words:} Liver transplant recipients, SARS-CoV-2 infection,
serum anti-SARS-CoV-2 IgM+IgG

\textbf{What's Known}

Immunosuppressed patients are regarded as a high-risk cohort of COVID-
19

It is estimated that COVID-19 will be more symptomatic and severe in LT
recipients due to immunosuppression treatments

\textbf{What's New}

Liver transplant recipients can asymptomatic of COVID- 19

\textbf{Introduction}

Coronavirus disease 2019 (COVID-19), caused by a novel coronavirus
called severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is
the most common global disease. The high-risk groups of this disease,
which has been declared a pandemic by the world health organization
(WHO) today, are still not fully determined. Immunosuppressed patients
are regarded as a high-risk cohort. In this view, previous experience
with similar viruses, such as SARS-CoV and MERS-CoV, suggests that solid
organ transplantation (SOT) recipients would be prone to have increased
morbidity and mortality. Early published studies in liver
transplantation (LT) and SOT recipients with COV\selectlanguage{polish}İ\selectlanguage{english}D-19 reported a rate of
up to \%20 {[}1{]}, exceeding the rate of the general population
{[}2{]}.

Initial symptoms of patients with COV\selectlanguage{polish}İ\selectlanguage{english}D-19 are various, and the
percentage of mild illness symptoms seen is about 80\% {[}3{]}. Patients
with SARS-Cov-2 may be completely asymptomatic or progress with severe
disease. Comorbidities and advanced age are the most important risk
factors among LT recipients and the general population {[}1{]}. It is
estimated that COVID-19 will be more symptomatic and severe in LT
recipients due to immunosuppression treatments. Our study aims to
determine the frequency of asymptomatic or mild disease in the LT
recipients.

\textbf{Methods:~}

For the study, patients who came for routine control between September
2020 and March 2021 in Ankara City Hospital Liver Transplant outpatient
clinic were screened. All patients were older than 18 years of age and
had undergone LT in the past. The ethics committee approved the study of
Ankara Bilkent City Hospital (Approval number: E2-21-280 ). The study
was conducted in accordance with good clinical practice principles and
the Declaration of Helsinki.

Study enrolment was performed when patients presented for scheduled
routine follow-up. Among all patients, patients whose serum COVID-19 IgM
+ IgG antibody was tested were recorded. Sars-Cov-2 polymerase chain
reaction (PCR) test was performed with a nasopharyngeal-oropharyngeal
swab in each patient with a positive antibody test within the first
three days the results. All participants completed a questionnaire
querying information including common clinical symptoms (fever, cough,
diarrhea, myalgia, nausea, and vomiting) in the last six months.
Additionally, we questioned all participants for a history of contact
with a covid-19 positive patient or hospitalization.

We evaluated the performance of COVID-19 serology testing on
chemiluminescent immunoassay (CLIA) per manufacture's protocol (ADVIA
Centaur\selectlanguage{ngerman}®) SARS-CoV-2 Total (COV2T) (Siemens Healthcare Diagnostics Inc.,
NY, USA) (Siemens Test). These serological tests use the SARS-CoV-2
Spike protein (S protein) as a viral labeling protein to detect
anti-SARS-CoV-2 antibodies. Test results were interpreted as positive if
the signal value of the Siemens Test (index) \selectlanguage{english}[?]1.0 of total antibodies.
All serum Anti-SARS-CoV-2 Total results of all patients were collected
before the vaccination for COV\selectlanguage{polish}İ\selectlanguage{english}D-19.

The statistical analyses were performed with IBM SPSS Statistics for
Windows, Version 26.0 software (IBM Corp., Armonk, NY, USA). Continuous
variables were expressed as median and range. Categorical variables were
summarized as count and percentage. Between-group comparisons were
performed using the Mann-Whitney U test for continuous variables and a
chi-squared test (or Fisher's exact test where appropriate) for
categorical variables. P values are given as indicated using the
x\textsuperscript{2} test or a non-parametric t-test. A p-value
\textless{}0.05 was considered to indicate statistical significance.

\textbf{Results:~}

We conducted a retrospective study of 91 LT recipients at an LT center
in Ankara City Hospital, with sample collection taking place between
September 2020- March 2021. Serum anti-SARS-CoV-2 IgM + IgG results were
positive in 32 of 91 patients. Seven (21.8\%) of 32 patients included in
the study were not included in the analysis because they had a known
history of OCVID-19. Three of seven (42.8 \%) had self-limited disease,
and none required hospitalization or supplemental oxygen treatment for
COV\selectlanguage{polish}İ\selectlanguage{english}D-19. On the other hand, three of seven (42.8\%) needed
hospitalization, and one of seven (14.4 \%) was already in the hospital
when he was diagnosed with COVID-19. Twenty-one patients (21/28, 75\%)
had no history of SARS-COV-2 infection and specific symptoms. We tested
all patients with positive serum antibodies for a naso-oropharyngeal
swab PCR test and, the results were negative.

The remaining 84 patients were included in the study (median age 52.1
years {[}IQR 21-68{]}; 60 (76.2\%) men, 14 (23.8 \%) women).
Hypertension was the most common comorbid disease (15/84, 17.8 \%),
followed by type 2 diabetes (10/84, 11.9 \%) (Table-1). All participants
were contacted and retrospectively surveyed for clinical symptoms of
COVID-19 in the prior six months (Table-2). There were no significant
differences between patients' symptoms with positive test results (serum
Ig G+IgM) and negative test results. While 7 of 28 patients with
positive serum antibody test were previously symptomatic patients who
were diagnosed, seven patients developed at least one nonspecific
symptom, but there was no diagnosis of COVID-19. Fourteen (50\%) of a
total of 28 patients were followed up completely asymptomatic. All
seropositive patients for SARS-Cov-2 were compared with seronegative
patients in terms of symptoms. There was no relationship between the
findings of the participants' system inquiries and COVID-19
seropositivity (Table-3).

Characteristics of seronegative and seropositive participants were
examined. While the mean age of the seropositive participants was 51.5 \selectlanguage{ngerman}±
9.8 years, the mean age of the seronegative group was 52.3 ± 11.5 years
(p: 0.378). There was no significant difference between the two groups
in terms of gender, body mass index (BMI), aspartate aminotransferase
(AST), alanine aminotransferase (ALT) (Table-2).

Covid antibody positivity was observed in four (36.3\%) of 11 people
with a history of risky contact with people diagnosed with COVID 19.
Serum SARS-COV-2 IgM + IgG antibody positivity was detected in six
(30\%) of 20 patients with a history of hospitalization. There was no
significant difference between hospitalization and serum antibody
positivity (p:0.554).

\textbf{Discussion}

In our study, patients who applied to our liver transplant outpatient
clinic were evaluated in terms of serum SARS-COV-2 Ig M + IgG level and
history of COVID-19 disease. The Serum antibody positivity rate was
30.7\% in liver transplant patients participating in our study. The
seroprevalence values for the region in which we conducted the current
study are unknown. However, seropositivity was found to be 12.3\%
(115/932) in a seroprevalence study conducted on healthcare
professionals in Turkey. The seropositivity among previously undiagnosed
healthcare workers was calculated as 2.7\% {[}4{]}.

Limited data are available for asymptomatic or subclinical infections in
the transmission of the SARS-CoV-2 virus {[}5{]}. In our study, the rate
of participants with an asymptomatic history of covid-19 was 7.6\%
(7/91). Seventy-five percent of all antibody-positive patients were not
diagnosed with COVID-19, and their inquiries had no specific symptoms of
COVID-19. When all participants were evaluated, 23\% (21/91) subclinical
or asymptomatic seropositivity was detected.

In previous studies, acute and past SARS-COV-2 infections were
documented in 3.7\% of LT recipients. In the same study, the
asymptomatic seropositivity rate was evaluated as 62.5\% (5/8) {[}6{]}.
The rate of asymptomatic COVID-19 in liver transplant recipients has
been determined by 6\% in the Spain series and 14\% in a multinational
study (n = 151) {[}7, 8{]}.

In our study, 66\% of patients with seropositive (14/21) were utterly
asymptomatic; at least one symptom was observed in seven participants.
However, there was no significant difference between the symptoms of
both groups.

There was no difference between serum AST and ALT levels in patients
with seropositive and seronegative. But we do not know serum AST and ALT
values in possible disease processes. Studies have been shown to be a
relationship between severe disease and elevated liver enzymes in
patients with COVID-19. In infected individuals with SARS-COV-2,
increased serum liver enzyme levels had seen approximately 15\% {[}9{]}.
In our clinical data, serum AST or ALT levels were found to be two times
or higher in 23\% of patients diagnosed with symptomatic covid (n=4/17).
Increased liver enzymes are usually reversible. As expected,
seropositivity is not associated with alone increased liver enzymes.

Asymptomatic or subclinical COVID-19 participants with seropositivity
include the history of risky contact with people diagnosed COVID-19 in
19\% and the history of hospitalization in 28\%. In contrast to the
expected, the higher rate of seropositivity was not associated with
contact with risky people or hospitalization.

Our limitation of the study is that patients are evaluated in a wide
period of 6 months to determine seroprevalence as serum antibody tests
are observed during routine follow-up.

In conclusion, studies related to the course of the disease in liver
transplant recipients are increasing gradually. However, the frequency
of asymptomatic or subclinical disease is not precise yet. Although the
number of patients in our study was low, the seropositivity rate
(30.7\%) and the rate of asymptomatic (75\%) among all the participants
were higher than expected. We need large-scale seroprevalence studies to
reach more reliable data.

\textbf{References}

1. Becchetti C, Zambelli MF, Pasulo L, et al. COVID-19 in an
international European liver transplant recipient cohort. Gut
{[}Internet{]}. 2020 Oct 1;69(10):1832 LP -- 1840. Available from:
http://gut.bmj.com/content/69/10/1832.abstract

2. Fishman JA, Grossi PA. Novel Coronavirus-19 (COVID-19) in the
immunocompromised transplant recipient: \#Flatteningthecurve. Vol. 20,
American journal of transplantation: official journal of the American
Society of Transplantation and the American Society of Transplant
Surgeons. 2020. p. 1765--7.

3. Oran DP, Topol EJ. Prevalence of Asymptomatic SARS-CoV-2 Infection: A
Narrative Review. Ann Intern Med. 2020 Sep;173{[}5{]}:362--7.

4. Alkurt G, Murt A, Ayd\selectlanguage{polish}ı\selectlanguage{english}n Z, et al. Seroprevalence of coronavirus
disease 2019 (COVID-19) among health care workers from three pandemic
hospitals of Turkey medRxiv (2020)

5. Weitz JS, Beckett SJ, Coenen AR, et al. Modeling shield immunity to
reduce COVID-19 epidemic spread. Nat Med. 2020 Jun;26{[}6{]}:849--54.

6. Rauber C, Tiwari-Heckler S, Pfeiffenberger J, et al. SARS-CoV-2
Seroprevalence and Clinical Features of COVID-19 in a German Liver
Transplant Recipient Cohort: A Prospective Serosurvey Study. Transplant
Proc {[}Internet{]}. 2020; Available from:
https://www.sciencedirect.com/science/article/pii/S0041134520329043

7. Colmenero J, Rodr\selectlanguage{ngerman}íguez-Perálvarez M, Salcedo M, et al.
Epidemiological pattern, incidence, and outcomes of COVID-19 in liver
transplant patients. J Hepatol. 2021 Jan;74{[}1{]}:148--55.

8. Webb GJ, Marjot T, Cook JA, et al. Outcomes following SARS-CoV-2
infection in liver transplant recipients: an international registry
study. lancet Gastroenterol Hepatol. 2020 Nov;5(11):1008--16.

9. Sultan S, Altayar O, Siddique SM, et al. AGA Institute Rapid Review
of the Gastrointestinal and Liver Manifestations of COVID-19,
Meta-Analysis of International Data, and Recommendations for the
Consultative Management of Patients with COVID-19. Gastroenterology.
2020 Jul;159{[}1{]}:320-334.e27.

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