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Q&A: Social distancing is key to prevent COVID-19 among liver transplant recipients

Robert Brown headshot
Robert Brown

There are many people in the United States living with liver disease. Patients with liver disease, in particular those who are awaiting a liver transplant, have a higher risk for being affected by COVID-19. Patients who recently received a liver disease diagnosis are also at higher risk because they take immunosuppressants.

Healio Gastroenterology and Liver Disease spoke with Robert Brown Jr, MD, MPH, vice chair of Transitions of Care and Clinical Chief of the Division of Gastroenterology and Hepatology in the Department of Medicine Weill Cornell Medical College and member of the American Liver Foundation’s National Medical Advisory Committee, about considerations for people living with liver disease, proper social distancing practices, hand hygiene etiquette and ways to treat transplant recipients. – by Monica Jaramillo

Healio: What are some important considerations physicians should keep in mind when dealing with COVID-19 in patients with liver disease?

Brown: For patients with mild liver disease, the recommendations are no different than that of the general population, which is social distancing, good hand washing, good cough etiquette and avoiding sick people. I don’t think people with early liver disease, meaning no cirrhosis, are at a higher risk for adverse outcomes of COVID-19 than other people because though COVID-19 does have liver manifestations, severe liver injuries are not usual or common. It’s mostly in the setting of multisystem organ failure; it’s hard to say that it was the COVID-19 per say or general illness of the patients. The presence of liver disease may make diagnosis more difficult. The corona virus can cause elevation in the liver enzyme, but it should not change overall the severity of most people. Now for patients who have more advanced liver disease, particularly those on a liver transplant waiting list or post-transplant of immunosuppression, I do believe their risk is higher. Most of that is not based on a lot of data. The data on transplant recipients and liver disease are mixed. I still don’t think we know enough. I think discretion is the better approach for these viral illnesses. In advanced liver disease we naturally see immunosuppression and also in post-transplant recipients and they are probably at increased risk. Obviously immunosuppressed patients may not have a fever, which may delay the diagnosis since we may a lot of our diagnosis based on the presence of a fever and a cough.

Healio: What is currently being done to promote social distancing among liver transplant recipients or post-transplant patients?

Brown: Among our transplant recipients, the most important thing is for them to stay in touch with their transplant program. One, stopping or reducing your immunosuppression on your own should not be done, it is likely dangerous. We are now doing all video visits. Our patients can shelter in place while still staying safe after a transplant. It does not help a patient to not develop COVID-19 but to develop liver rejection because they decide to stop immunosuppression. A routine lab check can be pushed off 2 to 3 weeks to see how things develop, but if routine lab checks can turn into a video visit, it will reduce the exposure of that transplant patient. We are doing 90% of out visits remotely. Most labs are being done a local lab. People are coming at off times so that they can minimize their exposure and being meticulous about cleaning things that they may come in contact with. The good thing about this virus, is that it is not a robust virus. It can’t stay on surfaces a long time. As an RNA virus, it is susceptible to cleaning products that we routinely use. If you are good about cleaning things you can minimize your risk. Social distancing is more than physical distance it is also keeping your circle small. We emphasize to our patients and our health workers that their circles have to be not only small but also well kept.

Healio: Apart from social distancing, what else should patients with liver disease do to prevent COVID-19?

Brown: As we recommend for older individuals, the degree of social distancing and social isolation for our patents on the transplant waiting list and our post-transplant patients is higher here in New York and California. I don’t think there is a huge difference between the liver disease patients and the general population because already a lot of precautions are being taken. In places where they are not being a restrictive, I think extreme social distancing as opposed to moderate social distancing is warranted. There are not any data that show wearing a mask will do anything in terms of reducing risk. Wearing gloves may reduce the risk but that’s only if you are really good about you glove hygiene. Several people make the mistake of putting on gloves, thinking that makes them safe and wear the same pair of gloves all day, without cleaning them and still touch their face. A glove can be the factor of the virus just as easily as your hands. People are generally better about doing hand hygiene than glove hygiene. What I recommend to my patients is frequent hand hygiene. If you have to be in a place where you have to touch things that a lot of other people have touched then wearing a pair of gloves that you discard promptly afterward and then perform hand hygiene, will be a good thing.

 

Disclosure: Brown reports no relevant financial disclosures.

Robert Brown headshot
Robert Brown

There are many people in the United States living with liver disease. Patients with liver disease, in particular those who are awaiting a liver transplant, have a higher risk for being affected by COVID-19. Patients who recently received a liver disease diagnosis are also at higher risk because they take immunosuppressants.

Healio Gastroenterology and Liver Disease spoke with Robert Brown Jr, MD, MPH, vice chair of Transitions of Care and Clinical Chief of the Division of Gastroenterology and Hepatology in the Department of Medicine Weill Cornell Medical College and member of the American Liver Foundation’s National Medical Advisory Committee, about considerations for people living with liver disease, proper social distancing practices, hand hygiene etiquette and ways to treat transplant recipients. – by Monica Jaramillo

Healio: What are some important considerations physicians should keep in mind when dealing with COVID-19 in patients with liver disease?

Brown: For patients with mild liver disease, the recommendations are no different than that of the general population, which is social distancing, good hand washing, good cough etiquette and avoiding sick people. I don’t think people with early liver disease, meaning no cirrhosis, are at a higher risk for adverse outcomes of COVID-19 than other people because though COVID-19 does have liver manifestations, severe liver injuries are not usual or common. It’s mostly in the setting of multisystem organ failure; it’s hard to say that it was the COVID-19 per say or general illness of the patients. The presence of liver disease may make diagnosis more difficult. The corona virus can cause elevation in the liver enzyme, but it should not change overall the severity of most people. Now for patients who have more advanced liver disease, particularly those on a liver transplant waiting list or post-transplant of immunosuppression, I do believe their risk is higher. Most of that is not based on a lot of data. The data on transplant recipients and liver disease are mixed. I still don’t think we know enough. I think discretion is the better approach for these viral illnesses. In advanced liver disease we naturally see immunosuppression and also in post-transplant recipients and they are probably at increased risk. Obviously immunosuppressed patients may not have a fever, which may delay the diagnosis since we may a lot of our diagnosis based on the presence of a fever and a cough.

Healio: What is currently being done to promote social distancing among liver transplant recipients or post-transplant patients?

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Brown: Among our transplant recipients, the most important thing is for them to stay in touch with their transplant program. One, stopping or reducing your immunosuppression on your own should not be done, it is likely dangerous. We are now doing all video visits. Our patients can shelter in place while still staying safe after a transplant. It does not help a patient to not develop COVID-19 but to develop liver rejection because they decide to stop immunosuppression. A routine lab check can be pushed off 2 to 3 weeks to see how things develop, but if routine lab checks can turn into a video visit, it will reduce the exposure of that transplant patient. We are doing 90% of out visits remotely. Most labs are being done a local lab. People are coming at off times so that they can minimize their exposure and being meticulous about cleaning things that they may come in contact with. The good thing about this virus, is that it is not a robust virus. It can’t stay on surfaces a long time. As an RNA virus, it is susceptible to cleaning products that we routinely use. If you are good about cleaning things you can minimize your risk. Social distancing is more than physical distance it is also keeping your circle small. We emphasize to our patients and our health workers that their circles have to be not only small but also well kept.

Healio: Apart from social distancing, what else should patients with liver disease do to prevent COVID-19?

Brown: As we recommend for older individuals, the degree of social distancing and social isolation for our patents on the transplant waiting list and our post-transplant patients is higher here in New York and California. I don’t think there is a huge difference between the liver disease patients and the general population because already a lot of precautions are being taken. In places where they are not being a restrictive, I think extreme social distancing as opposed to moderate social distancing is warranted. There are not any data that show wearing a mask will do anything in terms of reducing risk. Wearing gloves may reduce the risk but that’s only if you are really good about you glove hygiene. Several people make the mistake of putting on gloves, thinking that makes them safe and wear the same pair of gloves all day, without cleaning them and still touch their face. A glove can be the factor of the virus just as easily as your hands. People are generally better about doing hand hygiene than glove hygiene. What I recommend to my patients is frequent hand hygiene. If you have to be in a place where you have to touch things that a lot of other people have touched then wearing a pair of gloves that you discard promptly afterward and then perform hand hygiene, will be a good thing.

 

Disclosure: Brown reports no relevant financial disclosures.

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