Liver transplantation was successfully performed in a pediatric patient with Alagille syndrome (ALGS) and a concomitant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, according to a case report recently published in Hepatology Research.

The patient, a 3-year-old girl with liver cirrhosis, was admitted to a hospital for deceased-donor liver transplantation. As the patient’s liver condition worsened with a very high pediatric end-stage liver disease score of 43.8, liver transplantation was sought as a life-saving procedure.

The patient’s history revealed a SARS-CoV-2 infection 4 months before surgery. Although she was tested for SARS-CoV-2 at a local hospital as well as the hospital where the transplantation was performed, the tests repeatedly showed negative results.

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The transplantation was performed under full airborne, droplet, and contact precautions in a negative-pressure operating theater. The left lateral segment of the liver was used for split liver transplantation, and standard procedures were used for each vessel anastomosis and bile duct reconstruction.

Read more about ALGS complications

SARS-CoV-2 polymerase chain reaction (PCR) testing was performed at the end of the operation and every 12 hours thereafter. A qualitative PCR test of the nasopharyngeal specimen was positive at the end of the surgery, although the lower respiratory tract specimen remained negative.

The patient received standardized immunosuppression therapy consisting of tacrolimus and low-dose steroids. Remdesivir was not administered due to potential hepatotoxicity and the absence of coronavirus disease 2019 (COVID-19) exacerbation.

In the following days, antibody titers for the SARS-CoV-2 spike protein receptor-binding domain were positive, but the patient did not exhibit any symptoms of COVID-19. Although signs of T cell-mediated rejection of the liver graft could be observed 38 days after transplantation, the liver function tests improved with the adjustment of tacrolimus and steroids as well as the additional use of mycophenolate mofetil.

The patient was discharged from the hospital after 53 days without any complications or sequelae of COVID-19.

“A [liver transplantation] would have been performed for this patient even if her PCR test result had been positive at the time of the [liver transplantation], given she was not otherwise likely to have survived due to the decompensated liver cirrhosis,” Shimizu and colleagues wrote.

“However, if clinically relevant upper respiratory symptoms or exacerbating signs of COVID-19 had been observed, we would first have administered remdesivir to treat her COVID-19 along with close monitoring of her liver function.”

Organ transplantation has become more challenging since the beginning of the COVID-19 pandemic, and it is currently performed only as a life-saving procedure for patients who test positive for SARS-CoV-2 infection.


Shimizu S, Sakamoto S, Yamada M, et al. Successful pediatric liver transplantation case with a positive SARS-CoV-2 test at the time of transplant: a case report and literature review. Hepatol Res. Published online January 18, 2023. doi:10.1111/hepr.13881