The COVID‐19 pandemic has rapidly evolved and changed our way of life in an unprecedented manner. The emergence of COVID‐19 has impacted transplantation worldwide. The impact has not been just restricted to issues pertaining to donors or recipients, but also health care resource utilization as the intensity of cases in certain jurisdictions exceeds available capacity. Here we provide a personal viewpoint representing different jurisdictions from around the world in order to outline the impact of the current COVID‐19 pandemic on organ transplantation. Based on our collective experience, we discuss mitigation strategies such as donor screening, resource planning and a staged approach to transplant volume considerations as local resource issues demand. We also discuss issues related to transplant‐related research during the pandemic, the role of transplant infectious diseases and the influence of transplant societies for education and disseminating current information.

ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) has been performed in Japan to overcome the organ shortage. Reported herein are the results of this approach through March 2006 in the National Registry of the Japan Study Group for ABO-incompatible transplantation. The questionnaires consisted of patient characteristics, operative data, and strategies for preventing antibody-mediated rejection (AMR). Data of 291 patients (follow-up period, 8 months-15 years; mean, 35 months) from 28 institutions were collected. Age was younger than 1 year in 68 patients, 1 to 7 years in 60 patients, 8 to15 years in 27 patients, and 16 years or older in 136 patients. The strategy for the blood-type barrier was heterogeneous in terms of recipient age, transplant center, and era. Local infusion and rituximab prophylaxis were applied in 2000 and 2003, respectively. The 5-year patient survival rate was 85% in infants and 52% in adults. The major causes of death were infection and antibody-mediated rejection (AMR). Multivariate analysis showed that age group, preoperative condition, antibody titer, and infection significantly affected survival. Age group, antibody titer, and local infusion treatment significantly affected the incidence of AMR. Patient survival rates were significantly higher and the incidence of AMR was significantly lower in adult patients after 2000 (3 year-survival rate, 29%, 56%, and 61%; incidence of AMR, 47%, 27%, and 16%, through May 2000, from June 2000 through October 2003, and from November 2003, respectively). Conclusion: ABO-incompatible LDLT is a standard practice in children, and local infusion and rituximab prophylaxis are promising in adults. (Hepatology 2007.)

Background. Transplantation of hepatic grafts from ABO-incompatible donors is controversial because of the risk of hyperacute rejection mediated by preformed anti-ABO antibodies. The aim of the present study was to evaluate the outcome of liver transplants performed with ABO-incompatible living-donor livers and to detect risk factors for development of complications. Methods. From June 1990 to February 2000, 66 patients, 10 months to 55 years old (median, 2 years old), received 68 ABO-incompatible living-donor liver grafts. The antibody titer and clinical course were followed prospectively during a period ranging from 3 to 11 years. Results. The 5-year patient survival was 59%, 76%, and 80% for ABO-incompatible, ABO-compatible, and ABO-identical grafts, respectively (P <0.01). In patients <1 year old, ≥1 to <8, ≥8 to <16, and and ≥16 years old, 5-year survival was 76%, 68%, 53%, and 22%, respectively. The incidence of intrahepatic biliary complications and hepatic necrosis in ABO-incompatible living-related grafts (18% and 8%, respectively) was significantly (P <0.0001) greater than in ABO-compatible and ABO-identical grafts (both 0.6% and 0%, respectively). Predictive risk factors for increased mortality and morbidity were age greater than 1 year and elevated anti-ABO titers before transplantation. Conclusions. ABO-incompatible liver transplantation was carried out with relative safety in infants 1 year in long-term follow-up. Patients aged >8 years remain at considerable risk of early fatal outcome because of hepatic necrosis, and new strategies to prevent antibody-mediated rejection are required.

The outcomes of primary sclerosing cholangitis (PSC) after living donor liver transplantation (LDLT) in a large series have not been reported. We aimed to determine long-term patient and graft survival, risk factors for PSC recurrence, and the significance of recurrence after LDLT in a Japanese registry. Questionnaires concerning patient characteristics, treatments, and clinical courses were used. Data of 114 patients undergoing primary LDLT for PSC from July 1996 to December 2008 in 29 institutions were evaluated. For strict diagnoses of recurrence, patients with hepatic artery thrombosis (n = 8), ABO-blood-type-incompatible transplantation (n = 8), and established ductopenic rejection (n = 2) were excluded and 96 patients were analyzed for risk factors. Recurrence was diagnosed in 26 patients (27%) at 8 to 79 months after transplantation. Patient, graft, and recurrence-free survivals were 78, 74 and 57% at 5 years after LDLT, respectively. The graft loss rate was 69 versus 23% in patients with versus without recurrence, respectively. Multivariate analysis revealed that high MELD scores, first-degree-relative donors, postoperative CMV infection, and early biliary anastomotic complications were significant risk factors for recurrence. PSC recurrence was a significant risk factor of graft loss but not patient death. PSC recurrence was frequent and had significant impacts on outcomes after LDLT.