Clinical outcome in liver transplant patients with COVID-19 Overall, 16 (28%, 95% CI 17% to 42%) patients received outpatient care for COVID-19, while 41 (72%, 95% CI 59% to 83%) subjects were hospitalised, with a median (IQR) hospital stay duration of 10 days (7–22). Among hospitalised recipients, 4 (10%, 95% CI 3% to 23%) were admitted to the ICU and required invasive mechanical ventilation, while 11 (19%, 95% CI 10% to 32%) developed ARDS. Death was registered in seven cases (12%, median time from transplant to death was 6 years, IQR 3–13), all of whom were hospitalised with ARDS. Overall, case fatality rate was 12% (95% CI 5% to 24%) in our population, which increased to 17% (95% CI 7% to 32%) among hospitalised patients. General characteristics of patients who did not survive, of those with ARDS and of those who were hospitalised are summarised in tables 6 and 7. Five out of the seven patients who died had a history of cancer, of whom three had an active cancer at moment of the diagnosis of COVID-19. Moreover, 9 out of 11 patients with ARDS had a clinical history for cancer. Median (IQR) lymphocyte and platelet counts (×1000/μL) were significantly lower (0.49 (0.30–0.60) vs 0.80 (0.52–1.18), p=0.030; 93 (79-110) vs 170 (104–273), p=0.044, respectively) in the group of patients who did not survive. Table 6 Characteristics of liver transplant recipients died because of COVID-19 Case Sex (M/F) Age, years Ethnicity BMI, kg/m2 Comorbidity Symptoms at presentation Immunosuppression management Respiratory support ICU admission 1 M 67 Caucasian 27.8 History of renal tumour Fever, cough, dyspnoea CNIs alone NIMV No No change 2 M 78 Caucasian 23.1 History of PTLD Fever, cough, dyspnoea CNIs alone NIMV No CV disease No change Diabetes CKD 3 M 75 Caucasian 25.1 Active tumour: HCC recurrence Dyspnoea, CNIs alone NIMV No CV disease Fatigue/myalgia No change Arterial hypertension 4 M 55 Caucasian 21.6 – Fever, dyspnoea CNIs+steroids NIMV No Only CNIs discontinuation 5 M 70 Caucasian 28.5 Active tumour: HCC recurrence Fever, dyspnoea CNIs+steroids IMV Yes Arterial hypertension Only CNIs discontinuation 6 M 66 Caucasian 23.8 Active tumour: PTLD Fever, cough, fatigue/myalgia, GI symptoms Steroids IMV Yes Arterial hypertension No change 7 F 79 Caucasian 21.3 CV disease Fever, dyspnoea, fatigue/myalgia MMF alone NC No Diabetes Arterial hypertension CKD CKD, chronic kidney disease; CNIs, calcineurin inhibitors; CV, cardiovascular; F, female; IMV, invasive mechanical ventilation; M, male; MMF, mycophenolate mofetil; NC, nasal cannula; NIMV, non-invasive mechanical ventilation; PTLD, post-transplant lymphoproliferative disorder. Table 7 General characteristics of patients who did not survive, of those with ARDS and of those who were hospitalised Outcome Overall Death (n=7) P value ARDS (n=11) P value Hospitalisation (n=41) P value Yes No Yes No Yes No Sex, male 40 (70) 6 (86) 34 (68) 0.662 10 (91) 30 (65) 0.146 29 (71) 11 (69) 0.883 Age, years, median (IQR) 65 (57–70) 70 (67–77) 62 (57–70) 0.088 68 (63–73) 62 (55–70) 0.052 65 (57–71) 60 (54–68) 0.162 BMI, kg/m2, mean (SD) 26.0 (21.4–30.6) 24.5 (21.7–27.3) 26.3 (21.4–31.2) 0.185 25.5 (21.6–28.2) 26.2 (21.3–31.1) 0.625 25.5 (29.7–21.4) 27.4 (21.6–33.2) 0.258 HCC as indication to LT 20 (35) 5 (71) 15 (30) 0.084 8 (73) 12 (26) 0.011 15 (37) 5 (31) 0.703 Very long-term LT 21 (37) 3 (43) 18 (36) 0.701 4 (36) 17 (37) 1.000 16 (39) 5 (31) 0.582 Very short-term LT 11 (19) 2 (29) 9 (18) 0.610 3 (27) 8 (17) 0.429 9 (22) 2 (13) 0.710 Smoke history 7 (14) 1 (17) 6 (14) 1.000 1 (10) 7 (15) 1.000 5 (14) 2 (14) 1.000 Cardiovascular disease 21 (37) 3 (43) 18 (36) 0.700 5 (46) 16 (35) 0.511 14 (34) 7 (44) 0.502 Arterial hypertension 32 (56) 4 (57) 28 (56) 1.000 6 (55) 27 (57) 1.000 22 (54) 10 (63) 0.544 Diabetes mellitus 21 (37) 2 (29) 19 (38) 1.000 4 (36) 17 (36) 1.000 14 (34) 7 (44) 0.502 History of cancer 24 (42) 5 (71) 19 (38) 0.119 9 (82) 15 (33) 0.005 18 (44) 6 (38) 0.659 Active cancer 5 (9) 3 (43) 2 (4) 0.011 4 (36) 1 (2) 0.004 5 (12) 0 (0) 0.308 Dyspnoea at presentation 26 (46) 6 (86) 20 (41) 0.041 9 (82) 17 (39) 0.016 22 (54) 4 (27) 0.129 Leucocytes, ×1000/μL, median (IQR) 4.51 (3.33–6.00) 2.95 (1.77–4.51) 4.70 (3.65–6.00) 0.113 3.70 (1.93–5.52) 4.70 (3.65–6.00) 0.297 4.61 (3.39–6.85) 3.85 (3.27–5.13) 0.170 Platelets, ×1000/μL, median (IQR) 160 (91–268) 93 (79–110) 170 (104–273) 0.044 102 (88–134) 183 (104–280) 0.064 164 (91–270) 149 (96–202) 0.745 Lymphocytes, ×1000/μL, median (IQR) 0.79 (0.40–1.10) 0.49 (0.30–0.60) 0.80 (0.52–1.18) 0.030 0.49 (0.40–0.76) 0.81 (0.58–1.18) 0.064 0.73 (0.45–1.00) 1.02 (0.74–1.22) 0.126 AST, U/L, median (IQR) 38 (25–53) 48 (36–80) 35 (24–52) 0.134 38 (27–57) 38 (23–53) 0.358 45 (27–57) 21 (17–29) <0.001 ALT, U/L, median (IQR) 30 (20–42) 21 (16–74) 31 (21–42) 0.602 22 (16–30) 32 (22–44) 0.142 33 (23–57) 21 (18–30) 0.026 Overall immunosuppression reduction 22 (39) 2 (29) 20 (40) 0.695 4 (36) 18 (39) 1.000 18 (44) 4 (25) 0.236 Overall immunosuppression discontinuation 4 (7) 1 (14) 3 (6) 0.417 1 (9) 3 (7) 1.000 4 (10) 0 (0) 0.568 ACE inhibitors or sartans 13 (24) 3 (50) 10 (20) 0.136 3 (30) 10 (22) 0.685 10 (25) 3 (20) 1.000 Oxygen therapy 30 (54) 7 (100) 23 (47) 0.012 11 (100) 19 (42) <0.001 29 (71) 1 (7) <0.001 Steroids (for COVID-19) 19 (35) 4 (67) 15 (31) 0.167 6 (60) 13 (29) 0.077 18 (45) 1 (7) 0.010 Antibiotics 35 (63) 7 (100) 28 (57) 0.038 10 (91) 25 (57) 0.039 30 (73) 5 (33) 0.012  >1 antibiotic 16 (29) 4 (67) 12 (24) 0.049 6 (60) 10 (22) 0.024 15 (38) 1 (6) 0.023 Antiviral 5 (9) 1 (14) 4 (8) 0.501 1 (9) 4 (9) 1.000 5 (12) 0 (0) 0.309 Hydroxychloroquine 24 (44) 3 (50) 21 (43) 1.000 5 (50) 19 (42) 0.655 22 (55) 2 (13) 0.006 ALT, alanine aminotransferase; ARDS, acute respiratory distress syndrome; AST, aspartate aminotransferase; BMI, body mass index; HCC, hepatocellular carcinoma; LT, liver transplantation; MMF, mycophenolate mofetil,.