Welcome, everyone, to the 2020 academic debates. Today's topic is liver transplantation in the times of COVID-19, to transplant or not to transplant. This session is taking place live Friday, November 13, 2020, from 530 to 615 p.m. Eastern Standard Time, but the recording can be played on demand before the liver meeting digital experience closes February 15, 2021. We are the 2020 academic debate program chairs, Drs. Christina Lindenmeyer, Uchenna Ackman, and Oren Fix, that planned this event for you to enjoy. As this activity will be available for claiming AMA, PRA, Category 1 credits, and American Board of Internal Medicine MOC points, we will be providing disclosures for all faculty. These are our disclosures. We would like to present our Master of Ceremonies, the esteemed Michael Lucey of the University of Wisconsin. He will help us keep the debate fun and moving along. And we are also honored to have an expert panel of doctors, Dr. Andrea Reed of Massachusetts General Hospital, Dr. Elizabeth Verna of Columbia University in New York, and Dr. Laura Kulik of Northwestern University in Chicago. These panelists will challenge and critique our debate teams on their initial arguments and rebuttals. These are the disclosures for our MCN panelists. You the audience also have an important role to play. You'll be asked to vote on the best argument presented. As you listen to each team critique them on the following, construction of argument, quality of their argument slides, master the topic, their presentation styles, and their skill in responding to questions. For all of you in the audience joining us in the live session February 13th from 530 to 615 Eastern Standard Time, you get to vote on which team you think had the best argument. Polling will open following the full set of debate presentations, including the panelists and audience Q&As. And once that has taken place, we'll prompt you to go to the tab here in TLMDX called Polling to submit your vote. The winner will be announced at the end of the session. Also the Q&A is open now and at any time you may submit a question as well, and we will cover as many as we can during the audience Q&A. Now let's move into the debate and the debate teams. Today's debate will be centered on the topic, liver transplantation in the times of COVID-19, to transplant or not to transplant. A case will be presented to illustrate this argument. In each team debating has been assigned a different side. As we read through this case, we'd like to acknowledge Dr. Bilal Hamid of the University of California, San Francisco, who modeled this after a real patient experience and provided it to us for use in this debate. I'll present it to you now. A 35-year-old woman presents with one week of subjective fevers, progressive fatigue, nausea, and yellow discoloration of her eyes. She recently doubled the dose of an herbal weight loss supplement while working from home due to the COVID-19 pandemic. Admission vital signs were notable for an oxygen saturation of 99% on room air. Her exam revealed mild jaundice and asterixis. She appeared mildly lethargic, but was otherwise oriented. Laboratory findings on admission, I'll read them out for you now. Whole blood cell count of 17,000, alanine aminotransferase of just under 4,000 units per liter, whereas AST is 3,745, alkaline phosphatase 72, total bilirubin 5.3 milligrams per deciliter, her INR is 2.5, her creatinine is 1.5 milligrams per deciliter, and arterial ammonia level is 135 micromoles, C-reactive protein is 5.1, ESR is 63 millimeters per hour, ferritin is 1,532 nanograms per ml, and her arterial blood gases show a pH of 7.37, partial pressure of carbon dioxide of 39, and a bicarbonate level of 24. The patient's rapid COVID-19 test was positive in the emergency department and was confirmed by PCR testing. She has no respiratory symptoms currently. Laboratory investigation for etiologies and acute liver failure were negative. Abdominal ultrasound showed a normal appearing liver and patent vasculature, a chest CT, was unremarkable. The patient was started on N-acetylcysteine by IV infusion. Despite close monitoring and supportive care, her condition deteriorated. Her INR increased to six and her encephalopathy progressed to grade three on the fourth day of hospitalization, requiring endothelial intubation. Brain imaging showed mild cerebral oedema. She was evaluated for liver transplantation and found to be an otherwise good candidate. Her repeat COVID-19 PCR was again positive. So we have two arguments. On the one hand, in the setting of an emergent indication for liver transplantation for her acute liver failure, this patient should be considered for liver transplantation despite a positive COVID-19 while having no respiratory symptoms. On the other hand, in the setting of positive COVID-19 with no respiratory symptoms, liver transplantation is contraindicated. The first argument in the setting of an emergent indication for liver transplant for her acute liver failure, she should be considered for liver transplantation despite her positive COVID-19 test and in the absence of respiratory symptoms will be given by the Ohio State team. They are Lindsay Sobotka and Ashley Nickerson, and their mentor is Sean Gerard Kelly. Here are their disclosures. And as you can see, they have nothing to disclose of a financial nature. So I turn it over to the Ohio State team. Good evening. My name is Ashley Nickerson, and I'm here today to tell you why we should transplant this patient with acute liver failure that has an asymptomatic COVID-19 infection. You must first keep in mind the pillars of medicine that we agree to abide by when we take our OSAs positions, beneficence, we should make the decision most likely to benefit this patient, non-maleficence, we should not harm this patient, and justice, we should do what's right and fair. And what's right for this patient is an emergent life-saving liver transplant. Keep in mind she has no contraindications to transplant. She will die without a transplant. She has an asymptomatic COVID-19 infection. There's a lack of data to recommend against transplant, and we want to ensure an equal opportunity for life-saving therapy. We should not let fear and the negative impact of the pandemic risk the lives of patients in need of emergent liver transplants. We know that COVID-19 PCR remains positive weeks after negative viral cultures. Multiple studies have shown that by day 10, while COVID-19 PCR is positive, virus is actually not able to be detected from the respiratory tract. And going out as far as day 50, while COVID-19 PCR is positive, virus is still unable to be detected from the respiratory tract. So how do we know our patient even has an active COVID infection? She could have inquired this weeks ago and is simply shedding dead virus at this point leading to a positive PCR, but she is not actually infective. We also know that asymptomatic COVID patients typically remain asymptomatic. Looking at a study in the New England Journal of Medicine, they looked at 712 patients that were positive by COVID-19 PCR. 410 of these patients were asymptomatic and 96 were monitored. Of those 96, only 11 patients developed symptoms and that was associated with advanced age in those older than 60, not our young and healthy 35-year-old patients. One thing our opponents may bring up today is the risk that we may pose to other healthcare personnel involved in a COVID-positive liver transplant. However, we know that emergent procedures are safe in COVID-19 with proper personal protective equipment. COVID-19 particles measure greater than 5 to 10 micrometers and N95s filter greater particles greater than 0.3 micrometers. So we know that we can keep everyone in this liver transplant safe with the use of our proper PPE. We also know that mortality is actually not increased in our liver transplant patients that have COVID-19. Looking at two major studies, the first in Lancet, they looked at 151 liver transplant patients with COVID-19 versus their match cohort group. There was a 19% death in the liver transplant group, however, a 27% death in the cohort group. In our COVID-positive liver transplant patients, no deaths were liver-related and none of them developed graft dysfunction. In a study done in Easel, they looked at 111 liver transplant patients again with COVID-19 versus their match cohort group. There was an 18% death in the liver transplant group, however, a 27% death in the cohort group. In our COVID-positive liver patients, no deaths were liver-related and only three patients developed graft dysfunction, however, none of them developed graft failure. Another thing our opponents may bring up is the concern about immunosuppressing a COVID-positive patient. However, we know that immunosuppression is not associated with mortality in our liver transplant recipients. Referring to the previous slide from Lancet, the deaths in our liver transplant patients that were not associated were time from transplant and immunosuppression, which was associated with those risk factors was older age, non-liver cancer, and elevated serum creatinine, none of these risk factors of which our patient has. Some studies suggest that calcineurin inhibitors may even be protective against severe COVID-19. In a study of the Journal of Hepatology, they actually found that tacrolimus may be protective against severe COVID-19, leading to decreased ICU admissions and intubations, given the ability to downregulate the cytokine response that we know is responsible for causing the severe symptoms that we see with COVID. Have we done COVID-positive transplants? We have. The first one is a patient that underwent a lung transplant. This patient was hospitalized with symptomatic COVID. By day seven, he required intubation for respiratory failure. By day 13, had to be placed on ECMO. On day 58, this patient underwent a lung transplant. I would like to highlight here, this patient's PCR was positive, even up on the day of transplant. However, virus was not able to be detected from cultures as early as day 13. If a patient as sick as this, intubated on ECMO, can undergo a transplant and do well, our asymptomatic patient will do just fine. There's also another case of a COVID-positive patient at Cleveland Clinic. She was a 27-year-old female with no medical problems that developed acute liver failure due to Tylenol overdose from a symptomatic COVID-19 infection. She developed multi-system organ failure and was so sick that she required two rounds of plasma exchange as a bridge to transplant. She underwent a liver transplant with an uncomplicated recovery and is doing well. Again, if our asymptomatic patient has no symptoms at this time and is not as sick as this patient, she'll do just fine. You also may hear from our opponents say that the current AASLD guidelines recommend us not to transplant COVID-positive patients. However, I'd like to point out that these recommendations are for patients with chronic liver disease and not acute liver failure who need emergent liver transplants. These guidelines are also based on expert opinion. We simply do not have enough evidence to tell us not to transplant this patient at this time. Remember when we thought transplanting all of these patients was contraindicated, controlled HIV, hepatitis B, cholangiocarcinoma, and hepatocellular carcinoma? We'll all look back one day and remember when we thought transplanting asymptomatic COVID-19 patients was contraindicated too. The answer is yes to liver transplant and this patient. Thank you. I've obviously got, I've got a buckeye stuck in my tooth to look up what buckeyes are. It's an American chestnut. The buckeyes against the Quakers, I mean, it's an interesting conjunction. Anyway, now the chance to hear the other side of this argument that in the setting of positive COVID-19 with no respiratory symptoms, liver transplantation for the patient we have described is contraindicated. This argument will be made by the team from the University of Pennsylvania. They are Maureen Whitsitt and Vivian Ortiz, and their mentor is Ethan Weinberg. The next slide will show their disclosures and you can see them shown to you now. So take it away, the Penn team. Transplanting this patient is the wrong choice. The risk of post-operative and COVID-related complications threaten her survival. It places those involved with her care at risk of illness, and it may lead to excessive resource use for stressed hospital systems during the pandemic. Outcomes of COVID infection in solid organ transplant recipients are reported for those who are years out from transplant, but poorly defined in patients transplanted within the year. All we have are case reports to give us some insight into how poorly these patients can potentially do. There are seven cases of recipients currently in the literature who developed COVID after transplant as early as post-op day nine. Two died, three had acute rejection, and every patient had pneumonia. There are four cases of liver transplant for patients who had a recent COVID infection but recovered, and all PCR swabs were negative prior to transplant. To date, only one case exists of a lung transplant for a COVID PCR positive patient. The caveat is that in all of her preoperative swabs, the cycle threshold values were persistently high, and the virus could not be cultured. This roughly translates into a lack of viable virus in her respiratory tract, or a very low viral load, and a much lower risk of infectivity. Studies have shown that lower cycle thresholds correlate not only with risk of progression to severe disease, but with increased mortality and increased infectivity. Let me remind you that we do not have this information to understand just how great the risk is to both patient and staff. Data from a large international study demonstrated that when emergent or elective surgeries were performed on either actively infected COVID patients, or patients who contracted within 30 days post-op, that the overall 30-day mortality was 21%, with nearly half of all patients developing pulmonary complications, which include pneumonia, ARDS, or unexpected need for mechanical ventilation, and a higher ASA grade was the most predictive of bad outcomes. But the active virus in her respiratory tract has the potential to wreak havoc on other organ systems, as well as her graft. Arterial and venous thromboses occur in COVID patients despite prophylactic anticoagulation. So what if she were to clot off her hepatic artery or her portal vein? If she had a coronary thrombus or myocarditis, how would that impact graft perfusion? Would we need to make changes to her calcineurin inhibitor if she were to develop neurologic or renal impairment? And what if her liver tests never normalized? Is it COVID hepatitis, or is it rejection? Are we prepared to biopsy her in perpetuity, even when she's on anticoagulation? The lack of outcomes data in patients like ours six months into the pandemic is not surprising, but the cases that exist do not mirror our patients' predicament. There are too many unknowns. What is her viral burden or degree of infectivity? We can't even guarantee her survival. During the first SARS epidemic in the early 2000s, a SARS-infected post-liver transplant patient who traveled to two different hospitals unknowingly exposed 68 people, some of which were healthcare workers. Ten of them contracted SARS and one died. And nosocomial outbreaks with this pandemic continue to occur, with over 5,100 hospital acquire cases reported nationwide in May and June alone. And during my time in New York at the start of the pandemic, numerous surgeons and procurement team members were exposed at different institutions and some felt quite ill. Over 1,700 and counting healthcare workers have died since the start of the pandemic. Each patient interaction, each time you dock your PPE, you put your life at risk. A highly infectious patient in the OR is a nightmare. Imagine the technical difficulties for the surgeons operating for hours in N95s. With intense care provision in the ICU, nurses and respiratory techs are at risk, as are janitors and other essential staff. The point here is that the potential harm of transplant extends way beyond the patient. And resource shortage intensify these safety concerns. Lack of proper PPE is still a real issue, with providers reporting that they are reusing their N95s for extended periods of time. And the resource expenditure for the sick transplant patient will be immense, with expected greater need for transfusion, longer length of ICU stay. If you transplant a patient in the midst of a surge, be prepared to face shortages of IV tubing, sedatives, diastolic fluids. Vent splitting and resource rationing can quickly become a reality. It is crucial that we practice stewardship of our most precious resource. We have the responsibility to allocate organs not only to those in greatest need, but to those who are likeliest to survive with a transplant. This is a potentially futile transplant. And because it is a zero-sum game, another patient will potentially miss out on a chance at new life. We should not transplant this actively infected patient. Our very own ASLD and many other authorities would agree. And they say that it may be considered with negative PCR tests or two weeks after symptom resolution, which we still do not have. Look, we acknowledge that this is an incredibly difficult case of a woman whose life we would all want to save. Many of us at aggressive transplant centers are no strangers to assuming risk. However, what tips the scale and sets this case apart from others is that it endangers the health of the staff and patients by exposing them to a highly communicable disease of which we still do not have good treatment. Instead, this liver could be transplanted in a more suitable candidate in a less tenuous situation with a higher likelihood of good outcomes. We need to shift the focus on how this impacts the greater good. To transplant this patient would be to assume an absolutely unacceptable amount of risk with a potential for very deadly consequences. And in times like these, with an alarming dearth of facts and truth and reason, we all should ask ourselves, what would Fauci do? The decision to proceed blindly with transplantation with so many lives potentially endangered would be met with a face palm for sure. Thank you. Now it's time for the teams to confer with their mentors for two minutes. Let's hear how they respond to each other's arguments by hearing their rebuttals and their responses. The first rebuttal will come from the Ohio state. And if you recall, their argument was that in the setting of an emergent indication for liver transplantation for acute liver failure, this patient should be considered for liver transplant, despite a positive COVID test. And in the absence of respiratory symptoms, they've made that argument. The group from Penn has made the opposite argument. Let's hear the rebuttal of the Penn argument by the Ohio group. I'd like to congratulate the UPenn team on a fabulous debate. And we can at least agree that COVID-19 has become a major part of our lives and will remain so for a long time. It is therefore crucial that we use the available data to determine the best approach to liver transplantation in this specific patient with ALF and asymptomatic COVID infection. Let me be clear, we are talking about one specific patient. We are not advocating for liver transplantation in any candidate with a COVID-19 infection and telling you their outcomes will be equivalent. However, the information presented today clearly supports transplanting this woman. Our opponent tried to use the fear of complications associated with COVID-19 and high surgical mortality as a reason to withhold transplant. I again highlight this patient is asymptomatic with regards to a COVID-19 infection and there's simply no existing data to support the claims that she would fare poorly after a transplant. Without an emergent liver transplant, this young woman will surely die. Organs are allocated to appropriate candidates with the most urgent need for transplant, which clearly applies here. Transplanting this patient does not mean that we're neglecting the next patient on the wait list. We're simply giving priority to this critically ill patient who can tolerate the surgery and survive thereafter. This scenario demands an absolute contraindication to forego transplant and our opponents have failed to provide that. When we look back on liver transplant, liver transplantation care during the pandemic, we all want to ensure that the care provided was not based on fear and false information. As Winston Churchill once said, fear is a reaction. Courage is a decision. The obvious ethical and evidence-based choice is a transplant for this young woman who will die without one. Thank you for that rebuttal, Lindsay. Now is a chance for the Penn Group to respond. If you recall, they made the argument that in the setting of a positive COVID-19 test in the absence of respiratory symptoms, this patient with acute liver failure should not receive a transplant. They have heard the arguments in favor of transplantation made by the group from the Ohio State, and they're now going to respond to the Ohio State arguments with their own rebuttal. So over to the Penn Group. Though our competitor team brings up excellent points on the needs of this patient to be transplanted now, we ought to remain vigilant of the decision we take. It is true, her chances are grim without a transplant taking beneficence into account, but let's also remember about doing a harm and how this transplant is not only risky for those taking care of her, but may also be harmful to her. We have a tremendous responsibility to uphold certain ethical principles in the allocation process, one being utility. Do we serve the greater good of the community by transplanting her? SARS-CoV-2 is a systemic infection that we don't understand well, unable to predict the course of the transplant patients, and have minimal treatments for. Extrapolating from the experience in pediatrics, we, with acute liver failure and with upper respiratory, active viral respiratory infections, showed us that the rates of complications and mortality are high. What will we expect differently in adults? And even with the theoretical surgical recovery, there is great long-term morbidity from respiratory deficiencies to encephalopathy, among others. We don't know at which stage of the infection she's in. We cannot tell that she's not asymptomatic from it. We don't know if her liver damage is from COVID. So we're risking graft survival and further clinical deterioration by its typical cytokine storm triggered by the stress of transplantation. The last thing we want to do is to cause harm in this patient, and in such pursuit, risk our lives and that of our colleagues. We appreciate the opposing team's attention to the principle of justice, that there is a great medical urgency to transplant this sick young woman, and that there may not be enough time to find another suitable organ. But we can't let anecdotal experiences drive us to list patients infected with COVID-19. We must be patient. We must use scientific equipoise and let rigorous studies guide our clinical practice. We should hold off on transplanting COVID-positive patients until we can truly treat the systemic infection and fully understand when they're no longer contagious. As much as we would like to be able to transplant her, we just don't have the total package to do this safely, and the risk of proceeding with the surgery just too high compared to its benefits. Thank you, Vivian, for those rebuttals. Now is a chance, seeing that both teams have considered each other's arguments, let's hear from our panelists. We've assembled a panel of experts who are familiar with practice in the time of COVID, and I think we give them a chance to talk to our two teams. I'm going to do the same as I did in the intervening period and call on them in turn. I'll start with Betsy, then go to Andrea, then go to Laura. And after they've each had a chance to talk to both, ask a question to both teams, then if there are still questions to be asked, we'll have it in a more free form, but I'll make sure that everybody gets a chance to speak. So let's start with you, Betsy. Would you like to address a question to the Ohio State team and to the Penn team? Great, thank you again for excellent presentations and rebuttals. I think you all did an outstanding job. My first question is for the Ohio State team. I think you made a lot of compelling arguments, but one question I would have for you would be, are we sure that the patient really doesn't have symptomatic COVID-19, meaning are there risks other than pulmonary disease that we must consider when we're thinking about the safety of transplant in this particular patient? Dr. Nickerson, I can take this question. So obviously this patient is asymptomatic from a respiratory standpoint, and there's other complications associated with COVID that we know of. In this situation, though, we've seen multiple studies that have proven that the risk of some of those complications are quite low in patients that are considered to be asymptomatic from a respiratory standpoint. There's obviously been some concern for thrombosis, and in some of the studies that have come out of China, we've seen that the risk of thrombosis, specifically out of the asymptomatic patients, was as low as 4%. So I feel like even with some of those smaller risks that could be associated with asymptomatic COVID, the benefits of transplanting this patient most definitely outweigh some of those risks. And we've obviously dealt with issues in terms of prothrombotic states in patients that have undergone transplant before and have done well managing those situations. So I feel like there's no specific reason to think that we wouldn't be able to manage any potential complications which are unlikely to happen. And have you a question for Penn, Betsy? Yes, my question for the Penn team, and again I think you guys made excellent arguments sort of against transplanting this patient in the acute setting. I guess my question for you would be given her age and other, I would say, favorable attributes in terms of risk factors both for COVID outcomes and also in terms of transplant outcomes, how would you compare this patient and her potential post-transplant survival to many of the other high-risk transplants that we do, let's say, in elderly patients and multi-organ transplant patients? And how do you compare sort of their overall potential survival benefits such that you could conclude that this is not the right person to transplant? I can take this. Thank you, Dr. Varna. Great question. So I think that this patient is certainly high risk for bad post-operative outcomes. Unfortunately, we don't really have any data to kind of assess her risk except for our understanding that she likely does not have just acute liver failure. We think that COVID could potentially be contributing significantly to her clinical picture. And we know that someone who has severe acute liver injury with COVID, which she could potentially have, obviously the acute liver failure picture is clouding that. They have worse outcomes. I think that it's hard to compare her to older patients. We have a lot more data, frailty scores, et cetera. I just think that in her case, the potential for her COVID infection to kind of take over is too great. And so I think that just by nature of the fact that we don't think she's asymptomatic, I think that puts her at an exceedingly high risk post-operative, perioperative for all sorts of complications. Very good. I'm going to turn now to Andrea. And I recognize that for Laura, this gets harder for you, the last person to ask two questions. You've got to really be thinking hard now because four decent questions have already been taken out from your opportunity. But Andrea, do you have a question for the Ohio team and for the Penn team? I do. For the Ohio State team, thank you for an excellent review of the literature, recognizing that that literature for the most part did not include patients that were immediately post-transplant. You focused a lot on this patient being asymptomatic and it's already been established that we really truly don't know if she has no symptoms. She's intubated with cerebral edema. And so you're not really able to assess in terms of symptoms now. And my question for you is whether or not having her viral count would in any way change your recommendation, symptomatic or not. And then also the same question to the Penn group, would having this patient's viral count change the way that you would approach this patient? Dr. Spock, I can take this question. Of course. So I don't think that the viral load for us would change. To the best of our knowledge, we have to go off the information that we had. She was asymptomatic that we know of from that standpoint. And like we mentioned, we weren't even sure if she actually has an active infection at this time. So we really can't prove yes or no, she does. In regards to what you had mentioned about how she would do, well, looking at like, we don't have obviously many cases of liver transplant patients that are COVID positive. But the one I had presented at Cleveland Clinic, that was a COVID positive patient and multi-system organ failure that was so sick that she even needed plasma exchange and she still did fine after her transplant. And so I don't think that we have any reason to tell us that she would not do well at this time. I think the same question goes to Penn. Can I take this one? So I think again, going back to the question of whether or not she's asymptomatic, the important information that we do not have in this case is the cycle threshold. And some of these cases that were reported in the literature, including the lung transplant case that our opponent team cited, they all gave some sort of value for the cycle threshold that was very helpful information for the teams that were deciding to proceed with transplant. So essentially, it's just the number of amplification cycles that you need to detect genetic matter from the virus. And if we knew that her cycle threshold was low, meaning that she had a very high viral load, that would insinuate, or at least she's either very, very sick, severely ill, or she's at the beginning phases of her infection and we haven't even really seen COVID kind of manifest itself. So we, number one, can't say, oh, we're 10 days into the infection, or two weeks or whatever. We really need that cycle threshold information. Viral cell culture would be helpful too, but it's not very widely available. Now, the lung transplant case that the other team cited, I believe her cycle threshold was very high. She was 56 or so or more days out for her initial presentation, and she has single organ failure. The case, the Cleveland Clinic case, I don't really know much about. It would be interesting to know if the team had an understanding of the kind of the viral kinetics or the trajectory of her infection, because I think that's important to know. If her cycle threshold was very high, and some studies toss around high 20s, mid 30s, then in our minds, that would tell us that we are potentially dealing with a low viral load or maybe just fragments of viral RNA. And as much as it would still be very difficult decision to proceed with transplant, and we would still not transplant in that case, but teams who would be more willing to transplant, that could kind of sway you at least into thinking that she's not as infective, and she has a lower potential for progressing in terms of the severity of her COVID infection. Thank you for that answer. So we're now coming to our closer, Laura Kulik. She's going to bring heat to the mound. Fastball all the way. What are your questions for the Ohio State and for Penn? So I'd like to congratulate both teams. I think you both did an excellent job. My first question is for Ohio State, and we know that this is a young woman who was otherwise healthy. So we tend to be more aggressive in patients in general in this background, but specifically taking into account the COVID and not knowing, is there an end point or something that would change your mind if she needed a kidney transplant, or if her FiO2 was increasing to 60%, her presser requirement, at what point would it be a no return, specifically knowing that we have unknown answers regarding COVID on top of this? I can take this one, Dr. Nickerson. I feel like the point I really want to highlight here is we need an absolute contraindication to not transplant this patient. At this point, I don't feel like we have an absolute contraindication in her current STEM. Now we can talk about whether she was asymptomatic or symptomatic at the time of presentation, and her viral detection load, but at the end of the day, transplant is a yes or no question. We are deciding on this patient at this moment in time, and at this moment of time, she's an adequate candidate for transplantation, and she will die without this lifesaving intervention. Sure, is there limits to what we should do in transplantation in terms of how sick someone can be before we transplant them? Of course there's limits, and when you reach that absolute contraindication, I would agree that you should not perform a transplantation, but at the current state of this patient, we have not reached an absolute contraindication, and the answer to this patient is yes for transplant. Okay, and for the Penn team, one of the arguments has been that we would be denying an organ to someone else. Again, specifically in the face of this woman having COVID, if there was a viable living donor that was available, would that in any way change your mind in the fact that you wouldn't be taking an organ away from someone else? I think the same principle applies. If we take a living donor from a deceased donor, the principle applies. There's a high risk for infection and contagious to everyone taking care of her. We don't know exactly how the patient's gonna fare post-transplant. We don't know if she's gonna decompensate afterwards. And again, we're using a whole number of resources for this one patient. So I think that the principle applies. She's COVID positive. It is very dangerous to proceed with such transplantation without control of her systemic infection. Well, thank you very much for that discussion, and thank you to our panelists for their thoughtful questions and to the teams for their equally thoughtful answers. Now that the debate teams have been challenged by our panelists, it's time for you to also enter into the debate. You are audience, and you can ask your questions to their arguments before you vote. We'd like you to submit your questions through the Q&A tab. As we gather the questions to present to the teams, we'd like to take a couple of minutes to thank everyone who has made this debate possible. First of all, we must thank the teams from The Ohio State Medical Center and the University of Pennsylvania for putting forward such a great effort and enthusiastically entering into this debate this year in a completely new format. And it's important to recognize that despite the apparent passion both sides have presented their arguments, they were given the arguments to present. And so that's the art of debate is to be able to take an argument you're given and argue it coherently and cogently. And they have done a really excellent job. I'd like to thank our panelists for their questions, which were very to the point and really related to the topic under discussion, and I think expanded the discussion that we have had today. And I want to thank Dr. Bilal Hamid of the University of California in San Francisco for providing us with a real case to serve as the basis for our clinical vignette, which has been discussed by both teams. Finally, I want to thank the program chairs and the ASLD staff who have worked to develop this event and brought it together so well in these difficult and up to now unique circumstances for us. I want to remind the presenters from both the Ohio State and from Penn that you have an opportunity to turn your presentation into a publication. Thanks to the generosity of Nancy Rowe, who's the editor of the ASLD multimedia educational journal, Clinical Liver Disease. She instituted a practice of taking both sides of these arguments and presenting them side by side. And so if you write them up, she will present them and the readers can then see both sides of the argument and come away learning a lot more. So do take that opportunity. It makes your work all the more valuable. There will be another round of debates taking place at this year's liver meeting. Be sure to be tuned in on Saturday, November the 14th from 6.15 to seven o'clock Eastern Standard Time for the first ever pediatric topic, which will be covered. Once again, the city of brotherly love will be presented with the Children's Hospital of Philadelphia, CHOP, and they will be presenting one side of an argument and Colorado's Children's Hospital will present the other. Subject, the proposal will be that live vaccines should be given to pediatric liver transplants. So please tune in for that debate. Teams, well, thank you for that. It's been a great debate so far. And to think that this time last year, none of us had ever heard of COVID-19. A couple of reminders to the audience before we begin answering your questions. On the right side of your screen, there are two tabs, question and answer or Q&A and chat, submit your questions in the Q&A tab. Please indicate which team or speaker you are directing your question to, or if it's for both teams. We will do our best to answer as many questions as we can. Use the chat tab to engage with other attendees and to share resources. If we do not get a chance to answer every question today, and we've already got a lot, so it's quite likely we won't, the liver meeting digital experience offers a unique opportunity to connect with presenters through the platform. Navigate to your network and engagement center to search for a presenter by name. You may add them to your list of connections or request to schedule a meeting with them. Following the audience Q&A, we will ask all of the audience to go to the polls tab under the Q&A tab, where they will vote on which team they feel gave the best and strongest argument. Now let's dive into the questions from our audience. So the first question I'm going to ask is an ethical question. And it says, if care of the staff is such an important issue, why is it different from emergency care for other patients? We're often put in the place of giving urgent care where it puts the medical managing team at personal risk. Why should, in this circumstance of COVID-19, should COVID be the reason not to offer transplantation? And I'm going to ask that question to Maureen because it was the Penn argument that protection of the staff was so important. Maureen, how would you respond to that? I don't understand the question completely. COVID is something that we can't really compare to other medical conditions. It is a highly communicable and very serious virus that we don't have treatment for and it's very difficult to contain. You need negative pressure rooms, you need an adequate supply of PPE, you have to don and doff properly. There are many opportunities for people just interacting in the patient's room to get sick. And so I can't really think of any other disease, I guess Ebola, but in which the danger of infection to the staff is so high. So I'm not sure if I'm answering that question correctly, but I just think this is incomparable and I think that it is hard to guarantee the safety of the staff, if you have a shortage of PPE as we're seeing still throughout the entire country. Well, thanks for that. So I'm now going to ask a question and I'm going to ask it of Ashley on the Ohio State team. And it's a comparable question from the other direction in that we've just been told by one of the writers into the chat room that the patient with the lung transplant at the Cleveland Clinic was very likely not carrying the virus. And that's why they went ahead with the operation. My question to you is, if you were highly confident that the patient is carrying the virus, would it change your judgment about this patient? No, I don't think that it would because even looking at the patients who, so we're saying the patient's carrying the virus, she's asymptomatic for what we know at this time and looking at all the studies and how the patients that are asymptomatic do, they tend to remain asymptomatic and very few of them, and even a large study in China, only 4% of patients that were asymptomatic developed complications that would be worried about such as severe pulmonary infections, requiring intubation and thrombotic events. And so I don't feel that even if she was carrying this, that it would change anything for us. We would still go ahead and transplant her. And as we mentioned, we wanna look for an absolute contraindication not to transplant and we don't have that here. I'm going to come back to that if I have time. I'm going to now ask a question of Vivian. It's the same sort of question. So Vivian, if you were given full assurance by everybody at the Hospital of the University of Pennsylvania, that they had such an amount of resources, that they had gone to such extreme lengths, that they had taken every precaution that could be taken to protect the staff, would that allow you transplant this patient? I still don't think that's enough. I think there are several factors that go into the decision. It's not just PPE though, it's extremely important in order to guarantee that there is no transmission to anyone taking care of her. But there's also the fact that we don't have really good treatment for the COVID-19 infection. We really don't know how she's gonna fare post-transplantation. And we really don't know, we can't really define the hyper-inflammatory phase in this disease well enough to project when it's best to give her treatment. So for several reasons, I think we're still not there yet. We still need to learn more about it and go ahead transplanting a patient like this. Very good. I'm going to now ask a final question perhaps to the Ohio State group. I think Lindsay is the person who hasn't yet spoken in this segment. And it's really following up on the remarks that Ashley made just a moment ago, that you hadn't found an absolute contraindication. But as pointed out by the Penn team, a surge really creates real challenges for resources. So this is the mirror image of the case that I have painted for HUP. Here we're at the hospital for the Ohio State University Medical Center. And now they're under such extreme circumstances that resources are stretched. What is the point? Is there any point where resources would become so limited that you could not transplant this person? I would say absolutely not. This patient has cerebral edema and their INR is six. A liver transplant in this patient is emergent and we should still be doing emergent procedures in the time of COVID. Those are the patients that deserve those interventions and we should be using our resources for them. So if we need to allocate our PPE, we should be doing the emergent procedures like a liver transplantation. If we need to hold back our PPE, we should be doing that for the elective procedures. So even with the surge of COVID that's going on right now and concern for limited resources, it doesn't apply to this patient. Very good. What I'm going to say now is the time to vote. I'm going to ask you to go to the Q&A tab and the sub tab polls and vote for the team that you feel gave the best arguments. Remember our criteria, construction of the argument, quality of the argument slides, mastery of the topic. And I just want to make a quick editorial comment that I am very impressed at the mastery of both teams. You really have delved into a new topic and become masters of it, absolutely. So mastery of the topic, your presentation and styles. And finally, the skill you've had in responding to the questions, both the questions thrown up by the rebuttals of your opponent teams, the questions thrown up by our expert panelists. And now this final extemporary question and answer center, which comes from our audience this evening. So please assess all of those parts and then come to vote as to which team you think is best. And we're going to watch the voting in action. This is voting transparency, which is something that we would like to have throughout the country. There's not, you're going to see the votes emerge. That's what I'm told. You're going to actually see it happening in front of your very eyes here. so I'm waiting for for voting to start. So I'm told voting has started. I don't see it, but I'm told it's on the platform, not the Zoom. So there's a real danger here in having me, the person doing the talking. I'm the person where my grandchildren now take the remote control. It's not even my own children. You know, I've gone an extra generation. So, but yes, it's happening. And I'm told that there are several dead people have been voting from the state of Pennsylvania. That's, I think that's considered to be the norm, isn't it? You know, the dead walk there. So, yeah. And whenever Katie tells me that we have reached, yes, one side is going to need more dead people. That is the nature of voting. So I think the voting is completed and it is an unequivocal victory. So the victory goes to the Ohio State University team who have 70% of the vote and the University of Pennsylvania have 30% of the vote. Just remember, each team was given the side that they were arguing and it's an exercise. It's a mental exercise as to how well you can marshal the arguments and defend your points of view. And both of you did it very well. And so here I'm going to hand over again to Oren. I didn't know that I was ending this, but thank you so much, everybody. This has been wonderful. And thank you everybody for attending. Remember that we will have debates tomorrow. The pediatric debate tomorrow, I believe at 6.15 PM Pacific time. So please tune in. Thank you. Thanks very much. Thanks everybody for taking part.

liver transplantation

COVID-19

acute liver failure

transplant urgency

survival benefit

contraindications

COVID-19 transmission

post-operative outcomes

resource utilization