Arch Iran Med. July 2020;23(7):507-508 Letter to Editor The Impacts of the COVID-19 Pandemic on Liver Transplant Patients; Time to Change the Priorities Arash Dooghaie Moghadam, MD 1 ; Pegah Eslami, MD 1 ; Niloofar Razavi-Khorasani, MD 2 ; Bobak Moazzami, MD 2 ; Mostafa Mousavizadeh, MD 3 ; Mohammad Reza Zali, MD 1* ; Amir Sadeghi, MD 1* 1 Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2 Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran 3 Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran *Corresponding Authors: Amir Sadeghi, MD; Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +98-21-22432525; Fax: +98-21-22432517; Email: amirsadeghimd188@gmail.com. Mohammadreza Zali, MD; Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +98-21-22432525 Fax: +98-21-22432517. Email: ltrc.tehran@gmail.com 10.34172/aim.2020.50 doi ARCHIVES OF IRANIAN MEDICINE Dear Editor, The current coronavirus disease 2019 (COVID-19) crisis has emerged as a global pandemic. 1,2 Iran has been widely exposed to the COVID-19 and has the fifth highest death toll from COVID-19. The Taleghani Liver Transplant Center, one of the high-volume liver transplant centers in the Middle East, has provided new guidelines for its ward and attempted to provide an appropriate model for these patients based on previous pandemic studies. According to the published studies, the first experience with a pandemic in the transplantation era was due to H5N1 pandemic. 3 In addition, the information on the influenza virus reminds us that transplanted patients are likely to constitute a larger number of symptomatic patients due to immunosuppression, if they are exposed to the pathogen and the disease. An Italian study showed that 20% of healthcare workers were infected with the new coronavirus and some of them died. 4 Therefore, in order to minimize the risk of healthcare providers’ exposure and reducing patients’ flow to hospitals, telemedicine could be used as a cheap and effective method for educating patients in developing countries. 5 Patients should be trained about the risks of attending public centers and disease prevention, considering the high burden of liver transplantation and its heavy costs to health systems. Therefore, specific training should be provided on the Internet and web- based platforms for these patients. They should inform their transplant physicians before any referral to the health centers for a preliminary evaluation of symptoms and provide a complete list of their medications and their transplant records. Previously, it has been demonstrated that higher virus levels could be found in the transplanted tissue after death when compared to the non-transplanted individuals. 6 Moreover, in a study by Al-Ghamdi et al, unfavorable outcomes were more frequently reported for transplanted individuals in the MERS-CoV virus. 7 Therefore, the Taleghani Center decided to focus on pandemic prevention of post-transplant infection and limit its surgical operations to emergency surgery considering the low probable outcome. Furthermore, owing to the pandemic nature of this disease and the need for ICU beds, it is recommended to avoid over-hospitalization and elective surgery, to consider isolated places for the patients’ follow-up in the early days, and to conduct patients’ follow-up and referrals through phone calls or clinically outside the hospital. Another aspect highly considered in liver transplant patients is the mental health status of these patients associated with the poorer transplantation outcome and inappropriate drug consumption by the patients. Regarding COVID 19, Xiang showed that like other pandemics, there is a growing concern about the death of patients and quarantined people. 8 A study by Bao also reported stress was caused by uncertainty about the condition and the exact time of disease control. 9 Thus, they predicted a higher risk of hopelessness and anxiety owing to chronic disease in transplanted patients. Undoubtedly, these patients should undergo psychiatric telephone counseling during the crisis for psychological assessments and stress reduction techniques, home exercise activities, and proper nutrition. Moreover, Wang et al showed that lower family income was associated with a lower rate of health-related quality of life. 10 Accordingly, during this pandemic, financial support for these patients from the government or other foundations presumably improve their quality of life. Re-transplantation is also an important factor associated Open Access http://www.aimjournal.ir