Transplantation decline in COVID-19 pandemic may be due to ‘uncertainty’ in transplant community
Findings from two recently published articles point to a significant reduction in the number of overall solid-organ transplantation procedures performed, with the most notable decline seen in kidney transplantation.
Responses of surveyed transplantation centers across the United States led Brian J. Boyarsky, MD, of the department of surgery at Johns Hopkins University School of Medicine, and colleagues to suggest the “high rates of transplant program cessation are likely reflective of uncertainty regarding the impact of COVID-19 on [solid-organ transplantation] SOT candidates and recipients, and the potential for exponential case growth to overwhelm our current health care system.”
Noting several ways in which transplant centers can “mitigate risk” for candidates and recipients — including restricting access to transplantation based on urgency and limiting donors based on exposure risk — the researchers argued that current guidelines exist outside of evidence-based practice.
The survey, which was conducted between March 24 and March 31, addressed current transplant activity, COVID-19 impact on practices, testing algorithms and treatment practices. The researchers wrote that the response rate was high (79.3%), which they indicated may demonstrate “a strong national priority to better understand COVID-19.”
Results showed much heterogeneity in practices between centers, with complete suspension of live donor kidney transplantation reported by 71.8% of all centers (live donor liver transplantation suspended by 67.7%).
In addition, restrictions to deceased donor kidney transplantation were reported by 84% of centers with “more stringent restrictions” occurring in areas of greater COVID-19 incidence.
The researchers also provided examples of such restrictions. For live donor transplantation, these restrictions included conducting preemptive kidney transplants or transplanting only recipients who were “well” or had no dialysis access. For deceased donor transplantation, restrictions included transplanting only highly sensitized patients, those with negative crossmatch, higher acuity patients and those without dialysis access.
According to the researchers, “some centers reported transplanting only healthier recipients with the best quality organs and lowest risk of delayed graft function.”
Further findings demonstrated a shortage of COVID-19 tests (reported by 42.5% of centers).
For recipients with COVID-19, 78.1% of centers reported using hydroxychloroquine, while 25% used remdesivir (Gilead Sciences Inc.).
“Given the lack of uniform protocols, the variation in centerspecific practices is not surprising and likely driven by the anecdotal and reported experiences of transplant centers in other countries or hotspots within the United States, who have experience exponential increases in COVID-19 hospital admissions and deaths,” the researchers contended.
They added that the results support an “uncertainty” faced by the transplant community, as many respondents expressed concern for inadequate personal protective equipment and hospital level resources.
“Without successful evidence-based treatment paradigms or even consistent recipient and donor testing availability,” they concluded, “uncertainty will likely continue to drive variation and reduction in transplant volume.”
A joint analysis of transplant procedures in France and the United States also found a decline in transplantation rates, with researchers suggesting centers may be concerned that recipients could have “greater susceptibility to infection and increased viral burden,” as well as a lack of hospital resources (staff and equipment) to care for recipients after the procedure.
In a related press release, Peter Reese, MD, MSCE, associate professor of medicine and epidemiology at the University of Pennsylvania, said, “Our findings point to the far-reaching and severe ripple effects of the COVID-19 outbreak on health care, including life-saving organ transplants.”
Using organ procurement and transplantation data from two federal agencies (the National Organ Procurement Agency in France and the United Network for Organ Sharing in the United States), the researchers observed a temporal association between the increase in COVID-19 infections and the reduction in overall transplantation procedures, with researchers noting the reduction was “mostly driven by kidney transplantation.”
Since the COVID-19 outbreak, the overall reduction in deceased donor transplantation was 90.6% in France and 51.1% in the United States.
“Organs from deceased donors represent a time-limited opportunity, as they must be procured and used rapidly,” Reese said. “However, in order to protect the safety of their patients, centers must now carefully vet all donors to ensure there is minimal risk of COVID-19.”
The researchers emphasized the reduction was seen even in regions where COVID-19 cases were low, which they suggested expresses the effect “goes beyond infection prevalence.”
According to co-author Alexandre Loupy, MD, PhD, head of the Paris Transplant Group, these types of international comparisons of transplant activity are “very important.”
“Some transplant systems may develop best practices to support organ procurement and transplant that can be shared across borders,” he said in the press release.
Furthermore, the researchers contended that the continued and detailed mapping of transplantation trends will be essential, even as the COVID-19 burden lessens.
Mapping, they wrote, “will allow public health leaders and transplant organizations to identify areas where transplants have not recovered well and support is needed.”– by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.