Early Impact of COVID-19 on Transplant Center Practices and Policies in the United States

Brian J. Boyarsky; Teresa Po-Yu Chiang; William A. Werbel; Christine M. Durand; Robin K. Avery; Samantha N. Getsin; Kyle R. Jackson; Amber B. Kernodle; Sarah E. Van Pilsum Rasmussen; Allan B. Massie; Dorry L. Segev; Jacqueline M. Garonzik-Wang

Disclosures

American Journal of Transplantation. 2020;20(7):1809-1818. 

In This Article

Abstract and Introduction

Abstract

COVID-19 is a novel, rapidly changing pandemic: consequently, evidence-based recommendations in solid organ transplantation (SOT) remain challenging and unclear. To understand the impact on transplant activity across the United States, and center-level variation in testing, clinical practice, and policies, we conducted a national survey between March 24, 2020 and March 31, 2020 and linked responses to the COVID-19 incidence map. Response rate was a very high 79.3%, reflecting a strong national priority to better understand COVID-19. Complete suspension of live donor kidney transplantation was reported by 71.8% and live donor liver by 67.7%. While complete suspension of deceased donor transplantation was less frequent, some restrictions to deceased donor kidney transplantation were reported by 84.0% and deceased donor liver by 73.3%; more stringent restrictions were associated with higher regional incidence of COVID-19. Shortage of COVID-19 tests was reported by 42.5%. Respondents reported a total of 148 COVID-19 recipients from <1 to >10 years posttransplant: 69.6% were kidney recipients, and 25.0% were critically ill. Hydroxychloroquine (HCQ) was used by 78.1% of respondents; azithromycin by 46.9%; tocilizumab by 31.3%, and remdesivir by 25.0%. There is wide heterogeneity in center-level response across the United States; ongoing national data collection, expert discussion, and clinical studies are critical to informing evidence-based practices.

Introduction

COVID-19 has quickly and dramatically impacted the world.[1–5] Given the early nature of the pandemic, knowledge about COVID-19 and its impact on solid organ transplantation (SOT) patients is limited to case reports and expert discussion.[6–8] There is insufficient knowledge about the natural history of COVID-19,[9,10] including lack of understanding about the potential for donor-derived infection given imperfections in currently available diagnostic tests.[2,11] There is ongoing nosocomial and community spread,[12] and more severe illness has been observed for patients with underlying conditions.[3,13–17] Previous experience with related viruses, SARS-CoV in 2003,[18] and MERS-CoV in 2015,[19] demonstrated that SOT recipients may be anticipated to have prolonged viral shedding, potentially increasing transmissibility, morbidity, and mortality.[6,20]

There are several ways transplant centers can approach the COVID-19 pandemic to mitigate risk for SOT candidates and recipients. Specifically, centers can restrict access to transplantation based on urgency and limit use of donors based on exposure risk. Transplant centers can modify evaluation and monitoring practices of non–COVID-19-SOT patients, develop screening and testing algorithms for suspected cases and treatment protocols for confirmed cases. Furthermore, centers can risk-stratify COVID-19–SOT patients based on disease severity to help allocate appropriate resources to the sickest and most vulnerable patients. However, there are currently no evidence based-guidelines to inform these practices.

To better understand the early impact of COVID-19 on transplant activity across the United States, and to explore center-level variation in testing, clinical practice, and policies, we conducted a national survey of US transplant centers between March 24, 2020 and March 31, 2020. We gathered data in 4 domains: (a) current transplant activity, (b) COVID-19 impact on practices, (c) testing algorithms, and (d) treatment practices. We purposefully conducted our survey at a relatively early stage of US COVID-19 activity in the hopes that rapid dissemination of center-level practices, policies, and perceptions could inform decision-making in other centers in the United States and around the world.

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