Impact of COVID-19 in Solid Organ Transplant Recipients

Lara Danziger-Isakov; Emily A. Blumberg; Oriol Manuel; Martina Sester


American Journal of Transplantation. 2021;21(3):925-937. 

In This Article

The Impact of COVID-19 on Transplantation

COVID-19 had immediate impact on transplant activity as the infection became more widespread throughout the world. Initial reports from the Italian epicenter revealed a 25% decline in deceased donation nationally with a more pronounced decline in northern Italy where the rates of COVID-19 were highest.[22] During the height of the first wave of the pandemic in Spain, there was nearly an eightfold decrease in transplant activity.[23] France, the Netherlands, and the United Kingdom (UK) also experienced substantial declines with lower transplant rates driven by 50–90% decrease in deceased donation during the peak COVID-19 months.[24–26] Review of data from the United States' United Network of Organ Sharing (UNOS) comparing monthly transplants in January and February 2020 with those performed in April 2020 demonstrated a 35.9% decrease in organs transplanted.[27]

Several themes emerged from all reports. The impact on specific programs exposed notable regional variation, reflecting in part local COVID-19 rates,[28–31] but also individualized approaches to resource allocation and prioritization.[30] The impact on organ transplantation also varied with respect to organ type with preferential deferral of kidney transplant candidates who were stable on renal replacement therapy and/or had lower immunologic barriers to transplantation.[23,26,27,31,32] However, the majority of reports also noted a decline in transplantation in all organ types.[32] Living donor programs were generally curtailed or suspended in many sites.[25,32,33]

Reasons for the decline in donations were diverse and explained by changes at multiple levels in the transplant process, although the impact of individual policies remains uncertain at this time. An overall decline was driven by a decrease in available ICU beds for maintaining donors due to use for treatment of critically ill COVID-19 patients.[22] The demographics of the available donors shifted with a 5% decline in trauma death donors, 35% increase in donor death by substance abuse, and a decreased willingness to use donors with circulatory deaths in whom post-operative transplant recovery would be anticipated to be prolonged.[22,34] Donor screening practices varied but in many cases, donors with potential SARS-CoV-2 exposure or presentations consistent with COVID-19, regardless of testing results, were excluded.[23] Moreover, in many locations, instead of greater geographic sharing of organs, there was a preference for using local organs where regional COVID-19 rates were known and the ability to protect the procurement teams might have been greater.[33] Given restricted hospital access and concerns for SARS-CoV-2 exposures, the authorization process for deceased donation involved more telephonic and virtual communication.[34] Live donation also declined, in part due to concerns about exposing healthy living donors to a greater risk of contracting SARS-CoV-2.[25,35] Notably, restricted air travel may also have affected prompt organ transport, with potential impact on cold ischemic times.[36]

Other factors impacting transplantation included limitations of resources (beds, surgical suites, ventilators, blood products, and renal replacement therapies) and personnel due to local COVID-19 demands.[32,37] Surveys also revealed a reluctance to bring stable transplant candidates into hospitals where they might be at greater risk of being exposed to SARS-CoV-2.[32]

The impact on outcomes of the decline in organ donation and transplantation is difficult to assess at this time. Although recent reports from UNOS suggest that overall waitlist deaths may not have significantly increased in 2020,[27] an increase in waitlist hospitalizations and deaths were observed at least in some areas in the first wave of the pandemic.[27,38,39] In the US, waitlist deaths were more numerous in areas with the highest rates of COVID-19; a study from New York revealed a mortality of 34% of waitlist patients as compared to 16% of kidney transplant recipients.[39] Whether candidates died of COVID-19 or of the indirect effects of limited on-site care has not been elucidated. It is also unknown how many individuals died without being added to the waitlist; however, the reports of curtailed evaluations at some centers suggest the possibility that the pandemic may have indirectly contributed to deaths in individuals who never had access to transplant evaluation.[37,40]

Despite the ongoing community spread of SARS-CoV-2, there is evidence that transplant activity has been resumed in many locations.[28] Whether rising rates of SARS-CoV-2 infections will again impact donation and transplantation remains unclear. Guidance for transplant management including suspension and resumption of transplantation has been provided by national and international transplant societies/organizations (Table 1) and there are also published guidance documents; however, there has been heterogeneity of actual practices and these principles may guide activity during the second and third waves of the pandemic.[32,37,41–46] General recommendations for full resumption of transplantation activity[41,44] as well as recommendations on donation practices have been updated during the pandemic to improve the safety of both the donor organ and procurement teams[47–50] (Table 1). The increasing use of telemedicine for outpatient management at all phases of care has been described internationally during the pandemic and has been increasingly adopted.[32,51]