Impact of COVID-19 in Solid Organ Transplant Recipients

Transplantation as Treatment for Severe COVID-19

Given concerns for irreversible organ damage especially to the lungs from COVID-19, there has been increasing interest in transplantation for COVID-19 induced end-stage lung disease. First cases of lung transplantation in patients with COVID-19 have been reported in China and in Austria. In China, five lung transplantations were reported in PCR negative patients; one patient died 1 day after surgery.^[165,166] An Austrian team reported successful lung transplantation of a 44-year-old woman.^[167] Her PCR was still positive but non-infectivity was confirmed by negative culture. Two additional cases who had developed end-stage pulmonary fibrosis have been transplanted in the United States.^[168] Careful definition of clinical indications^[169] and long-term results are needed to more safely delineate when to consider transplantation as a treatment option for end-stage lung disease.

Table 1. General recommendations by selected transplantation societies for transplant center guidance
Society	Decision to transplant	Deceased donation	Living Donation	Transplant Candidates
American Society of Transplantation⁵²	Balance local COVID−19 epidemiology, resource availability (including of health care staff) with need for transplant. Temporary suspension of elective living donor transplantation or non-urgent deceased donor transplants may be considered based on local concerns.	Epidemiologic screen and ≥1 respiratory tract NAT (BAL for lungs) within 72 hours of donation.	Exclude living donors with COVID−19 (symptoms and/or NAT positive). Epidemiologic and NAT screening (respiratory tract only) within 72 hours of donation. Pre donation self- quarantine 14 days.	Defer transplantation for active SARS-CoV−2 infection. NAT negative at time of transplant; disease-free interval not specified.
American Society of Transplant Surgeons⁵³	Consider curtailing transplantation services when 20–25% of hospital resources are committed to COVID−19 care or there is a very rapid increase in COVID−19 population numbers. Assumes availability of appropriate PPE and measures for HCW screening, social distancing and COVID−19 free areas in transplant center.	Epidemiology screen including local donor hospital environment/exposures by NAT (BAL recommended). Chest CT findings of ground glass should be assessed in view of COVID−19 risk. Local team organ recovery preferred Strict adherence to use of PPE for all phases of recovery (including travel)	Exclude living donors who are NAT positive. NAT screening 2 days prior to donation. Negative CXR Asymptomatic donors should self-isolate for a minimum of 7 days, preferably 7–14 days. Special informed consent form of COVID−19 risk appreciation.	Transplant surgery/immunosuppression is not advised in symptomatic or asymptomatic infected individuals with COVID−19
The Transplantation Society⁵⁴	All transplant-related teams should develop plans for: HCW absences due to illness, identification of remote workforce, messaging for patients with contacts in case of illness, risk mitigation, screening of sick patients.	Epidemiologic and NAT screening of all donors. Defer use of donors with COVID−19 unless 14 days since symptom onset and ideally two negative NAT for SARS-CoV−2.	Epidemiologic and NAT screening of all donors. Defer use of donors with COVID−19 unless 14 days since symptom onset and ideally two negative NAT for SARS-CoV−2.	Discussion of risk benefit of transplantation with candidate during the ongoing pandemic. Defer transplantation of infected patients until 10–14 days since symptom onset, resolution of symptoms and two negative NAT tests separated by 24 hours.
International Society of Heart and Lung Transplantation⁵⁵	Decisions regarding transplantation made locally based on rate of SARS-CoV−2 infection in the community and availability of health care resources, unless otherwise directed by regional or national authorities. Regularly re-evaluate policy and consider individual patient risk benefit as well as local resource issues. Transplant cessation not recommended unless dictated by local circumstances.	Defer donors with active infection. Consider donors with former COVID−19 if two negative NAT 24–48 hours apart if complete clinical recovery and at least 28 days from symptom onset.	Not applicable	Defer transplantation for NAT positive candidates and those with consistent symptoms (regardless of NAT). If history of symptomatic COVID−19, defer transplantation until two negative NAT tests separated by 24–48 hours following full resolution of illness. If history of asymptomatic COVID−19, 14 days must have elapsed since diagnosis and must have two negative NAT tests 24–48 hours apart.

Table 1. General recommendations by selected transplantation societies for transplant center guidance

Society

Decision to transplant

Deceased donation

Living Donation

Transplant Candidates

American Society of Transplantation⁵²

Balance local COVID−19 epidemiology, resource availability (including of health care staff) with need for transplant.
Temporary suspension of elective living donor transplantation or non-urgent deceased donor transplants may be considered based on local concerns.

Epidemiologic screen and ≥1 respiratory tract NAT (BAL for lungs) within 72 hours of donation.

Exclude living donors with COVID−19 (symptoms and/or NAT positive).
Epidemiologic and NAT screening (respiratory tract only) within 72 hours of donation.
Pre donation self- quarantine 14 days.

Defer transplantation for active SARS-CoV−2 infection.
NAT negative at time of transplant; disease-free interval not specified.

American Society of Transplant Surgeons⁵³

Consider curtailing transplantation services when 20–25% of hospital resources are committed to COVID−19 care or there is a very rapid increase in COVID−19 population numbers.
Assumes availability of appropriate PPE and measures for HCW screening, social distancing and COVID−19 free areas in transplant center.

Epidemiology screen including local donor hospital environment/exposures by NAT (BAL recommended).
Chest CT findings of ground glass should be assessed in view of COVID−19 risk.
Local team organ recovery preferred
Strict adherence to use of PPE for all phases of recovery (including travel)

Exclude living donors who are NAT positive.
NAT screening 2 days prior to donation.
Negative CXR
Asymptomatic donors should self-isolate for a minimum of 7 days, preferably 7–14 days. Special informed consent form of COVID−19 risk appreciation.

Transplant surgery/immunosuppression is not advised in symptomatic or asymptomatic infected individuals with COVID−19

The Transplantation Society⁵⁴

All transplant-related teams should develop plans for: HCW absences due to illness, identification of remote workforce, messaging for patients with contacts in case of illness, risk mitigation, screening of sick patients.

Epidemiologic and NAT screening of all donors.
Defer use of donors with COVID−19 unless 14 days since symptom onset and ideally two negative NAT for SARS-CoV−2.

Discussion of risk benefit of transplantation with candidate during the ongoing pandemic.
Defer transplantation of infected patients until 10–14 days since symptom onset, resolution of symptoms and two negative NAT tests separated by 24 hours.

International Society of Heart and Lung Transplantation⁵⁵

Decisions regarding transplantation made locally based on rate of SARS-CoV−2 infection in the community and availability of health care resources, unless otherwise directed by regional or national authorities.
Regularly re-evaluate policy and consider individual patient risk benefit as well as local resource issues.
Transplant cessation not recommended unless dictated by local circumstances.

Defer donors with active infection.
Consider donors with former COVID−19 if two negative NAT 24–48 hours apart if complete clinical recovery and at least 28 days from symptom onset.

Not applicable

Defer transplantation for NAT positive candidates and those with consistent symptoms (regardless of NAT).
If history of symptomatic COVID−19, defer transplantation until two negative NAT tests separated by 24–48 hours following full resolution of illness.
If history of asymptomatic COVID−19, 14 days must have elapsed since diagnosis and must have two negative NAT tests 24–48 hours apart.

Impact of COVID-19 in Solid Organ Transplant Recipients

Transplantation as Treatment for Severe COVID-19

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