Transplant Saves Selected Patients With Irreversible COVID-19 Lung Disease

By Ronnie Cohen

April 09, 2021

(Reuters Health) - Double lung transplants are the only known way to save the lives of people with acute respiratory distress syndrome and irreversible lung damage from COVID-19, a new study shows.

The Lancet Respiratory Medicine study examined 12 of the first bilateral lung transplants in COVID-19 patients. They were performed between May and September 2020 on critically ill people between the ages of 18 and 66 in the U.S., Italy, Austria and India.

All but two of the patients survived and are doing well, said lead author Dr. Ankit Bharat, chief of thoracic surgery at Northwestern Medicine in Chicago.

"It's a really remarkable outcome, given how critically ill these patients were," he told Reuters Health in a phone interview. "Without the possibility of transplant, the medical team and the families were ready to withdraw care."

Bharat and his team at Northwestern performed the first COVID-19 lung transplant in the U.S. in June on Mayra Ramirez, a fit 28-year-old paralegal. Because she suffers from neuromyelitis optica, a central nervous system autoimmune disease, one theory about why she became so sick is because she was being treated with immune-suppressing steroids.

Ramirez is back to running most every day, and she recently beat Bharat in a squatting competition. "If you saw her," he said, "you would not believe she almost died."

Bharat and members of other worldwide transplant teams formed a consortium to examine best practices in lung transplantation as a result of a COVID-19 infection. They propose guidelines for lung transplant candidates, including that patients be younger than 65, have no pre-existing comorbidities, or only manageable ones, and have un-survivable lung injury.

In addition, they believe transplants should be performed only on people at least four weeks after they've been diagnosed with severe ARDS and irreversible lung damage. The patients studied received transplants a median of 70 days after being placed on ventilators or receiving extracorporeal membrane oxygenation (ECMO).

"You don't want to pull the trigger too fast," Bharat said. But, he added, "You also don't want to wait too long so that they develop a complication and die."

"If they are developing signs of catastrophic complications, patients should be considered at that point, or they will die," he said.

The panel also recommended that lung transplant candidates should not smoke, be dependent on drugs or alcohol or have irreversible brain damage. Candidates should have postoperative social and financial support, two negative COVID-19 polymerase chain reaction (PCR) tests 24 hours apart, and should generally have a body mass index in the range of 17 to 32 kg/m.

To date, more than 50 double lung transplants had been performed in the U.S. in people who suffered irreversible lung damage following infection with the novel coronavirus, said Bharat, who performed a dozen of them.

"All the American patients are alive and doing well," he said.

Bharat recently performed a lung transplant on one of the first people in Chicago to test positive for the coronavirus. The person had been released from the hospital, but persistent lung issues led to the double transplant.

Dr. Daniel Kaul, who directs the Transplant Infectious Disease Service at the University of Michigan, said in an email he was not surprised that lung transplantation succeeded in patients following COVID-19 infection, though physicians had little experience treating other similar forms of lung damage with transplantation.

In the past, patients with acute lung injury from infections generally have not been considered for transplantation.

Asked if he was concerned that the pandemic could further deplete an already scarce supply of healthy lungs for transplantation, Kaul, who was not involved with the study, said he believes the number of COVID-19 lung transplants is "likely to be small."

Bharat has been struck with the randomness of the novel coronavirus' severity and has felt compelled to step in to help.

"For the most part, these patients did everything right," he said. "I think as a medical community it's our responsibility to help these patients and save them and come up with innovative solutions to bridge the supply-demand gap" that limits the availability of organs for transplant.

SOURCE: The Lancet Respiratory Medicine, March 31, 2021.