Navigating the COVID-19 Pandemic: Initial Impacts and Responses of the Organ Procurement and Transplantation Network in the United States

Rebecca R. Goff; Amber R. Wilk; Alice E. Toll; Maureen A. McBride; David K. Klassen

Disclosures

American Journal of Transplantation. 2021;21(6):2100-2112. 

In This Article

Abstract and Introduction

Abstract

COVID-19 has been sweeping the globe, hitting the United States particularly hard with a state of emergency declared on March 13, 2020. Transplant hospitals have taken various precautions to protect patients from potential exposure. OPTN donor, candidate, and transplant data were analyzed from January 5, 2020 to September 5, 2020. The number of new waiting list registrations decreased, with the Northeast seeing over a 50% decrease from the week of 3/8 versus the week of 4/5. The national transplant system saw near cessation of living donor transplantation (−90%) from the week of 3/8 to the week of 4/5. Similarly, deceased donor kidney transplant volume dropped from 367 to 202 (−45%), and other organs saw similar decreases: lung (−70%), heart (−43%), and liver (−37%). Deceased donors recovered dropped from 260 to 163 (−45%) from 3/8 compared to 4/5, including a 67% decrease for lungs recovered. The magnitude of this decrease varied by geographic area, with the largest percent change (−67%) in the Northeast. Despite the pandemic, discard rates across organ has remained stable. Although the COVID-19 pandemic continues to evolve, OPTN data show recent evidence of stabilization, an indication that an early recovery of the number of living and deceased donors and transplants has ensued.

Introduction

On January 30, 2020, the World Health Organization declared a Public Health Emergency of International Concern related to the newly discovered coronavirus disease 2019 (COVID-19).[1] The United States (US) subsequently declared a public health emergency related to COVID-19 on January 31, 2020, and a national state of emergency on March 13, 2020.[2] Despite the adoption of public health measures such as social distancing and closure of non-essential businesses, the rates of COVID-19 in the US continued at a pace above other countries.[3] Centers for Disease Control (CDC) data showed that the US (and territories) currently lead the world in the number of confirmed cases at over 6.6 million from January 21 to September 17, 2020,[4] with three states reporting over 600,000 cases and five reporting over 200,000. The long-term impacts of COVID-19 on the healthcare system, and more specifically on the transplant system in the United States, remain unknown, but the initial impact on solid organ transplantation was dramatic.

The risks of disease transmission through solid organ transplantation and the implications for transplant recipients, transplant center staff, and Organ Procurement Organization (OPO) staff are unknown.[5] Recent publications detail potential impacts to donor organs, including kidney, liver, and heart, though sample sizes are small, data are limited, and not all reports have undergone peer review.[6–11] Given the respiratory nature of COVID-19, there are obvious impacts to the lungs. As suggested by Michaels et al., the initial responses were guided by the experience from past infectious disease emergencies, such as severe acute respiratory syndrome coronavirus (SARS), Middle East respiratory syndrome coronavirus (MERS), West Nile virus, and Zika. This included appropriate donor, patient, and staff screening, recipient evaluation, and development of patient logistics plans, such as multi-listing, to navigate the effects of the COVID-19 pandemic on transplantation. Moris et al. noted the importance of customizing clinical decision-making by patient within hospitals, including consideration of resource availability (such as staff and testing) during COVID-19 balanced with medical urgency (which may vary by organ) and transparent patient discussions regarding potential risk of transmission or death given the limited knowledge of COVID-19 implications.[5,12] An article detailing the Italian experience regarding COVID-19 and transplant described the preventative measures, including infection control and hygiene, limiting surgical activities, and screening/isolation that were implemented in an attempt to ensure safe practice.[13] Kumar et al. discussed various mitigation strategies and considerations, such as embedding transplant infectious disease specialists in programs.[14] Transplant clinicians voiced concerns and urgency for patients with debilitating, life-threatening illnesses, noting that lack of access to transplantation could result in high mortality.[15] Wall et al. presented a discussion on ethical decision-making for organ transplantation in a time of resource scarcity and practical limitations,[16] while Fix et al. and Tzedakis et al. proposed a template of clinical recommendations for liver transplantation.[17,18] Early documentation of the effect of COVID-19 on future need for organ transplantation, Chen et al. reported a successful lung transplantation in a patient with end-state respiratory failure due to COVID-19 infection.[19]

Qualitative data continue to be shared worldwide regarding the impact to transplantation from COVID-19;[20] reports described decreased transplant volumes, complete suspension of live donation in some centers, approaches to donor testing, and modified recipient follow-up through tools such as telehealth.[21,22] Studies from France and Spain showed profound decreases in deceased donor transplantation.[23,24] In the United States, Boyarsky et al. and Cholankeril et al. showed a major decrease in waiting list registrations and an increase in waitlist mortality, specifically for kidney transplantation.[25,26]

In March 2020, the Centers for Medicare and Medicaid issued guidance recommending that transplantation surgeries, classified as Tier 3b procedures, should not be postponed, if possible.[27] This allowed the transplant community to make decisions on a candidate-by-candidate basis to reduce the risk to transplant candidates, living donors, recipients, and care providers while continuing, when possible, to provide essential transplant services.

This report describes the initial impacts of the pandemic on the transplant system, including deceased and living donation as well as transplant candidates and recipients, in the United States and the responses of the OPTN to mitigate adverse outcomes.

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