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

Impact of the COVID-19 pandemic on services for patients with chronic kidney disease: findings of a national survey of UK kidney centres

BACKGROUND

Services for patients with kidney disease underwent radical adaptations in response to the COVID-19 pandemic. We undertook an online national survey of UK kidney centres to understand the nature, range, and degree of variation in these changes and to explore factors contributing to differing practice.

METHODS

The survey was designed by a multidisciplinary team of kidney professionals, service users and researchers. It enquired about centre services and staffing, including psychosocial provision, and changes to these in response to the COVID-19 pandemic. Links to the survey were sent to all 68 UK kidney centres and remained active from December 2021 to April 2022, and a revised version to nurses in late 2022 for additional data. Quantitative data were analysed descriptively. Content analysis on free-text responses identified common themes.

RESULTS

Analysable responses were received from 41 out of the 68 UK centres (60%), with partial data from an additional 7 (11%). Adaptations were system-wide and affected all aspects of service provision. Some changes were almost universal such as virtual consultations for outpatient appointments, with significant variation in others. Outpatient activity varied from fully maintained to suspended. Many centres reduced peritoneal dialysis access provision but in some this was increased. Centres considered that changes to transplant surgical services and for patients with advanced CKD approaching end-stage kidney disease had the greatest impact on patients. Few centres implemented adjustments aimed at vulnerable and underrepresented groups, including the frail elderly, people with language and communication needs, and those with mental health needs. Communication issues were attributed to rapid evolution of the pandemic, changing planning guidance and lack of resources. Staffing shortages, involving all staff groups particularly nurses, mainly due to COVID-19 infection and redeployment, were compounded by deficiencies in staffing establishments and high vacancy levels. Centres cited three main lessons influencing future service delivery, the need for service redesign, improvements in communication, and better support for staff.

CONCLUSION

Kidney centre responses to the pandemic involved adaptations across the whole service. Though some changes were almost universal, there was wide variation in other areas. Exploring the role of centre characteristics may help planning for potential future severe service disruptions.

The COVID-19 Pandemic and Adult Cardiac Transplantation: Impact, Interventions, and Implications

In this review, we provide a comprehensive overview of the impact of the COVID-19 pandemic on adult heart transplantation. We highlight the decline in the number of adult transplantations performed throughout the pandemic as a consequence of restrictions imposed on individual programs and hospitals. There were challenges to maintaining cardiac transplant activity at multiple levels, including organ donation in intensive care units, logistical difficulties with organ procurement, and rapidly changing resource considerations at health system and jurisdictional levels. We also review the impact of COVID-19 on cardiac transplant recipients. Despite the high rates of morbidity and mortality observed during the initial phases of the pandemic among heart transplant patients infected with COVID-19, the availability of effective vaccines, pre-exposure prophylaxis, and specific antiviral therapies have drastically improved outcomes over time. Vaccines have proven to be safe and effective in reducing infections and illness severity, but specific considerations in the immunocompromised solid organ transplant population apply, including the need for additional booster doses to achieve sufficient immunisation. We further outline the strong rationale for vaccination before transplantation wherever possible. Finally, the COVID-19 response created a number of barriers to safe and efficient post-transplantation care. Given the need for frequent evaluation and monitoring, especially in the first several months after cardiac transplantation, the pandemic provided the impetus to improve virtual care delivery and explore noninvasive rejection surveillance through gene expression profiling. We hope that lessons learned will allow us to prepare and pivot effectively during future pandemics and health care emergencies.

Changing landscape of living kidney donation and the role of telemedicine

PURPOSE OF REVIEW

There has been a decline in living kidney donation over the last two decades. Donors from low-income families or racial/ethnic minorities face greater disproportionate geographic, financial, and logistical barriers to completing lengthy and complex evaluations. This has contributed to the decreased proportion of these subgroups. The authors view telemedicine as a potential solution to this problem.

RECENT FINDINGS

Since the initial decline of donors in 2005, biologically related donors have experienced a lack of growth across race/ethnicity. Conversely, unrelated donors have emerged as the majority of donors in recent years across race/ethnicity, except for unrelated black donors. Disparities in access to living kidney donation persist. Telemedicine using live-video visits can overcome barriers to access transplant centers and facilitate care coordination. In a U.S. survey, nephrologists, surgeons, coordinators, social workers, and psychologists/psychologists across transplant centers are favorably disposed to use telemedicine for donor evaluation/follow-up beyond the coronavirus disease 2019 pandemic. However, with the waning of relaxed telemedicine regulations under the Public Health Emergency, providers perceive payor policy and out-of-state licensing as major factors hindering telemedicine growth prospects.

SUMMARY

Permanent federal and state policies that support telemedicine services for living kidney donation can enhance access to transplant centers and help overcome barriers to donor evaluation.

COVID-19 and liver disease

Knowledge on SARS-CoV-2 infection and its resultant COVID-19 in liver diseases has rapidly increased during the pandemic. Hereby, we review COVID-19 liver manifestations and pathophysiological aspects related to SARS-CoV-2 infection in patients without liver disease as well as the impact of COVID-19 in patients with chronic liver disease (CLD), particularly cirrhosis and liver transplantation (LT). SARS-CoV-2 infection has been associated with overt proinflammatory cytokine profile, which probably contributes substantially to the observed early and late liver abnormalities. CLD, particularly decompensated cirrhosis, should be regarded as a risk factor for severe COVID-19 and death. LT was impacted during the pandemic, mainly due to concerns regarding donation and infection in recipients. However, LT did not represent a risk factor per se of worse outcome. Even though scarce, data regarding COVID-19 specific therapy in special populations such as LT recipients seem promising. COVID-19 vaccine-induced immunity seems impaired in CLD and LT recipients, advocating for a revised schedule of vaccine administration in this population.

Telemedicine services for living kidney donation: A US survey of multidisciplinary providers

Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine can facilitate healthcare access/care coordination. Yet difficulties exist in telemedicine implementation and sustainability. We sought to examine centers' practices and providers' attitudes toward telemedicine to improve services for donors. We surveyed multidisciplinary providers from 194 active adult US living donor kidney transplant centers; 293 providers from 128 unique centers responded to the survey (center representation rate = 66.0%), reflecting 83.9% of practice by donor volume and 91.5% of US states/territories. Most centers (70.3%) plan to continue using telemedicine beyond the pandemic for donor evaluation/follow-up. Video was mostly used by nephrologists, surgeons, and psychiatrists/psychologists. Telephone and video were mostly used by social workers, while video or telephone was equally used by coordinators. Half of respondent nephrologists and surgeons were willing to accept a remote completion of physical exam; 68.3% of respondent psychiatrists/psychologists and social workers were willing to accept a remote completion of mental status exam. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation. However, providers (65.5%) perceived out-of-state licensing as a key policy/regulatory barrier. These findings help inform practice and underscore the instigation of policies to remove barriers using telemedicine to increase living kidney donation.

Outcomes of Anesthesiologist-Led Care of Patients Following Liver Transplantation During the COVID-19 Pandemic

Background

During the COVID-19 pandemic, anesthesiologists were redeployed as transplant ICU intensivists and a postanesthesia care unit was converted to a novel transplant ICU. This study compared the outcomes of patients undergoing liver transplantation under the new model with the prepandemic model.

Methods

Adult patients who underwent liver transplantation at an urban tertiary care center in the United States from December 28, 2015, through May 1, 2020, were identified and grouped according to date of procedure. Peri-COVID cases included transplants that were performed after March 3, 2020. Transplants performed before March 3, 2020, served as pre-COVID controls.

Results

A total of 523 liver transplant patients (30 study cases, 493 controls) were included. Kaplan-Meier survival analysis showed no significant difference in novel transplant ICU length of stay (N-TLOS) (median LOS 3.8 vs. 4.5 days, log-rank p = 0.60) and hospital length of stay (HLOS) (median LOS 14.2 vs. 14.5 days, log-rank p = 0.66). Cox proportional hazards regression with inverse probability of treatment weighting showed no difference in N-TLOS (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.67–1.23, p = 0.55) or HLOS (HR 0.90, 95% CI 0.65–1.25, p = 0.52). In addition, there were no significant differences (pre-COVID vs. COVID) in time to extubation (median [interquartile range] 28.7 [20.6–50.7] vs. 26.8 [17.4–40.8] hours, p = 0.35), one-year patient survival (12.0% vs. 6.7%, p = 0.055), one-year graft survival (13.4% vs. 6.7%, p = 0.43), and readmission to the ICU (15.0% vs. 20.0%, p = 0.68).

Conclusion

Care provided by non-intensivist anesthesiologists to patients undergoing orthotopic liver transplantation during a pandemic emergency resulted in outcomes similar to those of care provided by intensivists.

Impact of COVID-19 pandemic on clinicopathological features of transplant recipients with hepatocellular carcinoma: A case-control study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on the management of all diseases. Various diseases such as cancer have a higher risk of COVID-19-related death. Despite this fact, any delay or alteration in treatment of cancer may have fatal consequences. Hepatocellular carcinoma (HCC) is an aggressive liver cancer that requires multimodality treatment to improve survival.

AIM

To evaluate the impact of COVID-19 on the management of patients with HCC by determining changes in demographic, clinical and histopathological variables.

METHODS

Demographic, clinical and pathological variables of patients with HCC who had undergone liver transplantation between March 2020 and June 2021 (Pandemic group, n = 48) were retrospectively compared with that of the patients with HCC transplanted between November 2018 and March 2020 (Pre-pandemic group, n = 61).

RESULTS

The median age of the patients in the study was 56 (interquartile range = 15). Ninety-seven patients (89%) were male and 12 were female (11%). The most common etiology of liver disease was hepatitis B virus (n = 52, 47.7%). According to our results, there was a 21.3% drop in the number of patients transplanted for HCC. There was no difference in the demographic, clinical and pathological characteristics of the patients except blood alkaline phosphatase levels (P = 0.029), lymphovascular invasion (P = 0.019) and type of the liver graft that was transplanted (P = 0.017).

CONCLUSION

It is important to develop a surveillance strategy for liver transplant centers. The liver transplantation for HCC is justified and safe provided that strict surveillance protocols are applied.

Telehealth Use by Living Kidney Donor Transplant Programs During the COVID-19 Pandemic and Beyond: a Practical Approach

Purpose of Review

COVID-19 pandemic led to a decline in living kidney donor evaluations and transplants. This was due to concerns for donor and recipient safety, restrictions on elective cases, and diversion of staff and resources in centers with a higher incidence of COVID-19 infections. Telehealth was explored as a strategy to continue living donor evaluations during the pandemic, but faced barriers including restrictive physician licensing, reduced reimbursement, lack of infrastructure, prohibitive local policies, limited exam, and personal biases. This review highlights these barriers and potential solutions.

Recent Findings

Telehealth usage in the transplant population improves medication adherence, reduces hospitalization rates for recipients, and makes living donor evaluation convenient. Transplant centers have implemented telehealth successfully for living kidney donor evaluations. Broad use of telemedicine will be possible only if policies support the changing landscape of healthcare delivery.

Summary

Telehealth may increase access to timely kidney transplants by expediting living kidney donor evaluations. However, supportive infrastructure, regulatory policies, and reimbursement are needed to sustain access to telehealth for living kidney donor evaluation and care.

The Scope of Telemedicine in Kidney Transplantation: Access and Outreach Services

Access to transplant centers is a key barrier for kidney transplant evaluation and follow-up care for both the recipient and donor. Potential kidney transplant recipients and living kidney donors may face geographic, financial, and logistical challenges in engaging with a transplant center and maintaining post-transplant continuity of care. Telemedicine via synchronous video visits has the potential to overcome the access barrier to transplant centers. Transplant centers can start the evaluation process for potential recipients and donors via telemedicine, especially for those who have challenges to come for an in-person visit or when there are restrictions on clinic capacities, such as during a pandemic. Similarly, transplant centers can use telemedicine to sustain post-transplant follow-up care while avoiding the burden of travel and its associated costs. However, expansion to telemedicine-based kidney transplant services is substantially dependent on telemedicine infrastructure, insurer policy, and state regulations. In this review, we discuss the practice of telemedicine in kidney transplantation and its implications for expanding access to kidney transplant services and outreach from pretransplant evaluation to post-transplant follow-up care for the recipient and donor.

Coronavirus disease 2019 and renal transplantation

Ever since the severe acute respiratory syndrome virus causing coronavirus disease 2019 (COVID-19) struck the world, global health strategies have changed significantly. According to the Centers for Disease Control and Prevention, kidney transplant recipients are stratified as being high risk of developing fatal illness from COVID-19 infection. Kidney transplant is the gold-standard treatment for end-stage kidney disease subjects. During the pandemic, significant concerns have emerged regarding continuation of kidney transplant surgeries and management of kidney transplant recipients post-transplant. The added risk of immunosuppression in this cohort was and remains a theoretical concern, posing a potential risk of transplantation rather than benefit. This comprehensive review aims to cover most of the faced challenges in kidney transplantation in different stages of the pandemic. In addition, it will elucidate the epidemiology, nature, course of the disease, surgical consideration in donors and recipients as well as role of immunosuppression and management of COVID-19 infected kidney transplant recipients during these extraordinary circumstances.

Impact of COVID-19 on the number of transplants performed in Brazil during the pandemic. Current situation

The intense use of resources to combat COVID-19 causes concern in the entire transplant community because, in addition to physical limitations such as ICU beds, lack of homogeneous treatment protocols and uncertainties about the effects of immunosuppression on viral progression have significant impact on transplant surgeries. The aim of the present study is to comparatively assess the number of solid organ transplants performed in 2019 and 2020, as well as the impact of the COVID-19 pandemic on organ donation and transplant surgeries in Brazil. The last 10 years have shown increasing trend in the number of solid organ transplants, which have significantly decreased in 2020. Lung transplantations were mostly affected by the pandemic; these surgeries have been carried out only in Rio Grande do Sul and São Paulo states. Liver transplantations were the least affected ones, since the number of surgeries have only decreased by 10.8% in the first three quarters of 2020, in comparison to 2019. The number of active patients on the waiting list for heart and kidney transplantation has increased in 2020. Therefore, it is necessary developing strategies to keep the structure necessary for organ transplantation processes active and, consequently, to reduce the impacts of the pandemic on these patients.

Trends in Heart and Lung Transplantation in the United States Across the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a variable course across the United States. Understanding its evolving impact on heart and lung transplantation (HT and LT) will help with planning for next phases of this pandemic as well as future ones.

METHODS

We used Scientific Registry of Transplant Recipients data from before the pandemic to predict the number of waitlist registrations and transplants expected to occur between March 15, 2020, and December 31, 2020 (if no pandemic had occurred), and compared these expectations to observed rates. The observed era was divided into wave 1 (March 15-May 31), wave 2 (June 1-September 30), and wave 3 (October 1-December 31). We used multilevel Poisson regression to account for center- and state-level COVID-19 incidence.

RESULTS

During wave 1, rates of heart registrations and transplants were 28% (incidence rate ratio [IRR]: 0.72 [95% confidence interval (CI), 0.67-0.77]) and 13% (IRR: 0.87 [95% CI, 0.80-0.93]) lower than expected; lung registrations and transplants were 40% (IRR: 0.60 [95% CI, 0.54-0.66]) and 28% (IRR: 0.72 [95% CI, 0.66-0.79]) lower. Decreases were greatest in states with the highest incidence where registrations were 53% (IRR: 0.47 [95% CI, 0.36-0.62]) and 59% (IRR: 0.41 [95% CI, 0.29-0.58]) and transplants were 57% (IRR: 0.43 [95% CI, 0.31-0.60]) and 58% (IRR: 0.42 [95% CI, 0.29-0.62]) lower than expected. Whereas HT largely recovered during waves 2 and 3, LT continued to fall short of expectations through the end of the year.

CONCLUSIONS

The COVID-19 pandemic in the US substantially reduced thoracic transplant access. Ongoing evaluation of the risks and benefits of this dramatic practice change is critical to inform clinical decision-making moving forward.

Impact analysis of virtual ambulatory transplant pharmacists during COVID-19

INTRODUCTION

During the coronavirus disease 2019 (COVID-19) pandemic, transplant centers were challenged to meet the demand for new telemedicine strategies. The ability of lung transplant providers (LTP) to conduct face-to-face clinic visits for high-risk immunocompromised patients, such as lung transplant recipients (LTR), was limited. Through the implementation of comprehensive medication management visits, pharmacists were able to assist LTP in the transition to telemedicine.

METHODS

A retrospective chart review of telephone encounters from cardiothoracic (CT) transplant pharmacists at our center from March to September 2020 was completed. LTR scheduled for clinic visits with LTP were called prior to the visit by CT transplant pharmacists who conducted medication list reviews, adherence assessments, and medication access assistance. Clinical recommendations were communicated directly to the LTP and documented in patient electronic medical records. The primary outcome was the number of pharmacist-driven clinical interventions. Secondary endpoints included the clinical severity and value of service of each intervention, percentage of accepted recommendations, patient cost savings interventions, prevention of adverse events, and avoidance of inappropriate doses.

RESULTS

From March to September 2020, the CT transplant pharmacists conducted 385 virtual visits on 157 LTR with a median of 20 minutes spent per visit. There were 891 total interventions made by CT transplant pharmacists, including 778 medication discrepancies identified. Over 60% of encounters demonstrated some form of medication error and over 55% of encounters exhibited value of pharmacy services.

CONCLUSION

Implementation of CT transplant pharmacist telehealth visits has potential for increased patient access to pharmacy care and improved accuracy of medication lists. When focusing on the severity of errors and value of services, most demonstrated a level of significance. Further investigation is needed to analyze the impact of this service on patient outcomes as well as cost-effectiveness.

Transplant of SARS-CoV-2-infected Living Donor Liver: Case Report

Supplemental Digital Content is available in the text.

Given the high community prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), transplant programs will encounter SARS-CoV-2 infections in living donors or recipients in the perioperative period. There is limited data on SARS-CoV-2 viremia and organotropism beyond the respiratory tract to inform the risk of transplant transmission of SARS-CoV-2. We report a case of a living donor liver transplant recipient who received a right lobe graft from a living donor with symptomatic PCR-confirmed SARS-CoV-2 infection 3 d following donation. The donor was successfully treated with remdesivir, dexamethasone, and coronavirus disease 2019 (COVID-19) convalescent plasma. No viral transmission was identified, and both donor and recipient had excellent postoperative outcomes.

Pediatric liver and kidney transplantation in the era of COVID-19: a follow-up study from a tertiary referral center in Iran

BACKGROUND

We aimed to evaluate the impact of COVID-19 pandemic on pediatric transplant outcomes and determine whether to continue pediatric transplant activity or not, and how policies intended our center has been effective in preventing COVID-19 among organ transplant recipients.

METHODS

We conducted a single-center, retrospective, cohort study of hospitalized pediatrics after organ transplantation at Shiraz transplant center since March to August 2020. All liver and kidney transplanted children were included the study and their laboratory and clinical related COVID-19 characteristics were followed up till 3 months after transplantation during hospitalization period and then weekly by the transplant committee.

RESULTS

Fifty-one patients underwent transplantation including 11 kidney and 40 liver recipients. The mean age of the pediatric cases was 6.72 ± 5.47 years. A total of 11 patients died due to post-transplant complications, while none of the patients presented any sign or symptoms in favor of COVID-19 in the hospital course after transplantation. Six transplants including 2 kidney and 4 liver were canceled when positive PCR tests were detected in their donors before the surgery. In the 3 months of follow up, two patients presented with symptoms including high grade fever, malaise, rhinorrhea, and GI symptoms. Both patients had two negative PCR, and no radiologic or laboratory results regarding COVID-19 were also detected. One had positive influenza PCR, while the second one had a positive serologic test for EBV; CT, computed tomography CONCLUSION: Transplant programs could continue their activities during the COVID-19 pandemic with specific case selection, accurate screening methods and following protective protocols.

The impact of COVID-19 on kidney transplantation and the kidney transplant recipient - One year into the pandemic

The COVID‐19 pandemic has significantly changed the landscape of kidney transplantation in the United States and worldwide. In addition to adversely impacting allograft and patient survival in postkidney transplant recipients, the current pandemic has affected all aspects of transplant care, including transplant referrals and listing, organ donation rates, organ procurement and shipping, and waitlist mortality. Critical decisions were made during this period by transplant centers and individual transplant physicians taking into consideration patient safety and resource utilization. As countries have begun administering the COVID vaccines, new and important considerations pertinent to our transplant population have arisen. This comprehensive review focuses on the impact of COVID‐19 on kidney transplantation rates, mortality, policy decisions, and the clinical management of transplanted patients infected with COVID‐19.