Impact of COVID-19 pandemic on the size of US transplant waiting lists

Understanding the work-related challenges of organ and tissue donation coordinators during the COVID-19 pandemic: a mixed-method study

OBJECTIVES

This study aimed to explore the perceptions of donation coordinators in Canada and understand how the COVID-19 pandemic impacted their work activities.

DESIGN

A sequential mixed-method design incorporating a cross-sectional survey investigating demographic data, substance use and abuse and perceived stress related to the pandemic and semistructured qualitative interviews to further investigate those.

SETTING

Organ donation organisations across Canada.

PARTICIPANTS

Canadian organ and tissue donation coordinators working within deceased donation programmes. Participants were recruited using a purposive sampling technique for the survey and qualitative interviews. Recruitment and data collection took place between January 2022 and March 2023.

ANALYSIS

The data were analysed using descriptive statistics for the quantitative findings and content analysis for the qualitative data.

RESULTS

Of the 175 available coordinators, 120 participated in the survey, and 39 participated in the qualitative interviews. The great majority were female (n=98; 81.7%), registered nurses (n=117; 97.5%) and on average 42 years old (SD=9.64). The survey result for perceived stress showed that, on average, coordinators did not experience high stress levels during the pandemic. We also identified an increase in the consumption of substances to manage workplace stress near the pandemic's beginning. The qualitative interviews yielded two main themes (Personal Life Changes and Workplace Adjustments) in which coordinators reported their views on challenges with uncertainties, effects on their personal lives, redeployment, stressors and among others.

CONCLUSION

Our study's results provide a comprehensive understanding of the perceptions and experiences of coordinators in Canada during the COVID-19 pandemic. Using a combination of methods, we identified various ways coordinators were affected by the pandemic in their personal and professional lives. These findings highlight the need to support the development of adaptive strategies and promote resilience during crises.

Early Effects of the ESRD Treatment Choices Model on Kidney Transplant Waitlist Additions

Key Points

The ESRD Treatment Choices model did not lead to an increase in kidney transplant waitlisting. The COVID-19 pandemic had a substantial impact on kidney transplant waitlist additions. Financial incentives alone, in the short term, did not lead to a substantial effect on kidney transplant waitlisting practices.

Background

Despite the mortality benefit of kidney transplantation over dialysis, only 13% of patients with ESKD are on the transplant waitlist. Given the low rates of transplant waitlisting in the United States, Medicare launched the ESRD Treatment Choices (ETC) model in 2021, the largest mandatory trial of payment incentives in kidney disease, which randomized 30% of health care markets to financial bonuses/penalties to improve kidney transplantation and home dialysis use. This study examines the effect of ETC payment adjustments on US kidney transplant waitlist additions.

Methods

Using data from the Organ Procurement and Transplantation Network registry, we examined kidney transplant waitlisting trends between January 1, 2017, and June 30, 2022. Participants were divided into intervention and control arms of the ETC model. Using an interrupted time series design, we compared slope changes in waitlist additions after ETC model implementation (implementation date: January 01, 2021) between the two arms, while accounting for differential changes during the coronavirus disease 2019 pandemic. Results were stratified by race and ethnicity (White, Black, Hispanic, and other). To examine balance between the two ETC arms, we conducted supplementary analyses using United States Renal Data System and Medicare data.

Results

After implementation of the ETC model, there were 5550 waitlist additions in the intervention arm and 11,332 additions in the control arm (versus 14,023 and 30,610 additions before the ETC model). After ETC model implementation, there were no significant differences in kidney transplant waitlist additions between the two arms for the overall cohort (slope difference 6.9 new listings/mo; 95% confidence interval [CI], −7.4 to 21.1) or among White (slope difference 2.6/mo; 95% CI, −3.0 to 8.1), Black (slope difference 2.2/mo; 95% CI, −4.3 to 8.7), or Hispanic (slope difference 0.2/mo; 95% CI, −4.5 to 4.9) patients.

Conclusions

In the 18 months after implementation, the ETC model was not associated with significant changes in new kidney transplant waitlist additions.

Excess waitlist mortality among candidates for multivisceral liver-intestine transplant in acuity circle allocation

Candidates for multivisceral transplant (MVT) have experienced decreased access to transplant in recent years. Using Organ Procurement and Transplantation Network data, transplant and waiting list outcomes for MVT (ie, liver-intestine, liver-intestine-pancreas, and liver-intestine-kidney-pancreas) candidates listed between February 4, 2018, and February 3, 2022, were analyzed, including model for end-stage liver disease/pediatric end-stage liver disease and exception scores by era (before and after acuity circle [AC] implementation on February 4, 2020) and age group (pediatric and adult). Of 284 MVT waitlist registrations (45.6% pediatric), fewer had exception points at listing post-AC compared to pre-AC (10.0% vs 19.1%), and they were less likely to receive transplant (19.1% vs 35.9% at 90 days; 35.7% vs 57.2% at 1 year). Of 177 MVT recipients, exception points at transplant were more common post-AC compared to pre-AC (30.8% vs 20.2%). Postpolicy, adult MVT candidates were more likely to be removed due to death/too sick compared with liver-alone candidates (13.5% vs 5.6% at 90 days; 24.2% vs 9.8% at 1 year), whereas no excess waitlist mortality was observed among pediatric MVT candidates. Under current allocation policy, multivisceral candidates experience inferior waitlist outcomes compared with liver-alone candidates. Clarification of guidance around submission and approval of multivisceral exception requests may help improve their access to transplantation and achieve equity between multivisceral and liver-alone candidates on the liver transplant waiting list.

Post-COVID-19 Era In Heart Transplantation and Its Impact on the Early Postoperative Period After Surgery

BACKGROUND

End-stage heart failure patients were at increased risk for acquiring COVID-19 infection and progression to severe disease, given multiple health care contacts and underlying health conditions. Understanding the outcomes of such patients will help risk-stratify and guide optimization before heart transplant surgery. The aim of this study was to evaluate the impact of the COVID-19 pandemic on heart transplantation activity and outcomes in the early postoperative period.

METHODS

Retrospective data analysis of patients undergoing orthotopic heart transplantation in our institution from March 2020 to July 2023. The patient population (N = 208) included 176 (84.6%) men and 32 (15.4%) women. The perioperative data of the pandemic group, March 2020 to February 2022 (N = 151), and the post-pandemic group, March 2022 to July 2023 (N = 57), were compared.

RESULTS

The number of patients requiring inotropic support increased during the post-COVID-19 era (N = 48 [84.2%], vs N = 72 [47.7%], P < .001). There were no differences in renal complications. Duration of mechanical ventilation was longer in the post-pandemic group (19 hours [14-24] vs 14 hours [9-28], P < .05).

CONCLUSIONS

The extended duration of mechanical ventilation in the post-pandemic group may be related to the patient's preoperative condition. The number of heart transplant recipients with end-stage heart failure requiring inotropic support increased in the post-COVID-19 era. Although some efforts have been made to reduce the impact of the pandemic, more research is required.

Implementation of a National Liver Review Board for exception requests in the United States: A 2-year monitoring report

The exception point system for liver allocation in the United States allows for additional waitlist priority for candidates where the Model for End-Stage Liver Disease or Pediatric End-stage Liver Disease does not effectively represent their urgency or need for a transplant. In May 2019, the review process for liver exception cases transitioned from 11 Regional Review Boards (RRBs) to 1 National Liver Review Board (NLRB), intended to increase consistency nationwide, improve efficiency, and balance transplant access for candidates with and without exception scores. This report provides a review of liver exception request and review practices, waitlist outcomes, and transplant activity in the first 2 years after implementation of the NLRB and acuity circle-based distribution in the United States. We compared initial and extension exception request forms submitted from May 13, 2017 to May 13, 2019 (prepolicy or RRB era) to the period from February 4, 2020 to February 3, 2022 (postpolicy or NLRB era). During this time, the NLRB reviewed 10,083 initial exception requests and 12,686 extension requests. Notable postpolicy highlights include (1) an increase in the proportion of initial and extension requests that were automatically approved instead of manually reviewed; (2) a decrease in the overall approval rates of initial exception requests (87.8% for adult HCC, 64.3% for adult other diagnoses, and 71.5% for pediatric); and (3) reduction in the time from exception request submission to adjudication to a median of 3.73 days. The proportions of waitlist registration and deceased donor liver transplants for patients with exception scores decreased, and waitlist outcomes between patients with and without exception scores are now comparable. Implementation of the NLRB improved efficiency, reduced case workloads, and standardized criteria for exception cases, with similar waitlist outcomes between patients with and without exception scores and improved equity in terms of access to liver transplants.

COVID-19 and Access to Kidney Transplantation for Older Candidates in the United States: A National Registry Study

Rationale & Objective

Coronavirus disease (COVID)-19 has likely impacted accessibility to transplantation services among older adults (age ≥65 years). We quantified the impact of COVID-19 on kidney transplantation access for older kidney-only candidates registered on the United States (US) kidney waitlist.

Study Design

Retrospective analysis of registry data.

Setting & Participants

57,222 older adults who were part of or added to the US kidney waitlist between January 1, 2016 and February 28, 2022, identified using the Scientific Registry of Transplant Recipients (SRTR).

Exposures

Four COVID-19 waves and one nonwave period based on the national incidence of COVID-19 in the US (initial: March 15-May 30, 2020; winter 2020-2021: December 1, 2020-January 31, 2021; delta: August 1, 2021-September 30, 2021; omicron: December 1, 2021-February 28, 2022; nonwave: inter-wave periods).

Outcomes

Waitlist registrations, deceased-donor kidney transplants, living-donor kidney transplants, waitlist mortality, and waitlist removals due to deteriorating condition (hereafter referred to as removals).

Analytical Approach

Poisson regression for the adjusted incidence rate ratio (aIRR) of each outcome during the COVID-19 waves and the nonwave period relative to reference (January 1, 2016-December 31, 2019), adjusted for seasonality and secular trends.

Results

Waitlist registrations initially declined and increased henceforth. Deceased-donor kidney transplants and living-donor kidney transplants remained below-expected levels during all waves. Waitlist mortality peaked during the winter 2020-2021 wave (aIRR: 1.701.982.30) and has declined since; mortality rates were 139%, 107%, and 251% above expected for Black candidates, men, and candidates aged ≥75 years, respectively, during the winter 2020-2021 wave. Removals increased from 22% below expected levels (initial wave) to 26% above expected levels (omicron wave); removals were nonsignificantly higher than expected during the omicron wave for older Black and Hispanic candidates.

Limitations

The findings are not generalizable to those listed at earlier ages with prolonged waitlist times. Additionally, using national COVID-19 incidence does not consider local policy and health care variations. Lastly, aIRRs must be interpreted cautiously due to smaller daily event counts.

Conclusions

COVID-19 was associated with fewer transplants and increased mortality and removals in older kidney transplant candidates. Transplant providers should consider this impact and implement policies and practices to ensure the continuity of care.

Plain-Language Summary

The proportion of older adults on the kidney transplant waitlist is increasing, but the impact of COVID-19 on this population is not well characterized. In this study, we looked at incident waitlist registrations, deceased- and living-donor kidney transplants, and waitlist mortality and removals due to deteriorating condition over 4 waves of COVID-19. We found that transplantation services did not fully recover to prepandemic levels as of March 2022. Notably, racial/ethnic minorities and older men experienced lower rates of kidney transplants and higher rates of waitlist mortality, respectively, relative to White candidates and older women. Identifying vulnerable subpopulations affected by COVID-19 and its long-term impact is crucial for creating strategies to ensure the continuity of care in this population during public health emergencies.

Evolving Trends in Kidney Transplant Outcomes Among Older Adults: A Comparative Analysis Before and During the COVID-19 Pandemic

Background

Advancements in medical technology, healthcare delivery, and organ allocation resulted in improved patient/graft survival for older (age ≥65) kidney transplant (KT) recipients. However, the recent trends in these post-KT outcomes are uncertain in light of the mounting burden of cardiovascular disease, changing kidney allocation policies, heterogeneity in candidates' risk profile, and the coronavirus disease 2019 pandemic. Thus, we examined secular trends in post-KT outcomes among older and younger KT recipients over the last 3 decades.

Methods

We identified 73 078 older and 378 800 younger adult (aged 18-64) recipients using Scientific Registry of Transplant Recipients (1990-2022). KTs were grouped into 6 prepandemic eras and 1 postpandemic-onset era. Kaplan-Meier and Cox proportional hazards models were used to examine temporal trends in post-KT mortality and death-censored graft failure.

Results

From 1990 to 2022, a 19-fold increase in the proportion of older KT recipients was observed compared to a 2-fold increase in younger adults despite a slight decline in the absolute number of older recipients in 2020. The mortality risk for older recipients between 2015 and March 14, 2020, was 39% (adjusted hazard ratio [aHR] = 0.61, 95% confidence interval [CI], 0.50-0.75) lower compared to 1990-1994, whereas that for younger adults was 47% lower (aHR = 0.53, 95% CI, 0.48-0.59). However, mortality risk during the pandemic was 25% lower (aHR = 0.75, 95% CI, 0.61-0.93) in older adults and 37% lower in younger adults (aHR = 0.63, 95% CI, 0.56-0.70) relative to 1990-1994. For both populations, the risk of graft failure declined over time and was unaffected during the pandemic relative to the preceding period.

Conclusions

The steady improvements in 5-y mortality and graft survival were disrupted during the pandemic, particularly among older adults. Specifically, mortality among older adults reflected rates seen 20 y prior.

Abdominal Organ Transplantation: Noteworthy Literature in 2022

This review highlights noteworthy literature published in 2022 pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We begin by exploring the impacts that the COVID-19 pandemic has had across the field of abdominal organ transplantation, including the successful use of grafts procured from COVID-19-infected donors. In pancreatic transplantation, we highlight several studies on dexmedetomidine and ischemia-reperfusion injury, equity in transplantation, and medical management, as well as studies comparing pancreatic transplantation to islet cell transplantation. In our section on intestinal transplantation, we explore donor selection. Kidney transplantation topics include cardiovascular risk management, obesity, and intraoperative management, including fluid resuscitation, dexmedetomidine, and sugammadex. The liver transplantation section focuses on clinical trials, systematic reviews, and meta-analyses published in 2022 and covers a wide range of topics, including machine perfusion, cardiovascular issues, renal issues, and coagulation/transfusion.

Challenges in liver transplantation in the context of a major pandemic

Coronavirus disease-2019 (COVID-19) has led to a temporary suspension of liver transplant activity across the world and the remodeling of care for patients on the waiting list and transplant recipients with the increasing use of remote consultations. Emerging evidence shows that patients with more advanced liver disease are at increased risk of severe COVID-19 and death, whereas transplant recipients have similar risk with the general population which is mainly driven by age and metabolic comorbidities. Tacrolimus immunosuppression might have a protective role in the post-transplant population. Vaccines that have become rapidly available seem to be safe in liver patients, but the antibody response in transplant patients is likely suboptimal. Most transplant centers were gradually able to resume activity soon after the onset of the pandemic and after modifying their pathways to optimize safety for patients and workforce. Preliminary evidence regarding utilizing grafts from positive donors and/or transplanting recently recovered or infected recipients under certain circumstances is encouraging and may allow offering life-saving transplant to patients at the greatest need. This review summarizes the currently available data on liver transplantation in the context of a major pandemic and discusses areas of uncertainty and future challenges. Lessons learnt from the COVID-19 pandemic might provide invaluable guidance for future pandemics.