Transplantation during the COVID-19 pandemic: nothing noble is accomplished without danger

A Qualitative Study on the Effects of the COVID-19 Pandemic on Solid Organ Transplantation

Introduction: Solid organ transplantation is a lifesaving intervention requiring extensive coordination and communication for timely and safe care. The COVID-19 pandemic posed unique challenges to the safety and management of solid organ transplantation. This descriptive qualitative study aimed to understand how hospital stakeholders were affected by and responded to the COVID-19 pandemic to contribute toward improved healthcare delivery responses and strategies during times of systemic strain on the healthcare system. Methods: One-hour-long semistructured interviews were performed in 3 cohorts: healthcare professionals (N = 6), administrative staff (N = 6), and recipients (N = 4). Interviews were analyzed using conventional thematic content analysis. Thematic saturation was reached within each cohort. Findings: Twelve codes and 6 major themes were identified including the Impact on Clinical Practice, Virtual Healthcare Delivery, Communication, Research, Education and Training, Mental Health and Future Pandemic Planning. Reflecting on these codes and major themes, 4 recommendations were developed (Anticipation and Preparation, Maximizing Existing Resources and Networks, Standardization and the Virtual Environment and Caring for the Staff) to guide transplant programs to optimize healthcare pathways while enhancing the best practices during future pandemics. Conclusion: Transplant programs will benefit from anticipation and preparation procedures using ramping-down strategies, resource planning, and interprofessional collaboration while maximizing existing resources and networks. In parallel, transplant programs should standardize virtual practices and platforms for clinical and educational purposes while maintaining an open culture of mental health discussion and integrating strategies to support staff's mental health.

Ethical Issues in Kidney Transplant and Donation During COVID-19 Pandemic

The coronavirus disease-19 pandemic caused by the severe acute respiratory syndrome coronavirus has faced the transplant community with unprecedented clinical challenges in a highly vulnerable patient category. These were associated with many uncertainties for patients and health care professionals and prompted many ethical debates regarding the safe delivery of kidney transplantation. In this article, we highlight some of the most important ethical questions that were raised during the pandemic and attempt to analyze ethical arguments in light of core principles of medical ethics to either suspend or continue kidney transplantation, and to mandate vaccination in transplant patients, transplant candidates, and, finally, health care providers. We have come up with frameworks to deal responsibly with these ethical challenges, and formulated recommendations to cope with the issues imposed on patients and transplant professionals.

Utilization of SARS-COV-2 positive donors and recipients for liver transplantation in the pandemic era - An evidence-based review

The current SARS-COV-2 pandemic led to a drastic drop in liver donation and transplantation in DDLT and LDLT settings. Living donations have decreased more than deceased organ donation due to the need to protect the interest of donors. In the SARS-COV-2 pandemic, major professional societies worldwide recommended against the use of organs from donors with acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The basis for these recommendations are; SARS-CoV-2 could be transmitted to the recipient through organ transplantation and can result in severe manifestations; only limited effective targeted therapies are available, risk of transmission to the healthcare professionals, logistical limitations, and ethical concerns. In addition, end-stage liver disease patients on the waiting list represent vulnerable populations and are at higher risk for severe COVID-19 infection. Therefore, deferring life-saving transplants from COVID-positive donors during a pandemic may lead to more collateral damage by causing disease progression, increased death, and dropout from the waitlist. As this SARS-COV-2 pandemic is likely to stay with us for some time, we have to learn to co-exist with it. We believe that utilizing organs from mild/ asymptomatic COVID19 positive donors may expand the organ donor pool and mitigate disruptions in transplantation services during this pandemic.

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.

Development of an organ procurement team in South Australia in response to COVID-19

Background

Due to the nature of border closures and quarantine requirements in Australia during the COVID‐19 pandemic, the feasibility of interstate travel for organ retrieval created complex logistics. An organ procurement service in South Australia, to procure heart and lungs of local donors, was commenced to mitigate the impact of the travel restrictions imposed due to COVID‐19. The purpose of this review was to examine the initial data and feasibility of the service.

Methods

A single unit, multi‐site retrospective review from April 2020–August 2021 of all organ retrievals undertaken by the Flinders Medical Centre cardiothoracic service across Adelaide metropolitan area. Data was prospectively collected and analysed from the DonateLife South Australian centralized database. All data was de identified.

Results

A total of 25 organ procurements had been undertaken across 17 months since commencing the program. Total of 9 hearts and 16 bilateral lungs were procured with median age of donor of hearts 49 years (IQR 35.5–51. 5) and 60 years (IQR 44–72) for lung donation. Six organs were donated after determination of circulatory death and 19 after neurological determination of death. Median ischaemic time for heart donation was 4.4 h (IQR 3.0–5.8) and lung donation 4.4 h (IQR 3.4–6.1). All organs procured by the local South Australian team were successfully transplanted at the recipient site. Recipient sites included 8 in Victoria, 10 in New South Wales, 4 in Western Australia and 3 in Queensland.

Conclusions

The necessity of flexibility within the field of cardiothoracic surgery is evident during the COVID‐19 pandemic. The implementation of an organ retrieval service in South Australia has been successful with no apparent increased risk to successful transplant outcomes.

Global Effects of SARS-CoV-2 Era on Kidney Transplantation Activities: Analysis of WHO Data

Background

Uncertainty raises questions in kidney transplant during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic regarding the recipient, the donor, and health care professionals. The pandemic not only has disrupted kidney transplanted patients but also has influenced transplant systems, donation chains, and timely and safe transplant surgeries. In the present study, we aimed to explore the global effects of the SARS-CoV-2 pandemic on kidney transplant.

Methods

We collected transplantation statistics and SARS-CoV-2 pandemic data from the World Health Organization website on June 15, 2021. Spearman correlation analysis was applied to assess the strength of a monotonic relationship among quantitative variables. We also demonstrated the clinical characteristics of our kidney recipients with SARS-CoV-2 infection.

Results

Comparison of the mean of global kidney transplantation statistics between 2010 and 2019 with 2020 statistics showed a significant decrease in kidney transplant from living donors (P < .001). From the beginning of the pandemic to June 15, 2021, 1 of the 43 kidney transplant patients we treated in our clinic died of SARS-CoV-2 infection after discharge. Two of the patients we transplanted and saw in follow-up before the pandemic died of SARS-CoV-2 infection.

Conclusion

While the overall kidney transplant numbers have increased in the year to date, kidney transplants decreased drastically at the onset of the pandemic.

Impact of COVID-19 on Liver Transplantation in Hong Kong and Singapore: A Modelling Study

BACKGROUND

Liver transplantation (LT) activities during the COVID-19 pandemic have been curtailed in many countries. The impact of various policies restricting LT on outcomes of potential LT candidates is unclear.

METHODS

We studied all patients on the nationwide LT waitlists in Hong Kong and Singapore between January 2016 and May 2020. We used continuous time Markov chains to model the effects of different scenarios and varying durations of disruption on LT candidates.

FINDINGS

With complete cessation of LT, the projected 1-year overall survival (OS) decreased by 3•6%, 10•51% and 19•21% for a 1-, 3- and 6-month disruption respectively versus no limitation to LT, while 2-year OS decreased by 4•1%, 12•55%, and 23•43% respectively. When only urgent (acute-on-chronic liver failure [ACLF] or acute liver failure) LT was allowed, the projected 1-year OS decreased by a similar proportion: 3•1%, 8•41% and 15•20% respectively. When deceased donor LT (DDLT) and urgent living donor LT (LDLT) were allowed, 1-year projected OS decreased by 1•2%, 5•1% and 8•85% for a 1-, 3- and 6-month disruption respectively. OS was similar when only DDLT was allowed. Complete cessation of LT activities for 3-months resulted in an increased projected incidence of ACLF and hepatocellular carcinoma (HCC) dropout at 1-year by 49•1% and 107•96% respectively. When only urgent LT was allowed, HCC dropout and ACLF incidence were comparable to the rates seen in the scenario of complete LT cessation.

INTERPRETATION

A short and wide-ranging disruption to LT results in better outcomes compared with a longer duration of partial restrictions.

FUNDING

None to disclose.

Impact of COVID-19 pandemic on liver, liver diseases, and liver transplantation programs in intensive care units

Emerging worldwide data have been suggesting that coronavirus disease 2019 (COVID-19) pandemic consequences are not limited to the respiratory and cardiovascular systems but encompass adverse gastrointestinal manifestations including acute liver injury as well. Severe cases of liver injury associated with higher fatality rates were observed in critically ill patients with COVID-19. Intensive care units (ICU) have been the center of disposition of severe cases of COVID-19. This review discusses the pathogenesis of acute liver injury in ICU patients with COVID-19, and analyzes its prevalence, consequences, possible drug-induced liver injury, and the impact of the pandemic on liver diseases and transplantation programs.

The COVID-19 pandemic and organ donation and transplantation: ethical issues

Background

The COVID-19 pandemic has had a significant impact on the health system worldwide. The organ and tissue donation and transplantation (OTDT) system is no exception and has had to face ethical challenges related to the pandemic, such as risks of infection and resource allocation. In this setting, many Canadian transplant programs halted their activities during the first wave of the pandemic.

Method

To inform future ethical guidelines related to the COVID-19 pandemic or other public health emergencies of international concern, we conducted a literature review to summarize the ethical issues.

Results

This literature review identified three categories of ethical challenges. The first one describes the general ethical issues and challenges reported by OTDT organizations and transplantation programs, such as risks of COVID-19 transmission and infection to transplant recipients and healthcare professionals during the transplant process, risk of patient waitlist mortality or further resource strain where transplant procedures have been delayed or halted, and resource allocation. The second category describes ethical challenges related to informed consent in the context of uncertainty and virtual consent. Finally, the third category describes ethical issues related to organ allocation, such as social considerations in selecting transplant candidates.

Conclusion

This literature review highlights the salient ethical issues related to OTDT during the current COVID-19 pandemic. As medical and scientific knowledge about COVID-19 increases, the uncertainties related to this disease will decrease and the associated ethical issues will continue to evolve.

Solid Organ Transplantation During COVID-19 Pandemic: An International Web-based Survey on Resources' Allocation

Supplemental Digital Content is available in the text.

Solid organ transplants (SOTs) are life-saving interventions, recently challenged by coronavirus disease 2019 (COVID-19). SOTs require a multistep process, which can be affected by COVID-19 at several phases.

Exploring new frontiers: Organ transplant anaesthesia or bariatric anaesthesia

Unlike previous years, Anaesthesiology today is a major speciality encompassing many areas of modern medicine. Advent of various surgical sub-specialities resulted into the emergence of anaesthesia sub-specialities, as every group of surgery has specific need. Choosing the best-suited speciality is a complex matter. For that, one needs to have an idea about each one of them. A postgraduate anaesthesiology student does not have adequate exposure to choose the speciality. This article will give an overview of two important sub-specialities i.e., Organ Transplant Anaesthesia and Bariatric Anaesthesia.