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

Abstract

The global health crisis due to the fast spread of coronavirus disease (COVID-19) has caused major disruption in all aspects of healthcare. Transplantation is one of the most affected sectors, as it relies on a variety of services that have been drastically occupied to treat patients affected by COVID-19. With this report from two transplant centers in Italy, we aim to reflect on resource organization, organ allocation, virus testing and transplant service provision during the course of the pandemic and to provide actionable information highlighting advantages and drawbacks. To what extent can we preserve the noble purpose of transplantation in times of increased danger? Strategies to minimize risk exposure to the transplant population and health-workers include systematic virus screening, protection devices, social distancing and reduction of patients visits to the transplant center. While resources for the transplant activity are inevitably reduced, new dilemmas arise to the transplant community: further optimization of time constraints during organ retrievals and implantation, less organs and blood products donated, limited space in the intensive care unit and the duty to maintain safety and outcomes.

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

“…A higher incidence of COVID-19 infection has been reported among healthcare workers compared to the general population [ 18 , 19 ]. While a recipient may accept the risk of infection to gain the benefits of the transplant, it is also important to consider the impact of this decision on the health and safety of the medical team, particularly in situations where there is a shortage of protective equipment for the healthcare professionals [ 20 ], as was common during the early days of the COVID-19 pandemic and remains the case in some areas. Organ recovery from a COVID-19 positive donor also has the potential to expose numerous healthcare professionals both in and outside the operating room, and potentially contribute to community spread through their professional, personal, and community contacts [ 21 ].…”

“…As noted above, proceeding with transplant presents the risk of donor-derived infection, yet deferring can result in the risk of exclusion due to a patient’s disease progression or even death, or poorer post-transplant outcomes [ 26 ]. These considerations extend to other types of transplants as well [ 20 ].…”

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

“…Although the effect of SARS-CoV-2 on the immunosuppression is presently unknown, experts’ opinions suggest reducing the exposure to immunosuppressive drugs, particularly in COVID-19 patients. 24 , 63 , 64 At some centers, lymphodepletive agents have been toned down to avoid excessive immunosuppression. 4 , 65 , 66 Pulmonary complications are more frequent after transplant, 67 and available data suggest that 25% of transplanted patients with COVID-19 infection are critically ill. 68 Furthermore, SARS-CoV-2 exhibits the cytopathic effect on the liver and antiviral treatment may induce liver damage.…”

Exploring new frontiers

“…Additionally, there is a risk of infection with progression to severe disease in both transplant recipients as well as those in waiting list due to frequent healthcare contacts, underlying health problems along with immunosuppression. [ 19 ] Another issue with COVID is that the presentation of myocarditis with the raised troponin levels, recent left ventricular dysfunction and electrocardiogram (ECG) changes may mimic signs of rejection. Two heart transplant recipients with COVID-19 infection have been reported in China.…”