A COVID-19 patient can undergo a transplant when recovery occurs from infection/carrier state

The COVID-19 pandemic has adversely affected healthcare of other ailments such as organ transplant. Dr Rajiv Lochan, Lead Consultant – HPB and Liver Transplant Surgery, Aster RV Hospital gives an overview of the situation and the challenges, informs about the best practices for organ procurement and transplantation in the COVID-19 era and more, in an exclusive interaction with Lakshmipriya Nair

What has been the impact of COVID-19 on organ donation and transplantation?

COVID-19 pandemic has had a significant impact on both deceased organ donation and transplantation (both living donor and deceased donor). Last year there were 100 organ donations in Karnataka. Numerous individuals from the hospitals where donations occurred, in other hospitals in Karnataka, as well as patients in other states benefited from the noble act of these donors and their families. In Karnataka, there have been no deceased donor organ donations at all since mid-March, when the pandemic began and we started to see signs of it spreading into our part of the world.

Another reason for this decrease could be the ruling to remove donor hospital preference for organ allocation, which happened around the same time. This ruling has however been recently revoked. The absence of deceased donor identification and donation has led to a massive clinical problem for patients waiting for vital organs – heart, lung, liver and kidney transplants. The death rate of patients has now increased significantly, with patients succumbing to their cirrhosis related problems over the past five months.

In addition, patients with acute on the chronic liver disease (patients with chronic liver disease who present to hospitals with acute liver failure) who need a liver transplant quickly due to their disease severity have been particularly disadvantaged during this period. Of course, living donor transplants have been happening for seriously ill patients, but this is not an option for heart or lung wait-listed patients.

What are the major challenges being faced during these times in organ procurement and transplant?

There are a reduced number of deceased donor organs and several factors behind this decrease. To begin with, hospitals have fewer patients in the Intensive Care Unit (ICU) for non-coronavirus related issues. There is a decreased number of road traffic accidents (data by state road safety authority in a recent newspaper). Therefore, there are fewer brain-dead patients, whose families would in some cases donate their loved ones’ organs. In addition, due to the whole health care system now being geared to address the pandemic, there is significant collateral damage expected and this is true for patients needing transplants too.

Organ donation is a complex process involving multiple teams in the hospitals and in the State administration – emergency physicians, intensivists, grief counsellors, the state deceased donor allocation authority (SOTTO – Jeevasathakathe), organ transplant coordinators, hospital administration and state government health authorities where a post-mortem is required. In this environment, the focus naturally shifts towards the larger cause.

Notwithstanding all of this, there are instances where organ donations have happened, Kerala being an example.

Other challenges are as follows:

• Risk of infection from this virus. The infection risk has numerous dimensions
•  Risk of latent infection in the deceased donor being transmitted to the recipient/s
• Risk of recipient acquiring COVID -19 from the hospital environment/from visitors/family in the post-operative period
• Risk of spread of infection to treating teams – surgeons, anaesthetists, intensivists, nurses, physiotherapists, dieticians etc. A transplant patient stays in the hospital for around three weeks and there is a huge number of contacts made between the patient and health care personnel during this time, which significantly increases the risk of virus transmission if it is in the environment.

How are healthcare systems across the globe dealing with these dilemmas? What is the scenario in India? 

The above scenario is not unique to Karnataka or India. In fact, organ donation and transplantation activity have decreased significantly across the world.(https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2931040-0)

However appropriate screening of donors can result in successful transplantation, although at a lesser scale, as seen in America and in Kerala.(https://onlinelibrary.wiley.com/doi/full/10.1111/ajt.16138)

What are the best practices for organ procurement and transplantation in the COVID-19 era?

The key is an effective screening mechanism for both the donor and recipient/s.

The general recommendations are the following:

2020. a) The living donor transplant program may be temporarily suspended in line with the Ministry of Family and Health Welfare’s Advisory for Hospitals and Medical Institutions dated March 3, 2020. However, urgent life-saving transplant may be done only after appropriate counselling and consent.
2021. b) DDLT can be performed for acute liver failure or acute-on-chronic liver failure in highly selected cases after appropriate counselling and consent.
2022. c) Deceased donors should be appropriately screened with 2 negative RT-PCR tests from nasopharyngeal swabs or bronchoalveolar lavage specimens, with or without chest computed tomography. The potential recipient must be COVID-19-negative by RT-PCR with or without negative chest computed tomography.
2023. d) The possible impact of COVID-19 on a transplant recipient and false-negative rates of the current tests along with risks must be mentioned clearly in the consent.
2024. e) Transplant should be performed in an experienced centre, with adequate protection (personal protective equipment) of the entire transplant team (COVID-free safe transplant pathway). The transplant team should be dedicated and, if possible, divided into two teams to facilitate care.
2025. f) Post-transplant care should include COVID-19 testing as per clinical judgment, and follow-up in the clinic can be done via telemedicine in the absence of clinical issues.

Are donors or recipients more at risk of contracting COVID-19? Will it affect their recovery from infection adversely? Do we have any data on this?

Yes. Organ recipients are definitely at a higher risk of contracting COVID-19 due to their long stay in hospital and their immune-compromised status (due to immunity reducing medications). This has been documented in kidney and liver recipients with a significantly increased mortality risk in those infected. Therefore, the recommendation is to perform transplants in only those who are very ill/ have a condition which will lead to disease worsening if the operation is postponed (liver tumours etc.). A balance between the risk of post-transplant infection and continuing with medical treatment/ death on the transplant wait-list has to be weighed and discussed with the recipient family before proceeding with the transplant. This is the general recommendation by most health-care and specialist transplant organisations across the world.

 Is organ retrieval from patients who deceased of COVID-19 possible? Is it recommended? Please explain in detail.

The answer to this question is a No. In somebody with a systemic viral illness, the general recommendation is not to accept organs from somebody with suspected or active infection (deceased donors and loving donors). Acceptance of deceased liver donors in the past few months have decreased worldwide because of the unknown risks associated with COVID-19 transmission or postoperative infection in the immediate post-transplant period. The risk of viremia in a liver donor (up to 15 per cent of cases) potentially places all recipients at risk of acquiring it through an organ transplant. Donor screening before acceptance has become mandatory around the world, using a combination of clinical, radiologic, and laboratory criteria. This varies in different countries between universal nucleic acid testing or reverse transcriptase-polymerase chain reaction (RT-PCR) using nasopharyngeal swabs or bronchoalveolar lavage. Recipient screening is also being done in a few countries, including in our hospital using nucleic acid testing or RT-PCR.

The American Society of Transplant Surgeons COVID-19 task force has recommended testing in all donors. The International Liver Transplant Society has issued a general guideline that suggests avoiding transplant and immunosuppression for someone with developing or active disease. Most countries have deferred transplant for non-urgent indications, including LDLT, while DDLT has been continued for urgent indications, such as acute liver failure or acute-on-chronic liver failure with appropriate consent. This is the recommendation from the Liver Transplant Society of India too. So far, no donor-derived infection has been reported. In fact, there is a report of a successful living donor liver transplant from a donor who has recovered from COVID-2019.

 Can a COVID-19 patient undergo organ transplant? If yes, how can it be done safely for both, patient and the caregivers?

This question has a few scenarios associated with it, mainly whether the recipient is a carrier or has the COVID-19 illness. Patients with the COVID-19 illness do poorly with the active infection and so transplantation is best avoided in such individuals.

It could be possible for a COVID-19 positive patient to undergo a transplant when recovery occurs from the infection/carrier state. A lung transplant has been performed for a COVID-19 infected individual. Her lung was badly scarred following the respiratory infection with COVID-19 and following recovery from the acute illness, the patient underwent a successful lung transplant. The basic principle in these types of situations is minimising immunosuppression, of course along with a safe and technically successful transplant operation.

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