Organ transplantation during the COVID-19 pandemic: Making the best patient care decision

To the Editor:

It is with great interest and sadness that we read the experience of Akalin et al and Pereira et al^{1 , 2} with unprecedented mortality (18%-28%) in transplant recipients in New York City. High mortality reports in transplant patients have created anxiety among some community practitioners as evidence for why transplants should not be performed at this time,^{3 , 4} contrary to the recommendations from multiple transplant organizations.

As always, when assessing the benefits and risks of transplantation, the comparison should be the population of individuals with end-stage organ disease and associated comorbidities. Data from Lombardy, Italy, and Kidney Community Emergency Response suggest mortality of 22%-25% in hospitalized coronavirus disease 2019 (COVID-19) end-stage renal disease (ESRD) patients.^{5 , 6}

Although kidney transplantation can provide significant survival benefit compared to dialysis, there is genuine concern that transplantation in the midst of this pandemic may lead to unacceptable outcomes, and transplant in emergency situations has been proposed.⁷

This approach needs to be balanced with the risk of exposure to COVID-19 in the dialysis settings; ESRD-related COVID-19 mortality, patient wishes, compliance with viral precautions, regional prevalence of COVID-19, as well as the Organ Procurement Organization (OPO) and transplanting institute’s ability for timely COVID-19 testing. COVID-19 has wide geographic variability; for example, in the Greater Houston area he COVID-19 case rate per 100 000 population is 180 compared to the New York City case rate of 1455 according to Johns Hopkins Corona Resource Center.

Here, we share our experience of performing 29 acute - transplants during this pandemic so far (24 deceased donor kidney -, 2 living donor kidney, 1 simultaneous kidney pancreas, and 2 livers), with our approach of mitigating COVID-19 risk.

Patients and potential living donors were contacted by the transplant center to educate them on US Centers for Disease Control and Prevention COVID-19 prevention recommendations. COVID-19 information was made part of the informed consent process. During the initial stages of the pandemic, deceased donor offers were screened for COVID-19 risk factors and tested if risk factors were present. From March 20, 2020 onwards, all donors and recipients were screened with history and COVID-19 polymerase chain reaction (PCR) testing. COVID-19 PCR results from OPO are now available at the time of organ offer. Recipient COVID-19 testing had an initial turnaround time of 8 hours, with further improvement to 4 hours towards the end of March 2020 with rapid PCR testing. Living donor COVID-19 testing was performed within 24 hours prior to scheduled surgery. With streamlining of the testing process, we have not experienced delays or cancellation of procedures. After discharge, patients are being followed via telehealth visits, and home phlebotomy services to minimize exposure risk. So far, all recipients and living donors are doing well, without any signs or symptoms suggestive of COVID-19 infection. Two posttransplant infection-related admissions were attributed to urinary tract infection. Sixteen patients (66%) had COVID-19 PCR testing 2-3 weeks posttransplant, along with ureteric stent removal, all with negative results. Two chronic kidney transplant patients required admission for mild COVID-19 symptoms.

During the COVID-19 pandemic, patients with ESRD, especially in low COVID-19 areas, may still benefit from transplantation with a comprehensive COVID-19 mitigation strategy with social distancing, telehealth, and home phlebotomy as integral components.