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  • Kulkarni S
  • Flescher A
  • Ahmad M
  • Bayliss G
  • Bearl D
  • et al.
J Med Ethics. 2023 Jun;49(6):389-392 doi: 10.1136/medethics-2021-107574.

The transplant community has faced unprecedented challenges balancing risks of performing living donor transplants during the COVID-19 pandemic with harms of temporarily suspending these procedures. Decisions regarding postponement of living donation stem from its designation as an elective procedure, this despite that the Centers for Medicare and Medicaid Services categorise transplant procedures as tier 3b (high medical urgency-do not postpone). In times of severe resource constraints, health systems may be operating under crisis or contingency standards of care. In this manuscript, the United Network for Organ Sharing Ethics Workgroup explores prioritisation of living donation where health systems operate under contingency standards of care and provide a framework with recommendations to the transplant community on how to approach living donation in these circumstances.To guide the transplant community in future decisions, this analysis suggests that: (1) living donor transplants represent an important option for individuals with end-stage liver and kidney disease and should not be suspended uniformly under contingency standards, (2) exposure risk to SARS-CoV-2 should be balanced with other risks, such as exposure risks at dialysis centres. Because many of these risks are not quantifiable, donors and recipients should be included in discussions on what constitutes acceptable risk, (3) transplant hospitals should strive to maintain a critical transplant workforce and avoid diverting expertise, which could negatively impact patient preparedness for transplant, (4) transplant hospitals should consider implementing protocols to ensure early detection of SARS-CoV-2 infections and discuss these measures with donors and recipients in a process of shared decision-making.

  • Darılmaz Yüce G
  • Ulubay G
  • Tek K
  • Savaş Bozbaş Ş
  • Erol Ç
  • et al.
Exp Clin Transplant. 2023 May;21(5):451-459 doi: 10.6002/ect.2021.0361.
OBJECTIVES:

The clinical features and treatment approaches, outcomes, and mortality predictors of COVID-19 in solid-organ transplant recipients have not been well defined. This study investigated the clinical features of COVID-19 infection in solid-organ transplant recipients at our center in Turkey.

MATERIALS AND METHODS:

Our study included 23 solidorgan transplant recipients and 336 nontransplant individuals (143 previously healthy and 193 patients with at least 1 comorbidity) who were hospitalized due to COVID-19 disease in our hospital between March 2020 and January 2021. Demographic, clinical, and laboratory data of patients were compared. We used SPSS version 20.0 for statistical analysis. All groups were compared using chi-square and Mann-Whitney U tests. P <.05 was considered statistically significant.

RESULTS:

Mean age of solid-organ transplant recipients was 49.8 ± 13.7 years (78.3% men, 21.7% women). Among the 23 recipients, 17 (73.9%) were kidney and 6 (26.1%) were liver transplant recipients. Among nontransplant individuals, 88.7% (n = 298) had mild/moderate disease and 11.3% (n = 38) had severe disease. Among transplant recipients, 78.3% (n = 18) had mild/moderate disease and 21.7% (n = 5) had severe disease (P = .224). Transplant recipients had greater requirements for nasal oxygen (P = .005) and noninvasive mechanical ventilation (P = .003) and had longer length of intensive care unit stay (P = .030) than nontransplant individuals. No difference was found between the 2 groups in terms of mortality (P = .439). However, a subgroup analysis showed increased mortality in transplant recipients versus previously healthy patients with COVID-19 (P <.05). Secondary infections were major causes of mortality in transplant recipients.

CONCLUSIONS:

COVID-19 infection resulted in higher mortality in solid-organ transplant recipients versus that shown in healthy patients. More attention on secondary infections is needed in transplant recipients to reduce mortality.

  • Caliskan G
  • Sayan A
  • Kilic I
  • Haki C
  • Girgin NK
  • et al.
Exp Clin Transplant. 2023 May;21(5):460-466 doi: 10.6002/ect.2021.0090.
OBJECTIVES:

The outbreak of coronavirus disease 2019, known as COVID-19, has rapidly evolved to a global pandemic. This pandemic represents an unprecedented public health issue not only for the general population but also for patients on the transplant wait list. Multiple organizations around the world have published recommendations for the proper conduct of transplant procedures, including donor and recipient screening and perioperative management. We investigated the efficacy of these new recommendations and the effects of SARS-CoV-2 infection on the deceased donation rate, donor organ management, and the time from family consent to procurement.

MATERIALS AND METHODS:

The characteristics of potential donors diagnosed with brain death between July 15, 2019, and November 18, 2020, were evaluated retrospectively.Demographic and clinical features,the time elapsed from the clinical diagnosis until confirmation, and rates of acceptance were recorded. Potential donors diagnosed with brain death before the pandemic and during the pandemic were compared according to these variables.

RESULTS:

Within the study period, 40 patients were diagnosed with brain death: 13 before the pandemic and 27 during the pandemic. The organs from 2 donors were procured before the pandemic. Organs from 3 of 8 donors were procured during the pandemic (the organs from 5 of these 8 patients were not donated). The organ donation time was 8.5 ± 2.12 hours (minimum-maximum, 7-10 hours) in the period before the pandemic and 54 ± 11.53 hours (minimummaximum, 45-67 hours) during the pandemic.

CONCLUSIONS:

The number of donors decreased significantly in our hospital during the pandemic and was similarto the overallrate inTurkey.The duration of the donation process has been prolonged, and strategies to improve rates of organ donation, including infection control, have become a focus of concern.

  • Kolonko A
  • Kuczaj AA
  • Musialik J
  • Słabiak-Błaż N
  • Hrapkowicz T
  • et al.
Pol Arch Intern Med. 2022 Nov 28;132(2) doi: 10.20452/pamw.16139.
INTRODUCTION:

The COVID-19 pandemic has disproportionately affected patients who have undergone solid organ transplantation (SOT).

OBJECTIVES:

We aimed to assess a cohort of transplant recipients who developed COVID‑19, with a focus on immunosuppressive regimen, blood tacrolimus levels, clinical course, and patient and graft outcomes.

PATIENTS AND METHODS:

During the first 12 months of the pandemic, we identified ambulatory SOT recipients, including kidney, liver, and heart transplant recipients, diagnosed with SARS‑CoV‑2 infection. Baseline and follow‑up data on graft function, immunosuppression, and patient and graft outcomes were assessed.

RESULTS:

Of the 2091 ambulatory patients, we identified 201 transplant recipients (9.6%) with SARS‑CoV‑2 infection (kidney transplant, n = 112; heart transplant, n = 56; liver transplant, n = 33). Patients after recent kidney (during 2015-2020) or heart (during 2020) transplant were significantly more often diagnosed with COVID ‑19 than patients with a longer time since transplant. Additionally, blood trough tacrolimus levels measured during or shortly after COVID‑19 in 23 kidney graft recipients were significantly increased by a median of 76.1% (interquartile range, 47.4%-109.4%) relative to predose trough levels. However, liver function parameters were not elevated, necessitating a tacrolimus dose reduction in 73.9% of the patients.

CONCLUSIONS:

In our study, kidney transplant recipients showed significant disturbances of tacrolimus metabolism, which may account for kidney function worsening during COVID‑19. Moreover, infection was more common in patients with recent kidney or heart transplant, which suggests that the level of immunosuppression may affect morbidity related to SARS‑CoV‑2 infection.

  • Sahin MF
  • Beyoglu MA
  • Turkkan S
  • Tezer Tekce Y
  • Yazicioglu A
  • et al.
Exp Clin Transplant. 2022 Sep;20(9):842-848 doi: 10.6002/ect.2020.0567.
OBJECTIVES:

The COVID-19 pandemic, which emerged in late 2019, adversely affected all solid-organ transplant processes. Here we share the donor presentations evaluated in a lung transplant center during the COVID-19 pandemic,the measures taken at every stage of transplant management, and the outcomes of our transplants.

MATERIALS AND METHODS:

Data from 15 lung donors selected by the national coordination center presented to our lung transplant center as of March 11, 2020, when the first COVID-19 case was reported in Turkey, and data of 5 lung transplant cases in this period were retrospectively analyzed. All donors were examined in detail for COVID-19 disease. Procurement processes for accepted donors,transplant surgeries of recipients, and postoperative follow-up and care processes of recipients were carried out with the least number of personnel, but all with appropriate personal protective equipment.

RESULTS:

There were 15 donor organs procured by our center during a 9-month period coincident with the COVID-19 pandemic. The number of donor presentations to our center between the same dates in the previous year was 78. Five of the 15 donors were accepted, and of those accepted, 4 were male and 1 was female. There was no statistically significant difference between the accepted and rejected donors in terms of the ratio of Pao2 to fraction of inspired oxygen, age, duration of endotracheal intubation (days), and smoking (pack-years). All SARS-CoV-2 reverse transcription-polymerase chain reaction tests performed on bronchoalveolar lavage samples and nasopharyngeal, conjunctival, and rectal samples collected from the recipients during the follow-up period were negative. No pathological finding suggestive of COVID-19 infection was noted in the radiological evaluations.

CONCLUSIONS:

Lung transplant can be successfully managed during the COVID-19 pandemic period, despite the high risk of infection.The major obstacle to the continuity of lung transplantin this period was the limited number of donors.

  • Yazıcıoğlu B
  • Bakkaloğlu SA
  • European Society for Pediatric Nephrology
  • Yazicioglu B
  • Bakkaloglu SA
Pediatr Nephrol. 2022 Aug;37(8):1867-1875 doi: 10.1007/s00467-021-05226-1.
BACKGROUND:

Coronavirus disease-2019 (COVID-19) has been challenging for patients and medical staff. Radical changes have been needed to prevent disruptions in patient care and medical education.

METHODS:

A web-based survey was sent to European Society for Pediatric Nephrology (ESPN) members via the ESPN mailing list to evaluate the effects of the COVID-19 pandemic on delivery of pediatric nephrology (PN) care and educational activities. There were ten questions with subheadings.

RESULTS:

Seventy-six centers from 24 countries completed the survey. The time period was between the beginning of the pandemic and May 30, 2020. The number of patients admitted in PN wards and outpatient clinics were significantly decreased (2.2 and 4.5 times, respectively). Telemedicine tools, electronic prescriptions, online applications for off-label drugs, and remote access to laboratory/imaging results were used in almost half of the centers. Despite staff training and protective measures, 33% of centers reported COVID-19 infected staff, and 29% infected patients. Difficulties in receiving pharmaceuticals were reported in 25% of centers. Sixty percent of centers suspended living-related kidney transplantation, and one-third deceased-donor kidney transplantation. Hands-on education was suspended in 91% of medical schools, and face-to-face teaching was replaced by online systems in 85%. Multidisciplinary training in PN was affected in 54% of the centers.

CONCLUSIONS:

This survey showed a sharp decline in patient admissions and a significant decrease in kidney transplantation. Telemedicine and online teaching became essential tools, requiring integration into the current system. The prolonged and fluctuating course of the pandemic may pose additional challenges necessitating urgent and rational solutions.

  • Peled Y
  • Ram E
  • Mandelboim M
  • Lavee J
  • Sternik L
  • et al.
Am J Transplant. 2022 Jul;22(7):1931-1932 doi: 10.1111/ajt.16998.
  • Dorfman L
  • Nassar R
  • Rozenfeld Bar-Lev M
  • Shafir M
  • Oseran I
  • et al.
Pediatr Transplant. 2022 Jun;26(4):e14250 doi: 10.1111/petr.14250.
BACKGROUND:

The COVID-19 pandemic has affected medical care worldwide. Thus, we aimed to assess the impact of the COVID-19 pandemic on pediatric LT recipients.

METHODS:

A cross-sectional study based on a structured internet or telephone survey was conducted among pediatric LT recipients. Survey results were compared with results of a survey conducted among pediatric patients with IBD.

RESULTS:

Seventy-six pediatric LT patients participated in the study. Of them, 58 (76.3%) reported fear of severe COVID-19 infection due to LT or LT-associated medications. Half of the patients reported needing emotional support. Most patients (51, 67.1%) reported strictly following official guidance, while more stringent protective measures were taken by 64 (84.2%) patients. None of the patients discontinued their medications due to COVID-19. Compared to pediatric patients with IBD, a higher proportion of pediatric LT recipients reported fears of contracting severe COVID-19 infection due to their illness or medications (45, 59.2% vs. 110, 45.1%).

CONCLUSION:

Among pediatric LT recipients a higher proportion reported fear of severe COVID-19 infection, implemented additional protective measures and expressed a need for emotional support, compared to patients with IBD. Medical teams should provide adequate information and offer a support system for this vulnerable population.

  • Hippen BE
  • Axelrod DA
  • Maher K
  • Li R
  • Kumar D
  • et al.
Am J Transplant. 2022 Jun;22(6):1705-1713 doi: 10.1111/ajt.16995.

An electronic survey canvassing current policies of transplant centers regarding a COVID-19 vaccine mandate for transplant candidates and living donors was distributed to clinicians at US solid organ transplant centers performing transplants from October 14, 2021-November 15, 2021. Responses were received from staff at 141 unique transplant centers. These respondents represented 56.4% of US transplant centers, and responding centers performed 78.5% of kidney transplants and 82.4% of liver transplants in the year prior to survey administration. Only 35.7% of centers reported implementing a vaccine mandate, while 60.7% reported that vaccination was not required. A minority (42%) of responding centers with a vaccine mandate for transplant candidates also mandated vaccination for living organ donors. Centers with a vaccine mandate most frequently cited clinical evidence supporting the efficacy of pre-transplant vaccination (82%) and stewardship obligations to ensure organs were transplanted into the lowest risk patients (64%). Centers without a vaccine mandate cited a variety of reasons including administrative, equity, and legal considerations for their decision. Transplant centers in the United States exhibit significant heterogeneity in COVID-19 vaccination mandate policies for transplant candidates. While all centers encourage vaccination, most centers have not mandated COVID-19 vaccination for candidates and living donors, citing administrative opposition, legal prohibitions, and concern about equity in access to transplants.

  • Caballero-Marcos A
  • Citores MJ
  • Alonso-Fernández R
  • Rodríguez-Perálvarez M
  • Valerio M
  • et al.
Liver Transpl. 2022 Jun;28(6):1039-1050 doi: 10.1002/lt.26389.

Long-term humoral immunity and its protective role in liver transplantation (LT) patients have not been elucidated. We performed a prospective multicenter study to assess the persistence of immunoglobulin G (IgG) antibodies in LT recipients 12 months after coronavirus disease 2019 (COVID-19). A total of 65 LT recipients were matched with 65 nontransplanted patients by a propensity score including variables with recognized impact on COVID-19. LT recipients showed a lower prevalence of anti-nucleocapsid (27.7% versus 49.2%; P = 0.02) and anti-spike IgG antibodies (88.2% versus 100.0%; P = 0.02) at 12 months. Lower index values of anti-nucleocapsid IgG antibodies were also observed in transplantation patients 1 year after COVID-19 (median, 0.49 [interquartile range, 0.15-1.40] versus 1.36 [interquartile range, 0.53-2.91]; P < 0.001). Vaccinated LT recipients showed higher antibody levels compared with unvaccinated patients (P < 0.001); antibody levels reached after vaccination were comparable to those observed in nontransplanted individuals (P = 0.70). In LT patients, a longer interval since transplantation (odds ratio, 1.10; 95% confidence interval, 1.01-1.20) was independently associated with persistence of anti-nucleocapsid IgG antibodies 1 year after infection. In conclusion, compared with nontransplanted patients, LT recipients show a lower long-term persistence of anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies. However, SARS-CoV-2 vaccination after COVID-19 in LT patients achieves a significant increase in antibody levels, comparable to that of nontransplanted patients.