Chapter 12: Transplantation

INTRODUCTION

Solid organ transplantation (SOT) of kidney, liver, pancreas, intestine, heart, and lung is one of the biggest advances in medicine and has become a life-saving treatment for end-stage organ diseases. One particular peril to organ transplantation is the risk of emerging infectious diseases. Over the last several decades, infectious respiratory diseases such as severe acute respiratory syndrome coronavirus (SARS-CoV), influenza A/H1N1, and more recently SARS-CoV-2, the virus that causes COVID-19, have threatened the general public and have challenged the transplantation community.¹

Some of these emerging diseases have been limited to specific geographic areas, and transplantation centers have been able to adapt and proceed with transplantation safely and efficiently. However, COVID-19, a novel, rapidly growing, highly contagious virus, has forced drastic changes in medical practice within a short period of time. It has greatly impacted transplantation centers throughout the United States and worldwide, while increasing pressure on intensive care units (ICU) who faced a surge of COVID-inflicted critical illness.

EPIDEMIOLOGY

COVID-19 was first identified as the source of a cluster of pneumonia cases in Wuhan, China.² It spread rapidly throughout China, followed by increasing cases throughout the world and by March 2020 the World Health Organization (WHO) declared an international pandemic. As of October 2020, nearly 34 million cases and over 1 million deaths have been reported worldwide.³

The COVID-19 virus is particularly transmissible. The most common modes of transmission are through respiratory droplets during close-range contact with an asymptomatic or symptomatic carrier and to a lesser degree, contact transmission.^4,5 Airborne transmission is less likely, but raises potential risk during aerosol-generating procedures such as endotracheal intubation, open suctioning, and bronchoscopy.⁶ The virus has also been detected in stool, ocular secretions, and semen, but their role in transmission remains unknown.⁷

The general population lacks immunity and is at risk for acquiring the novel coronavirus. The average incubation period for COVID-19 is approximately 5 days⁸ and around 97.5% of individuals who develop symptoms usually do so within 11.5 days.⁹ The most common symptoms among hospitalized individuals were fever, dry cough, shortness of breath, fatigue, nausea/vomiting, diarrhea, and myalgia.¹⁰ The spectrum of symptoms vary from mild febrile illness to severe illness, including acute respiratory distress syndrome (ARDS), acute kidney injury, and multi-organ failure. Older age and medical conditions such as diabetes, cardiovascular disease, chronic pulmonary disease, chronic kidney disease, chronic liver disease, malignancy, obesity, and recipients of solid organ transplants are associated with increased risk for severe COVID-19 illness.¹¹

TRANSPLANT CANDIDATES

At this time, there are over 100,000 individuals in need of a lifesaving organ transplant on the United Organ Network for Organ Sharing (UNOS) waitlist.¹² With the COVID-19 pandemic, transplantation centers faced many new challenges. These new challenges were related to organ procurement, screening policy of donor and ...