Comorbidities: Transplantation

Transplantation

During a health crisis such as the COVID pandemic, it is crucial to carefully balance cost and benefits in performing organ transplantation (Andrea 2020). There is no doubt that the current situation has deeply affected organ donation and that this represents an important collateral damage of the pandemic. All Eurotransplant countries have implemented preventive screenings policies for potential organ donors. For detailed information on the national policy, please visit https://www.eurotransplant.org/2020/04/07/covid-19-and-organ-donation/. Preliminary data indicate a significant reduction in transplantation rates even in regions where COVID-19 cases are low, suggesting a global and nationwide effect beyond the local COVID-19 infection prevalence (Loupy 2020). During March and April, the overall reduction in deceased donor transplantations since the COVID-19 outbreak was 91% in France and 51% in the USA, respectively. In both France and the USA, this reduction was mostly driven by kidney transplantation, but a substantial effect was also seen for heart, lung, and liver transplants, all of which provide meaningful improvement in survival probability. Solid organ transplant recipients are generally at higher risk for complications of respiratory viral infections (in particular influenza), due to their chronic immunosuppressive regimen, and this may hold particularly true for SARS-CoV-2 infection. The first cohort of COVID-19 in transplant recipients from the US indeed indicated that transplant recipients appear to have more severe outcomes (Pereira 2020). Some key studies:


Comorbidities : Introduction | Hypertension / CVD | Diabetes mellitus | COPD and smoking | HIV infection | Immunosuppression | Cancer | Transplantation | Other comorbidities


Liver: In the largest cohort, 16/100 patients died from COVID-19. Of note, mortality was observed only in patients aged 60 years or older (16/73) and was more common in males than in females (Belli 2020). Although not statistically significant, more patients who were transplanted at least 2 years earlier died than did those who received their transplant within the past 2 years (18% vs 5%). A systematic search on June 15 revealed 223 liver transplant recipients with COVID-19 in 15 studies (Fraser 2020). The case fatality rate was 19.3%. Dyspnea on presentation, diabetes mellitus, and age 60 years or older were significantly associated with increased mortality (p=0.01) with a trend to a higher mortality rate observed in those with hypertension and those receiving corticosteroids at the time of COVID-19 diagnosis. However, in a multicenter cohort study, comparing 151 adult liver transplant recipients from 18 countries with 627 patients who had not undergone liver transplantation, liver transplantation did not significantly increase the risk of death in patients with SARS-CoV-2 infection (Webb 2020).

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Kidney: In a single center with 36 kidney transplant recipients, 10/36 died (Akalin 2020). Patients appear to have less fever as an initial symptom, lower CD4 and CD8 T cell counts and more rapid clinical progression.

Heart: In a case series of 28 patients who had received a heart transplant in a large academic center in New York, 22 patients (79%) were hospitalized. At the end of the follow-up, 4 remained hospitalized and 7 (25%) had died (Latif 2020). In Germany, mortality was also high, and 7/21 patients died (Rivinius 2020).


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References

Akalin E, Azzi Y, Bartash B. Covid-19 and Kidney Transplantation. N Engl J Med. 2020 Apr 24. PubMed: https://pubmed.gov/32329975. Full-text: https://doi.org/10.1056/NEJMc2011117

Andrea G, Daniele D, Barbara A, et al. Coronavirus Disease 2019 and Transplantation: a view from the inside. Am J Transplant. 2020 Mar 17. PubMed: https://pubmed.gov/32181969. Fulltext: https://doi.org/10.1111/ajt.15853

Belli LC, Duvoux C, Karam V, et al. COVID-19 in liver transplant recipients: preliminary data from the ELITA/ELTR registry. Lancet Gastroenterology & Hepatology, June 4, 2020.  Full-text: https://doi.org/10.1016/S2468-1253(20)30183-7

Fraser J, Mousley J, Testro A, Smibert OC, Koshy AN. Clinical Presentation, Treatment, and Mortality Rate in Liver Transplant Recipients With Coronavirus Disease 2019: A Systematic Review and Quantitative Analysis. Transplant Proc. 2020 Jul 30:S0041-1345(20)32634-8. PubMed: https://pubmed.gov/32891405. Full-text: https://doi.org/10.1016/j.transproceed.2020.07.012

Latif F, Farr MA, Clerkin KJ, et al. Characteristics and Outcomes of Recipients of Heart Transplant With Coronavirus Disease 2019. JAMA Cardiol. Published online May 13, 2020. Full-text: https://doi.org/10.1001/jamacardio.2020.2159

Loupy A, Aubert O, Reese PP, et al. Organ procurement and transplantation during the COVID-19 pandemic. Lancet May 11, 2020. Full-text: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31040-0/fulltext

Pereira MR, Mohan S, Cohen DJ, et al. COVID-19 in Solid Organ Transplant Recipients: Initial Report from the US Epicenter. Am J Transplant. 2020 Apr 24. PubMed: https://pubmed.gov/32330343. Full-text: https://doi.org/10.1111/ajt.15941

Rivinius R, Kaya Z, Schramm R, et al. COVID-19 among heart transplant recipients in Germany: a multicenter survey. Clin Res Cardiol. 2020 Aug 11. PubMed: https://pubmed.gov/32783099. Full-text: https://doi.org/10.1007/s00392-020-01722-w

Webb GJ, Marjot T, Cook JA, et al. Outcomes following SARS-CoV-2 infection in liver transplant recipients: an international registry study. Lancet Gastroenterol Hepatol 2020, published 28 August. Full-text: https://doi.org/10.1016/S2468-1253(20)30271-5