Between restrictions on operating room access, disrupted air and courier services, and a laborious but necessary testing process, organ transplant procedures have taken a serious hit during the coronavirus pandemic.
(CN) — Dr. Shimul Shah is used to working in a high demand, low-supply environment — like what most health care facilities are now facing.
Shah is a multi-organ transplant surgeon at the University of Cincinnati College of Medicine. During the Covid-19 pandemic, organ transplant surgeons like Shah, and the organizations that help find the donors and recipients, face even higher stakes.
With hospitals restricting access to operating rooms, airline and courier services reducing capacity and surgical teams requiring higher levels of personal protection in the operating room, organ transplants in some areas of the country are taking a serious hit during the pandemic. According to the United Network of Organ Sharing (UNOS), transplants dropped for the first time in seven years — after seven consecutive years of record numbers of transplants.
“Obviously the numbers are down,” UNOS spokesperson Anne Paschke said.
According to UNOS, the number of organ transplants in the United States dropped below the 2019 number the week of April 6, and number of living donor transplants began to drop below 2019 on March 16. In the hard-hit area of the northeastern United States, there were 235 living donor organ transplants as of April 21 — about 34% lower than one year ago.
But the week of April 20 started to show signs of growth in nationwide transplants.
“Hopefully by next week we’ll see this is becoming a trend,” Paschke said.
Since organ transplants are not elective surgery they are able to continue, but with some very new parameters.
For instance, organ and tissue transplants — and the teams that perform them — often fly commercial airlines to travel to hospitals to harvest an organ. Those organs and tissue specimens may then be flown to where the recipient lives. But with commercial airline traffic down sharply, the way transplants are performed and organs are recovered has changed. Now, rather than fly a transplant surgeon and a team to a distant locale, transplant organizations are relying on local surgical teams.
“We’re encouraging local procurement as much as possible,” Paschke said.
For Dr. Shah at the University of Cincinnati College of Medicine, the Covid-19 pandemic has brought new challenges, but also opportunities for restructuring operations.
When the novel coronavirus began breaking out in Italy and China, Shah said, “It showed we had no idea what Covid meant to transplantation. There was nowhere to read about anything on it.”
Because there was very little information on Covid and how it could be spread during the organ harvest and transplant process, “We had to peel back to doing only extremely vital transplants,” Shah said.
The coronavirus appears to spread mainly through aerosolized droplets of lung fluid, so transplant operations have changed. Surgical and support teams don’t enter the operating room until at least 15 minutes after the patient has been intubated, so that any aerosolized droplets are removed from the air, Shah explained. “We’re learning as we go,” he said.
Heart and liver transplant operations pose a high risk of aerosolization because they are much longer operations, according to Shah.
Certain transplant recipients have contracted the Covid-19 virus, Shah said, but not through the transplant itself, or in the hospital. Rather, the recipients seem to be picking it up in the community after the transplant, he said.
Ohio was one of the first states in the nation to issue stay-at-home orders, so the state has a low rate of infection, Shah said. “That has saved our state,” he said. His hospital has 80% fewer coronavirus cases than was predicted.
And it’s also led to his transplant program being able to resume operations with deceased donor transplants three weeks ago. “We’ve been able to transplant a lot of people,” Shah said.
In New York, however, the situation is much more dire. With over 200,000 Covid infections and 11,000 deaths in the state as of April 15, “The situation changes daily, if not hourly,” Chad Ezzell, chief clinical officer at LiveOnNY, said. “Facilitating the organ donor recovery process in the current environment has been extremely challenging.”
Ezzell said that while there has been a 300% increase in referrals to the LiveOn donor center, the number of “vented” referrals, or people on ventilator life support, “has significantly decreased, limiting the number of donation opportunities. We have had to adjust our approach to which donors we are pursuing.”
LiveOnNY, the organization connects from the operating room with organ-donor families via Facetime during the organ withdrawal process “so they can be present with their family members in the O.R. during the withdrawal process.”
Per LiveOnNY’s policy, organ donors must test negative for coronavirus prior to any hands-on evaluation of the donor in order to minimize Covid exposure to staff, Ezzell said. Donors are often moved out of ICU into stretchers and portable beds “to free up precious ICU beds and scarce ventilators for other patients,” Ezzell said.
Ezzell said the organ transportation systems that LiveOnNY used previously have “basically collapsed.” Local couriers used to transport specimens or serology to labs and organ transplant centers have had “significant reductions in staff,” which “caused great delays in service.”
As a temporary work-around, LiveOnNY now uses its own staff to transport specimens and organs, Ezzell said, and flights out of New York City have led to extended “cold times” of the organs — the length of time the organ is kept refrigerated.
According to UNOS, there were 39,719 organ transplants in the United States in 2019, an 8.7% increase from 2018. Of those, 7,397 involved living donors — surpassing the 2004 record of 6,992.
Of the 58 organ-procurement organizations, or OPOs, that coordinate deceased-organ donation, 48 saw a year-over-year increase in 2019, and 41 set new all-time annual records for donation.
There are currently 112,720 people on the organ-donor waiting list, most involving requests for kidneys. Of those, 68,961 people are active waiting list candidates. Deceased donation has increased by 38% since 2014, according to the Organ Procurement and Transplantation Network.
Changes in health care policy have allowed more organs and tissue to be harvested, and that has helped drive seven straight years of record growth in transplants, Paschke, the UNOS spokesperson, said. Public policy has much to do with that growth. For example, President Barack Obama signed the Hope Act in 2014, which allowed liver and kidney transplants to take place among HIV-positive donors and HIV-positive recipients. Starting in May, heart, lung and pancreas transplants can now take place among people with HIV, according to Paschke.
“All these things put together, all the collaboration on many fronts, have led to the advances we’re seeing,” Paschke said. “The whole medical community is fighting for us, for all people to be able to give and receive the gift of life.”
Dr. Christian Benden of SwissTransplant, a national Swiss foundation for organ donation and transplantation, said his country is slowly reopening facilities for kidney transplants as the pandemic slows in Switzerland.
Benden said SwissTransplant avoids any transplants from patients who have symptoms of Covid-19, have had close contact with a confirmed case of the coronavirus, or have traveled to a risk area in the last 14 days.
“Patients are dying on our transplant waiting lists” as his organization must evaluate the risks of viral transmission, Benden said.
LifeCenter spokeswoman Andi Johnson said the interaction with the hospitals where a person is on life support and ready to donate an organ has changed during the pandemic.
Since outside staff are not allowed in intensive care units where the donor patients are, “The family is being serviced over the phone,” she said. “That looks a little different now. You want to be sitting in the room with the family and supporting them.”
Delays in coronavirus testing of the donor — whether living or deceased — can add precious time in a situation when hours count. When an organ transplant such as a kidney can’t take place, that means a person is on dialysis longer. For a person who is already immunocompromised, “that does not help their condition,” Johnson said.
Cornea transplants are not being performed, however, as those are deemed elective surgeries. “Those surgeries just aren’t happening now,” Johnson said.
LifeCenter is one of 58 organ-procurement organizations in the United States that facilitates transplants. These are all federally licensed as well as locally so they can serve regional communities. LifeCenter serves 16 counties in southwest Ohio, northern Kentucky and southeast Indiana.
At the University of Cincinnati, the pandemic has shut down the number of living donations that Shah sees because of the risk of coronavirus exposure to the donor while in the hospital.
His transplant program at the University of Cincinnati does about 130 liver transplants and about 200 kidneys annually, he said. “We have a very busy program,” he said.
When the pandemic began to emerge, Shah had to look at the two extremes of operations: Being safe and shutting everything down, or continuing transplants. “There has been a whole spectrum of possibilities,” he said. “But we’re taking advantage of the opportunity to do transplants, as long as they’re safe.”
During the pandemic, Shah’s team is not traveling to other hospitals to perform organ retrievals, instead relying on local surgical teams. “They know the local situation,” he said.
But while the risk to his team of exposure while traveling is reduced, Shah said relying on local teams presents a new component to the transplant.
“Recovery of the organ is as important as putting it in,” he said.
Shah trained to be a transplant surgeon who specializes in livers because of how unique the liver is. Forty years ago, he said, the liver transplant work he’s doing now “was almost impossible to think about. To be able to save the lives of people who are on the brink of death is very rewarding.”
Now, he’s sometimes able to take a liver and by halving it, two people get a new lease on life.
“Forget about Covid,” he said. “Liver transplantation is cutting edge all the time. We tend to not know everything about it.”
But with more demand for transplants than there often is supply, transplant surgeons like Shah know this kind of situation — even in pandemic.
“This is something we’re very used to,” he said.