Keywords
transplantation - lung - infection - intensive care
Introduction
The current COVID-19 pandemic affects health care systems in all countries worldwide,
however, to a variable extent depending on the caseload in each country. In Germany,
a pre-emptive strategy was chosen, and hospital capacities and particularly intensive
care unit (ICU) beds were reserved for patients with COVID-19. Simultaneously, elective
outpatient visits as well as elective hospital stays and surgeries were postponed.
So far, the number of COVID-19 patients did not reach the capacity limits of the health
care system. Lung transplantation in patients with end-stage pulmonary disease is
not elective surgery, yet it requires substantial resources in the ICU for donor as
well as for recipient management and carries the potential risk for viral spread both
via the transplanted organ as well as by procurement teams during travel. Lung transplantation
might lead to an increased risk for severe acute respiratory syndrome coronavirus
2 (SARS-CoV-2) infection due to the highly immunosuppressed state and the lung as
the primary affected organ. No clear recommendations for lung transplantation and
treatment of COVID-19 infections in transplanted patients exist. Thus, we aimed to
provide a cross-sectional overview of current limitations and adaptions in lung transplant
programs in Germany due to the COVID-19 pandemia caused by SARS-CoV-2 in April 2020.
Methods
A cross-sectional survey assessing various aspects of lung transplant activity was
sent out to all active lung transplant programs (n = 12) in Germany by the lung transplant working group of the German Transplantation
Society on April 1, 2020. All responses until April 30, 2020, were anonymized and
taken into account. Seven multiple choice questions addressing the program volume,
precautions in donor and recipient selection and testing, procurement activity within
the Eurotransplant region, changes in immunosuppression, and limitations in ICU capacity
were posed. A possibility for comments was provided for each question.
Results
Eight centers responded to the survey within the requested time frame. Four centers
(50%) reported that their activity is not restricted, but four centers (50%) reported
about moderate general limitations. One center (13%) reported limitations of transplantation
activity due to shortage of ICU capacities, whereas seven centers (88%) were not limited
by ICU beds. As additional safety measure, mandatory donor SARS-CoV-2 testing has
been implemented in the entire Eurotransplant region. All eight centers require negative
SARS-CoV-2 testing either by nasopharyngeal swab or bronchoalveolar lavage. One center
(13%) requested a negative chest computed tomography scan additionally. Seven centers
(88%) did not report any difficulties during organ procurement procedures within the
Eurotransplant region, whereas one center (13%) mentioned problems with SARS-CoV-2
testing.
Recipient selection was unchanged independent of Lung Allocation Score (LAS) status
and urgency in six centers (75%). Two centers (25%) restricted their activity to patients
with high Lung Allocation Score (LAS) only. In five centers (63%), mandatory SARS-CoV-2
testing in recipients by nasopharyngeal swab and/or bronchoalveolar lavage is performed
prior to transplantation. In three centers (38%), recipients are not tested prior
to the transplant procedure. Recipient immunosuppression remained unchanged in all
centers.
According to Eurotransplant data, 128 bilateral and 11 single lung transplant procedures
were performed in Germany from January to April 2020. In 2019, 126 bilateral and 12
single lung transplantations were performed during the same time frame (www.eurotransplant.org). On a national level, the number of patients on the lung transplant waiting list,
the number of overall organ donors, as well as mortality on the lung transplant waiting
list showed no significant changes within the first 5 months of 2020 ([Fig. 1]). The number of new registrations on the lung transplant waiting list decreased
from 43 in February and March 2020 to 26 in April and 16 in May 2020.
Fig. 1 Lung transplant activity in Germany, January to May 2020.
Discussion
These data reflect the situation analyzed by our cross-sectional survey in Germany
in April 2020. The trend remains unchanged in May 2020 based on Eurotransplant data.
Germany has a health care system which in the past was frequently criticized for having
too many hospital and ICU beds. The number of ICU beds is highest in Europe (33.9
beds per million inhabitants) followed by Austria (28.9).[1] The Organisation for Economic Co-operation and Development average is 15.9 beds
per million inhabitants (www.oecd.org). Due to acute recruitment of resources stimulated by developments of the COVID-19
situation in other countries, this capacity was increased to 40 ICU beds per million
inhabitants. According to the register of the German Interdisciplinary Association
for Intensive Care and Emergency Medicine (DIVI), more than 32,000 ICU beds are currently
available.[2] The number of patients with COVID-19 requiring hospitalization and ICU treatment
was so far relatively moderate and did by far not reach capacity limits. Thus, while
elective patients were postponed, the need for triage in acute or urgent situations
was not given in most hospitals. Therefore, limitations in lung transplantation were
moderate so far. The disease exhibits a high variability in reproduction rate and
local clusters of disease develop easily if adequate precautions are not taken. Neither
antiviral drugs with proven benefit nor vaccination against COVID-19 is currently
available. Until then restrictions in transplantation activity might be required due
to local hospital resources as well as external factors such as travel restrictions.
Systematic data collection is encouraged to gain knowledge and advance therapeutic
options as fast as possible. The Lean European Open Survey for SARS-CoV-2 Infected
Patients (LEOSS) registry has been created to register data on all patients with SARS-CoV-2
infection and includes patients after solid organ transplantation as well.
COVID-19 in patients after lung transplantation has been reported in a limited number
of cases.[3]
[4] So far no definite conclusions on optimal management of SARS-CoV-2 patients after
lung transplantation can be drawn. In contrast to the first report in solid organ
transplant recipients which suggested a similar disease presentation compared with
the general population,[3]
[4]
[5]
[6] a recent experience in 36 infected kidney transplant recipients suggests a more
rapid progression and a higher mortality of 28% compared with the general population.[7] However, experimental data suggest a potential inhibition of coronavirus replication
by calcineurin inhibitors.[8] Several uncertainties remain on the role of immunosuppression in virus replication
and susceptibility to COVID-19. The trend toward a reduction of new waiting list registrations
in April and May 2020 might be a temporary COVID-19-induced effect and needs to be
closely observed.
Conclusion
Although COVID-19 has a significant impact on transplant activities in other countries,[9]
[10] its influence on lung transplantation activity in Germany has been moderate so far.
Rapid adaption to changes in COVID-19 reproduction rates might be required until effective
antiviral therapy or vaccination is available.
