Transplant Care Transformed in the Face of COVID-19

As New York City hospitals braced for a potentially overwhelming surge of COVID-19 cases, Columbia University Medical Center nephrologist Sumit Mohan, MD, MPH, and his colleagues had to transform the way they provided kidney transplant care.

“We put a pause on nearly all kidney transplants,” said Mohan, an associate professor of epidemiology and medicine at Columbia University. All elective procedures were put on hold to free up space and ventilators for a surge of COVID-19 patients. For kidney transplant patients with living donors, they decided it was safer to postpone surgeries to prevent donors or immune-suppressed recipients from becoming infected with SARS-CoV-2 in hospitals with large numbers of COVID-19 patients. They concluded that the risks were also too high for most recipients of deceased donors’ kidneys, who in addition to being at risk of infection while immunosuppressed could also experience infection transmission from a donor organ, particularly given the severe shortage of tests for the virus in the early days of the pandemic.

“We inactivated the majority of patients on our kidney transplant list,” he said. Only a small subset of patients who are highly sensitized and unable to accept 99% of donor organs were kept active in case a rare compatible organ became available.

“Our clinics were essentially emptied out except for a small set of urgent visits, Mohan said. “Whatever didn’t need an in-person visit became a telemedicine visit.”

Drawing from experience

To care for kidney transplant patients who became infected with SARS-CoV-2, Mohan and colleagues drew on the experience of collaborators from Northern Italy. Their Italian colleagues were seeing large numbers for transplant recipients hospitalized, a high rate of acute kidney injury, and an influx of kidney failure.

“That conversation alerted us to the need to start preparing,” Mohan said.

Infectious disease specialists also helped by tapping their past experiences with respiratory infections and previous coronavirus outbreaks. Jay Fishman, MD, director of the Transplant Infectious Disease & Compromised Host Program at Massachusetts General Hospital, explained that transplant patients typically have more severe, prolonged symptoms of respiratory infections like pneumonia. Such patients also experienced more severe disease during outbreaks of the Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome, which are also caused by coronaviruses.

To help transplant patients fight COVID-19, Mohan and colleagues developed a standardized approach, the cornerstone of which included reducing patients’ immunosuppression (1). This is a common tactic in helping transplant patients fight infection, Fishman noted.

“We are always balancing immunosuppression against the risk of infection,” Fishman said. “That’s where we live.”

But COVID-19 can trigger an excessive immune response, and inflammation has added a challenge. Fishman noted that there is some question about whether immunosuppressive drugs may protect transplant patients against COVID-19–linked inflammation, but no one knows for sure. “We’ve taken a middle ground where we turned down immune suppression, but we don’t want rebound inflammation to occur,” he said.

With all our decision-making, “we were trying to be as systematic and data-driven as we could be in the chaos, and everyone understood that this was an all-hands-on-deck approach,” Fishman said.

Fishman said he hopes programs will be able to take what they have learned from COVID-19 to help improve transplant patient care even after the pandemic ends. As examples, he cited greater use of telehealth, reductions in unnecessary testing, more rapid testing therapies through collaborations across the country, and better use of electronic medical record data.

“All of these things are things that we’ve learned, it would be a shame not to build on them for our patients in the future,” Fishman said.

June 2020 (Vol. 12, Number 6)

Reference

1. The Columbia University Kidney Transplant Program JASN. April 2020. https://doi.org/10.1681/ASN.2020030375