COVID-19 and solid organ transplants

Patients who have undergone solid organ transplantation (heart, lung, liver, kidney) are at high risk for infection with the new SARS-COV-2 coronavirus infection. This is mainly due to their reduced immune response due to the lifelong immunosuppression they receive. Immunosuppression is non-selective and is achieved by a combination of drugs that mainly suppress the activation of the T-lymphocyte, intervening in the 3 main pathways of its activation. A “classic” immunosuppressive regimen for all solid organ transplants includes one of the two calcineurin inhibitors, usually Tacrolimus, an antidepressant, mainly mycophenolic acid, and corticosteroids. increased susceptibility to viral infections, such as herpes and opportunistic infections.

Specifically for the SARS-COV-2 virus, the incidence of infection in solid organ recipients, despite their increased permissibility, is lower than in the general population with reported rates of about 3% of those transplanted in various European countries with the lowest rates. between 0.2 and 0.5%. This is due to the even stricter recommendations for the implementation of hygiene and social isolation measures than to the general population and their observance by the patients themselves.

Transplants that have COVID-19 have, as expected, a more severe disease and a worse prognosis with higher rates of hospitalization and intubation, while mortality is about 15-19% for recipients of all organs except the lung, where mortality reaches 62%.

As for the treatment, the measures of the general population apply for prevention, with greater meticulousness and increased vigilance. Treatment includes all drugs used in other COVID-19 patients, with adjustment to reduced renal or hepatic function and consideration of their interactions with immunosuppressants. The general principles applicable to all severe, opportunistic or viral infections apply to the treatment of immunosuppression and include a reduction in the overall burden of immunosuppression. As a first step, discontinuation of immunosuppressive drugs is recommended, which promotes viral replication but also causes leukopenia itself such as antidepressants (mycophenolic acid and the much less commonly administered azathioprine) and can be drastically reduced and / or discontinued. calcineurin. In any case, the decision is individualized and takes into account both the severity of the infection and the risk to life against this loss of the graft. Of course, for the heart, lungs and liver, the loss of the graft is synonymous with the loss of life.

In addition to solid organ recipients, the “victim” of the COVID-19 pandemic is transplantation, which has declined sharply in all countries over the past 2.5 months but fluctuates from 30% in Italy to 50% in the United Kingdom. and 80% in Spain. The causes are many and obvious: intensive care units and hospital doctors in general have given priority to rescuing patients from COVID-19 and even the few potential donors have been “lost” in this endeavor. Despite the increased vigilance and strict adherence to the measures by the staff, there is always – negligible but real – risk of infection for all hospitalized patients and this can be fatal in the recipient of the instrument during the immediate postoperative and postoperative period, while there is also potential risk of transmitting the virus from donor to recipient.

As a result, almost all living donor transplant programs (kidney and liver) have been discontinued in all countries with few exceptions and a drastic reduction in transplants from deceased donors, as already mentioned, with the exception of those involving the heart and lungs. In Greece, all live donor transplants were stopped immediately, this only applies to the kidney, while the transplants of all organs by deceased donors continued. The fact that transplantation activity in Greece has been at extremely low levels over time has also contributed to this decision. Thus, for the months of March and April 2020, there was only one donor who underwent a heart transplant and two kidney transplants. Compared to the corresponding period of 2019, there were 15 donors, which translates into a 85% reduction in transplant activity. One donor was rejected because the 2nd PCR was positive for SARS-COV-2, while 3 kidney and liver transplants were performed during this time with 2 donors from Bulgaria, where the transplant program was completely stopped. The encouraging thing is that since May 1, 3 donors have been reported, while of the 2 that were appropriate, a heart transplant, 1 liver and 4 kidney transplants were performed. At Laiko Hospital, where 80% of live kidney transplants are performed in our country, the donor kidney transplant program was launched on May 1 with one transplant per week for the first two weeks and two per week thereafter.

It is striking that in the period from the beginning of the pandemic to the present day, there has been only one case of COVID-19 in a transplanted kidney, which survives. This demonstrates in the best way the effectiveness of compliance with the measures of social isolation and the strict recommendations given by the transplant units as well as the distance Medicine applied to monitor the population of all the transplanted organs. Since mid-May, a program for the reopening of the regular transplant clinics at the People’s Hospital has been prepared, taking the appropriate measures for the regular monitoring of our approximately 1500 transplanted patients.
Finally, for patients with kidney transplantation, their comparison with hemodialysis patients is overwhelmingly in favor of transplantation. To date, 28 cases of COVID-19 have been reported in our country in hemodialysis patients and one in a patient under peritoneal dialysis, while 6 deaths (21%) have occurred, corresponding to that of other countries where mortality in hemodialysis patients is 25-30%.

In conclusion, the pandemic inevitably affects the recipients of solid organs, who have an increased risk of both infection and mortality from the SARS-COV-2 virus, while transplantation is also an important “victim”.
In our country, as in the general population, the effects of the infection on transplant patients were negligible due to the application of known measures, but the already meager transplant activity was minimized. We hope that the doubling of beds in intensive care units due to COVID-19 will change in the foreseeable future and the transplant landscape.

I.N. Boletis
Professor of Pathology-Nephrology

Sm. Marinaki
Assistant Professor of Nephrology