Lung Transplantation and the COVID-19 Pandemic

What you need to know now

By Sameep Sehgal, MD
Assistant Professor, Thoracic Medicine and Surgery
Lewis Katz School of Medicine at Temple University

The COVID-19 pandemic has had a profound impact on the lung transplant landscape. Immunosuppressants, comorbidities, and lack of response to vaccines put previous lung transplant recipients at high risk if infected with coronavirus, causing great concern and need for precautions. At the same time, COVID is a catalyst for lung transplantation in a small but growing number of patients. High-volume, experienced transplant centers have resources in place both to help keep transplant patients safe and to perform often-complex post-COVID transplant procedures.

DANGERS OF COVID IN LUNG TRANSPLANT RECIPIENTS

A multi-center study in 2020 found that recipients of solid organ transplants who were later hospitalized for COVID-19 had a high mortality rate—20.5% for all solid organ transplant recipients (SOTR) and approximately 50% for those who’d had lung transplants.1The authors found that mortality correlated more with a patient’s associated comorbidities than with the intensity of the immunosuppressant medications they received; however, both likely play a role. A larger study (currently in press) that I conducted with colleagues at Temple and multiple other centers found somewhat lower rates—approximately 16% mortality for non-lung SOTR and 24% mortality for lung transplant recipients—but supported the general trend.2 Because lung transplant recipients are on high levels of immunosuppressants and often have dangerous comorbidities, and because COVID-19 attacks the lungs primarily (and has the potential to induce graft rejection), this tragic result is not unexpected. My colleagues and I also recently conducted a study suggesting COVID-positive SOTRs are likely to have shorter ICU stays and longer time spent on mechanical ventilation compared with non-SOTR COVID patients—data that may also reflect poorer outcomes among SOTRs.3

The American Society of Transplantation, the International Society of Heart and Lung Transplantation, and others recently issued a statement noting much lower vaccine response rates for SOTRs than for the general population and recommending COVID vaccination pre-transplant if at all possible.4 We still encourage post-transplant lung recipients to get vaccinated; however, they should continue to take other precautions to avoid infection, especially if community spread is high.


WHEN IS A POST-COVID PATIENT A CANDIDATE FOR LUNG TRANSPLANT?

Post-COVID transplant candidates should:6

  • Have irreversible lung failure due to COVID-19 disease (including radiological evidence) but otherwise be healthy enough for transplant, and have no other organ failure.
  • Be conscious and able to participate actively in both their treatment decisions and their own posttransplant care.
  • Be past the point of active COVID-19 infection (PCR negative).
  • Have been given sufficient time to allow for potential lung recovery that would negate the need for transplant (at least four to six weeks after onset of the damage).
  • Preferably be younger than 65 years of age.

AVOIDING TRANSPLANT DELAYS

Despite concerns about post-transplant COVID patients, experienced transplant centers such as Temple were able to continue to perform life-saving lung transplants throughout the pandemic while maintaining a high level of patient safety. The United Network for Organ Sharing reported in January 2021 that 2020 was another record year for deceased-donor transplants in the United States, with more than 33,000 performed; the U.S. Department of Health & Human Services’ Organ Procurement and Transplantation Network reported 2,539 lung transplants performed in 2020.5 Anecdotally, however, we have seen some patients delay transplant evaluation, possibly due to fear of COVID-19. We urge physicians to encourage timely evaluation and transplantation, as delays can lead to a patient no longer being a good candidate for this life-saving procedure.

TELEMEDICINE: THE NEW NORMAL?

As with many medical disciplines, the pandemic shifted a great deal of transplant evaluation and follow-up care to virtual media. Now that we know we can safely and thoroughly conduct certain transplant follow-up visits via telemedicine, some proportion of these visits—perhaps one-third of those at Temple—will likely remain virtual while the others are returning to an in-person format. Such changes may represent efficiencies for patients and medical systems.

Fibrosis in lung tissue

WHEN COVID-19 NECESSITATES LUNG TRANSPLANTATION

In a small number of patients, damage from COVID-19—usually fibrotic scarring—is both permanent and life-threatening. If all other therapies fail, such patients may sometimes be candidates for lung transplantation.

We still lack comprehensive data on post-COVID transplant outcomes, although what we have suggests they are similar to lung transplant outcomes in general. However, the procedure is often complicated, as severe post-COVID patients may be in poor condition due to long ICU stays and comorbidities. For that reason, post-COVID patients should undergo lung transplantation at an experienced, high-volume transplant center with larger donor organ availability.6 Temple has performed five lung transplants on post-COVID patients; so far, they are all doing well.

To discuss a case or refer a patient for transplant evaluation, please call the Temple Access Center at 800-TEMPLE-MED (800-836-7536) with information about the patient’s condition and health considerations.

While the COVID-19 pandemic is being brought under control in some locations, its effects will continue to be felt in thoracic medicine and lung transplantation for quite some time.

References
1 Kates, O.S., et al. 2020. “COVID-19 in solid organ transplant: A multi-center cohort study.” Clin Infect Dis. ciaa1097, https://doi.org/10.1093/cid/ciaa1097
2 Heldman, M.R., et al. 2021. “COVID-19 in hospitalized lung and nonlung solid organ transplant recipients: A comparative analysis from a multicenter study.” Am J Transplant. 21 (8): 2774-2784. https://doi.org/10.1111/ajt.16692
3 Heldman, M.R., et al. 2020. “Healthcare resource use among solid-organ transplant recipients hospitalized with COVID-19.” Clinical Transplantation 35 (2): e14174. https://doi.org/10.1111/ctr.14174
4 American Society of Transplantation, International Society of Heart and Lung Transplantation, et al. “Statement on COVID-19 Vaccination in Solid Organ Transplant Recipients.” May 7, 2021. https://www.myast.org/ statement-covid-19-vaccination-solid-organ-transplant-recipients#
5 OPTN data as of May 27, 2021.
6 Cypel, M., and Keshavjee, S. 2020. “When to consider lung transplantation for COVID-19.” Lancet Respir Med. 8 (10): 944-946. https://doi.org/10.1016/S2213-2600(20)30393-3