The COVID-19 pandemic poses special challenges to patients with organ failure. Those waiting for transplant or who had received a transplant tend to have more severe disease due to weak immunity. Patients with severe heart, lung, or liver failure and waiting for transplant are at a high risk for dying if a transplant does not happen within a short period of time. But if there are clusters of COVID-19 disease in the region around the hospital or if there are COVID-19 patients already admitted in the hospital then, the course ahead becomes a quandry.
Performing a transplant surgery in such situation will increase the risk of exposure to the recipient during the surgery and in the recovery period. This exposure could happen from the donor or healthcare providers or other patients in the hospital. It is possible that the hospital resources could become limited due to COVID-19 cases and the care of the transplant recipients may get compromised.
Non-urgent transplant surgeries such as kidney transplants in relatively stable patients on dialysis may be avoided in areas of high prevalence of COVID-19. If the recipient is critically ill and the surgery is unavoidable then care must be taken to check both the donor and the recipient for COVID-19 prior to transplant.
Elective living donation transplants could continue in regions with low incidence and in hospitals with no infected patients. Deceased donation can continue in countries/regions with low incidence of COVID-19 but with stringent precautions.
Currently, there is no evidence to support blood-transfusion related transmission of the virus particles and no additional precautions need to be taken by the blood bank during transplant surgeries. But voluntary blood donation may decrease and hence available blood must be used judiciously.
All brain dead donors should be adequately screened for recent travel and potential exposure to virus. Deceased donation involves significant amount of interaction with the donor family, and increased human movement in hospital. Transplant coordinators should follow appropriate preventive measures to avoid exposure during evaluation. Donors with active infection or exposure to COVID-19 should not be considered for transplantation. Organ transportation throws additional challenges. Also deceased organ donation from hospitals with COVID-19 patients should be avoided due to risk of cross contamination.
Regular visits to the doctor should be limited during this period of virus spread. Physicians can use telemedicine to reduce visits but continue interacting with the patient. Routine investigations should be limited and any elective procedures must be postponed. Dialysis patients and their treating physician should identify another small volume unit for dialysis needs if the situation arises where the primary centre is overwhelmed with COVID-19 patients.
The role of pre-emptive placement of AV fistula should be evaluated in patients with advanced renal failure to avoid the occurrence of emergent needs during COVID-19 epidemic. Transplant recipients with mild symptoms including runny nose, cough, throat pain and low-grade fever should be considered as suspected case of COVID- 19. They should be asked to self-quarantine themselves at home and consideration must be given to lower the immunosuppression.
A majority of mild illnesses resolve spontaneously, with time and rest. However, such patients should be asked to closely monitor their symptoms. Patients with severe symptoms such as breathing difficulty, high fever and lack of oxygen should be admitted to the hospital.
Immunosuppressive therapy should be discontinued or reduced in patients with severe illnesses. Currently, there are no proven therapies to cure coronavirus infection. The treatment in the hospital includes oxygen and organ supportive care until the lung injury resolves. Certain anti viral medication have been used on experimental basis with some reported benefits.
