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Performing Organ Transplants Safely Amid the COVID19 Outbreak


Darrell Merritt wasn’t sure when the call would come.

The 54-year-old man, who had experienced complications following a kidney transplant procedure at a local hospital in the late 1990s, knew he faced long odds for getting a new kidney — the antibodies he developed following the procedure left him incompatible with 99.7 percent of the population. When his transplanted kidney failed in 2006, Merritt started to undergo dialysis treatments: three-hour sessions, three times a week. For 14 years.

On March 26, Merritt received a call. There was a match. 

“I was shocked,” said Merritt, who underwent successful kidney transplant surgery at the Hospital of the University of Pennsylvania on March 28. “You have to understand — I have been waiting for this for a long time, so it wasn’t even on my radar at the moment. To be honest, I was a little hesitant at first given everything that is going in the world right now. But I trust this team and knew I couldn’t pass on this opportunity — and I’m glad I went through with it.”

Pandemic Poses Unique Barriers to Organ Transplantation

Shortly after the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic in mid-March, Pennsylvania Gov. Tom Wolf ordered hospitals statewide to suspend non-urgent and elective procedures to preserve resources and limit exposure to the disease. Organ transplantation — an urgent, often life-saving procedure — was allowed to continue. Many transplant centers, including the Penn Transplant Institute (PTI), continued to perform procedures, but the pandemic raised questions and posed unique challenges for both organ procurement and transplantation.

Unlike living donor transplant procedures, which could be scheduled weeks in advance, organs from a deceased donor need to be procured and used rapidly, representing a time-limited opportunity. But COVID-19 testing shortages, particularly early on, made it difficult to confirm that potential donors who died of something unrelated were not infected. In order to protect the safety of patients, transplant centers needed to carefully vet all donors to ensure there is minimal risk of COVID-19, explained Abraham Shaked, MD, PhD, director of the PTI. For example, the PTI is not accepting organs from deceased donors who tested positive for COVID-19 or those who are suspected to have had been exposed to the disease.

The unique challenges, coupled with fewer organ donations, led to a tremendous reduction in transplant procedures in the United States throughout the pandemic, according to an international team of researchers that included Peter Reese, MD, MSCE, an associate professor of Medicine and Epidemiology at the Perelman School of Medicine at the University of Pennsylvania. Deceased donor transplants — which accounted for about 80 percent of the nearly 40,000 transplanted performed nationwide in 2019 — dropped by about half in the United States from late February into early April.

Despite the added challenges, the PTI continued to perform some life-saving organ transplants for patients, like Merritt, on the wait list.

“He found his needle in the haystack organ offer,” said Ty B. Dunn, MD, MS, surgical director of Kidney and Pancreas Transplantation at Penn. “His story is a perfect example of the hope and power of organ transplantation — even amid a pandemic.”

Carefully Evaluating the Risks and Benefits of Transplant Procedures During the Outbreak

In early March, the medical and surgical directors of each organ transplant program within the PTI — heart, kidney, liver, lung, and pancreas — met to devise program-specific guidelines for transplant. For every case, the team evaluated the potential risk and benefit of transplant amid the COVID-19 outbreak versus the risk incurred by waiting. The team decided they would not delay transplant for those who are critically in need when an organ became an available. However, the PTI decided to pause its living donor (liver, kidney, and uterus) transplant procedures — a decision that reflects a trend among transplant centers nationwide. In the United States, transplants from living donors dropped from 151 in the second week of March to just 16 in the first full week of April, according to the United Network for Organ Sharing (UNOS). The majority of living donor organ transplants can be safely postponed due to the availability of supportive care, such as dialysis. However, in some cases, delays can be associated with an increased risk for the recipient as some may become too ill for transplant.

“Living donor transplant procedures are life-saving operations,” said Kim M. Olthoff, MD, chief of Transplant Surgery. “However, the donors don’t need surgery, so we have to balance the risk and benefit of the procedure for both the donor and the recipient.”

The PTI leaders also implemented changes to the center’s practices, ranging from how the team retrieves an organ all the way through to post-operative communication with the patient and family. In the past, a full Penn team may have boarded a small plane to retrieve an organ from a hospital in the midwest or the west coast. However, amid the COVID-19 outbreak, Shaked said the PTI is limiting the number of people who board the plane.

“We had to think about how best to protect our team,” said Shaked, who recently boarded a small plane to a hospital in Michigan alongside Olthoff and the two pilots. He added that the PTI also created “donor bags” to ensure that anyone who enters a donor hospital — whether nearby or elsewhere in the country — has the necessary personal protective equipment (PPE).

Nearly all of the patients who have received a call from a transplant coordinator amid this pandemic have moved forward with the transplantation procedure. That includes John Iplenski, a 29-year-old from Delaware who was diagnosed with congestive heart failure in 2012. Iplenski, who received a left ventricular assist device (LVAD) in March 2017, underwent a successful heart transplant on March 27. He was discharged from the Hospital of the University of Pennsylvania on April 8.

“I had zero hesitation. This team has already saved my life multiple times,” Iplenski said. “It’s crazy to think I’ve had my new heart for about a month now. I feel great — I haven’t had this much energy since I was 15.”

Safely Increasing the Number of Organ Transplant Procedures

In late April, the number of transplants performed nationwide started to slowly climb, inching closer to the normal rate, according to UNOS. The trend mirrors a slight uptick in other medical procedures, including elective surgeries, in recent weeks. Pennsylvania state officials on April 27 issued new guidance allowing hospitals to resume elective and non-urgent surgeries, as long as they have sufficient protective equipment, staff and capacity.

As hospitals nationwide adopt strategies to safely increase the number of procedures, the PTI has implemented extra precautions to minimize the risk to patients while continuing to perform these urgent procedures. The transplant institute also resumed its living donor kidney and liver programs in mid-May to help expand access to people on the wait list, including kidney patients who often need to leave their homes to undergo dialysis treatment, explained Dunn.

“We are ever-mindful that most kidney transplant candidates have a number of underlying conditions such as high blood pressure, diabetes or heart disease — factors that may increase their risk of developing a more severe form of COVID-19. Unfortunately, many of these patients need to go out into the community multiple times a week to undergo dialysis treatments,” Dunn said. “It’s important we consider that long-term, everyday risk when weighing whether to move forward with a transplant. COVID-19 appears to be with us for the foreseeable future, so we are focused on nimbly developing best practices that allow for safer transplants.”

Although the number of on-site appointments will continue to increase, the transplant team will continue to use telemedicine services to connect with patients. Since the onset of the pandemic, the team dramatically increased its use of telemedicine, both for transplant recipients and their families, as well as patients on the wait list. The PTI has also offered virtual evaluations for potential transplant candidates.

“While we implement strategies to protect the health of patients who undergo transplant procedures, it’s equally important to continue to provide care for patients who remain on the wait list,” Olthoff said. “Our team has used telemedicine to help monitor their status, adjust their treatment regimen and, when appropriate, advise them to come into the hospital for treatment.”

Now, about two months after his transplant procedure, Merritt said he feels great. In the first few weeks following his surgery, Merritt went to Penn twice a week for follow-up appointments. Meanwhile, a nurse visited him at his home twice to evaluate his condition and make sure his recovery was going well. Now, most of his conversations have shifted to phone calls. He has his first telemedicine appointment this week.

“After all of these years of not knowing whether we’d find a match, it’s an amazing feeling,” Merritt said. “I just feel so fortunate to have received a new kidney — especially with everything that’s going on in the world right now.”   


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