key: cord-0712735-oab402yo
authors: Boyarsky, Brian J.; Po‐Yu Chiang, Teresa; Werbel, William A.; Durand, Christine M.; Avery, Robin K.; Getsin, Samantha N.; Jackson, Kyle R.; Kernodle, Amber B.; Van Pilsum Rasmussen, Sarah E.; Massie, Allan B.; Segev, Dorry L.; Garonzik‐Wang, Jacqueline M.
title: Early impact of COVID‐19 on transplant center practices and policies in the United States
date: 2020-05-10
journal: Am J Transplant
DOI: 10.1111/ajt.15915
sha: 4ce91aededb8c26fe81e94119716361cd584d378
doc_id: 712735
cord_uid: oab402yo

COVID‐19 is a novel, rapidly changing pandemic: consequently, evidence‐based recommendations in solid organ transplantation (SOT) remain challenging and unclear. To understand the impact on transplant activity across the United States, and center‐level variation in testing, clinical practice, and policies, we conducted a national survey between March 24, 2020 and March 31, 2020 and linked responses to the COVID‐19 incidence map. Response rate was a very high 79.3%, reflecting a strong national priority to better understand COVID‐19. Complete suspension of live donor kidney transplantation was reported by 71.8% and live donor liver by 67.7%. While complete suspension of deceased donor transplantation was less frequent, some restrictions to deceased donor kidney transplantation were reported by 84.0% and deceased donor liver by 73.3%; more stringent restrictions were associated with higher regional incidence of COVID‐19. Shortage of COVID‐19 tests was reported by 42.5%. Respondents reported a total of 148 COVID‐19 recipients from <1 to >10 years posttransplant: 69.6% were kidney recipients, and 25.0% were critically ill. Hydroxychloroquine (HCQ) was used by 78.1% of respondents; azithromycin by 46.9%; tocilizumab by 31.3%, and remdesivir by 25.0%. There is wide heterogeneity in center‐level response across the United States; ongoing national data collection, expert discussion, and clinical studies are critical to informing evidence‐based practices.

COVID-19 has quickly and dramatically impacted the world. [1] [2] [3] [4] [5] Given the early nature of the pandemic, knowledge about COVID-19 and its impact on solid organ transplantation (SOT) patients is limited to case reports and expert discussion. [6] [7] [8] There is insufficient knowledge about the natural history of COVID-19, 9, 10 including lack of understanding about the potential for donor-derived infection given imperfections in currently available diagnostic tests. 2, 11 There is ongoing nosocomial and community spread, 12 and more severe illness has been observed for patients with underlying conditions. 3, [13] [14] [15] [16] [17] Previous experience with related viruses, SARS-CoV in 2003, 18 and MERS-CoV in 2015, 19 demonstrated that SOT recipients may be anticipated to have prolonged viral shedding, potentially increasing transmissibility, morbidity, and mortality. 6, 20 There are several ways transplant centers can approach the COVID-19 pandemic to mitigate risk for SOT candidates and recipients. Specifically, centers can restrict access to transplantation based on urgency and limit use of donors based on exposure risk.

Transplant centers can modify evaluation and monitoring practices of non-COVID-19-SOT patients, develop screening and testing algorithms for suspected cases and treatment protocols for confirmed cases. Furthermore, centers can risk-stratify COVID-19-SOT patients based on disease severity to help allocate appropriate resources to the sickest and most vulnerable patients. However, there are currently no evidence based-guidelines to inform these practices.

To better understand the early impact of COVID-19 on transplant activity across the United States, and to explore center-level variation in testing, clinical practice, and policies, we conducted a national survey of US transplant centers between March 24, 2020 and March 31, 2020. We gathered data in 4 domains: (a) current transplant activity, (b) COVID-19 impact on practices, (c) testing algorithms, and (d) treatment practices. We purposefully conducted our survey at a relatively early stage of US COVID-19 activity in the hopes that rapid dissemination of center-level practices, policies, and perceptions could inform decision-making in other centers in the United States and around the world.

We studied transplant centers in the United States with an annual volume of ≥100 transplants per year (calculated by the average total number of SOTs in 2018 and 2019). These 111 centers perform 87.6% of the adult transplant volume in the United States.

The survey instrument was developed using an iterative process, based on a thorough review of the literature surrounding COVID-19, [21] [22] [23] [24] [25] and discussions with transplant surgeons and transplant ID physicians. The final survey was approved by two transplant surgeons and two transplant ID physicians with input from members of the transplant team (Supplement).

The survey was conducted between March 24, 2020 and March 31, 2020. At each center, we identified one clinical transplant leader who we anticipated would have knowledge about their center's COVID-19 practices and policies. Participants were e-mailed links to the survey, and encouraged to either fill out the survey themselves if they felt comfortable, gather data from among colleagues and provide a center-wide response, or pass the survey along to someone who they felt was more appropriate to answer the questions.

The online survey was hosted by Qualtrics. Respondents were not compensated.

We asked questions in 4 domains: (a) current transplant activity, 

Using data from the Johns Hopkins COVID-19 incidence map and the CDC, we linked the cumulative incidence of COVID-19 in each state on March 24 (the day the survey was administered) to each respondent's survey answers. 26, 27 We divided the total number of cases in each state by state population (from the US Census) to derive cumulative incidence per million population (PMP). 28 Twenty-two centers in 8 states whose COVID-19 cumulative incidence were above national average (163 PMP) were defined as centers in high-impact areas.

For statistical purposes, each question was treated as a complete case analysis. We tested the association between transplant activity and level of COVID-19 impact by Fischer's exact test and reported significance level using P < .05. All analyses were performed using Stata 16.0/MP for Linux.

Among the 111 transplant centers surveyed, 88 responded (79.3%) ( 

Among LDKT programs, 56/78 (71.8%) reported full suspension of transplantation ( Figure 1A ). Operational restrictions (some or major)

were reported in 19/78 (24.4%) of LDKT programs. Among DDKT programs, 65/81 (80.2%) were operating with some or major restrictions. Among LDLT programs, 21/31 (67.7%) were suspended.

LDLT programs were more likely to be suspended in higher impact areas (P = .03). Among DDLT programs, 16/60 (26.7%) were operating without restriction. Pancreas transplantation was suspended at 22/56 (39.3%). Among heart programs, 6/32 (18.8%) were continuing without restriction. For lung programs, 5/27 (18.5%) were operating without restriction.

preemptive KTs, well-recipients, and those with lack of dialysis access. Some restrictions were driven by limited operating room (OR) staffing. Common DDKT restrictions included: transplanting only highly sensitized patients, those with negative crossmatch, higher acuity patients, and those without dialysis access.

Others reported transplanting only healthier recipients with the best quality organs and lowest risk of delayed graft function (DGF). Among those LDLT operating with restrictions, respondents noted transplanting patients only with high probability of mortality in 1-3 months; others reported that the LDLT evaluation process has stopped or slowed down. Common restrictions on DDLT included: transplanting higher acuity (MELD > 25 or acute liver failure) patients, inpatients only, those who were not anticipated to require blood products intraoperatively, first-time transplants, and those with tumors without other options. Some respondents reported being limited by supplies and capacity.

Reasons for suspension of pancreas transplantation included: avoiding occupying ICU beds, and because of risk of prolonged hospitalization with increased risk of readmission. Some heart programs were restricting to the most severe cases (status 1-3, inpatients). Some lung programs were restricting by lung allocation score (LAS) >45, though some reported inactivating the majority of patients.

Regarding respondents' perceptions about continuation of trans- Figure 1B ).

In-person outpatient visits for SOT recipients were reported to be lim- 

Regarding level of concern about COVID-19 risk for current SOT concerned (Figure 2) , which did not change based on state-level cumulative incidence of COVID-19 (P = .8 

In this national survey of transplant centers during the COVID-19 pandemic, we found substantial reduction in transplant activity, wide variation in COVID-19 testing practices, and use of off-label ongoing national data collection, expert discussion, and clinical studies are critical to informing evidence-based practices.

We acknowledge all respondents for their participation in this time-sensitive survey. This work was supported by grant number T32DK007713- 

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Additional supporting information may be found online in the Supporting Information section

Early impact of COVID-19 on transplant center practices and policies in the United States