Practical Considerations for Solid Organ Transplantation During the COVID-19 Global Outbreak: The Experience from Singapore

Abstract

The current coronavirus disease 2019 (COVID-19) pandemic has not only caused global social disruptions but has also put tremendous strain on healthcare systems worldwide. With all attention and significant effort diverted to containing and managing the COVID-19 outbreak (and understandably so), essential medical services such as transplant services are likely to be affected. Closure of transplant programs in an outbreak caused by a highly transmissible novel pathogen may be inevitable owing to patient safety. Yet program closure is not without harm; patients on the transplant waitlist may die before the program reopens. By adopting a tiered approach based on outbreak disease alert levels, and having hospital guidelines based on the best available evidence, life-saving transplants can still be safely performed. We performed a lung transplant and a liver transplant successfully during the COVID-19 era. We present our guidelines and experience on managing the transplant service as well as the selection and management of donors and recipients. We also discuss clinical dilemmas in the management COVID-19 in the posttransplant recipient.

FIGURE 1.

Decision-making grid on patient selection for transplant during pandemics. ^aThe complexity of the transplant is determined by (a) surgical complexity, (b) extent of medical comorbidities, and (c) immunological risk. ^bIn general, medically urgent transplants are performed for patients with (a) liver failure with a high 28-d mortality, (b) heart failure patients who are on MCS with evidence of device-related complications or those who require continuous high-dose inotropic support, or (c) patients with end-stage lung disease who cannot sustain long on the waitlist. Semiurgent transplants are indicated for patients with hepatocellular carcinomas. There is a low indication for transplant for stable heart failure patients who are well supported on MCS, and dialysis patients with no access issues. ^cDecision to proceed with transplantation is contingent on the availability of manpower, operating theater facilities, medical equipment, surgical and intensive care beds, blood products, and adequacy of PPE. MCS, mechanical circulatory support; PPE, personal protective equipment.