Impact of COVID-19 in solid organ transplant recipients

Abstract

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exploded onto the world stage in early 2020. The impact on solid organ transplantation (SOT) has been profound affecting potential donors, candidates, and recipients. Importantly, decreased donations and the pressure of limited resources placed on health care by the pandemic also disrupted transplant systems. We address the impact of COVID-19 on organ transplantation globally and review current understanding of the epidemiology, outcomes, diagnosis, and treatment of COVID-19 in SOT recipients.

Keywords: COVID-19; United infection and infectious agents - viral; antibiotic: antiviral; health services and outcomes research viewpoint; immunosuppression / immune modulation; infectious disease; organ procurement; organ transplantation in general.

FIGURE 1

Time course of SARS-CoV-2 infection and development of COVID-19. After infection with SARS-CoV-2, individuals may transmit the virus 1–2 days prior to and approximately 8 days after the onset of clinical symptoms (red curve). SARS-CoV-2 RNA as determined by PCR (orange curve) is detectable for longer periods of time. Infection is followed by the induction of SARS-CoV-2-specific CD4 and CD8 T cells (blue curve) that contribute to the control of viral replication. In addition, a hyperactive immune response contributes to immunopathology associated with COVID-19. As outlined by stippled curves, PCR positivity after infection may be prolonged in transplant recipients, with potential implications for prolonged infectivity. In addition, induction of specific immunity may be less pronounced given immunosuppressive drug therapy. Implications for therapeutic management are indicated. This includes antiviral drugs or convalescent plasma together with reduction in immunosuppression in the early period of infection to ensure control of viral replication, and immunomodulatory or anti-inflammatory treatment regimens associated with restoring or intensified immunosuppression in the later stages of infection to counteract immunopathology.

FIGURE 2

Timeline of SARS-CoV-2 identification, selected announcements, and therapeutic milestones related with COVID-19. The yellow line shows the cumulative number of cases worldwide (source: John Hopkins Coronavirus research Center). COVID-19, coronavirus disease 19; FDA, Food and Drug Administration; HCQ, hydroxychloroquine; PEP, postexposure prophylaxis; RCTs, randomized clinical trials; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; SOT, solid organ transplant; WHO, World Health Organization.