Solid Organ Transplantation During COVID-19 Pandemic: An International Web-based Survey on Resources' Allocation

Abstract

Solid organ transplants (SOTs) are life-saving interventions, recently challenged by coronavirus disease 2019 (COVID-19). SOTs require a multistep process, which can be affected by COVID-19 at several phases.

Methods: SOT-specialists, COVID-19-specialists, and medical ethicists designed an international survey according to CHERRIES guidelines. Personal opinions about continuing SOTs, safe managing of donors and recipients, as well as equity of resources' allocation were investigated. The survey was sent by e-mail. Multiple approaches were used (corresponding authors from Scopus, websites of scientific societies, COVID-19 webinars). After the descriptive analysis, univariate and multivariate ordinal regression analysis was performed.

Results: There were 1819 complete answers from 71 countries. The response rate was 49%. Data were stratified according to region, macrospecialty, and organ of interest. Answers were analyzed using univariate-multivariate ordinal regression analysis and thematic analysis. Overall, 20% of the responders thought SOTs should not stop (continue transplant without restriction); over 70% suggested SOTs should selectively stop, and almost 10% indicated they should completely stop. Furthermore, 82% agreed to shift resources from transplant to COVID-19 temporarily. Briefly, main reason for not stopping was that if the transplant will not proceed, the organ will be wasted. Focusing on SOT from living donors, 61% stated that activity should be restricted only to "urgent" cases. At the multivariate analysis, factors identified in favor of continuing transplant were Italy, ethicist, partially disagreeing on the equity question, a high number of COVID-19-related deaths on the day of the answer, a high IHDI country. Factors predicting to stop SOTs were Europe except-Italy, public university hospital, and strongly agreeing on the equity question.

Conclusions: In conclusion, the majority of responders suggested that transplant activity should be continued through the implementation of isolation measures and the adoption of the COVID-19-free pathways. Differences between professional categories are less strong than supposed.

FIGURE 1.

A total of 1819 participants to the survey from 71 nations.

FIGURE 2.

Stratification of answers in relation to “Stop SOTs program” according to region (A), macrospecialty (B), and organ of interest (C). COVID-19, coronavirus 2019; SOT, solid organ transplant.

FIGURE 3.

Color representation according to answer rates to the main question in each nation.

FIGURE 4.

Stratification of answers in relation to “equity question” and according to region (A), macrospecialty (B), and organ of interest (C).

FIGURE 5.

Stratification of answers in relation to the “living-donor question” and according to region (A), macrospecialty (B), and organ of interest (C).

FIGURE 6.

Trends of daily number of infected persons (A) and deaths (B) for each region are illustrated. Data from Asia except China, China, Africa, and Oceania have been reported separately. COVID-19, coronavirus 2019.

FIGURE 7.

Contextual factors and the decision to stop transplant. A and B, Stratification of answers according to number of deaths and infected patients in Italy (A) and all country excluding Italy (B); C. Stratification according to Income Adjusted Human Development Index and to gross domestic product in all countries excluding Italy. COVID-19, coronavirus 2019; GDP, gross domestic product.

FIGURE 8.

Stratification of answers to main question (should organ transplant SOT be stopped?) according to equity question. PA, partially agree; PD, partially disagree; SA, partially agree; SD, strongly disagree; SOT, solid organ transplant.