Lung Transplantation for Patients With COVID-19

Abstract

The COVID-19 pandemic has caused acute lung injury in millions of individuals worldwide. Some patients develop COVID-related acute respiratory distress syndrome (CARDS) and cannot be liberated from mechanical ventilation. Others may develop post-COVID fibrosis, resulting in substantial disability and need for long-term supplemental oxygen. In both of these situations, treatment teams often inquire about the possibility of lung transplantation. In fact, lung transplantation has been successfully employed for both CARDS and post-COVID fibrosis in a limited number of patients worldwide. Lung transplantation after COVID infection presents a number of unique challenges that transplant programs must consider. In those with severe CARDS, the inability to conduct proper psychosocial evaluation and pretransplantation education, marked deconditioning from critical illness, and infectious concerns regarding viral reactivation are major hurdles. In those with post-COVID fibrosis, our limited knowledge about the natural history of recovery after COVID-19 infection is problematic. Increased knowledge of the likelihood and degree of recovery after COVID-19 acute lung injury is essential for appropriate decision-making with regard to transplantation. Transplant physicians must weigh the risks and benefits of lung transplantation differently in a post-COVID fibrosis patient who is likely to remain stable or gradually improve in comparison with a patient with a known progressive fibrosing interstitial lung disease (fILD). Clearly lung transplantation can be a life-saving therapeutic option for some patients with severe lung injury from COVID-19 infection. In this review, we discuss how lung transplant providers from a number of experienced centers approach lung transplantation for CARDS or post-COVID fibrosis.

Keywords: ARDS; COVID-19; lung transplantation; pulmonary fibrosis.

Figure 1

Case 1: A, Diffuse ground-glass opacities on CT obtained at the time of admission; B, CT chest obtained at initial clinic follow-up 5 months after developing COVID-19 demonstrates diffuse ground-glass opacities, upper lung peripheral consolidation and traction bronchiectasis.

Figure 2

Case 2: CT chest with upper lobe predominant pulmonary fibrosis and traction bronchiectasis along with areas of ground-glass opacities.

Figure 3

Figure illustrating the clinical course of COVID-19 acute lung injury and the optimal timing of lung transplantation.

Figure 4

Algorithm for potential diagnostic approach to evaluation of inpatient lung transplant candidates with COVID-19. ∗Adequate time to recovery should consider the individual clinical situation of the patient and must weigh the likelihood of recovery against the risk of development of complications that may be fatal without transplantation.