COVID-19 hits organ transplants in India as wait and risks for patients increase

While the demand for organ transplants has gone up, as have the risks amid COVID-19 infections, donors have become harder to come by.
Patient in a hospital
Patient in a hospital
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In May, 26-year-old Raghul Gandhi, a national level Kabbadi player from Puducherry, underwent a successful liver transplant at MGM Healthcare, a super-speciality hospital in Chennai. What made his case both dire and unique is that he tested positive for the novel coronavirus after developing acute liver failure. Usually, a liver transplant would have been done at a COVID-free stage, four to five weeks after recovery from COVID-19. However, the doctors made an exception in Raghul’s case. His brother in Chennai was the donor, and a 50-member team worked to get the approvals in place within six hours for what would usually have taken three to four weeks. 

While Raghul recovered after the procedure and COVID-19, there are others who have not been as lucky. Dr Joy Varghese, director of hepatology and liver transplantation at Gleneagles Global Health City in Chennai, shares that while they have performed several successful transplants during the pandemic, in some cases, where patients have come to the hospital in hopes of a transplant, they have turned out to be coronavirus-positive during the screening process. “They then have to be placed in the COVID ward till they are at the non-infectious stage. However, we have lost some patients due to this delay due to COVID-19,” says Dr Joy.

While doctors would usually want to wait for a COVID-19 patient to recover from the illness before proceeding with the transplant, in some emergency cases, such as Raghul’s, waiting is not possible. Though there are patients who have recovered after the transplant and from the COVID-19 infection as well, some doctors also express concern of aggression from the organ recipient’s family if they do not recover. “Certainly, the possibility of life-threatening complications goes up when the patient has COVID-19 infection at the time of the transplant,” says Dr Elan Kumaran, senior consultant and head of Liver Diseases and Transplantation Centre at Kauvery Hospital, Chennai.

Organ transplants on the whole have been affected due to the pandemic, say doctors. For one, the demand has gone up, as have the risks, donors have become harder to come by – especially for lung and heart transplants, which can only be done from cadavers. Liver and kidney transplants can be done from living as well as cadaveric donors.

Paucity of cadaveric donors during pandemic

Usually, after a person undergoes an organ transplant, they are given immunosuppressants so that the body’s immune system does not reject the new organ. Understandably, lowered immunity is a risk factor during the pandemic. This is one of the reasons that doctors were apprehensive about carrying out transplants in 2020, especially in the initial eight months or so. “Even if we wanted to save the life of a patient, we were not sure if we should ask a healthy person (donor) to come to the hospital, be operated on, and then stay in the hospital for recovery,” Dr Elan says.

Once this uncertainty eased a little and there were guidelines – from the Indian Society of Organ Transplantation (ISOT), the National Organ and Tissue Transplant Organisation (NOTTO) and international organisations like the International Liver Transplantation Society (ILTS) – transplants picked up comparatively. The guidelines give certain criteria for both deceased and living organ donors — epidemiological criteria (international travel, contact with a COVID-19 patient), clinical criteria (history of respiratory failure, fever, acute respiratory infection, pneumonia) and laboratory criteria (COVID-19 test 72 hours before the transplant). Further, for beneficiaries, the guidelines talk about assessing COVID-19 risk in cases of lifesaving transplants; recipients returning from abroad; and managing immunosuppression after the transplant.  

However, another problem remained: the paucity of cadaveric donors. When a person is declared brain dead, there is an eight-hour window during which their organs can be harvested for donation. “However, during this pandemic, even if the deceased person doesn’t have COVID-19 and is an eligible donor, the family would be worried about taking the body back to their hometown, getting permissions etc. It has become difficult to convince them. If a patient doesn’t have any potential relative or family who can be a living donor (in case of liver, kidney transplants), the wait for cadaveric donors becomes longer,” explains Dr Joy.

In the case of lung transplants, there is an additional hurdle because COVID-19 is a respiratory disease. Deceased persons who would have recovered from COVID-19 but are found to have scarring or residual changes in the CT scan cannot be donors, points out Dr Vijil Rahulan K, Additional Director at the Health Lung Transplant Institute at KIMS Hospital, Secunderabad in Telangana.

Further, even in cases where there is a living donor, if they are found to have COVID-19 during the pre-transplant screening, the surgery would have to be delayed till the donor recovers and tests negative, even if they are asymptomatic. This also applies to donors who have an active infection.  

While the paucity is felt for those seeking heart transplants as well, the scarcity of cadaveric donors for lung transplants is felt even more because of COVID-19 itself.

“The lung is the primary organ that COVID-19 affects – so we need to make sure there are no lingering after-effects in the lungs. It takes a while for the COVID-19 patient to completely normalise, and most have residual issues. Ideally, after the RT-PCR test is negative, we have to wait for three to four weeks. If everything would have been found to be okay after that, only then a cadaveric donor can be considered for the lung transplant,” says Dr Vijil.

Tweaking the treatment to new risks

As per the Indian Society of Organ Transplantation (ISOT) guidelines from March 2020, “There is no consensus regarding modification in the immunosuppressive regimen of transplant recipients with COVID-19. The dose adjustment has to balance the infection control and the organ rejection.” Although it does suggest some other modifications, doctors tell TNM say that it depends on a case-to-case basis. Normally, Dr Joy says, if a beneficiary has not contracted COVID-19 after the transplant surgery and is not at heightened risk of exposure, then no change needs to be made in immunosuppressants. “If a person does get COVID-19 after the surgery, then with adequate modification of immunosuppressants, the infection can be successfully managed,” adds Dr Elan.

Further, doctors are also trying to create bio-bubbles to ensure the safety and health of donors and recipients – by minimising their contact beyond certain people and ensuring that health workers involved in the care of patients aren’t involved in the care of others, among other measures.

All the doctors whom TNM spoke to strongly recommend that the beneficiary and the living donor take COVID-19 vaccines before the surgery to minimise the risk of infection. “Except in cases of acute liver failure, where an emergency transplant needs to be done, it is usually elective. The pre-surgery processes, registration, screening take three to four weeks, so we encourage the donor and recipient to take the vaccine in the meantime,” Dr Joy says.

“If the patient has had COVID-19, then there is no need for vaccination immediately, as the immunity will remain for up to three months, at least after recovery from the infection. But usually, we try to see if the patients can get both doses before surgery,” concurs Dr Vijil.

However, Dr R Balasubramaniyam, Chief Nephrologist at Kauvery Hospital, Chennai, points out that because the government policy and vaccine availability in India so far are only for people above 18 years of age, doctors are at a loss on what to do when it comes to younger patients. “If we can’t vaccinate them, should we keep children on dialysis and only do the transplant when the pandemic is over? This is a grey area. I hope the government allows vaccination of children, especially those with comorbidities, soon,” he says.

The cost of delaying transplants

Unlike lung, heart or liver, kidney transplants can be delayed significantly even if the organ fails, by keeping the patient on dialysis. However, Dr Balasubramaniyam notes that while this could decrease the risk of COVID-19 infection, the biggest fallout is cost. “Patients have limited resources. So, say, if a patient decides to continue with dialysis in hopes of doing a transplant when it’s safer, they may not actually have the resources left to finance the transplant itself after a while,” he explains.

“Another worry is – what if the patient gets COVID-19 while on dialysis? Patients with kidney ailments are more prone to COVID-19 too,” he adds.

This situation translates across the board – while patients may be able to delay transplants, it comes at a price, which is often the deterioration of their health. This, in turn, increases the risk of infections and makes recovery difficult. “Usually, the success rate in liver transplant is 95%. However, if we wait till the patient is very sick, like if they have been to be admitted to the ICU for a long time, the success rate drops down to 70-80%. That is the main difference we are seeing this time – the patients who come for transplant are sicker than they would have been during the pre-pandemic time,” says Dr Joy.

Incidentally, the increasing number of mucormycosis (‘black fungus’ infection) cases in the country are not a new risk for transplant beneficiaries. “This was always a risk for transplant patients due to immunosuppression, so we look out for it anyway,” Dr Elan says.

Rising demand for lung transplants

Due to the pandemic, there is now a new subset of people who need lung transplants – those whose lungs have been severely affected by COVID-19 itself. “From June 2020 to July 2021, we have done 54 lung transplants, of which 13 have been post-COVID cases. Most of the recipients are those who have had to be on a ventilator for a long time, or have undergone ECMO (extracorporeal life support). They are weaker compared to other patients, have lower immunity and this would have an impact even post the transplant surgery,” says Dr Vijil.

Doctors also say that younger patients have a better chance of recovering post-transplant, and for this reason, some doctors are not taking up cases of patients above 55-60 years of age. “Even non-COVID patients seeking lung transplant are hesitant, and preferring to wait till after the pandemic,” Dr Vijil adds.

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