Organ transplantation and COVID-19

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has transformed the world. Up to May 16, 2021, 162.2 million individuals (2.1% of the world’s population) had become infected, of whom 15.5 million were in Brazil (7.3% of this coun-try’s population), and 3.36 million of these infected individuals had died (432,628 in Brazil). 1 Thus, in Brazil, the mortality rate up to that date was 2/1,000 of the population and, for 2.8% of the infected individuals, the virus was lethal. This scenario has negatively affected the econ-omy of many countries, causing great losses to thousands of companies, and even bankrupt-cies; and it has left millions of workers unemployed. The social distancing and isolation that have become necessary to combat the pandemic have harmed social relationships, school activities and non-essential work activities. Meetings and congresses have also been affected. Organ transplantation could not remain immune to the coronavirus disease (COVID-19). Organ and activities, and the patients receiving these organs, have also been affected in various ways, as we describe in the following list:


Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has transformed the world. Up to May 16, 2021, 162.2 million individuals (2.1% of the world's population) had become infected, of whom 15.5 million were in Brazil (7.3% of this country's population), and 3.36 million of these infected individuals had died (432,628 in Brazil). 1 Thus, in Brazil, the mortality rate up to that date was 2/1,000 of the population and, for 2.8% of the infected individuals, the virus was lethal. This scenario has negatively affected the economy of many countries, causing great losses to thousands of companies, and even bankruptcies; and it has left millions of workers unemployed. The social distancing and isolation that have become necessary to combat the pandemic have harmed social relationships, school activities and non-essential work activities. Meetings and congresses have also been affected.
Organ transplantation could not remain immune to the coronavirus disease (COVID-19).
Organ donation and transplantation activities, and the patients receiving these organs, have also been affected in various ways, as we describe in the following list: there were decreases in donation and transplantation rates of between 36% and 90% during the peak months of the first wave of COVID-19. 2 This impact on donation and transplantation rates was regional: for example, New York and northern Italy were among the areas most affected, but this impact was temporary. Activities were then resumed as the pandemic subsided in those areas. 3,4 In Brazil in 2020, compared with 2019, the donor rate declined by 13%. 5  The decline in the transplantation rate also varied according to the type of organ: greater for lung and kidney transplantations and smaller for liver and heart transplantations. It also varied according to the type of donor, such that the decline was greater for transplantations with a living donor. Because this is an elective procedure, many such procedures were postponed so as to avoid the risk of donor contamination during the investigation and organ removal. 2,8 In Brazil, in 2020, there were declines in the transplantation rates for liver (10%), pancreas (13%), heart (17%), kidney (25%) and lung transplants (39%). The decrease in the number of transplantations with a living donor was greater for kidney transplants (64%) than for liver transplants (13%). There were also variations in the timing of these declines because the pandemic reached different Brazilian states at different times and affected geographical regions differently. Thus, for example, the kidney transplantation rate decreased by 8% in the central-western region and by 80% in the northern region, which has been worst affected by the pandemic. 5 Analysis on waiting lists is somewhat more complex. On the one hand, with fewer transplantation procedures taking place, there was an accumulation of patients in waiting lists; but on the other hand, the number of patients entering the lists also declined, given that investigations on many patients were postponed. 2 In addition, in many centers, some of the patients, especially those awaiting transplants of non-vital organs (such as kidney and pancreas transplants), were moved from the active to the inactive category to avoid the most severe phase of the pandemic. In Brazil, for example, declines in the numbers of patients entering the lists, of 18% for liver transplants and 13% for kidney transplants, were observed in 2020. There were also increases in the mortality rates among patients in the lists, of 27% for kidney transplants (going up from 5.2% to 6.6%) and 5% for liver transplants. 5 Activities in transplantation centers either were maintained or were reduced to transplantations only in special cases, or were temporarily suspended, according to the levels of risk for potential recipients, living donors and professionals; and also according to the conditions in these hospitals. 9   These data, if confirmed by other studies, suggest that alternative strategies need to be used in relation to these patients, such as greater numbers of doses; or use of mycophenolate suspension for some days before and after vaccination; or a temporary change to azathioprine or mammalian target of rapamycin (mTOR) inhibitor.
These seem to present a better serological response to the vaccine, but this needs to be confirmed.
Thus, organ transplantation has also been dramatically affected by COVID-19, with regard both to transplantation activities and to the severity of cases (with elevated morbidity and mortality) and poor response to vaccination among transplant patients.