By James W. Lytle
After a banner year for organ transplantation in the United States in 2019, the success became a tattered memory by April 2020, when the COVID-19 pandemic hit major cities in the U.S. with its full fury.
A record number of 39,178 organs were donated in 2019, including 7,397 organs from living donors, also an all-time high. After several years of adverse media and regulatory scrutiny, LiveOn NY, the organ procurement organization (OPO) that serves the Metropolitan New York City region, proudly reported that a total of 938 organs had been transplanted in 2019, another record that represented more than a fifty percent increase over the transplant total in 2015.
By late April 2020, however, organ transplantation activity in New York State had reportedly declined by ninety percent.
It is not surprising that the New York organ transplantation system was severely disrupted by COVID-19 when New York City emerged as the ground zero of the pandemic. But a recent webinar hosted by the New York region’s transplant hospitals and organ procurement organizations highlighted the unique impacts of the pandemic on organ transplantation. The following impacts were discussed in the webinar:
- Concern over potential risks to recipients from infected organs led to the issuance of new protocols by the American Society for Transplantation. These protocols required review of the donor’s epidemiological and clinical history and COVID-19 testing at or around the time of procurement. Lack of confidence in the reliability of testing led transplant centers from other parts of the country to refuse New York organs even when they appeared to be COVID-free, and some high priority and long-waiting transplant hopefuls chose to defer transplants during the pandemic, even when clinicians recommended proceeding with the transplant.
- Transplant recipients who received transplants before the pandemic were found to be at very high risk of COVID-19, due to immunosuppression and coexisting conditions. Montefiore Medical Center reported that 36 kidney transplant recipients tested positive for COVID-19 between March 16 and April 1, 28 of whom were admitted to the hospital. Ten of the 36 recipients died—a 28 percent mortality rate. These findings led some transplant centers in New York to proceed with transplants only when the risk of mortality from deferring the transplant for three months was deemed to be greater than the risk of mortality from COVID-19.
- Transplant centers have faced staffing and facilities challenges. For example, some have relocated their units to more distant corners of their hospital complexes to maintain distance from COVID-19 patients, or faced severe staffing challenges when key transplant team members were redeployed to assist with the avalanche of COVID-19 cases or became ill themselves. The lockdown precluded or impeded organ recovery teams from travelling across town or across the country to recover organs. Limited access to testing, PPE, key medications, dialysis fluid and other critical resources—problems widely encountered in the pandemic—significantly impacted transplantation.
- LiveOnNY became a “virtual OPO” overnight, equipping its 170-member staff with the technology and communications capacity to do most of its work remotely. Critical discussions with the potential donor family could not occur face to face when neither the OPO staff nor family members could be at the potential donor’s bedside. Given the scarcity of ICU beds and ventilators, hospitals pressured the OPO to determine the suitability of the donor expeditiously to free up those scarce resources as soon as possible.
- Under the NY “routine referral” law, hospitals are required to notify the OPO of a hospital death to help identify potential donors. When the pandemic peaked, the volume of calls skyrocketed from the usual seventy-five calls per day to over 600, overwhelming the OPO’s call center, even though most of those patients were likely unable to donate. The stress of keeping up with that volume of mostly futile “referrals” and the anguish over the inability to fulfill its transplant mission placed an extraordinary burden on the OPO.
Meanwhile, the list of persons awaiting transplants—now over 111,000 in the U.S. and 10,000 in New York State— continues to grow. In the near term, the list may be diminished mostly by potential recipients dying or becoming too ill for a transplant. The national organ transplant system, whose performance in the best of times has been widely criticized, will need to rise to the occasion once the pandemic subsides.
The crisis may, however, prove to be a turning point. The rapid deployment and adoption of new technologies to facilitate the complicated process of organ transplantation may pay dividends: just as telehealth is likely to play a larger role in the post-pandemic healthcare system more generally, technology also may play a critical role in key elements of the post-pandemic organ donation process, including family outreach, grief counseling, managing procurement logistics and remote patient monitoring.
The nimbleness and flexibility displayed by the OPOs and the transplant centers to adapt to the COVID-19 challenge may also signal a greater capacity by the organ transplant community to reform and transform itself.
Finally, the crisis resulted in an unprecedented level of communication, resource sharing and mutual support among the transplant centers and the OPOs—entities that have often been seen as more cutthroat than collaborative, more competitive than cooperative, and more likely to point fingers than to pick each other up.
There may be, accordingly, some reason to believe that the lessons learned from the COVID-19 experience may enhance the performance of the American organ transplant system. For the sake of those tens of thousands of Americans awaiting a transplant, let’s hope so.
James W. Lytle is Senior Counsel at Manatt, Phelps & Phillips, LLP and a fellow in the Advanced Leadership Initiative at Harvard University.