This is not a pandemic “silver lining” story.
This is a could-have-been-far-worse story about how the pandemic did not fuel a catastrophe in transplantation or worsen the persistent gap between people who need organs and the donations that supply them. But just as the pandemic is not over yet, neither is the potential danger of related ramifications for people whose organs may fail and need replacement.
Covid-19’s first surge last year flooded hospitals in the United States and nearly drowned those in the Northeast. They couldn’t find enough personal protective equipment for beleaguered workers, they didn’t yet have reliable testing for patients or staff, and they couldn’t know when the nightmare might end. Within that maelstrom, many transplants had to be put on hold: How do you perform life-saving operations when the supply of already scarce donor organs nose-dives?
Turns out, you turn to your neighbors. That’s one reason why, by the end of 2020, the number of transplants performed nearly equaled the number completed the year before, experts told STAT. Another reason: With family members of potential donors banned from hospital waiting rooms, organ procurement organizations had staff contact them at home.
There were 39,036 transplants across the United States in 2020, which given the pandemic, compares favorably with the 39,719 transplants in 2019. The number of transplants from deceased donors actually increased in 2020, reaching 33,310 compared with 32,322 the year before. The overall difference comes from living donor transplants, which went down significantly, from 7,397 to 5,726.
That translated into more deaths of people on the transplant waiting list: In 2020, 5,994 people died waiting for an organ, compared with 5,233 in 2019.
As Covid’s waves rose and fell unevenly across the country last year, one region’s shortage of deceased-donor organs could be alleviated by another region’s supply as yet untouched by the pandemic’s reach. If people in metropolitan New York, for example, died of strokes or heart attacks at home because they were too afraid of catching Covid to go to the hospital, their organs were no longer available in the time-sensitive window required for transplant. But elsewhere in the country in spring 2020, families continued to make donations and patients checked in to hospitals to receive them.
“Our fear that the most acute patients — who can’t wait — were going to miss their opportunity for transplant did not materialize. The system was really able to scramble and pull itself together and meet the needs of those patients,” said Alexandra Glazier, president and CEO of New England Donor Services. “The annual growth of deceased organ donation has averaged almost 5% a year for over 10 years in the U.S., and it has been unthwarted by the pandemic, which is, I think, a story of hope.”
Theresa Caldron of Broken Arrow, Okla., says she owes her life to her deceased kidney donor — and to her home near Tulsa not yet seeing its peak of Covid cases. She also credits her life-saving kidney transplant in April 2020 to the person ahead of her on the waiting list. That patient declined the organ from an Oklahoma donor, afraid of catching Covid-19 in the hospital where the transplant operation would take place.
Caldron, a registered nurse who has worked in neonatal units and pediatric ICUs, aboard medical helicopters, and in emergency rooms, had no such fear when she answered a transplant coordinator’s call from the family car in a Chick-fil-A parking lot. She and her husband, also a registered nurse, talked about how it could be a better moment for her operation than before Covid. Hospitals were canceling elective surgeries, so they sent nurses home. And almost everyone else was staying home, too.
“I know that sounds ironic,” she said, but “it was a perfect time for him to take off and go home and help out. Logistically, when we thought about it, everybody was being so cautious about germs — and you have to be that way after a transplant, no matter if there’s a pandemic or not.”
Caldron was diagnosed with kidney failure in 2009, the result of an autoimmune disease called Wegener’s granulomatosis, and placed on a waiting list in 2017. For six months, she received peritoneal dialysis at home overnight as her health declined, resigned to the typical three-year wait for a donor organ.
When she got the long-awaited call for her transplant, her knowledge of hospital procedures made it easier to say goodbye to her family at the entrance of St. John Medical Center in Tulsa. Her surgery prep started with a Covid test, and the same nurse cared for her during her entire stay in a relatively empty hospital. She went home to recover in a world where people wore masks and kept their social distance. Her four teenage children weren’t going to school or any of their other usual activities, limiting the chances of second-hand infection.
While Covid cases hit Oklahoma hard by late summer, transplants for the year in the South Midwest region edged higher than in 2019 (3,993 versus 3,988). In New England, recovery from spring 2020 was not complete by year’s end (4,479 transplants versus 4,921 the year before), but far better than anticipated, Glazier of New England Donor Services said.
She attributes that result to organ procurement organizations that reached out to prospective donor families in their homes when hospital rules prohibited visitors. Her group also employs two transplant surgeons, who perform surgical recovery of organs at the donor hospital and send them to the hospital where the intended recipient is waiting. That eliminated some of the need for hospital transplant teams to travel to the donor hospital to recover organs, and then back to perform the transplant.
As part of the national allocation system, New England Donor Services has sent kidneys to patients who were at the top of the list as far away as California, Glazier said. Kidneys remain viable for transplant outside the body for 24 hours, longer than the 6- to 10-hour window for other organs. But there are exceptions: With the help of newer technologies, for example, a donor heart was brought from New Mexico to a recipient in Boston last winter.
Across the U.S., deceased-donor liver transplant numbers rebounded after a pause in the spring. At Intermountain Healthcare in Utah, numbers continued a previous growth trend, in part because liver surgeons traveled from the hospital in Salt Lake City to see patients at clinics closer to their homes in Nevada and Idaho in preparation for their operations.
“We didn’t want patients traveling to our site at greater risk of getting sick,” said Richard Gilroy, liver transplant medical director at Intermountain.
“With obesity, we’ll see that the earthquake was Covid-19 and then the tsunami is going to hit the shores in about five years.”
Richard Gilroy, Intermountain Healthcare
Gilroy himself fell ill with Covid after traveling in a car with an infected health care worker, but he has recovered. “Even though I’m a 53-year-old diabetic, I have a greater chance of getting through it than, say, any of my patients,” he said.
Having his hospital perform more liver transplants in 2020 compared to the year before is gratifying, but Gilroy and other liver specialists worry the pandemic will fuel a rising need for liver transplants this year and in years to come. People with alcohol use disorder lost their support systems when the world went into near lockdown.
“It’s an unrecognized consequence of the Covid-19 pandemic, which is we created a lot more alcohol-associated liver disease,” he said, citing a March study. “Over the coming months or years, we’re going to see an increased demand for a scarce resource.”
It’s not just alcohol, he said, but also a rise in unhealthy eating that can contribute to fatty liver disease. “With obesity, we’ll see that the earthquake was Covid-19 and then the tsunami is going to hit the shores in about five years.”
Gilroy suggests getting upstream of the problem by refocusing efforts to manage alcohol and helping people become more active and eat better, challenges made greater by the pandemic’s isolation. Otherwise, “we’ll have a lot more people dying, waiting.”
More people may need lung transplants, too, as Covid-scarred lungs fail. Surprisingly, some Covid-19 patients recover from the damage to their lungs and no longer appear to require a transplant. But others may need new organs, and figuring out which patients to transplant will be tricky, said Todd Astor, medical director of the lung and heart-lung transplant center at Massachusetts General Hospital in Boston.
“The long-term effects of this virus can affect almost every organ system. And how will that impact the likelihood of a patient surviving the surgery and doing well post transplant?” he said. “Essentially, it’s like finding a new disease that’s an indication for transplant and developing a whole new set of guidelines to how you then go about evaluating and transplanting those patients.”
As the coronavirus pandemic continues, no one disputes the life-changing power of a successful transplant. Theresa Caldron is fully vaccinated against SARS-Cov-2, but still takes precautions. Her antibody levels are low, likely because of the immunosuppressive drugs she must take to protect her transplanted kidney. But she recently hiked with her family on quiet trails in Colorado, a trip she used to spend resting in the shade while they climbed without her.
“This time I actually hiked,” she said. “And I cried when I was done because I didn’t think I’d ever get to do that again.”