The supply of donated organs has long chased the demand for transplants without much chance of catching up.
That gap only widened during the spring of 2020 when the coronavirus pandemic brought living donations to “a near halt” and limited deceased organ transplant procedures to only the most dire of cases.
Coronavirus brought new challenges to the transplant community, forcing it to alter how it procures donor organs, and adding new levels of risk assessment in evaluating which organs can be safely transplanted, all at a time when hospitals were constantly preparing for the next surge of COVID-19 patients.
Despite the obstacles, the medical community bounced back in the late spring and through the rest of the year to finish only slightly behind previous year totals for combined living and deceased donations. The U.S. conducted 39,034 transplants in 2020, the second-highest annual total behind only 2019 when there were 39,719.
In Michigan, there were transplants involving 160 living donors, which is about 25% fewer than a typical year but followed national trends for 2020. Dr. Christopher Sonnenday, director of Michigan Medicine’s transplant center in Ann Arbor, said that is to be expected during times of economic uncertainty.
“There are a lot of factors that weigh into the decision to be a living donor and one is economic,” he said. “Some can’t afford to take a bunch of time off work to do this incredibly generous thing.
“Anytime there’s an economic downturn, there’s also a decrease in living donations. But it’s hard to know how much of the downturn related to fear associated with COVID and how much with the craziness of the last year and all the pressures many individuals have felt.”
On the other hand, there were a record 374 deceased donors, which meant a third-consecutive year with more than 1,000 transplanted organs, according to Gift of Life Michigan.
“How did we recover after this horrendous six-week period and still do the same number of (transplants from) deceased donors?,” asked Dr. Marwan Aboujioud, chair of Henry Ford Health System’s transplant institute.
“It’s because we, as a transplant community, started pushing the limit.”
Early days came with plenty of unknowns
There were a number of major constraints in the early days of the pandemic, each affecting the health community’s ability to prepare for and conduct transplants.
For starters, hospitals were limiting surgical procedures to only emergencies in an effort to free up staff for COVID-19 patients and to preserve scarce resources like personal protective equipment. Testing capacity was also limited.
Additionally, there was an effort to avoid risking further infections by bringing more people into hospitals than necessary. That included organ procurement teams from other hospitals, as well as patients in need of transplants and those living donors offering up an organ.
“If someone was stable and could be at home, they opted not to bring them in because of all the unknowns,” said Dorrie Dils, CEO for Gift of Life Michigan.
There was also the concern of whether or not an organ donor had previously been exposed to coronavirus, and if they could transmit the virus to the recipient through transplant.
In Ann Abor, a recipient of a lung transplant was infected with coronavirus as a result of their new organs and died, which led to a change in the type of testing done on donor lungs nationally. Instead of doing a typical oral swab, doctors began testing fluid directly from the lungs, which proved more accurate.
“We’re not using lungs from donors who have been infected with COVID and in cases where we’re not sure, we’re generally not using those organs,” Dr. Sonnenday said. “If we believe it’s possible it’s a recent COVID-19 infection and we don’t know their history and they test positive, generally those organs are not being used.
“Our understanding is changing though. Some centers are starting to consider those organs for the most desperate patients who are vaccinated.”
By late May, Dils said it was “starting to become clear how” the transplant community could do its work “in this new world, in the middle of a pandemic.”
“In Michigan, we’ve been through three surges ... and each has brought challenges to us, whether it’s our employees getting sick and dealing with staff being out sick or exposed, or dealing with all the restrictions within hospitals,” she said.
“We’ve had to adjust a lot but thankfully none of those things have been insurmountable. We’ve been able to continue providing life-saving gifts for those who need them and allowing donors to continue being donors.”
Pushing the limits
On average, 18 Americans died each day in 2020 while waiting for an organ donor. The 6,588 waiting lists deaths was more than each of the previous two years.
Michigan has about 2,500 people on its transplant waitlist, of which about 80% are waiting for a kidney, according to Gift of Life Michigan. The same rate is typically true for the national list, which included more than 107,000 people as of April 2021.
“We realize that the need for organs isn’t letting up,” said Dr. Aboujioud, who also serves as president of the American Society of Transplant Surgeons. “These wait lists keep growing and we realize that the slightly increased risk from certain types of donors doesn’t mean they don’t yield good organs.
“The transplant community did the heroic thing. They took a beating from COVID and then figured out how to be safe, to do safe transplants, and we came back and did a few more transplants in 2020 than the year before because we pushed the limit.”
By ‘pushing the limit,’ he means using organs from donors who are labeled “increased risk” because of one of a number of factors, including they were old, obese, had diabetes, a history of drug use or were previously incarcerated, among other factors. Instead of simply ruling them out, Aboujioud said there’s value in pairing those increased-risk donors with patients who have higher risk of dying on the wait list.
He used the example of a 70-year-old on dialysis with liver or kidney disease and a 25% chance of dying on the waiting list. If there’s a 3-5% chance of an “increased risk” organ not working, and a 1% chance of the patient developing treatable Hepatitis C, is it worth the risk to try the transplant instead of waiting for a healthier donor to come along?
“At 70 years old on dialysis, your risk of dying is really high,” he said. “Now if I give you kidney with increased risk, it might not last you 15 years but the statistics say you won’t live 15 years ... When I say I can give you five years off dialysis, would you take it? I surely would.”
“It’s an area the transplant community has battled with for some time. When I say increased risk, it’s for us to manage the risk. We won’t give you a bad organ but we’ll match a donor with a recipient and redefine expectations.”
In the past, vital organs such as the heart, liver, kidneys, intestines, lungs and pancreas could only be donated in the case of brain death, excluding cardiac arrest deaths in which there is irreversible loss of function of the heart and lungs. But over time, the transplant community has evolved to successfully use organs in either cause of death.
Since 2011, the number of donors who died from cardiac arrest per year nationally has quadrupled while brain dead donors increased steadily. At the same time, “increased risk donors” among the brain-dead donor population increased from 800 in 2011 to 3,490 in 2020, while the same risk group for cardiac arrest donors spiked from about 100 in 2011 to 1,000.
“That tells you there’s something happening out there,” Aboujioud said. “We’re trying to take more calculated risks. The science is evolving, our attitudes are evolving, the patients’ attitudes are evolving and the outcomes are the same or better.”
Looking to the future, Aboujioud estimates that transplant volume could be further increased “at least 20%” if regulatory agencies changed how they evaluate transplant centers. He said centers discard organs that could provide positive outcomes for patients who are dying on the list, but they don’t try to use them because of the risk that could effectively lower the perceived quality of the health system.
“We’re the only discipline in medicine where our outcomes with patient survival, organ survival, death on the list, are reported publicly and compared to other programs and given a 1-5 star rating,” he said.
“It limits innovation ... We want to reduce discards but you won’t do that if we don’t let up a little on how we regulate.”
Evolving practices
Transplant centers have had to be flexible during the pandemic, adopting both short-term and long-term changes along the way.
Early on, there was hesitance to use any organs from an individual who tested positive for COVID-19. Over time, transplant centers have begun to use kidneys and livers from those individuals, ideally paired with a recipient who is fully vaccinated against the virus.
The change has helped transplant numbers for those organs improve, and after the first quarter of 2021, Dr. Sonnenday said they’re ahead of pace from 2019.
Other changes that could stick long-term were to the organ procurement process and the introduction of more virtual care.
For decades, transplant centers would send teams of surgeons to other hospitals to evaluate and collect donor organs before transporting them back to the center and carrying out the procedure.
But the risk of entering another hospital with COVID-19 patients was unnecessary, so the community shifted from the long-held practice. Instead, teams from the hospital in possession of the deceased donor would connect with the recipient’s care team to evaluate the organ, using things like real-time biopsy videos. Then they’d ship the organs themselves, saving time and travel expenses for the procurement team.
“Pretty quickly, a lot of us started transitioning to procuring organs for each other,” Sonnenday said. “It’s built more collaboration and trust across the transplant community.”
Like other aspects of medical care, COVID-19 forced a quicker transition to using virtual appointments when possible. Initial consultation visits and opportunities to learn more about the transplant process were successfully moved virtual, as were many follow-up visits, and doctors said it’s been well-received by caregivers and patients alike.
Lastly, the pandemic sounded the same alarms of inequitable health care across minority communities when it comes to transplants as it did for other types of care.
Related: Barriers around Covid-19 vaccine help explain low vaccination rate in Michigan’s Black communities
“Increasing organ donation in minority communities is a very important goal that we have,” Dils said. “We believe minority communities have questions about organ donations and the process, and we’re working very hard to get those questions answered.”
What does the future hold?
In a small number of COVID-19 cases, individuals have recovered from the disease but their lungs have been destroyed in the process, leaving them dying from lung failure. Transplant centers have begun doing transplants on those patients, though it’s not yet clear what effect that might have on the number of individuals needing transplants.
“We’re just, in general, understanding more about the long-haul COIVD people and what they’re actually experiencing medically and whether it will eventually lead to a need for additional transplants,” Sonnenday said.
It’s not yet clear if COVID-19 will result in more patients seeking organ transplants, or fewer potential donors being ruled out because their battle with the respiratory illness compromised their organs.
But neither possibility is being ruled out.
“This story is still being written on the aftermath of the pandemic,” Dils said. “It remains to be seen what the long-term effects of COVID-19 will be on individuals who had significant illness from it.
“Certainly it’s believed that those who have had heart inflammation or decreased function of the heart and lungs, that it might ultimately require a transplant.
Dils added that just because someone who had a serious case of COVID-19 might be ruled out as a heart or lung donor, it doesn’t preclude them from donating other organs.
“An important message is there is the potential that a greater number of individuals might need transplants because of long-lasting effects of COVID-19,” Dils said. “Now more than ever, we need people to say yes (to becoming a donor).”
In 2019, there were 350,000 names added to the Michigan Organ Donor Registry. Registrations dropped to 225,000 in 2020, due in-part to the closure of Secretary of State offices and then subsequent scheduling challenges caused by the backlog.
Individuals interested in signing up to become a donor can sign up for the registry through the Michigan Secretary of State, or by visiting the Gift of Life Michigan website, here.
One donor can provide up to eight life-saving organs, as well as tissues and corneas that can improve the lives of 75 people.
“An amazing thing to do as our last legacy is to save others’ lives through donation and we hope everyone says yes and has those conversations with their families,” Dils said.
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