Patients needing a transplant go through extensive testing and evaluation before earning a place on the transplant waitlist. When a donor becomes available, the OPO enters his or her medical information into a nationwide computer database. The system uses factors like location, progression of illness, and time on the waitlist to generate a list of potential recipients. The OPO team then contacts the hospitals of the top-matched patients and offers the organ. When someone accepts, the surgery can happen within hours.
The waitlist had 110,266 people as of June 30. Even in the best times, candidates on the waitlist outnumber available organs. Plus, some people become too sick for a transplant and die after leaving the waitlist, and others need an organ but are not yet sick enough to be listed.
The United Network for Organ Sharing (UNOS), the nonprofit that manages U.S. organ transplants, says around 17 people on the waitlist died every day in 2018.
So far this year, deaths among sick waitlist patients do not appear to have increased, but it may take more time to see the full picture.
“I think the waitlist mortality will blip up, but I don’t know,” said Dr. Marwan Abouljoud, a liver surgeon and president of the American Society of Transplant Surgeons. “Their illness did not stop while organ donation was slowing down.”
Because of the pandemic, some waitlist patients are temporarily “inactive,” meaning they will not accept organ offers. In mid-March, UNOS, which runs the OPTN under a contract with the federal government, created a new code to track such patients—“inactive due to COVID-19.” The first week, 1,100 patients became inactive under the new code. The next week, the number more than doubled. Anne Paschke at UNOS said the code covers patients who had COVID-19, were exposed to it, or feared catching it in the hospital.
“Transplant centers and patients have to weigh the risk of getting a transplant, becoming immunosuppressed and then potentially exposed to the coronavirus versus the risk of not getting a transplant,” Paschke said. In mid-May, more than 3,700 waitlist patients were inactive due to COVID-19.
Transplant programs can also decline to accept a particular organ for a particular patient for various reasons. In March UNOS implemented new refusal codes to help track the impact of the coronavirus. Preliminary data viewed by WORLD show that from March 25 to May 3, transplant programs refused transplant organ offers 232,455 times due to coronavirus-related reasons. (One organ may have multiple refusals.) Those reasons could include donors or transplant candidates who had either tested positive for the virus or been exposed to it, or temporary shortages of transplant program workers or available operating rooms.
It is unclear whether transplanting an organ from a donor who has SARS-CoV-2 could transmit the virus to the recipient, although Paschke said OPOs are testing organ donors for the virus. The American Society of Transplantation, in a draft guidance document, recommended testing for the virus in donors “whenever feasible.” It acknowledged such testing wouldn’t always be feasible for deceased-donor transplants “due to time constraints or logistical issues.”
DESPITE THE CHALLENGES the pandemic has introduced, transplant coordinators have worked hard to keep life-saving transplants coming. The U.S. transplant program appears to have fared better than programs in some other countries. For example, in April, as the United Kingdom battled the coronavirus outbreak, surgeons there performed only 99 organ transplants, the fewest in 36 years, the BBC reported.
In the United States, creativity and collaboration have proven essential.
Early in the pandemic, Kevin Cmunt at Gift of Hope heard constantly changing safety guidance. At first, the directions said not to wear a mask, but then hospitals required them for everyone. Gift of Hope staffers scoured the internet for masks, and some began to sew their own. Cmunt shared updates and ideas with other OPO directors through online chat rooms and forums. Early on, most OPOs only tested donors if they showed COVID-19 symptoms. But Cmunt said Gift of Hope began testing all donors for the coronavirus, following the lead of an OPO director in Seattle, an early epicenter of the viral outbreak.
Transplant centers also connected: Jennifer Milton, who runs the transplant center at University Health System in San Antonio, said she received a steady stream of information from Seattle and New York. A New York team warned that if a single member on a transplant team was infected, the entire transplant team could be quarantined. “We started hearing from them, ‘Keep your team apart,’” she said. “We were able to implement that in a day—24 hours.”
As Milton’s transplant workers dealt with the added pressure, several transplant recipients sent messages and cards to encourage them. One lung recipient had breakfast delivered for workers at her hospital.
Cmunt said the Gift of Hope staff holds virtual Friday cocktail hours and bingo nights to stay connected and share life updates and tips about homeschooling. “I’m really proud of them, that they’ve been able to continue to make donations happen under some trying circumstances,” he said.
IN MAY, AS STATES RELAXED lockdown orders and hospitals rescheduled more surgeries, transplant numbers started to get back on track, rising almost to pre-pandemic levels. Meanwhile, many patients like Michael Twitchell are still waiting for an organ, unsure how much the pandemic has affected their chances.