Lung transplantation feasible as a last resort for selected patients with severe COVID-19

Tuesday, 13 Apr 2021

Lung transplantation is a feasible option for COVID-19 patients with irreversible lung injury but should be reserved for carefully selected patients, early results suggest.

Researchers led by Professor Ankit Bharat, of Northwestern University in Chicago, wrote in The Lancet Respiratory Medicine about the results from a series of 12 bilateral lung transplantations, in part to help guide the future use of transplantation in COVID-19. The procedures were done at six high-volume transplant centres in the US, Italy, Austria, and India.

The median age of the recipients was 48 years, and three of the 12 patients were female. Patients had a median of seven days from COVID-19 diagnosis to ICU admission, and eight days from diagnosis to intubation. They were on the transplant waiting list for a median of six days.

Patients continued on mechanical ventilation for a median of 16 days postoperatively. At 30 days, the survival rate was 100%. The median ICU stay was 20 days, and the median hospital stay was 37 days.

There was some major post-transplantation morbidity, including acute kidney failure (33%), haemothorax (25%), and critical illness neuropathy (25%). Still, after a median follow-up of 80 days, 11 of the 12 patients were alive and recovering well.

The researchers said further work was needed to identify patients who were likely to progress to irreversible lung damage and who thus might benefit from early lung transplantation. Biomarkers such as KRT17 have been suggested as predictive of lung failure, but this has yet to be confirmed.

“We propose that patients considered for lung transplantation for severe COVID-19 should preferably be younger than 65 years, have no or manageable pre-existing comorbidities, and have lung injury from which they are unlikely to survive without lung transplantation – a decision made in a multidisciplinary manner,” the authors wrote.

They added that double-lung transplantation was recommended, as patients with COVID-19 have severely damaged lungs and might be susceptible to developing severe nosocomial pneumonia with post-transplantation immunosuppression.

“We recommend that consideration of lung transplantation be limited to patients requiring mechanical ventilation or [ECMO] despite several weeks of optimal medical care, with advanced disease severity, radiological signs of irreversibility, and a high risk of developing life-threatening complications,” they said.

In their article they said that consideration of lung transplantation as a life-saving therapy for COVID-19 patients was important given the sheer number of COVID-19 cases throughout the world, and the cumulative number of deaths from COVID-19-associated ARDS.

However they acknowledged there were concerns over the use of the transplantation in the COVID-19 setting, such as the risk of SARS-CoV-2 from viral pneumonia recurring in the allograft, and severe inflammation of the pleura and pulmonary hilar structures, which might constitute technical barriers to the procedure.

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