ABSTRACT
Purpose: SARS-CoV-2 can result in a range of infections from asymptomatic disease to progressive COVID-19 and death. In some patients with COVID-19 Lung Disease (C19LD), lung transplantation (LTx) may be lifesaving. Up to 10% of LTx in the US is currently for patients with C19LD. Understanding the characteristics and outcomes of these patients is critical. Method(s): A open-access electronic registry was established to collect de-identified data from pts who have undergone LTx for C19LD from centers globally. The study was IRB approved at Northwestern with a wavier for consent (no PHI is collected sites could submit data about pre-Tx, peri-Tx and post-Tx course). Follow-up for 1-yr post-LTx was collected. Result(s): To date, 23 patients with complete day 30 post-LTx data have been entered into the registry. Patient demographics and pre-Tx status are shown in Table 1. 3 patients required oxygen prior to COVID-19 infection. All sites required neg PCR tests prior to listing (22 (95.7%) require 2 neg PCRs). LTx occurred 150 days post-infection and none developed COVID-19 in the first 30 days. Post-Tx ICU LOS averaged 18.6 days with total post-tx hospitalization of 36.3 days (See Table 2). Most LTx experienced infectious and non-infectious morbidity. Most (47.8%) required an additional 36.8 days of rehab. 1 patient died within 30 days due to sepsis. Conclusion(s): The contribution of cases to this international registry is ongoing. While outcomes of LTx for C19LD are generally good, patients experience prolonged post-transplant hospitalization, rehabilitation and significant morbidity.
ABSTRACT
Purpose: Describe outcomes of patients (pt) with pre-tx COVID-19. Method(s): Multicenter study of SOT/HCT candidates who had a positive (pos) SARS-CoV-2 PCR pre-tx. Result(s): Pre-tx: Of 208 pt, median age was 56 (range 3-76). 87.8% were SOT candidates (40.5% kidney, 40.5% liver, 9.8% lung, 6.9% heart, 2.3% pancreas) and 13.9% were HCT candidates (54.2% allo, 45.8% auto). Pt underwent a median of 2 tests (range 1 - 14). In 41% of pt, > 1 neg PCR was required by the tx center before reactivation. Neg PCR was documented in 67.4% of pt at a median of 41 days (18-68) after pos PCR. Waitlist mortality was 11.0%;deaths were due to COVID-19 in 60% (12/20). Post-tx (all pt): 78 pt underwent tx at a median of 65.5 days (range 17-324) from COVID-19;71/78 have completed 4-weeks of follow-up. 24/78 (30.7%) pt were still PCR pos at time of tx (details below). 54/78 (69.2%) pt underwent routine PCR testing post-tx;62% were tested regularly for 8 weeks. Only 1 pt, who remained asymptomatic, developed recurrent pos PCR on surveillance testing 18 days post-tx. 1 pt had graft loss. There were no deaths at 4 weeks post-tx. Pt transplanted without a negative PCR: 24 pt with COVID-19 did not have neg PCR at time of tx: 9 (37.5%) kidney, 9 (37.5%) liver, 2 (8.3%) SLK, 1 (4.2%) lung, 1 heart (4.2%), 2 auto-HSCT (8.3%), 2 allo-HSCT (8.3%). Of 24 pt who were reactivated at a median of 21 days (range 8 - 38) from COVID-19 diagnosis, 7 underwent tx emergently (5 liver, 1 lung, 1 heart). 20/24 completed 4-weeks of follow-up;all were alive. PCR Cycle thresholds (Ct) increased over time, suggesting a reduction in SARS-CoV-2 viral loads with time elapsed since COVID-19 diagnosis. Conclusion(s): Short-term outcomes of transplantation in SOT/HCT candidates with prior COVID-19 were promising in this small cohort, even with a positive PCR going into transplant. Whether documentation of a negative PCR should be required for all tx candidates with a history of COVID-19 prior to transplantation should be investigated further, particularly among lung tx candidates. For certain tx candidates with COVID-19, relying time-based strategy instead of a test-based strategy may be safe.
ABSTRACT
Purpose: Lung transplant may be a viable treatment option for select patients with non-recoverable COVID-19-associated acute respiratory distress syndrome (ARDS) and COVID-19-associated pulmonary fibrosis. This study aims to characterize the utilization and outcomes of lung transplant among patients with COVID-19- associated ARDS and pulmonary fibrosis. Method(s): We analyzed the Organ Procurement Transplant Network database to characterize the prevalence and characteristics of patients with COVID-19-associated ARDS and pulmonary fibrosis who were added to the waiting list and/or received a lung transplant between March 13, 2020 and July 31, 2021. Result(s): We found that 207 lung candidate registrations were added to the waiting list and 182 lung transplants were conducted for patients with COVID-19-associated ARDS or pulmonary fibrosis. The majority of lung candidates and lung transplant recipients with COVID-19-associated diagnoses were male, had private insurance, were disproportionately Hispanic and had a higher lung allocation scores (LAS) compared to patients with non-COVID-19 diagnoses. There was no significant difference in 30-day post-transplant survival among recipients with COVID-19- associated diagnoses compared to non-COVID-19 diagnoses. Conclusion(s): Future research on post-transplant outcomes among lung transplant recipients with COVID-19-associated diagnoses is warranted. Further study of outcomes may assist in refining the appropriate LAS waitlist mortality and posttransplant survival scoring for these patients. (Figure Presented).
ABSTRACT
Background. Studies of solid organ transplant recipients (SOTr) hospitalized for Covid-19 have focused on short-term outcomes with approximately 30 days of follow-up time. Intermediate-term mortality and associated risk factors for intermediate-term death have not previously been reported. Methods. Using data from a multi-center registry, we assessed mortality by 90 days among SOTr hospitalized for Covid-19 between 3/1/2020 and 12/31/2020. Multivariable Cox-proportional hazard models were used to compare risk factors for mortality by 28 and 90 days. Covariates were selected a priori based on known predictors of death in SOTr hospitalized for Covid-19. All patients were followed for 90 days or were censored at the time of death or last clinical contact, if this occurred prior to day 90 after diagnosis. Results. Among SOTr hospitalized for Covid-19, 198/979 (20%) died within 90 days of diagnosis and 37/198 (19%) of deaths occurred between days 29 and 90. Risk factors for mortality by day 90 days included age >65 years (1.8, 95% CI 1.3-2.4, P< 0.001), lung transplant (compared to non-lung) (1.6, 95% CI 1.1-2.4, P=0.02), chronic lung disease (2.2, 95% CI 1.5-3.4, P=0.002) and heart failure (1.9, 95% CI 1.2-2.9), which were similar to risk factors reported for 28-day mortality (Table 1). Diagnosis during the second half of 2020 (6/20-12/31/20) was associated with lower mortality by 28 days (aHR 0.7, 95% CI 0.5-1.0, P=0.03) compared to diagnosis during the early half of 2020 (3/1-6/19/20);however, mortality by 90 days was similar in the late and early time periods (aHR 0.9, 95% CI 0.7-1.2, P=0.54). Obesity and mTOR inhibitor use were also associated with death by 28 but not 90 days. Kaplan-Meier survival curves by time period of diagnosis are shown in Figure 1. Vertical tick marks represent censored cases. Early 2020 refers to cases diagnosed between March 1 and June 19, 2020 and late 2020 refers to cases diagnosed between June 20 and December 31, 2020. Conclusion. Approximately 20% of deaths among SOTr hospitalized for Covid-19 occurred between days 29 and 90. Future investigations are required to discern the mechanism(s) for the improvement in early, but not late, mortality among SOTr with Covid-19 during the course of the pandemic.
ABSTRACT
Purpose: Actual and comorbidity-adjusted mortality in hospitalized patients with COVID-19 has declined in the general population during the course of the pandemic. Whether a similar reduction has occurred in solid organ transplant recipients (SOTR) is unknown. Methods: We used a multicenter prospective registry of SOTR with laboratoryconfirmed COVID-19 to compare 28-day mortality between the early COVID-19 pandemic (3/1/20- 6/19/20) and a late (more recent) period (6/20/20-11/20/20) for those with 28 day follow-up by 11/12/20. A multivariable logistic regression model including previously identified risk factors for mortality (age >65 years, obesity, diabetes mellitus (DM), congestive heart failure (CHF), chronic lung disease, absolute lymphocyte count <0.5 x 109/L, and abnormal chest imaging) was used to adjust for covariates. Results: Of 938 SOTR with COVID-19, 638 (68%) were hospitalized;165 (26%) hospitalized cases occurred in the late (more recent) period and 472 (74%) cases occurred in the early period . The proportion hospitalized was similar in both periods [late: 165/244 (67.6%) vs. early: 472/692 (68.2%])]. The prevalence of several baseline comorbidities was lower in the late cohort: DM [74/165 (44.8%) vs. 251/472 (54.9%), p=0.01), chronic lung disease [5/165 (3.0%) vs. 47/472 (10.0%)], p=0.01), and CHF [5/165 (3.0%) vs. 37/472 (7.8%), p= 0.03). Presenting features were similar between periods (Figure 1), and treatment with remdesivir, convalescent plasma, and corticosteroids was more frequent in the late period (Figure 2). Crude 28-day mortality was lower in the late period (12.7% vs 20.8%, p=0.02), but mortality did not differ significantly from the early period after adjusting for comorbidities (crude OR 0.56 (95% CI 0.33-0.93) vs. adjusted OR 0.62, (95% CI 0.34-1.10), p=0.11. Conclusions: There have been shifts in the demographics of SOTR hospitalized for COVID-19 during the course of the pandemic. Although crude mortality was lower in the more recent period, the comorbidity-adjusted mortality has remained constant. Advancements in management strategies shown to reduce mortality in the general population might not be applicable to SOTR.
ABSTRACT
Purpose Outcomes of lung transplant recipients (LTR) hospitalized for COVID-19 and comparisons to non-lung solid organ transplant recipients (SOTR) are incompletely described. Methods Using a multicenter prospective registry of SOTR, we examined 28-day outcomes (mortality [primary outcome], intensive care unit (ICU) admission, mechanical ventilation, and bacterial pneumonia) among both LTR and non-lung SOTR hospitalized with laboratory-confirmed COVID-19 diagnosed between March 1, 2020 and September 21, 2020. Data were analyzed using Stata (StataCorp, College Station, TX);chi-square tests were used to compare categorical variables and multivariable logistic regression was used to assess risk factors for mortality. Results The cohort included 72 LTR and 392 non-lung SOTR (Table 1). Overall, 28-day mortality trended higher in LTR vs. non-lung SOTR (27.8% vs. 19.9%, P=0.136). Other 28-day outcomes were similar between LTR and non-lung SOTR: ICU admission (45.8% vs. 39.1%, P=0.28), mechanical ventilation (32.9% vs. 31.1%, P=0.78), and bacterial pneumonia (15.3% vs. 8.2%, P=0.063). Congestive heart failure, diabetes, age >65 years, and obesity (BMI >= 30) were independently associated with mortality in non-lung SOTR, but not in LTR (Table 2). Conclusion In this large prospective cohort comparing lung and non-lung SOTR hospitalized for COVID-19, there were high but not significantly different rates of short-term morbidity and mortality. Baseline comorbidities appeared to drive mortality in non-lung SOTR but not LTR. Further studies are needed to identify risk factors for mortality among LTR.