Clinics (Sao Paulo). 2020;75:e1978.

Lung transplantation during the COVID-19 pandemic

Marcos N. Samano , Paulo M. Pêgo-Fernandes

DOI: 10.6061/clinics/2020/e1978

While Brazil is second only to the United States in terms of the absolute number of kidney and liver transplants, the number of lung transplantations remains modest. According to the Brazilian Registry of Transplantation, in 2019 only 106 lung transplants were performed across seven institutions. Three hospitals were responsible for 83% of these procedures, of which the Instituto do Coração (InCor) of HCFMUSP was responsible for 42% of these transplants. The reason for having only a few centers trained to perform lung transplantation lies in the complexity of the organ which is one of the most immunogenic organs. With only a few centers, patients with advanced lung disease have difficulty in seeking care. As of December 2019, 187 patients were on the waiting list for lung transplant, and over the course of the year, 39 patients died while still on the waiting list, which denotes a mortality rate of 21.2%. This demonstrates the severity of the situation; the demand for transplants is greater than the availability of organs. We wished to examine the expected effect of the new coronavirus disease 2019 (COVID-19) pandemic on lung transplantation.

COVID-19 is a disease caused by the severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2) first reported in December 2019 in the city of Wuhan, China, and has spread rapidly around the world. Since the lung is the principal organ affected by COVID-19, the first concern for transplantation during this pandemic is to establish safe organ donation. How do we establish safety? Initial recommendations were based on the likelihood of donor infection and their exposure to known or probable cases within 14 days prior to donation. In that scenario, reverse transcription polymerase chain reaction (RT-PCR) tests for SARS-CoV-2 were desirable but not mandatory, along with chest computed tomography to assess pulmonary infiltrates suspicious of viral injury (). However, as community transmission became more prevalent, ANVISA (Agîncia Nacional de Vigilância Sanitária - National Agency of Health Surveillance) established the need for RT-PCR tests for SARS-CoV-2 for all cadaveric donors. Based on discussions with experts around the world, we have decided to accept donors in the following situations: (1) SARS-CoV-2 negative RT-PCR within 24 hours before transplantation, (2) no history of COVID-19 or previous suspicion, (3) preferably with chest tomography showing no pulmonary infiltrates suggestive of acute injury in less than 24 hours before transplantation. With regards to the recipient, the nasal swab is collected however, as there is no time to wait for the results of the RT-PCR, we proceed with the transplant in recipients without symptoms, and with a negative chest tomography with no signs of recent pulmonary infiltrates.

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