COVID-19 and 'lockdown' in organ transplantation in the UK.

Coronavirus disease 2019 (COVID-19) is an ongoing public health emergency and presents immense challenges to healthcare services worldwide. The largest spread and death rates are reported in the USA, Italy, Spain, and the UK. Within the UK, more than 275,000 people have tested positive and 39,000 deaths have occurred as of 1 June 2020. To limit transmission of the virus, the British government implemented strict quarantine, social distancing, self-isolation and hand hygiene measures on 23 March 2020 in accordance with the World Health Organization guidelines.

Currently, much of the attention is on finding treatment, developing a vaccine, re-establishing the economy and containing the virus. A largely neglected area is the potential implications of COVID-19 on organ transplantation. Guidelines for organ transplantation programmes are beginning to emerge in some countries. In the Sichuan Province of China, living donors (LD), transplant recipients and their families are being screened. However any recipients from high-risk areas are not being offered transplantations. Italy observed a 25% reduction in organ procurement during the initial phase after which guidelines were produced to ensure both routine and urgent transplant activity is maintained. At present all donors are screened and only negative donors are considered. Similar recommendations have been provided by the American Society of Transplant Surgeons. In contrast, Canada has adopted a precautionary approach suspending all kidney transplants whilst liver transplants are being assessed on a case-by-case basis.

The ongoing pandemic has presented several challenges for transplantation services in the UK. NHS Blood and Transplant (NHSBT) is advising clinicians to screen all deceased donors (DD) and patients with COVID-19 are automatically excluded from the donor register. Many transplant centres across England are closed. In addition, there has been a complete cessation of LD and a drastic reduction in DD transplantations. NHSBT data show a 72.8% reduction in DD transplants in April 2020 compared with April 2019. Based on this, we have estimated that there could be 904 fewer transplantation surgeries in the three-month period of March to May 2020 (Table 1 ). This is a net addition of approximately 16% to the current waiting list which includes 5699 patients (as of 1 April 2020). This has enormous implications for the median time to transplant which currently stands at 706 days in the case of kidney. Further divided by ethnicity, the median time to kidney transplantation is 830 days for Asian and 965 days for Black (compared with 640 days in white Caucasians) at present. Thus, the greatest impact could be seen in the Black, Asian and Minority Ethnic community prolonging the wait time to three years.

Table 1

Estimated shortfall of organ transplantations in March–May 2020 in the UK by donor type.,

	Organ transplant activity 2019/2020a				Shortfall in COVID-19b
	Total	First 3 quarters (Apr–Dec)	Last quarter (Jan–Mar)	Average shortfall in the last quarter	March	April	May	Total
Deceased donor (DD)	3762	2915	847	125	199	236	236	671
Living donor (LD)	1001	770	231	25	61	86	86	233
Total donors	4763	3685	1078	150	260	322	322	904

Notes: The organ transplantation activity has been divided into two subperiods. The last quarter is affected by COVID-19 outbreak, whereas the first 3 quarters are considered as the normal.

The average number of transplantations conducted per month during the first 3 quarters (normal) were 324 for DD and 86 for LD.

The shortfall is calculated based on the 72.8% reduction in DD cases between 01/04/2020 and 26/04/2020 as reported in the Organ Donation and Transplantation data. No LD cases were performed during the COVID-19 lockdown period.

This raises several questions. What is the way forward? How long will the lockdown of organ transplantation services continue? Will transplantation services remain suspended until a vaccine is developed? Previous data have shown that more than one-third of healthy kidneys were transplanted from DD aged 60 and older. Thus, can patients died of COVID-19 with healthy kidneys be used to save the lives of transplant patients and reduce the added burden on services before a vital opportunity is lost?