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Original Clinical Science—General

Solid Organ Donation and Transplantation Activity in the Eurotransplant Area During the First Year of COVID-19

Putzer, Gabriel MD1; Gasteiger, Lukas MD1; Mathis, Simon MD1; van Enckevort, Arjan MD2; Hell, Tobias PhD3; Resch, Thomas MD4; Schneeberger, Stefan MD4; Martini, Judith MD1

Author Information
doi: 10.1097/TP.0000000000004158
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Abstract

INTRODUCTION

The first wave of the coronavirus disease 2019 (COVID-19) pandemic in spring 2020 severely impacted transplant activity worldwide.1-6 Main reasons for the dramatic decline were the sudden and unforeseen lack of resources, on the one hand, and the lack of specific recommendations for maintaining transplantation activities during a pandemic, on the other hand. Concerns about potential donor-to-recipient transmission, screening strategies, posttransplant management, ethics and legal issues, and more caused great uncertainty and even led to a temporary suspension of nonvital transplants.7,8

The decrease in COVID-19 cases during summer 2020 reduced the burden on healthcare systems, and guidelines emerged that outlined how to maintain transplantation activity in case of a second wave.3,6,9-11 Obviously, the question arises whether the experience gained during the first wave helped us to guide transplant activity better during the second wave. Unfortunately, the second (and third) wave in winter 2020 to 2021 lasted longer and was far more intense than the first wave, suggesting a negative influence on transplant activity.

This study aimed to illustrate the impact of COVID-19 on organ transplantation in the Eurotransplant (ET) region during the first 12 mo of the pandemic. The ET region comprises Austria, Belgium, Croatia, Germany, Hungary, Luxembourg, the Netherlands, and Slovenia and has a total population of around 137 million people. To determine whether transplant activity in ET countries adapted to this new reality, we analyzed the numbers of all organ donations and transplantations (ODTs) performed during the first 12 mo of the COVID-19 era and compared them with those of the previous 5 y.

MATERIALS AND METHODS

ODT data for all ET countries from March 1, 2015, to February 28, 2021, were obtained from the Eurotransplant International Foundation registry. The data are public and anonymous, thus eliminating the need for approval by an ethics committee. For better differentiation of donor characteristics, organ donors were divided into living and deceased donors, and deceased donors were divided into donors after brain death and donors after circulatory death. Furthermore, reported kidneys were differentiated into living and deceased donations, whereas transplanted kidneys were distinguished into standard criteria donations and extended criteria donations. To allow for a more detailed description of ODT dynamics in the period from 2020 to 2021, we divided the observation period into three 4-mo periods, ranging from March 1 to June 30 (period 1), July 1 to October 30 (period 2), and November 1 to February 28 (period 3). Hence, period 1 represents the first wave of the COVID-19 pandemic, period 3 the second wave, and period 2 the interval in between them. ODT data for the period from 2020 to 2021 were then compared with those for the respective period of the previous 5 y. COVID-19 cases for ET countries were taken from the OurWorldInData.org database, which collects the worldwide COVID-19 figures on a daily basis. To objectify the magnitude of the 2 COVID-19 waves, the area under the curve was calculated for the respective course of confirmed new COVID-19 cases.

Statistical Analysis

Statistical analysis was conducted using R, version 4.0.3. A significance level of 5% was used for all assessments. Differences in the number of ODTs between the observation period from 2020 to 2021 and the corresponding periods in the previous 5 y are given as estimated mean differences with 95% confidence intervals and assessed with the Poisson test.

RESULTS

Organ Donation

During the observation period from 2020 to 2021, the total number of organ donors in the ET region decreased by 18.3% (2960 versus 3622; P < 0.0001) compared with the average of the previous 5 y (Table 1). The number of living and deceased donors decreased by 32.1% (957 versus 1409; P < 0.0001) and 9.5% (2003 versus 2214; P < 0.0001), respectively. The number of donation after brain death donors decreased by 11.6% (1662 versus 1881; P < 0.0001), whereas the number of donation after circulatory death donors remained unchanged (341 versus 333; P = 0.3388; Table 1). The decline in organ donors is reflected in a decrease in the number of all organs reported in the ET area, including hearts, lungs, livers, pancreas, and kidneys (all P < 0.0001; Table 1). With respect to kidney grafts, donations from living and deceased donors decreased by 34.8% (858 versus 1315; P < 0.0001) and 12.3% (3555 versus 4052; P < 0.0001), respectively.

TABLE 1. - Number of organ donors, organs reported, organs transplanted, and patients on waiting lists during the first 12 mo of COVID-19 (defined as March 1, 2020, to February 28, 2021) compared with the mean values of the respective periods during the previous 5 y
Count (2020–2021) Mean count (2015–2019) Decrease (%) P
Donors reported
 Total 2960 3622 (3570-3676) 18.3 <0.0001
 Living 957 1409 (1376-1442) 32.1 <0.0001
 Deceased 2003 2214 (2173-2255) 9.5 <0.0001
  DBD 1662 1881 (1843-1919) 11.6 <0.0001
  DCD 341 333 (317-349) –2.4 0.3388
Organs reported
 Heart 724 834 (809-860) 13.2 <0.0001
 Lung 2000 2145 (2105-2186) 6.8 <0.0001
 Liver 2089 2219 (2178-2260) 5.8 <0.0001
 Pancreas 732 882 (857-909) 17.0 <0.0001
 Kidney 4413 5367 (5303-5432) 17.8 <0.0001
  Living 858 1315 (1284-1347) 34.8 <0.0001
  Deceased 3555 4052 (3997-4108) 12.3 <0.0001
Organs transplanted
 Total 6160 7044 (6970-7118) 12.5 <0.0001
 Heart 571 607 (585-629) 5.9 0.001
 Lung 1257 1293 (1262-1325) 2.8 0.0228
 Liver 1439 1620 (1585-1655) 11.2 <0.0001
 Pancreas 152 203 (190-215) 25.0 <0.0001
 Kidney 2741 3321 (3271-3372) 17.5 <0.0001
  SCD 1583 1866 (1828-1904) 15.2 <0.0001
  ECD 1158 1456 (1422-1489) 20.5 <0.0001
Waiting list
 Total 14 260 14 835 (14 728-14 942) 3.9 <0.0001
 Heart 1108 1147 (1118-1177) 3.4 0.0091
 Lung 623 767 (743-791) 18.7 <0.0001
 Liver 1459 1661 (1626-1697) 12.2 <0.0001
 Pancreas 397 433 (415-452) 8.3 0.0001
 Kidney 10 673 10 827 (10 736-10 919) 1.4 0.0009
Data are presented as mean (95% CI).
CI, confidence interval; COVID-19, coronavirus disease 2019; DBD, donation after brain death; DCD, donation after circulatory death; ECD, extended criteria donation; SCD, standard criteria donation.

The mean number of actively listed patients waiting for a heart, lung, liver, pancreas, and kidney transplantation significantly decreased during the first 12 mo of the pandemic compared with the previous 5 y (Table 1).

Organ Transplantation

The number of transplantations performed decreased significantly for all organ entities in the ET region, with abdominal organs being more affected than thoracic organs (Table 1). No single ET country was able to prevent a decline in the total number of organ transplantations (all P < 0.001); however, stable rates for heart transplantation could be maintained in Austria (minus 8.7%; P = 0.103), the Netherlands (minus 3.0%; P = 0.6673), and Slovenia (minus 14.7%; P = 0.0774); stable rates for lung transplantation in Germany (minus 0.5%; P = 0.7764), Hungary (plus 16.6%; P = 0.0501), and the Netherlands (plus 3.7%; P = 0.3087); stable rates for liver transplantation in Austria (minus 5.9%; P = 0.0897) and the Netherlands (minus 4.3%; P = 0.2101); and stable rates for pancreas transplantation in Germany (minus 6.3%; P = 0.1619) and Hungary (minus 9.1%; P = 0.5828). Kidney transplantations decreased significantly in all countries (all <0.05). Standard criteria donation and extended criteria donation kidney transplantations decreased by 15.2% (1583 versus 1866; P < 0.0001) and 20.5% (1158 versus 1456; P < 0.0001), respectively (Table 1).

Temporal Analysis

The total number of organ donors decreased by 26.2% in period 1, by 5.5% in period 2, and by 23.1% in period 3 (all P < 0.0001) compared with the mean number of the corresponding periods of the preceding 5 y (Table 2). As a result, the number of performed transplantations decreased by 16.5% in period 1, by 4.9% in period 2, and by 16.4% in period 3 (all P < 0.0001). Details on the temporal development of the ODT numbers during the observation period are presented in Table 2. A graphical presentation of ODT numbers in relation to cumulative COVID-19 cases in the ET countries is shown in Figure 1. Calculation of the area under the curve of cumulative COVID-19 cases found that the magnitude of the second COVID-19 wave was 12-fold higher than that of the first wave (Figure 1).

TABLE 2. - Number of organ donors, organs reported, and organs transplanted during the observation periods 1–3 during 2020–2021 compared with the average numbers of the corresponding periods of the previous 5 y
Period 1 Period 2 Period 3
Count (2020–2021) Mean count (2015–2019)a Decrease (%) P Count (2020–2021) Mean count (2015–2019)a Decrease (%) P Count (2020–2021) Mean count (2015–2019) Decrease (%) P
Donors reported
 Total 881 1193 (1163-1224) 26.2 <0.0001 1130 451 (433-470) 5.5 0.0091 949 1234 (1203-1265) 23.1 <0.0001
Living 243 478 (459-497) 49.1 <0.0001 406 451 (433-470) 10.0 <0.0001 308 480 (461-499) 35.8 <0.0001
Deceased 638 715 (692-739) 10.8 <0.0001 724 745 (721-769) 2.8 0.0869 641 754 (730-778) 15.0 <0.0001
DBD 544 609 (587- 631) 10.6 <0.0001 590 632 (610-654) 6.7 0.0001 528 640 (618-662) 17.5 <0.0001
DCD 94 106 (98-116) 11.7 0.0049 134 113 (103-122) –19.0 <0.0001 113 114 (105-124) 0.9 0.8334
Organs reported
 Heart 237 273 (259-288) 13.3 <0.0001 261 280 (266-295) 6.9 0.0085 226 281 (266-296) 19.5 <0.0001
 Lung 634 699 (676-723) 9.3 <0.0001 710 731 (707-755) 2.8 0.0839 656 715 (692-739) 8.3 <0.0001
 Liver 664 713 (690-737) 6.9 <0.0001 757 744 (721-769) –1.7 0.3097 668 761 (737-786) 12.2 <0.0001
 Pancreas 216 290 (275-305) 25.4 <0.0001 276 296 (282-312) 6.9 0.0065 240 296 (282-312) 19.0 <0.0001
 Kidney 1327 1759 (1723-1797) 24.6 <0.0001 1695 1782 (1745-1819) 4.9 <0.0001 1391 1826 (1789-1864) 23.8 <0.0001
  Living 207 446 (427-465) 53.6 <0.0001 375 421 (404-440) 11.0 <0.0001 276 448 (430-467) 38.4 <0.0001
  Deceased 1120 1314 (1282-1346) 14.7 <0.0001 1320 1361 (1328-1393) 3.0 0.0129 1115 1378 (1346-1411) 19.1 <0.0001
Organs transplanted
 Total 1923 2304 (2262-2346) 16.5 <0.0001 2266 2381 (2339-2425) 4.9 <0.0001 1971 2358 (2316-2401) 16.4 <0.0001
 Heart 191 197 (185-210) 3.1 0.3316 202 206 (193-219) 1.8 0.5711 178 204 (192-217) 12.8 <0.0001
 Lung 369 436 (418-455) 15.4 <0.0001 469 442 (424-461) –6.2 0.0048 419 415 (397-433) –1.0 0.6701
 Liver 462 527 (507-548) 12.3 <0.0001 512 545 (525-566) 6.1 0.0011 465 548 (572-569) 15.1 <0.0001
 Pancreas 50 70 (63-78) 28.8 <0.0001 66 69 (62-76) 3.8 0.4741 36 64 (57-71) 43.6 <0.0001
 Kidney 851 1073 (1045-1102) 20.7 <0.0001 1017 1120 (1091-1150) 9.2 <0.0001 873 1128 (1099-1158) 22.6 <0.0001
  SCD 505 611 (590-633) 17.4 <0.0001 609 651 (629-674) 6.5 0.0002 469 603 (582-625) 22.3 <0.0001
  ECD 346 462 (443-481) 25.1 <0.0001 408 469 (450-488) 13.0 <0.0001 404 525 (505-545) 23.0 <0.0001
aData are presented as mean (95% CI).
CI, confidence interval; DBD, donation after brain death; DCD, donation after circulatory death; ECD, extended criteria donation; SCD, standard criteria donation.

F1
FIGURE 1.:
The light gray and dark gray lines (solid for the period 2020–2021 and dashed for the period 2015–2019 averages) represent organs reported and organs transplanted, respectively. The solid black line represents the 14-d moving average of daily new COVID-19 cases in the Eurotransplant region. COVID-19, coronavirus disease 2019.

DISCUSSION

This retrospective analysis shows that the first 12 mo of the COVID-19 pandemic caused a significant drop in organ donation and transplantation activities in the ET region, with all ET countries being similarly affected. The decrease in ODTs during the second wave was comparable with that during the first one, although the incidence of COVID-19 cases was unequally higher during the second wave.

Limited knowledge of the new infectious disease caused by severe acute respiratory syndrome coronavirus 2, the unknown impact of infection in immunosuppressed organ recipients, and possible severe acute respiratory syndrome coronavirus 2 donor-to-recipient transmission moved several transplantation societies to the recommended postponement of nonurgent kidney and pancreas transplantations in March 2020.7 As the rapid progression of the pandemic demanded that substantial healthcare resources be made available quickly,12 many surgical intensive care units (ICUs) were converted to COVID-19 ICU facilities, and medical staff was relocated to prevent critical healthcare areas from collapse.7 These measures most likely caused an additional reduction in ODTs during the first trimester of our observation period compared with the previous 5 y, which is in line with reports from various countries describing a similar development during the first wave (spring 2020) of the COVID-19 crisis.1,2,4,7,13-15 In addition, societal and habitual changes during lockdown periods may have contributed to the decrease in potential organ donors. One example could be the decrease in the number of traumatic brain injuries because of falls and road traffic accidents.16

As the numbers of COVID-19–infected patients began to decline toward the end of spring and early summer 2020, transplant activities in the ET region recovered slightly, although they remained below the level of the previous 5 y. With the emergence of the second wave by the end of summer 2020 (third period in our observation), ODT activities again significantly declined, comparable with period 1. This finding cannot be attributed to recommendations to postpone organ transplantations but probably reflects the need to again convert surgical units and ICUs to COVID-19 units. Although it may seem that our experience from the first wave was of little help in sustaining ODT activity during the second wave, it is important to acknowledge that the daily incidence of COVID-19 infections was disproportionately higher in winter 2020 to 2021 than in spring 2020 (Figure 1). The fact that ODT activity remained comparable suggests that efforts to maintain transplant volume during the second wave of the pandemic were partially successful. These include, for example, coordinated interdisciplinary management of surgical volume and intensive care capacity.15 Also, the increasing availability of tests and protective equipment may have contributed to the stabilization of ODT activity in the third trimester.

In conclusion, despite the lessons learned from the first wave and the significant efforts made during the second wave to stabilize transplant activity, the number of ODTs dramatically decreased also during the second wave compared with the same period in previous years; however, it must be emphasized that, despite the severity of the second COVID-19 wave, the decline was not greater than that of the first wave.

ACKNOWLEDGMENT

We are indebted to the Eurotransplant International Foundation for providing the data.

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