In one year, as of the end of December 2020, there have been more than 90 million people infected and almost 2 million deaths from coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in 224 countries. The situation has not improved, and several countries are continuing to experience second waves and are recording significant numbers of infections and deaths. Morocco, a country located in northern Africa with an estimated population of 34 million inhabitants, currently has more than 400 000 cases of COVID-19, with a significant peak during the months of August and September 2020 for both infections and deaths.1
The disastrous repercussions on health have affected various fields, including organ donation and transplantation, an area that has not been spared, which has already suffered from severe shortages and vulnerabilities of the system, and which will face one of the greatest shortages in its history. The measures taken during the confinement period, between March and June, have had drastic consequences, with all non-COVID-19 hospital activities completely suspended or reduced. Accordingly, during the pandemic, most transplant societies recommended temporary suspensions of transplant activity, especially with living donors, and many teams around the world adopted this attitude.2-4
The nephrology community has had to prepare for the gradual resumption of organ donation and transplant for the period following shutdown.5 The whole nephrology community had thought that recovery would be easy, with a rapid regression of the pandemic; however, the recovery has been more difficult, at least in some countries and regions, due to the de novo explosion of cases of contamination and the occurrence of a second wave, raising fears of a second and real SARS-CoV-2 pandemic.
During the period from March to August, has transplant activity really declined? Few publications are available on the subject, and the data published mainly concern the first 3 months, from March to May. The period from June to August has also been marked by a significant increase in cases of contamination in many countries, including the United States, Latin American countries, South Africa, and others. To identify and compare changes to organ donation and transplantation over a 90-day period from March to May 2020 (pandemic period) versus March to May 2019, Ahmed and associates6 conducted an anonymous Web-based survey, which was distributed to 19 select organ procurement organizations (OPOs) throughout the United States. Among the 17 OPOs that responded to the survey (response rate of 89.5%), organ authorization decreased by 11% during the pandemic period (1379 vs 1552; P = .0001), organ recovery for transplant decreased by 17% (P = .0001), with a further 18% decrease in the number of organs transplanted (P = .0001), and donor cause of death due to trauma decreased by 4.5% but cause of death due to substance abuse increased by 35% during the pandemic period.
In Spain, national activity has fallen sharply, from more than 300 kidney transplants over 2 weeks to 30 kidney transplants in a 2-week period during March and April 2020.7 A few centers in Spain had recorded a maintained level or even an increase in their transplant activity, which occurred as a result of proper hospital organization but also as a result of effective intervention of their national transplant organization.7 This organization has played a key role in this crisis, in particular in the identification of the least affected hospitals, which allowed better graft distribution.
In Italy, Vistoli and colleagues8 reported that, between March 1 and March 15, 2019, a total of 100 kidney transplants were performed versus a total of 65 kidney transplants performed during the first 2 weeks of March 2020, which also included a deep decline in living-related kidney transplant procedures. Of note, the authors stated that almost 200 kidney transplants were performed during the month of February 2020 versus 175 during the month of February 2019, with a slight increase in living-related kidney transplant procedures.
LiveOnNY, an OPO in the greater New York City metropolitan area, reported a significant decrease in potential donors during April 2020 of 2% versus 11% in 2019 and a decrease in the number of organs removed and not transplanted.9 Lentine and colleagues,10 in their survey of 118 of 194 active living donor kidney transplant programs in the United States, reported that the volume of living donor kidney transplant activity during the pandemic was decreased by at least 50% from pre-pandemic levels of 93% of responding programs; in addition, 66% of programs had halted living donor kidney transplant procedures completely.
The Kingdom of Saudi Arabia, Turkey, Egypt, and Kuwait have also reported significant drops in the number of kidney and liver transplants performed during the months of February and March 2020.3 Morocco does not have a national transplant organization, and kidney transplant activity, estimated at 50 kidney transplants annually, has not resumed since March 2020 and is encountering organizational difficulties at the national level. In addition, the most active kidney transplant centers, in Morocco, are located in the cities most affected by the virus.
Although kidney transplant activities may have been relatively maintained in some areas, the transplant activities for other organs, particularly hepatic and pulmonary, have been significantly reduced due to the importance and difficulty of pre- and postoperative monitoring.9
Several reasons may explain this unprecedented global shortage of organs. First, prolonged confinement and maintaining a state of health emergency have produced high levels of concern and anxiety in the general population, and resumption of pretransplant consultations for living donors may be difficult, as patients are reluctant to go to the hospital for fear of being infected. Moreover, the suspension of pretransplant consultations may be demotivating for living donors. Second, the number of potential organ donors has significantly decreased because of the drop in traffic accidents observed during shutdown and after shutdown and because of positive SARS-CoV-2 tests in donors, as well as to the currently well-established short-term kidney consequences of SARS-CoV-2 of acute kidney failure, hematuria, and proteinuria.6,11 Third, surgical scheduling of new kidney transplant procedures from living donors has been problematic because operating rooms have been constantly occupied for priority pathologies, especially emergencies and cancers. In Morocco, the lack of a national organ transplant organization has also had major consequences on transplant activity in terms of identifying active hospitals, reorientation of activities, and prioritization and distribution of grafts.
Kidney transplant centers remain unable, around the world, to meet the needs of the population with end-stage renal disease. The number of patients enrolled on wait lists continues to grow because the incidence of end-stage kidney disease has not diminished. Indeed, the incidence may even increase because, during this pandemic, the kidney function of many COVID-19 patients, especially those with diabetes, hypertension, and obesity, has worsened, with progression to more severe stages, even terminal stage. Moreover, treatment of patients with chronic kidney disease has been delayed during confinement, and the kidney function of these patients has also probably deteriorated due to difficulty with access to care.
Another aspect of the suspension of kidney transplant programs, although less noticed but still contributing to the burden of material losses, especially in developing countries, is the expiration of precious pharmaceutical products, such as solutions for the conservation of kidney grafts, intravenous and oral immunosuppressive drugs, and intravenous induction drugs (basiliximab and thymoglobulin). Added to this is the difficulty of importing products from abroad, which are not available at the national level and very essential for transplantation.
To this day, the repercussions of the pandemic and those related to possible additional waves are uncertain and unpredictable. The major international transplant registries will provide, in their next annual reports, more accurate and comparative data between countries, compared with previous years and according to other important parameters, such as age, sex, ethnicity, and associated comorbidities. At a time when countries thought they would achieve a certain balance between needs and organ transplants performed, the COVID-19 pandemic has completely and abruptly unbalanced transplant programs and destroyed the fruits of long years of perseverance and hard work. Only the prioritization and strengthening of organ transplant programs by governments, especially in developing countries, could guarantee a return to normal, over perhaps some years, to the former state of equilibrium. An increase of potential donors, whether living donors or donors after brain death, could also contribute to overcoming the current crisis, and Maastricht regulations and the promotion of donations from deceased donors should also be discussed. It is also time to invest in the development of an artificial implantable kidney, which would meet the needs of the population of patients on dialysis and which would be an unprecedented medical technological revolution.
DOI : 10.6002/ect.2020.0371
From the 1Nephrology Dialysis and Kidney Transplantation Unit, University
Hospital Mohammed VI, University Mohammed First, and the 2Laboratory of
Epidemiology, Clinical Research and Public Health, Medical School, University
Mohammed First, Oujda, Morocco
Acknowledgements: The author has not received any funding or grants in support of the presented research or for the preparation of this work and has no declarations of potential conflicts of interest.
Corresponding author: Yassamine Bentata, Avenue Hassan II, rue Kadissia, numéro 12, Oujda, Morocco