Home Research funding Lung transplantation for ARDS associated with COVID-19

Lung transplantation for ARDS associated with COVID-19

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We read with interest the study of Lancet respiratory medicine by Ankit Bharat and his colleagues,
1
  • Bharat A
  • Machuca TN
  • Querrey M
  • et al.
Early results after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries.

concerning a case series of patients with acute respiratory distress syndrome (ARDS) associated with COVID-19 who were bridged to extracorporeal membrane oxygenation (ECMO) lung transplantation. COVID-19 has affected millions of patients, some of whom will develop ARDS

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  • Grasselli G
  • Tonetti T
  • Protti A
  • et al.
Pathophysiology of acute respiratory distress syndrome associated with COVID-19: a multicenter prospective observational study.

and some of whom will die. The transition of patients to lung transplantation with ECMO is increasingly used with increasing success.

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  • Langer F
  • Aliyev P
  • Schäfers HJ
  • et al.
Improved results of bridge-to-transplant: extended assistance to extracorporeal membrane oxygenation to achieve optimal donor lungs for marginal recipients.

Bharat and his colleagues take the concept one step further and propose a more liberal use of transplantation for ARDS associated with COVID-19. This approach raises medical problems. There are certain criteria that can help decide whether a patient with ARDS is suitable for a transplant. Good recovery potential, thorough pre-transplant evaluation, single organ failure, and informed consent are needed to ensure high success rates. In the case series of Bharat and his colleagues,

1
  • Bharat A
  • Machuca TN
  • Querrey M
  • et al.
Early results after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries.

patients did not necessarily meet these requirements. As expected, patients had a complicated intraoperative and postoperative course (eg. [ICU]). The success of a transplant procedure cannot be judged solely by whether a patient can be discharged from the ICU. At least a year, if not more, is needed before such a procedure can be considered successful.

In addition, there is an ethical dilemma. Transplantation for irreversible lung disease is characterized by a worldwide shortage of organ donors. Patients with a good prognosis may die on the waiting list.
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  • Gottlieb J
  • Smits J
  • Schramm R
  • et al.
Lung transplantation in Germany since the introduction of the lung allocation score.

Therefore, the recipients must be carefully selected. The organ shortage is not relieved but rather worsened by the COVID-19 pandemic. Accepting highly urgent applicants with ARDS during the pandemic will put patients on the wait list at a disadvantage, increase waiting list mortality, reduce post-transplant survival,

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  • Riou J
  • Boëlle PY
  • Christie jd
  • Thabut G
High emergency organ allocation rule in lung transplantation: a simulation study

and distort the discriminatory capacity of any organ allocation system. About 600 patients are listed for lung transplantation in the Eurotransplant region. At most, 1% of these patients have a Lung Allocation Score (LAS) of 85 and above, thus patients reported

1
  • Bharat A
  • Machuca TN
  • Querrey M
  • et al.
Early results after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries.

will surpass 99% of patients on the current waiting list. In our center alone, we identified five patients who fulfilled the criteria mentioned by the authors. These issues need to be carefully considered, as this could significantly distort allocation systems. Given the high mortality of COVID-19 patients on ECMO, we agree with the authors that lung transplantation should be considered as an option; however, we suggest setting the LAS to 0 by default for patients with ARDS associated with COVID-19, thus allowing a relief allowance for transplantation only.

HW reports consultancy fees from Actelion, Bayer and Janssen; and speaker fees from Actelion, Bayer, Biotest, Boehringer Ingelheim, Janssen, MSD, Pfizer and Roche, outside of the submitted work. RB has received research funding from the German Lung Research Center (Deutsches Zentrum für Lungenforschung) for the COPD and Systemic Consequences-COmorbidities Cohort Study (COSYCONET; grant number 82DZLI05A2), and the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF; grant number 01GI0881); and grants from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Grifols and Novartis, during the preparation of this correspondence. RB reports grants from BMBF for Asthma and COPD Skills Network (AsCoNet) and Sander-Stiftung, Krebshilfe and Mukoviszidose eV; grants and personal fees from AstraZeneca, Boehringer Ingelheim and Novartis; and personal costs of CSL Behring, GlaxoSmithKline and Grifols, outside of the submitted work. All other authors declare no competing interests.

The references

  1. 1.
    • Bharat A
    • Machuca TN
    • Querrey M
    • et al.

    Early results after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries.

    Lancet Respir Med. 2021; 9: 487-497

  2. 2.
    • Grasselli G
    • Tonetti T
    • Protti A
    • et al.

    Pathophysiology of acute respiratory distress syndrome associated with COVID-19: a multicenter prospective observational study.

    Lancet Respir Med. 2020; 8: 1201-1208

  3. 3.
    • Langer F
    • Aliyev P
    • Schäfers HJ
    • et al.

    Improved results of bridge-to-transplant: extended assistance to extracorporeal membrane oxygenation to achieve optimal donor lungs for marginal recipients.

    ASAIO J. 2019; 65: 516-521

  4. 4.
    • Gottlieb J
    • Smits J
    • Schramm R
    • et al.

    Lung transplantation in Germany since the introduction of the lung allocation score.

    Dtsch Arztebl Int. 2017; 114: 179-185

  5. 5.
    • Riou J
    • Boëlle PY
    • Christie jd
    • Thabut G

    High emergency organ allocation rule in lung transplantation: a simulation study

    ERJ Open Res. 2017; 3: 00020-02017