Lung transplants after Covid-19 raise difficult issues

When the first wave of the coronavirus pandemic hit the United States in the spring, I wrote that some people with severe Covid-19-related lung injury would never recover their lung function.

As a lung transplant specialist and lead author on the most recent guidelines for selecting lung transplant candidates, I was concerned that transplant specialists would soon be asked to evaluate Covid-19 patients for lung transplants. The response I got from some of my colleagues in the transplant community was one of surprise: “Really? You think some of these folks will be seeking transplants?” they asked. “Yes, I do,” I said then.

Now I say, “Yes, we have.” And likely with more to come.

First, as we knew in the spring, the experiences of people with non-Covid acute respiratory distress syndrome (ARDS) suggest that lung function in a subset of these patients will not recover and some will be significantly impaired by their disease.

Although many post-ARDS patients have not needed transplants in the past, given the overwhelming number of coronavirus infections worldwide, there will be many Covid-19 patients who progress to ARDS and sustain permanent lung damage as a result of Covid-19 pneumonia. I call this group of patients “Covid ARDS survivors.” Months after leaving the hospital, these patients will shuffle or be wheeled into lung transplant clinics all over the world to be evaluated for lung transplants.

The second group of Covid patients will be even more challenging because they are even sicker. They are the ones I am now getting called about a few times a week: people who can’t be weaned from a ventilator or extracorporeal membrane oxygenation (ECMO) support and who are stuck in an ICU with no chance of lung recovery. They will die without a transplant, but are also more likely to die from the transplant or have poor outcomes from it than those who don’t require lifesaving support of this kind, because of the problems associated with being in an ICU environment for weeks or months.

Some will have co-infections, malnutrition, and aren’t able to walk, or have problems with organ systems other than their lungs, most notably the heart, kidney, gastrointestinal system.

Even more worrisome, some have neurological issues, either due to the coronavirus itself or as a result of being sedated with medications while in the ICU. Regardless of the cause, uncertainty about a patient’s brain function certainly gives transplant specialists like me pause while evaluating a person for a transplant, even setting aside the issue of being unable to provide meaningful consent for a rigorous and life-altering procedure.

Validated guidelines for which Covid-19 patients should, and shouldn’t, be candidates for lung transplant don’t currently exist. Yet experts in the field generally think that the best candidates are those who are younger (say, under age 60), who aren’t actively infected with either the coronavirus or some other virulent pathogen, who have good potential to be rehabilitated from activity and nutrition standpoints, and who have no evidence of organ dysfunction aside from lung disease.

These are, of course, only general considerations based on the small number of transplants performed to date, but they seem to represent the best current thinking.

A final point that needs to be raised: While all of us like (and need) to hear success stories relative to the Covid-19 pandemic, centers that perform lung transplants in Covid-19 patients who do not survive the procedure, or who do poorly after it, should report these outcomes just as diligently as when they publish their success stories. By doing that — in addition to forming a national transplant registry that tracks all lung transplants done for Covid-19 patients — the lung transplant community will learn more quickly how best to treat this very complicated set of patients.

As I wrote last spring, lung transplantation for Covid-19-related lung disease is an unwelcome byproduct of the pandemic, but one I believe will be a part of transplant practices for years to come. Now is the time to build and share lung transplant experiences, just as the transplant community has historically done with regard to other vexing clinical challenges. It’s the best way we can provide optimal care to these patients, who have already been through arduous ordeals.

David Weill is a transplant physician, principal of the Weill Consulting Group, former director of the Center for Advanced Lung Disease and the lung and heart-lung transplant program at Stanford University Medical Center, and author of the forthcoming memoir, “Exhale: Hope, Healing and a Life in Transplant” (Post Hill Press, May 2021).