COVID-19 leaves pancreas and islet transplant programmes under threat
COVID-19 has had a devastating impact on islet and pancreas transplantation, with many centres suspending their programmes and major reductions in organ retrievals. On day one of the 11th European Pancreas and Islet Transplant Association Symposium and 40th Artificial Insulin Delivery Systems, Pancreas and Islet Transplantation Workshop, delegates heard how this community is rising to the challenge.
Academic clinical fellow Sivesh Kathir Kamarajah set the scene with data showing that there is a wide variation in peri-operative management and the availability of pancreas transplants, leaving patients in a ‘luck of the draw’ situation according to where they live.
His team devised a survey about pancreas programmes specifically because although a reduction in liver and renal transplants had been reported, it wasn’t clear what was happening with pancreas transplants. It received responses from 28 centres in 16 countries.
Just under half had shut down their programmes because of intensive care units (ICU) being at capacity, lack of donors and staff shortages. In the half that carried on, 11% saw a more than 75% drop in referrals and 39% had a greater than 75% reduction in organ retrievals.
He added that it remains unclear what the optimum time is to wait for a transplant after a patient has tested positive for COVID-19, but 35% of centres advocated waiting for one month or more.
The next presentation was relevant to the above as Ann E Ogbemudia from the Nuffield Centre of Surgical Sciences, University of Oxford, discussed strategies for keeping a transplant programme going during the pandemic.
Her centre suspended its programme in March 2020 due to the pressure on ICU facilities and concern about a theoretical risk associated with alemtuzumab (an induction agent used to help prevent rejection), namely long-term effect on T-cell depletion and response to impending vaccination.
When the centre resumed its activities in August 2020, the team revised the recipient and donor criteria to increase the rate of donation and transplantation, and reduce peri-operative co-morbidity. This will be of interest to centres that are struggling to maintain numbers – when this centre compared activity from the same period in 2019, they were down only 30-40%.
Firstly, they introduced a limit to travel time to reduce the risk of cold ischaemia and both donors and recipients now need to be younger and slimmer. For example, pre-pandemic, a DBD donor could be under 65 with a body mass index (BMI) of less than 32; now, it’s under 50 with a BMI of less than 27. In recipients, age and BMI went from under 60 and lower than 30 to under 50 and lower than 27, plus their general health had to be better (e.g. no aortic stenosis).
She also outlined their new enhanced recovery (ER) strategy, designed to ease pressure on intensive care. It’s a designated bed providing level 2 high-dependency unit (HDU) care from a transplant nurse and a recovery nurse with support from the medical teams. They audited their previous patients to see what factors might result in needing level 3 intensive care and this revealed factors such as late night and early morning surgeries, and patients with co-morbidities, so they can identify patients who are eligible for ER.
After a telephone screening for COVID-19, followed by a polymerase chain reaction (PCR) test, they have new protocols for peri-operative practice – the patient is put in an isolated side room upon admission, followed by urgent nasal swab, patients wear minimum level 1 personal protective equipment (PPE), there is COVID-19 testing on days one, three and seven, and no visitors are allowed. She noted that they have the benefit of a separate facility to the main hospital, which enabled them to ringfence their patients.
Lastly, they make greater use of telemedicine in outpatient care – patients are reviewed weekly for the first month, fortnightly until month four and then once a month. If face-to-face is required, staff wear PPE and patient footfall is limited.
With planning and caution, she concluded, it is therefore possible to continue a transplant programme, adding as another lesson learned that alemtuzumab appears safe to use after all (although this is based on small numbers).
To finish, Dr Cyril Landstra from Leiden University Medical Centre gave an important insight into how people who have had beta-cell replacement therapy have been affected by lockdowns, both physically and psychologically.
She began by outlining the impact of lockdown on the general population – it places a great deal of pressure on people, and can result in anxiety, irritability, insomnia, less physical activity and alterations in diet.
People with type 1 diabetes are at higher risk of complications from COVID-19 and another study from their centre showed that lockdown had caused increased anxiety and stress, and this had affected glycaemic control.
However, for patients with type 1 diabetes and who have had a pancreas or islet transplant, another layer of risk is added, which led her team to hypothesise that lockdown may have an even more significant impact on these patients.
They devised a questionnaire for type 1 diabetes patients and transplantation patients, and their theory proved correct. There was a striking difference between the behaviours of the two groups, with those who'd had a transplant adhering far more strictly to lockdown. Almost 46% did not leave the house at all, three times as high as patients with type 1 diabetes. More than 50% did not go grocery shopping, whereas under 20% of type 1 patients avoided that.
They also had a higher level of fear of COVID-19 infection and worsened glycaemic control, with a rise in HbA1c of almost 1.7 mmol/l.
Other data showed that a third had more anxiety and stress, 40% were doing less physical exercise and had gained weight, and a quarter had to inject more insulin.
Therein lies a problem with lockdown – it’s necessary to protect the most vulnerable but it can create lifestyle changes that put them at even higher risk.
While lockdown is unavoidable, this research is a vital tool for those who care for patients after transplantation. As Dr Landstra concluded, knowing that they have a higher level of fear compared with type 1 diabetes patients and behave differently under lockdown means that a greater emphasis can be put on the importance of self-management and a healthy lifestyle during consultations, and extra support can be provided.
The opinions expressed in this article are those of the author, Dr Eleanor D Kennedy.