Lung transplantation can potentially be a life-saving treatment for patients with non-resolving COVID-19-associated respiratory failure, reports a new research published in Science Translational Medicine.
Fear of infection recurrence
Concerns limiting lung transplantation include recurrence of SARS-CoV-2 infection in the allograft, technical challenges imposed by viral-mediated injury to the native lung, and the potential risk for allograft infection by pathogens causing ventilator-associated pneumonia in the native lung.
Importantly, the native lung might recover, resulting in long-term outcomes preferable to those of transplant.
Study design
The study included the first three consecutive patients undergoing lung transplantation for severe COVID-19. In addition, lung biopsies were collected from patients who died from severe COVID-19 or other lung diseases.
The research group performed single molecule fluorescent in situ hybridization (smFISH) to detect both positive and negative strands of SARS-CoV-2 RNA in explanted lung tissue from the three patients and in additional control lung tissue samples.
Extracellular matrix imaging and single cell RNA sequencing was conducted on explanted lung tissue from the three patients who underwent transplantation and on warm post-mortem lung biopsies from two patients who had died from COVID-19-associated pneumonia.
Lungs from these five patients with prolonged COVID-19 disease were free of SARS-CoV-2 as detected by smFISH, but pathology showed extensive evidence of injury and fibrosis that resembled end-stage pulmonary fibrosis.
Conclusion
Their findings suggest that some patients with severe COVID-19 develop fibrotic lung disease for which lung transplantation is their only option for survival.
The research group offer some recommendations based on their results:
- Proposing a bilateral rather than single lung transplantation for patients with severe COVID-19.
- Lung transplant should only be considered when sufficient time has elapsed since the onset of ARDS and lung recovery is deemed unlikely.
- The patients should be involved in the transplant decision whenever possible and the consent to proceed with transplantation can be made through a reliable medical power of attorney, aligned with the patient’s health goals.
- Two negative PCR tests of bronchoalveolar fluid or nasopharyngeal swabs in non-intubated patients, prior to their listing for lung transplant to ensure clearance of the virus, are required.
- Patients with severe COVID-19 have a shorter period of preoperative morbidity and may recover with intensive post-operative rehabilitation, hence pre-transplant rehabilitation may be encouraged but not required.
Finally, some patients with severe COVID-19 have multi-organ failure. Whether multi-organ transplant for these patients is safe or feasible will require additional consideration.
Did you subscribe to our daily newsletter?
It’s Free! Click here to Subscribe!
Source: Science Translational Medicine
