Lung Transplantation for the Treatment of COVID-19 Fibrosis

Lung Transplantation for the Treatment of COVID-19 Fibrosis

By: Grant A. Turner, MD, MHA, and Laura Frye, MD
Transplant Network
Published: July 27, 2021

SARS-CoV-2 and its clinical illness, COVID-19, cause varying degrees of disease, ranging from asymptomatic infections to severe respiratory illness, including ARDS. Some who survive the initial illness may be left physically debilitated and have significant residual pulmonary fibrosis.

For many, the treatment is supportive with oxygen, physical rehabilitation, and time for recovery. For a select few, recovery to a state that liberates the individual from the acute care setting is impossible, and lung transplantation is considered.

While COVID-19 is a new issue, transplantation has been performed previously in post-ARDS pulmonary fibrosis secondary to influenza.¹ Unfortunately, guidelines are not available to support the practice of lung transplantation for an acute infectious illness causing pulmonary fibrosis. We reviewed the current literature and discussed potential future research that will guide care in the coming months to years.

What Does the Research Say?

Case series describing the use of lung transplantation in COVID-19 have helped describe patient characteristics, operating room setup for transplantation of a patient with an acute infectious disease at the beginning stages of a global pandemic, and the pathology of the first patient who underwent lung transplantation for COVID-19 fibrosis.^2-4

More recently, in a review of 12 patients transplanted at four centers internationally, the average time from onset of disease to transplantation was 79 days, with an average time from initiation of mechanical ventilation to transplantation of 70 days.⁵ Eleven patients were on extracorporeal membrane oxygenation (ECMO) as a bridge therapy to transplantation, 10 of whom were awake for this therapy.⁵ The average time on ECMO therapy was 55 days (range 44-79). Of the 12 patients, 11 survived to the time of publication, similar to individuals transplanted without COVID-19.⁵ This study can help to inform transplantation centers regarding characteristics in patients with COVID-19 pulmonary fibrosis who have undergone successful lung transplantation, can guide discussion with health care teams and patients on ideal candidates, and can inform the use of ECMO as a bridge to transplantation in COVID-19-associated pulmonary fibrosis.

Looking at criteria for transplantation evaluation, suggestions have included: Age less than 65 years, single-organ dysfunction, adequate time from illness onset, radiological evidence of irreversible disease, informed consent, potential for physical rehabilitation, negative SARS-CoV-2 polymerase chain reaction result (likely 2, preferably from a lower respiratory tract source), and access to a high-volume transplantation center with a broad donor pool and low waitlist mortality.^5,6 Additionally, candidates should meet classic criteria for transplantation.^5,6

What We Still Need to Know

While case reports are added, future research with larger cohorts will be necessary to answer many questions, including: Who is a good candidate for ECMO as a bridge to transplantation? How long should we wait before deciding to transplant someone with COVID-19-associated pulmonary fibrosis? Even more worrisome, with the paucity of solid organs for transplantation, how will we decide if individuals who had COVID-19 infection in the past can be organ donors, and more specifically, lung donors?

References

1. Wang Q, Pan S, Zhang S, et al. Lung transplantation in pulmonary fibrosis secondary to influenza A pneumonia. Ann Thorac Surg. 2019;108(4):e233-e235.
2. Chen XJ, Li K, Xu L, et al. Novel insight from the first lung transplant of a COVID‐19 patient. Eur J Clin Invest. 2021;51(1):e13443.
3. Chen JY, Kun Q, Liu F, et al. Lung transplantation as therapeutic option in acute respiratory distress syndrome for coronavirus disease 2019-related pulmonary fibrosis. Chin Med J. 2020;133(12):1390-1396.
4. Bharat A, Querrey M, Markov NS, et al. Lung transplantation for patients with severe COVID-19. Sci Transl Med. 2020;12(574):eabe4282.
5. Bharat A, Machuca TN, Querrey M, et al. Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries. Lancet Respir Med. 2021;9(5):487-497.
6. Cypel M, Keshavjee S. When to consider lung transplantation for COVID-19. Lancet Respir Med. 2020;8(10):944-946.

Grant A. Turner, MD, MHA

Dr. Turner is a Lung Transplant Fellow at the University of California, Los Angeles. He is the Fellow-in-Training Member of CHEST’s Transplant Network Steering Committee. You can reach him on Twitter at @GrantTurnerMD.

Laura Frye, MD

Dr. Frye is an Assistant Professor at the University of Wisconsin with a focus in lung transplantation and interventional pulmonology. She is a member of the CHEST Transplant Network and the Bronchoscopy Domain Task Force. You can reach her on Twitter at @LauraFryeDrL.

Read more COVID in Focus: Perspectives on the Literature:

Immunomodulation Therapy in Severe COVID-19 Infection: Where Do We Stand?

Clinical Outcomes of COVID-19 in Patients With COPD

Diagnosis and Containment of Patients With Suspected Lung Cancer in the COVID-19 Pandemic—What Does the Literature Say?