9 febrero, 2022

No COVID Vax, No Transplant: Unfair or Good Medicine?

Right now, more than 106,600 people in the U.S. are on the national transplant waiting list, each hoping to hear soon that a lung, kidney, heart, or other vital organ has been found for them. It’s the promise not just of a new organ, but a new life.

Well before they are placed on that list, transplant candidates, as they’re known, are evaluated with a battery of tests and exams to be sure they are infection-free, their other organs are healthy, and that all their vaccinations are up to date.

Now, COVID vaccinations — and some people’s resistance to them — have turned what used to be routine preparation controversial.

In January, a 31-year-old Boston father of two declined to get the COVID-19 vaccine, and Brigham and Women’s Hospital officials removed him from the heart transplant waiting list. And in North Carolina, a 38-year-old man in need of a kidney transplant says he, too, was denied the organ when he declined to get the vaccination.

Those are just two of the most recent cases. The decisions by the transplant centers to remove the candidates from the waitlist have set off a national debate among ethicists, family members, doctors, patients, and others.

On social media and in conversation, the question persists: Is removing them from the list unfair and cruel, or simply business as usual to keep the patient as healthy as possible and the transplant as successful as possible?

Two recent tweets sum up the debate.

“The people responsible for this should be charged with attempted homicide,” one Twitter user said, while another suggested that the more accurate way to headline the news about a transplant candidate refusing the COVID-19 vaccine would be: “Patient voluntarily forfeits donor organ.”

Doctors and ethics experts, as well as other patients on the waiting list, say it’s simply good medicine to require the COVID vaccine, along with a host of other pre-transplant requirements.

Transplant Protocols

“Transplant medicine has always been a strong promoter of vaccination,” says Silas Prescod Norman, MD, a clinical associate professor of nephrology and internal medicine at the University of Michigan, Ann Arbor. He is a kidney specialist, or nephrologist, who works in the university’s transplant clinic.

Requiring the COVID vaccine is in line with requirements to get numerous other vaccines, he says.

“Promoting the COVID vaccine among our transplant candidates and recipients is just an extension of our usual practice.”

“In transplantation, first and foremost is patient safety,” Norman says. “And we know that solid organ transplant patients are at substantially higher risk of contracting COVID than non-transplant patients.”

After the transplant, they are placed on immunosuppressant drugs, also called anti-rejection drugs, that weaken the immune system while also decreasing the body’s ability to reject the new organ.

“We know now, because there is good data about the vaccine to show that people who are on transplant medications are less likely to make detectable antibodies after vaccination,” says Norman, who’s also a medical adviser for the American Kidney Fund, a nonprofit that provides kidney health information and financial assistance for dialysis.

And this is not a surprise due to the immunosuppressive effects, he says.

“So it only makes sense to get people vaccinated before transplantation,” Norman says.

Researchers compared the cases of more than 17,000 people who had received organ transplants and were hospitalized from April through November 2020, either for COVID (1,682 of them) or other health issues. Those who had COVID were more likely to have complications and to die in the hospital than those who did not have it.

Vaccination Guidelines, Policies

Federal COVID-19 treatment guidelines from the National Institutes of Health state that transplant patients on immunosuppressant drugs used after the procedure should be considered at a higher risk of getting severe COVID if infected.

In a joint statement from the American Society of Transplant Surgeons, the American Society of Transplantation, and the International Society for Heart and Lung Transplantation, the organizations say they “strongly recommend that all eligible children and adult transplant candidates and recipients be vaccinated with a COVID-19 vaccine [and booster] that is approved or authorized in their jurisdiction. Whenever possible, vaccination should occur prior to transplantation.”

Ideally, it should be completed at least 2 weeks before the transplant, it says.

The organizations also “support the development of institutional policies regarding pre-transplant vaccination. We believe that this is in the best interest of the transplant candidate, optimizing their chances of getting through the perioperative and post-transplant periods without severe COVID-19 disease, especially at times of greater infection prevalence.”

Officials at Brigham and Women’s Hospital, where the 31-year-old father was removed from the list, issued a statement that reads, in part: “Our Mass General Brigham healthcare system requires several CDC-recommended vaccines, including the COVID-19 vaccine, and lifestyle behaviors for transplant candidates to create both the best chance for a successful operation and to optimize the patient’s survival after transplantation, given that their immune system is drastically suppressed. Patients are not active on the waitlist without this.”

Ethics Amid Organ Shortage

“Organs are scarce,” says Arthur L. Caplan, PhD, director of the Division of Medical Ethics at NYU Langone Medical Center and School of Medicine in New York City. That makes the goal of choosing the very best candidates for success even more crucial.

“You try to maximize the chance the organ will work,” he says. Vaccination pre-transplant is one way.

The shortage is most severe for kidney transplants. In 2020, according to federal statistics, more than 91,000 kidney transplants were needed, but fewer than 23,000 were received. During 2021, 41,354 transplants were done, an increase of nearly 6% over the previous year. The total includes kidneys, hearts, lungs, and other organs, with kidneys accounting for more than 24,000 of the total.

Even with the rise in transplant numbers, supply does not meet demand. According to federal statistics, 17 people in the U.S. die each day waiting for an organ transplant. Every 9 minutes, someone is added to the waitlist.

https://www.medscape.com/viewarticle/967944?src=soc_fb_220205_mscpedt_news_tho_transplant&faf=1#vp_1

Créditos: Comité científico Covid