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South African Transplant Society

COVID-19 VACCINATION

Position Statement on COVID-19 Vaccination in South Africa

The South African Transplantation Society (SATS) recommends that all patients for organ transplantation, healthcare professionals in transplant teams, and family members be vaccinated against COVID-19.

We recognize and advocate for the use of vaccines in the prevention of COVID-19 infections. There is clear scientific evidence for the use of vaccinations to reduce the risk of both hospitalization and death in COVID-19 infections, with the benefit of vaccination far outweighing its risk.

The mortality rate for transplant recipients from COVID-19 is reported to be 20%, which is 10-fold higher than the general population (1), due to their need for lifelong immunosuppression medication.

With such a scarce resource such as organs for transplantation, there is an ethical obligation to ensure that the gift of donation is used in the best way possible and for maximum benefit. Given the ongoing extreme shortage of donors, transplant centers will consider COVID-19 positive deceased donors as potential donors given early favorable results of transplants from selected COVID-19 positive donors. (2)

As such, transplant centers require patients to demonstrate adherence to optimum medical therapy prior to surgery and that patients undertake to continue such therapy after transplantation. Adherence to best medical therapy (e.g., for diabetes and hypertension), being fully vaccinated including booster doses (e.g., against hepatitis B), abstinence from alcohol consumption (in cases of alcoholic liver cirrhosis) are already established as routine in a transplant assessment and work-up.

Transplant centers should appropriately counsel patients and their donors about their need for COVID-19 vaccination. They should play an active role in ensuring that misinformation and vaccine hesitancy are appropriately addressed as part of that work-up. For children receiving transplants, it is important that family members are also fully vaccinated.

Further information:

Currently in South Africa there are two SARS-CoV-2 vaccines being used in the national vaccine program: the Pfizer-BioNTech and the Johnson & Johnson vaccines. The Pfizer-BioNTech vaccine is an mRNA vaccine that is given as two doses separated by 21 days. The Johnson & Johnson vaccine is an adenovirus-vectored DNA vaccine given as a single dose.

Both were evaluated in randomized controlled trials involving over 40,000 participants to evaluate efficacy and safety before being used in vaccine programs. In these trials, the Pfizer-BioNTech vaccine resulted in a 95% reduction in COVID-19 infections (3). A similar reduction in cases of severe COVID-19 was observed. The Johnson and Johnson vaccine resulted in an 85% reduction in severe-critical COVID-19 (4). Even with the spread of the delta variant of the virus, both vaccines remain highly effective at preventing severe COVID-19 that results in hospital admission and death.

Mild side effects are common with all SARS-CoV-2 vaccines and reflect the immune system being stimulated by the vaccine. Severe side effects have been reported in a transparent manner during the trials and during programmatic use but are exceptionally rare. The overwhelming benefits of vaccination in terms of preventing death from COVID-19 far outweigh the risks of these rare severe side effects.

As a professional society, we therefore strongly recommend the use of vaccination for COVID-19 and would encourage all people (including transplant recipients) to be vaccinated and so help protect themselves and others.

References:

  1. M. Alfishawy et al. Int J Org Transplant Med 2020; Vol. 11 (4): p145-162
  2. Gupta G, Azhar A, Gungor A, Molnar MZ. Early Data on Utilization and Discard of Organs From COVID-19 – infected Donors: A US National Registry Analysis. 2022;00(00):19-21. doi:10.1097/TP.0000000000004091
  3. Polack, Fernando P., et al. "Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine." New England Journal of Medicine (2020).
  4. Sadoff, Jerald, et al. "Safety and efficacy of single-dose Ad26. COV2. S vaccine against Covid-19." New England Journal of Medicine 384.23 (2021): 2187-2201.

Kind regards,

Dr David Thomson - SATS President, on behalf of the EXECUTIVE COMMITTEE

11 July 2022

Dr David Thomson – SATS President, on behalf of the EXECUTIVE COMMITTEE

Downloadable Version

Blood Group Incompatible (ABOi) Transplantation

Statement of the South African Society of Transplantation

Date: 11 May 2023

Introduction and Context

There is a global organ shortage resulting in many patients dying on transplantation wait lists. This has resulted in the development of numerous alternative clinical techniques to increase the availability of donor organs. The use of blood group incompatible organs from both deceased donor and living donors is a well validated and safe method for improving both access to transplantation and the number of transplants to be performed. In the era of improved pharmacotherapies such as the availability of the CD-20 monoclonal antibody Rituximab, improvements in isoagglutinin control and testing, ABOi transplantation is safe and results in equivalent patient and graft survival when compared to blood group compatible transplantation.

Purpose of this statement

  • To inform the circumstances and contexts under which ABOi transplantation can be considered
  • To advise on best practice principles through which ABOi transplantation should be performed at transplant centres
  • To propose a centralised, national platform for the development of treatment protocols, the collection of data and the development of new methodologies, techniques, and pharmacotherapies as they pertain to ABOi transplantation to ensure that a standardised and consistent baseline for care is established in South Africa

Context and Clinical Circumstances under which ABOi should be considered

ABOi transplantation can be considered in the following circumstances, provided there is informed consent from the patient or their surrogate, and a standardised institutional protocol for ABOi transplantation exists:

  • In all solid organ recipients where there is the availability of a deceased donor ABOi organ, and when there is no better suited compatible recipient of the same blood group, and where the risk of denying access to transplantation is outweighed by the benefit to patient survival.
  • In the acute organ failure setting where a viable living donor option exists, and there is no viable or available ABO compatible living donor or deceased donor, and where the risk of denying access to transplantation is outweighed by the benefit to patient survival.
  • In the elective setting where there is no available ABO compatible living donor
  • Where the recipient has a viable and available ABOi donor where the treating clinical team deems there to be no clinical contraindications to treatment and the option of a paired exchange has been explored.

These options should also be considered in children and adolescents in centres who have experience with this.

ABOi transplantation should not be considered at this time in the following situations:

  • If the recipient has a viable and available deceased donor or living donor ABO compatible donor offer
  • In the setting of donation after circulatory death (DCD)
  • If the measured isoagglutinin titre using the dithiothreitol (DTT) treatment of plasma method is greater than 512 for the donor organ blood type
  • If there is not informed consent
  • If there is no standardised protocol for the management of ABOi transplantation at the institution offering the transplant

Protocol Development and Data Collection

  • Institutions must develop institutionally contextualised and agreed upon protocols for the management of ABOi transplantation in their centre in line with accepted international standards
  • Such protocols should be available for review
  • We recommend the establishment of a National ABOi solid organ patient database for improving access and quality of ABOi transplantation for the South African population.

Best Practice Principals

  • We recommend the use of a separate ABOi consenting process and form for recipients of ABOi organs which outlines the processes and risks associated with ABOi transplantation.
  • We recommend the use of both PBS and Dithiothreitol (DTT) validated isoagglutinin testing for the estimation of IgG and IgM anti-A and anti-B antibody titres in recipient plasma samples.
  • We recommend that institutional protocols utilise either plasmapheresis techniques and/or immunoadsorption columns for the pre- and post-operative control of isoagglutinin titres in recipients of ABOi solid organ transplants and that the safety and efficacy of the techniques in question must consider individual as well as institutional factors such as bleeding risk, haemodynamic compromise, cost and availability.
  • We recommend that the protocolised care of ABOi recipients include the use of the CD20 monoclonal antibody therapy Rituximab.
  • We do not recommend the routine use of splenectomy as a method to control isoagglutinin levels in recipients of ABOi solid organ transplantation.
  • Immunosuppression regimens and immunomodulatory techniques and protocols must be adaptable to the individual patient requirements and treatment runs.

Conclusion

ABOi transplantation is a viable alternative for solid organ recipients and must be performed by experienced and well-trained clinical teams. The use of ABOi organs is safe and results in improved access to and availability of transplantation.

References

  1. Girlanda R. World Journal of Transplantation © 2016. 2016;6(3):451–60.
  2. Lee EC, Kim SH, Park S, Lee EC, Kim SH, Park S. Outcomes after liver transplantation in accordance with ABO compatibility: A systematic review and meta-analysis. 2017;23(35):6516–33.
  3. Yadav DK, Hua YF, Bai X, Lou J, Que R, Gao S, et al. Review Article ABO-Incompatible Adult Living Donor Liver Transplantation in the Era of Rituximab: A Systematic Review and Meta-Analysis. 2019;2019.
  4. Geyer M, Fischer KG, Drognitz O, Walz G, Pisarski P, Wilpert J. ABO-incompatible kidney transplantation with antigen-specific immunoadsorption and rituximab - Insights and uncertainties. Contrib Nephrol. 2009; 162:47–60.
  5. de Magnée C, Brunée L, Tambucci R, Pire A, Scheers I, Sokal EM et al. Is ABO-Incompatible Living Donor Liver Transplantation Really a Good Alternative for Pediatric Recipients? Children. 2021;8(7):600.
  6. Peruhova M, Georgieva V, Yurukova N, Sekulovska M, Panayotova G, Mihova A, et al. ABOnonidentical liver transplantation from a deceased donor and clinical outcomes following antibody rebound: A case report. World J Transplant. 2020;10(5):138–46.

Contact Information

Prof Mignon McCulloch
Tel: +27(0)827804097
Email: mignon.mcculloch@uct.ac.za
President of South African Transplant Association (SATS)

Downloadable Version

Sharan Rambarran

“Sharan Rambarran completed his surgical training in 2008 at UKZN. In 2013 he completed a sub-speciality certificate in surgical gastroenterology, with a specific focus on hepatopancreaticobiliary (HPB) surgery. At this stage he headed up the Upper GI unit at Addington Hospital and was a core member of the GI Surgical Division at Inkosi Albert Luthuli Central Hospital. During this time he helped establish and run advanced endoscopy at IALCH and was involved with outreach to remote hospitals helping up-skill medical professionals at peripheral hospitals across KZN.

Sharan has won a number of travelling international fellowships - Advanced Endoscopy to Kyushu, Japan 2009, Minimal Access Karl Storz surgical fellowship to Straubing, Germany 2015 and two further gastroenterology fellowships to Amsterdam, Netherlands. Sharan moved to Johannesburg Wits Donald Gordon Medical Centre in 2016 after a chance meeting with the Johannesburg team inspired a bold move to pivot into transplant surgery.

After completing the fellowship offered by Wits Transplant in 2019, Sharan has now taken up the role as lead surgeon of the Liver Transplant Program at WDGMC.

Sharan is hoping to help drive South Africa into a new era of transplant surgery by demystifying this extremely specialised but vitally needed field of surgery."

Meshack Nkosinaye Motha

Meshack Nkosinaye Motha is an aspiring surgeon with specialized expertise in transplant surgery. Based in Johannesburg, South Africa, he has made significant contributions at the CMJAH Transplant Unit and the Wits Hospital Complex. With over 100 cadaveric solid organ procurements, he has advanced renal transplantation in the public sector and is actively involved in expanding to liver and pancreatic transplantation.

Motha’s extensive training includes rotations in general surgery and specialized exposure in trauma, burns, cardiothoracic, and pediatric surgery. He holds multiple qualifications, including a Master of Medicine in Surgery and a Fellowship in the College of Surgeons.

He has contributed to medical research and publications, presenting findings on gallbladder cancer staging and transplant complications. His leadership roles include coordinating surgical education and memberships in prominent transplant and surgical societies. A regular attendee of international conferences, he remains committed to academic growth and innovation in transplant surgery.

Fun Fact- adrenaline Junky (enjoy bungee jumping and skydiving)

Carla Wilmans

Carla Wilmans is the Administrative Unit Head of the Transplant Unit at Wits Donald Gordon Medical Centre (WDGMC). She also manages the Medical and Surgical Faculty Practice, the Colorectal Unit as well as the Clinical Associate body at the hospital.

Carla obtained her B.Pharm (with distinction) from the University of the Witwatersrand and has worked in various sales, marketing and business management roles in the pharmaceutical and healthcare industries(Pharmacia, Roche, Amgen and Fresenius Medical Care)

Carla was actively involved in the development and publishing of the Wits Transplant Procurement Handbook and Family Approach to Consent Strategy(FACTS).

She is passionate about working with people and working strategically to implement efficient service delivery and workflow processes to ensure that all patients and families who come through the WDGMC Transplant Unit, Faculty Practice and the Colorectal Unit experience exceptional care.

In her spare time, Carla enjoys playing padel and running.

Thozama Siyotula

Specialist paediatric surgeon in the division of Paediatric surgery Red Cross War Memorial Children’s Hospital, Cape Town MMED Masters of medicine through the university cape town 2021 (University of Cape Town) FCPS Fellow of the college of paediatric surgeons 2021 MBBCH Bachelor of Medicine and Bachelor of Surgery (MBBCH) University of the Witwatersrand Johannesburg 2011 Convener 5th year paediatric surgery undergraduate, University of Cape Town Committee Member: International Pediatric Transplant Association Multi-Organ Transplant Committee Research interest include post-surgical neonatal outcomes, paediatric transplantation, hepatic arteriovenous malformations and Global surgery. She aspires to be a clinician scientist. Publication Pediatr Surg Int (2022). Recipient of the Mail and Guardian 200 Young South Africans of 2020, previous president of SAPSTA 2019/2020 and SASSIT executive member 2017/2018. “The greatest views are after the hardest climbs, but summit we must”

Prof Jerome Loveland

Jerome worked as the Clinical Head of Paediatric Surgery, Chris Hani Baragwanath Academic Hospital (CHBAH) from 2008 until 2022, and held the position of Academic Head, Department of Paediatric Surgery, Wits, from 2014 to 2023 when his 10 year tenure expired. In 2022 he was appointed Academic Head of Transplantation at Wits, and is the Clinical Head of Transplantation at the Wits Donald Gordon Medical Centre (WDGMC). He is in good standing with the Health Professionals Council of South Africa (HPCSA). Jerome served on the Exco of the South African Association of Paediatric Surgeons (SAAPS) from 2012 to 2024, and was the Vice President of SAAPS from 2016 to 2024. Jerome has also been an active member of the Exco of the College of Paediatric Surgeons of South Africa (CMSA) from 2014 to 2024. Jerome was an Exco member of the South African Transplantation Society (SATS) from 2007 - 2019, Secretary of SATS from 2009 – 2015, and President of SATS for the periods 2015 – 2017, and 2017 – 2019. He is also the founding member and Chairman of the Board of the “Surgeons for Little Lives” charity, this from 2014 to date. In 2023 Jerome was appointed to the Council of St John’s College, Johannesburg.

Jerome was awarded the Swann Morton Research Prize for best trainee publication in 2004, the Oscar Norwich Traveling Fellowship in 2007, and numerous Research Grants. In 2010 he received a Letter of Commendation from Wits, was promoted to Senior Lecturer in 2011, to Associate Professor in 2013, and to full Personal Professor in June 2018. In 2016 he was the recipient of the “Exceptional Service” award from the School of Health Sciences. In 2010 President Jacob Zuma awarded him the Presidential Award for “Excellence in Paediatric Surgical Care, Baragwanath Hospital”. In September 2020, Jerome was awarded the “Golden Eagle” Award, by his alma mater, St John’s College, in recognition of his contribution to Paediatric Surgery in South Africa, and the children that he serves. In September 2021, Professor Loveland was awarded the Vice Chancellor’s Individual Award for Academic Citizenship by Professor Zeblon Vilakazi, Vice Chancellor of the University of the Witwatersrand.

Dr Priya Walabh

Text to follow soon.

Mande Toubkin

Employer: Netcare Limited

Position: National Emergency Trauma, Transplant, Disaster Management and Corporate Social Investment Manager, Netcare

Qualifications: Dip General Nursing, Dip Midwifery (Honors), Dip Paediatric Nursing Science (Honors), Trauma Nursing (Honors), Hospital Nursing Management, Aviation Health Care Providers, FSA Interaction Management, Dip Medical and Surgical Nursing Trauma (Honors), Dip Medical and Surgical Nursing Critical Care (Honors) MSC Master of Science in Medicine (Emergency Medicine), fEMSSA, fANSA, Graduate Stanford University Compassion Ambassador, advisor on ministerial disaster management committee.

Other positions: Director and Secretary of the Emergency Medicine Society of South Africa, Director Netcare Foundation.

Publications: Disaster Travel Medicine: The South African Rescue mission abroad, Guideline for the assessment of Tauma Centers in South Africa (SAMJ 2011), Transplant Clinical Governance Manual (HQS), Characteristics and outcomes of hospitalized patients in South Africa during the COVID-19 omicron wave compared with previous waves (JAMA 2021),

Current responsibilities: Overall day-to-day management of Netcare Emergency, Trauma Transplant, Corporate Social Investment and Disaster Management Director of the Netcare Foundation NPO PBO.

Dr Francisca van der Schyff

Dr Francisca van der Schyff trained at the University of Cape Town to obtain her medical degree, with honors, in 2006.
She obtained her specialist qualification as a general surgeon in 2016, cum laude.

She spent an additional 2 years in the department of Paediatric surgery at the University of Pretoria before accepting a training post in transplantation at the Wits Donald Gordon Medical center.
She has since qualified as an abdominal transplant surgeon and is currently working as a full-time consultant within the transplant team at the Donald Gordon Medical Center.

She has previously published on biliary atresia and necrotizing enterocolitis in children and her current field of research include graft tolerance in children post liver transplant. She currently serves as a member of the Vanguard committee of the European Society of Organ Transplantation and President elect of the South African Transplant Society.

Wacky fact: I married my childhood sweetheart!

Dr David Thomson

David Thomson is a transplant surgeon and critical care specialist at Groote Schuur Hospital and the University of Cape Town. He completed his undergraduate training in 2002 at the University of Kwa-Zulu Natal and went on to specialise in surgery at the University of Cape Town completing his FCS(SA) in 2011 and MMed(Surgery) in 2012 and Critical Care in 2015. He currently works as a critical care subspecialist and as a surgeon in the liver and renal transplantation unit, leading the ECMO program. His interests are medical education and system improvement. He created the massive open online course Organ Donation: From Death to Life hosted on Coursera.org to improve education around organ donation and transplantation. He is a past President of the Southern African Transplantation Society and led development on a report on Organ and Tissue Donation in South Africa: Creating a National Strategic Roadmap in collaboration with the International Society for Organ Donation and Procurement. He worked on the World Brain Death Project and is the lead author on the South African Guidelines for Determination of Death published in 2021. Wacky fact: Enjoys basketball and chess. Known to play online poker seriously.

PROF MIGNON MCCULLOCH
MBBCH DCH DTM&H FRCPCH FCP(Paeds)

Full Professor & Head of Clinical Unit of Paediatric Nephrology and Solid Organ Transplantation (including kidney, liver, and heart) at Red Cross War Memorial Children’s Hospital and Senior Lecturer at the University of Cape Town. She is also the immediate Past president of the International Paediatric Transplantation Society (IPTA) involved in promoting paediatric transplantation worldwide.

Also, immediate Past-President of the South African Paediatric Association (SAPA) dealing specifically with COVID issues in the last 2 years as an important advocacy voice for children She is also a Paediatric Intensive Care (PICU) consultant and on the Saving Young Lives (SYL) Steering Committee. Her other interests include Paediatric Nephrology and care of critically ill children specifically with AKI requiring all forms of Dialysis and Transplant in infants and children.

This includes doing training Fellows and outreach work in various parts of Africa developing paediatric renal and transplant programs as well as Adolescent transition programs.
Wacky Fact: She is also an amateur surfer