Practical recommendations for kidney transplantation in the COVID-19 pandemic

Abstract

Kidney transplantation at the time of a global viral pandemic has become challenging in many aspects. Firstly, we must reassess deceased donor safety (for the recipient) especially in communities with a relatively high incidence of coronavirus disease 19 (COVID-19). With respect to elective live donors, if one decides to do them at all, similar considerations must be made that may impose undue hardship on the donor. Recipient selection is also problematic since there is clear evidence of a much higher morbidity and mortality from COVID-19 for patients older than 60 and those with comorbidities such as hypertension, diabetes, obesity and lung disease. Unfortunately, many, if not most of dialysis patients fit that mold. We may and indeed must reassess our allocation policies, but this must be done based on data rather than conjecture. Follow-up routines must be re-engineered to minimize patient travel and exposure. Reliance on technology and telemedicine is paramount. Making this technology available to patients is extremely important. Modifying or changing immunosuppression protocols is controversial and not based on clinical studies. Nevertheless, we should reassess the need for induction therapy across the board for ordinary patients and the more liberal use of mammalian target of rapamycin inhibitors in transplant patients with proven infection.

The Management of Immunosuppression in Kidney Transplant Recipients with COVID-19 Disease: An Update and Systematic Review of the Literature

“…Despite a few data being identified on induction agents in KT recipients with COVID-19 infection [ 107 ], the induction therapy is a very relevant aspect in KT, as it is widely used to provide fast and effective protection against acute allograft rejection [ 108 ]. Yet, at the same time, induction therapy may increase the risk of infectious diseases [ 109 , 110 ].…”

Safety of Antithymocyte Globulin Use in Kidney Graft Recipients During the COVID-19 Pandemic

“…These concerns were mirrored by a substantial drop in the use of lymphocyte-depleting induction agents during first “pandemic” months, which was noted in the USA [ 9 ] and also in Poland (unpublished data). On the other hand, avoiding ATG could lead to increased incidence of rejection episodes, while the full anti-rejection protocol accumulates a much larger dose of immunosuppression [ 10 ]. Another consequence is the possible transplantation delay in case of high-immunologic risk patients, as recent evidence clearly suggested the advance of ATG over basiliximab induction in this population [ 11 , 12 ].…”

Outcomes of Patients Receiving a Kidney Transplant or Remaining on the Transplant Waiting List at the Epicentre of the COVID-19 Pandemic in Europe: An Observational Comparative Study

“…Although some KT transplant centres preferred to stop their services [ 34 , 35 ], most units decided to adopt specific limitations, aiming to obtain a more favourable balance between risks and benefits. The main options were to restrict transplant procedures to recipients with a low surgical, anaesthesiologic, and immunological risk profile or, alternatively, to life-threatened patients without dialysis access options [ 36 ]. Our team maintained the KT programme throughout the entire course of the pandemic, without formal restrictions, striving to offer a high-quality service to all the patients registered on the TWL.…”