Renal Transplant Guidelines with Reference to COVID-19 Infection

These guidelines have been prepared by COVID-19 Working Group of Indian Society of Nephrology and endorsed by the Indian Society of Organ Transplantation (ISOT). In view of the rapidly changing scenario of COVID-19 infection, these guidelines may be revised/updated from time to time.

Organ transplant recipients are at a risk for more severe COVID-19 if they get SARS CoV-2 viral infection. Further, there is a potential risk of infection transmission from the donor to recipient through organ transplantation. Also, there are issues in recipient and donor selection for transplant. In view of these issues’ organ transplants at the time of COVID-19 pandemic should be undertaken with caution and should be done only at the center where facilities of management of COVID-19 patients are available.

1. The pre, peri, and posttransplant areas, including the operation theaters need to be specifically ear-marked for this purpose

2. Staff involved in the care of transplant patients must not be involved in the care of other patients

3. There has to be adequate availability of personal protective equipment (PPE) for the care of these patients

4. The center should not be the one ear-marked for the treatment of COVID-19 patients and needs to have protocols for patient movement around the hospital to prevent the nosocomial acquisition of COVID.

Deceased Donors Transplants

Following individuals, having any of the following criteria, who are potential deceased donor should NOT be accepted as deceased donors:

1. Epidemiological criteria –

   • International travel in the last 14 days before the onset of current event leading to brain stem death

   • Contact in last 14 days before the onset of current event leading to brain stem death with a confirmed case of COVID-19 or a health care worker with direct patient contact

2. Clinical criteria –

   • Where the cause of death was due to unexplained respiratory failure

   • Where there was a history of fever or acute respiratory infection (e.g., shortness of breath, cough, and sore throat) with or without fever.

   • Severe bilateral community-acquired pneumonia in the absence of any other cause.

3. Laboratory criteria -

   • Confirmed COVID-19 positive case or test found positive while donor work-up is being done.

Living related Transplants

The living donor transplant program may be temporarily suspended in line with the Ministry of Health and Family Welfare (MoHFW)'s advisory for Hospitals and Medical Institutions dated 3^rd March 2020, accessible at https://www.mohfw.gov.in/pdf/AdvisoryforHospitalsandMedicalInstitutions.pdf

However, if transplant is being done in view of the emergency medical need of recipient, following individuals, who are living donor should NOT be accepted as donors:

1. Epidemiological criteria –

   • International travel in the last 14 days

   • Contact in last 14 days with a confirmed case of COVID-19 or a health care worker with direct patient contact

2. Clinical criteria –

   • History of fever or acute respiratory infection (e.g. shortness of breath, cough, sore throat) with or without fever

3. Laboratory criteria -

   • Confirmed COVID-19 positive or test found positive while donor work-up is being done.

   Reverse transcription-polymerase chain reaction (RT-PCR) test of potential donors should be undertaken as suggested for deceased donors

Transplantation Recipients

Similar to the general population, transplant recipients should also strictly follow the travel advisories issued by the various ministries of the Government of India from time to time. They should take extra precaution as they have a risk of developing severe COVID-19 disease, if they acquire SARS CoV-2 viral infection.

Transplant Recipients Returning from Abroad

All transplant recipients who have been exposed to a confirmed or suspected COVID-19 patient within the last 14 days or who have returned from nations with COVID-19 outbreaks should undergo quarantine and isolation for 14 days and should be tested for SARS CoV-2 infection.

If any transplant recipient has fever, cough, or breathing difficulty, they should immediately call their respective transplant centers. All transplant centers must have guidelines in place specifying which patients need testing and inpatient management and which patients can stay at home with close follow-up with various means like mobile and email etc.

If they are advised to visit the hospital, they should wear a mask while coming to hospital premises. In case of a medical emergency like difficulty in breathing, they should report to the nearest emergency department.

Treatment and modification of immunosuppression

There are two issues of management of organ transplant patients with COVID-19

1. Management of COVID-19 in the transplant patient

   There is a scarcity of data and consensus on effective treatments of COVID-19 as such and more so in transplant patients. Few centers have tried antivirals, hydroxychloroquine, and macrolides in COVID-19 patients with variable results. However, as of now, there is no treatment approved by the Central Drugs Standard Control Organization (CDSCO) or the Foods and Drug Administration (FDA) for COVID-19

2. Handling of immunosuppressive medicines with COVID-19

   There is no consensus regarding modification in the immunosuppressive regimen of transplant recipients with COVID-19. The dose adjustment has to balance the infection control and the organ rejection. However, there is an overall agreement of stopping antimetabolite drugs and decrease calcineurin inhibitors by 50%. Steroids should be continued on same doses. (Massachusetts General Hospital COVID-19 Treatment Guidance).

Posttransplant follows up Measures

Transplant patients are at risk for severe COVID 19 if they acquire infection due to their immunosuppressed state. They may not manifest symptoms like the general population. Fever may be absent as reported from a study from China. Transplant units are advised to consider ways to limit hospital attendance for patients, such as:

1. Rescheduling nonurgent out-patient appointments

2. Virtual or telemedicine or telephonic appointments

3. Home delivery of immunosuppression if feasible.

Patients with stable graft function and adequate drug supply can avoid routine follow-up visits to transplant hospitals.

Tissue Transplantation

At present, there is no evidence to suggest the transplant of coronaviruses by blood transfusion.

Personnel Precautions working in the program

The health and safety of all the health care workers in the transplant program is of paramount importance. Transplanting hospitals are advised not to expose any of their staff if there is even the slightest risk of virus transmission from both epidemiological and clinical criteria.

It is likely that this pandemic may require the current resources to be utilized elsewhere, hence there is even more reason to practice caution when deciding on proceeding with donation and transplantation. It is with this in mind that all elective live living kidney and liver transplant should be postponed.