ISOT Consensus Statement for the Kidney Transplant Recipient and Living Donor with a Previous Diagnosis of COVID-19

Abstract

The National Organ and Tissue Transplant Organization (NOTTO) has previously published transplant-specific guidelines with reference to COVID-19.[1] The mortality is higher in dialysis patients with COVID-19 (12%–30%) than posttransplant COVID-19 patients (11.3%) and both are higher than the general population (<2%) in India.[2345] With the resumption of the kidney transplant program in various parts of India, new issues are expected to occur. There is uncertainty, regarding the safety of performing kidney,[678] liver,[9101112] and lung[13] transplantation in a recipient recently recovered from COVID-19. At present, we have limited evidence-based information about safety and feasibility of kidney transplantation from living donors, who have recovered from COVID-19.[14] Recently, Indian Multi-center cohort studies have reported successful kidney transplantation in recipients from living donors with a previous diagnosis of COVID-19.[1516] Guidelines of Other Professional Societies The American Society of Transplantation (AST) recommends that patient who recovered after COVID-19 should be asymptomatic and should preferably have two negative SARS-CoV-2 polymerase chain reaction (PCR) test at least 24 h apart in view of limited sensitivity (70%) of single test, though the optimal timing of multiple tests is unknown.[17181920] The American Society of Anesthesiologists and Anesthesia Patient Safety Foundation Joint Statement on elective surgery and anesthesia for patients after COVID-19 infection suggested waiting time from the date of COVID-19 diagnosis to surgery as follows: Four weeks for an asymptomatic patient or recovery from only mild, nonrespiratory symptoms Six weeks for a symptomatic patient (e.g., cough, dyspnea) who did not require hospitalization Eight to 10 weeks for a symptomatic patient with comorbidities like diabetic, immunocompromised state, or hospitalized Twelve weeks for a patient who was admitted to an intensive care unit due to COVID-19 infection.[20] The United Network for Organ Sharing/AST suggested proceeding for transplant from a previously infected potential donor if: The timing is between 21 and 90 days from initial symptoms Symptoms have resolved and An infectious disease expert is consulted.[21] National Institute of Clinical Excellence guidelines for live donors with recovered COVID-19 infection, recommends deferring transplants for 28 and 14 days of comprehensive social distancing and hand-hygiene measures. Donation should resume only after the donor is clinically asymptomatic and has negative nasopharyngeal swab test result for nCoV 2019 and another negative test within 3 days before donation.[22] NOTTO guidelines suggest accepting donors with a previous diagnosis of COVID-19 with documented two negative COVID-19 tests and complete symptom resolution for 28 days and another negative test at the time of donation.[1] Consensus Statement for Kidney Transplant Recipient and Donor with a Previous Diagnosis of COVID-19 We recommend that prospective kidney transplant recipients and donors with a previous diagnosis of COVID-19 should be considered for transplantation after comprehensive pre-transplant evaluation using a combination of clinical, radiologic, and laboratory criteria, with individualized risk-benefit analysis. Based on currently available limited data, we suggest that kidney transplant recipients and prospective living donors with a previous diagnosis of COVID-19 should be considered for transplantation with the following criteria. Regular social distancing, hand hygiene and face-mask use after recovery from covid-19 infection Complete symptom resolution for at least 28 days. The ideal disease-free interval is unknown. The appropriate length of time between recovery from COVID-19 and surgery with respect to minimizing postoperative complications should be individualized, taking into consideration symptom, COVID-19 severity, associated comorbidities, and the benefit/risk ratio of further delaying the surgery Documented two negative SARS-CoV-2 PCR tests including one negative test at the time of transplant surgery. This is done to avoid known false-negative rates of single PCR test in COVID-19. The two negative PCR tests should be at least 24 h apart due to the limited sensitivity (70%) of single test Normal chest imaging by CT scan within 24–72 h before transplants Donors-recipient pair should sign written informed consent explaining them individualized risk-benefit analysis including a potential risk of COVID-19 infection due to reactivation or re-infection during the hospital stay and after transplant Adequate screening in pretransplant evaluation with special attention given to the cardiopulmonary system by a multi-disciplinary team and a planned regular long-term follow-up after discharge. Enhanced frequent follow-up should be ensured by telemedicine or face to face as required and feasible. We suggest using standard drugs and doses of induction and maintenance immunosuppressive drugs based on the recipient's immune risk stratification as was being practised before COVID-19. We suggest that the donors-recipient pair must be advised to continue to take safety precautions post-transplant. We suggest that the donors-recipient pair should get prompt PCR testing and treatment if they have any suspicious symptoms of COVID-19 infection due to reactivation or re-infection after transplantation. We recommend that transplant recipients and their household members should be vaccinated with ANY coronavirus vaccine that is authorized and approved for use by the local health authority. The World Health Organization suggests that individuals may wish to defer their own COVID-19 vaccination for up to six months from the time of SARS-CoV-2 infection.[23] Ministry of Health and Family Welfare, Government of India suggest that infected individuals should defer COVID-19 vaccination for 14 days after symptoms resolution.[24] Centers for Disease Control and Prevention suggest that there is no recommended minimum interval between recovery from the infection and vaccination. Current evidence suggests that the risk of SARS-CoV-2 reinfection is low in the months after initial infection but may increase with time due to decreasing neutralizing antibody titers. Vaccination should be deferred for at least 90 days[25] in people who previously received passive antibody therapy such as convalescent plasma as part of COVID-19 treatment. Disclaimer COVID-19 pandemic is evolving dynamically. Therefore, this consensus statement is a live and dynamic document and will require updating as per the evolving situation. Note: This special article is being published simultaneously in the Indian Journal of Transplantation and the Indian Journal of Nephrology. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Topics & Concepts