As COVID-19 started to take hold in countries like China and Italy, Marian Michaels, MD, MPH, thought the transplant community in the United States and Canada would benefit from having information about the then-rising epidemic so they could establish solid plans for their patients and programs. She had no idea how prescient that decision would be.
Michaels, a pediatric infectious diseases physician at UPMC Children’s Hospital of Pittsburgh, gathered fellow infectious disease transplant experts to publish a framework for keeping patients and hospital staffs safe during an outbreak of COVID-19 (1). Michaels noted that individual transplant centers may be affected by COVID-19 differently depending on the amount of virus in their institutions and their patient populations, so each must regularly update protocols regarding how they can continue to perform transplants safely and when they may need to slow things down.
“The emergence of COVID-19 is not the first time the transplant community has had to contend with emerging viruses, nor will it be our last,” Michaels and colleagues write in the paper. “Consequently, we should learn from past experiences with novel viruses and put safeguards in place for transplant centers and OPOs [organ procurement organizations] to protect transplant recipients and healthcare workers … and to mitigate the impact of this epidemic on transplant outcomes.”
Based on lessons learned from previous outbreaks of related viruses, such as the 2002 outbreak of SARS-CoV and the 2012 outbreak of MERS-CoV, Michaels said transplant programs should have the following protocols in place:
• Targeted, screening of patients and visitors, and for OPOs, of potential donors.
• Plans for placement and evaluation of recipients with risk factors for the pathogen when they are sick and require evaluation.
• Backup plans for recipients requiring evaluation for other reasons if a transplant center is temporarily closed.
• Consideration for candidates to be listed at alternative centers for transplant if an epidemic is geographically confined.
• The ability to communicate with transplant recipients and potential living donors to keep them apprised of updated information and recommendations.
What has changed with COVID-19 are additional recommendations for transplant patients and their family members to protect themselves by wearing masks, practicing good hand hygiene, and physical distancing, Michaels said. Living donors also should self-quarantine before the donation so they are not exposing themselves prior to surgery.
Uday Nori, MD, an associate professor of medicine and program director of the nephrology fellowship program at The Ohio State University Wexner Medical Center, agreed with Michaels that transplant centers are making decisions based on their own unique needs at this time. While Nori’s medical center canceled elective procedures including living donor kidney transplants, for now, the program has actively been performing about two deceased donor kidney transplants per day.
“Other centers have been passing up organs so we started getting many more imports,” he said. “I feel really good about it. We don’t want to waste any donor organs because they’re precious … and there’s only a finite amount of time before they are discarded.”
The program did add some extra precautions, Nori said. Every donor and recipient is checked for COVID-19 through testing from the National Kidney Registry. The medical center’s transplant unit is maintaining its policies of restricting visits from children, as well as deliveries of fresh fruit or flowers. Nurses who work in the transplant unit have not participated in a float pool to provide backup help for other units that may have COVID-positive patients.
Additionally, physicians modified the immunosuppression protocol so those at high risk for COVID would not be as heavily immunosuppressed, and they are conducting more post-transplant follow-up visits by phone or video.
“I’m very optimistic,” Michaels said. “I know this has been very hard on all of us, and it’s been difficult watching our friends and patients hospitalized, but I’ve been amazed at the resiliency and also the ability of people to work together.”
Nori said the volume of information pouring out about COVID-19 now is almost overwhelming. He estimates he spends about two hours a day sifting through updated information about the pandemic, including emails he receives through an American Society of Transplantation listserv called Outstanding Questions in Transplantation Research.
“It’s one of the most valuable things I’ve seen for COVID, because people are sharing even unpublished manuscripts because they don’t want people to be hamstrung by not having information on a daily basis,” said Nori, a member of the Kidney News editorial board.
“When COVID-19 hit the US, I don’t feel we had as many protocols in place for dealing with this as we have now,” Michaels said. “Being able to say what your resources and capacity are and having educational tools ready to get to patients is going to put us ahead of the game more [in the future] than what we had for this pandemic.”
Being able to say what your resources and capacity are and having educational tools ready to get to patients is going to put us ahead of the game more [in the future] than what we had for this pandemic.
Michaels M, La Hoz R, Danziger-Isakov L, et al. Coronavirus disease 2019: Implications of emerging infections for transplantation. Am J Transplant. 2020 Feb 24. doi: 10.1111/ajt.15832.