key: cord-0683681-y0wp77mw authors: Chandorkar, Aditya; Coro, Ana; Natori, Yoichiro; Anjan, Shweta; Abbo, Lilian M.; Guerra, Giselle; Mattiazzi, Adela D.; Mendez‐Castaner, Lumen A.; Morris, Michele I.; Camargo, Jose F.; Vianna, Rodrigo; Simkins, Jacques title: Kidney transplantation during coronavirus 2019 pandemic at a large hospital in Miami date: 2020-08-02 journal: Transpl Infect Dis DOI: 10.1111/tid.13416 sha: 9678b4ba61892ca3bdfc3dbd8315d0eb2b053dd2 doc_id: 683681 cord_uid: y0wp77mw BACKGROUND: Coronavirus 2019 (COVID‐19) pandemic has resulted in more than 350 000 deaths worldwide. The number of kidney transplants has declined during the pandemic. We describe our deceased donor kidney transplantation (DDKT) experience during the pandemic. METHODS: A retrospective study was conducted to evaluate the safety of DDKT during the COVID‐19 pandemic. Multiple preventive measures were implemented. Adult patients that underwent DDKT from 3/1/20 to 4/30/20 were included. COVID‐19 clinical manifestations from donors and recipients, and post‐transplant outcomes (COVID‐19 infections, readmissions, allograft rejection, and mortality) were obtained. The kidney transplant (KT) recipients were followed until 5/31/20. RESULTS: Seventy‐six patients received kidneys from 57 donors. Fever, dyspnea, and cough were reported in 1, 2, and 1 donor, respectively. Thirty‐eight (66.6%) donors were tested for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV2) prior to donation (mainly by nasopharyngeal or bronchoalveolar lavage polymerase chain reaction [PCR]) and 36 (47.3%) KT recipients were tested at the time of DDKT by nasopharyngeal PCR; all of these were negative. Our recipients were followed for a median of 63 (range: 33‐91) days. A total of 42 (55.3%) recipients were tested post‐transplant for SARS‐CoV2 by nasopharyngeal PCR including 12 patients that became symptomatic; all tests were negative except for one that was inconclusive, but it was repeated and came back negative. Forty (52.6%) KT recipients were readmitted, and 7 (9.2%) had biopsy‐proven rejection during the follow‐up. None of the KT recipients transplanted during this period died. CONCLUSIONS: Our cohort demonstrated that DDKT can be safely performed during the COVID‐19 pandemic when preventive measures are implemented. In December 2019, several clusters of a severe acute respiratory illness were described in Wuhan, China. 1, 2 These were the first cases of what was to later become the Coronavirus 2019 (COVID-19) pandemic. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2), a novel beta-coronavirus, was identified as the causative agent. 1, 2 While initial spread was limited to China, the first international case was confirmed in Thailand on January 13, 2020. 1 By January 30, 2020, the World Health Organization declared that the outbreak was a public health emergency of international concern. 3 As of June 1, 2020, the COVID-19 pandemic has been responsible for 6,206,773 cases and 372,752 deaths worldwide, in 188 countries and regions. 4 The United States (US) has borne the brunt of the pandemic, with nearly 29% and 28% of all worldwide cases and deaths, respectively. In the state of Florida, most of the cases have occurred in South Florida. The Counties of Miami-Dade, Broward, and Palm Beach alone have accounted for 55% of all cases and deaths of the Sunshine State. 5 Solid organ transplant (SOT) recipients face significant risk from respiratory viral infections as they tend to be more severe in the immunocompromised host. For example, influenza in SOT recipients is associated with pneumonia in 14%-49% of patients 6, 7 and is commonly associated with subsequent viral, bacterial, and fungal pneumonia, with a co-infection rate of 7%-29%. 8, 9 Kidney transplantation is a vital intervention for patients with end-stage renal disease (ESRD). Kidney transplantation significantly improves survival as it was demonstrated in a study that showed that the mortality rate was 48%-82% lower among kidney transplant (KT) recipients compared with people who remained on long-term dialysis. 10 The risk of hospitalization from infection is also lower in KT recipients. 11 In addition, kidney transplantation is associated with significant improvements in patient satisfaction and quality of life. 12, 13 However, KT recipients are at a higher risk of complications from COVID-19 due to their degree of immunosuppression and comorbidities. 14, 15 An observational study of 36 COVID-19-positive KT recipients showed 78% of patients requiring admission and 30% requiring intubation with a 28% mortality at 3 weeks. 14 Another study from Italy revealed a rapid clinical and radiographic deterioration with 25% mortality after a median period of 15 days from symptom onset among KT recipients. 15 In this report, we describe our experience in conducting kidney transplants during the COVID-19 pandemic at a single, large transplant center located in the State of Florida. This is a single-center retrospective study conducted at Jackson were included in the study and were followed until 5/31/20. The standard induction regimen in our institution is methylprednisolone 500 mg IV daily and anti-thymocyte globulin (ATG) 1 mg/Kg IV daily (three doses each), and basiliximab 20 mg IV (on post-operative days 0 and 3 or 4). Since late January 2020, when the first case of COVID-19 was reported in the United States, our hospital has implemented several preventive measures to prepare for the upcoming crisis. • Screening and appropriate triage of patients under investigation for COVID-19. • Scale up local testing capacity, especially in-house testing to meet the demands due to the increasing number of COVID-19 cases. • Screening for potential symptoms of COVID-19 in every patient admitted for transplant. • Monitoring all SOT recipients with a very low threshold to test (and re-test whenever necessary) for SARS-CoV2 with a nasopharyngeal swab PCR test. • Education of transplant candidates and recipients on the importance of maintaining social distancing, using adequate personal protection, reducing in-person visits if feasible, utilizing telemedicine applications for routine care visits if feasible and reducing the number of non-essential laboratory visits. • A separate location was opened in the transplant clinic to test symptomatic transplant patients to avoid transmission to other patients. • The use of surgical mask in all the medical campus facilities was made mandatory for all the healthcare workers and employees. • The entrance of non-employees to our hospital was restricted. • The living kidney donor and kidney/pancreas programs were placed on hold. • High-risk population: patients over the age of 75 years, patients between 70 and 75 years old with significant comorbidities, patients with HIV and sensitized patients (unless crossmatch was negative and no human leukocyte antigen (HLA)-donor-specific antibodies were noted on Luminex ® ) were placed on hold. • Preemptive transplantation was also placed on hold unless the patients were very close to require dialysis (Glomerular filtration rate under 15 mL/min). • At the beginning of 4/2020, additional measures were implemented in our DDKT program: All donors must test negative for SARS-CoV2 and not reside in COVID-19 hot spots, and recipients must test negative for SARS-CoV2 upon admission for transplant. DonorNet ® was reviewed to obtain the donors' information. We obtained epidemiological and travel history within 1 month prior to donation. We investigated if donors had fever, cough, and dyspnea before hospital admission by reviewing the medical-social questionnaire obtained from donors' relatives. We assessed the donors' by ELITechGroup was used to test the local donors. 16 The information of the SARS-CoV2 polymerase chain reaction (PCR) platforms used to test the imported donors was not available. The medical charts were reviewed to obtain demographics (age, gender, ethnicity, and Florida County of residence), to evaluate if they had symptoms of COVID-19 or abnormal CXR at the time of transplantation. Findings suggestive of atelectasis, pleural effusion, and pulmonary edema were not included, same as donors. We investigated for the following symptoms: cough, dyspnea, fevers, chills, chest pain, fatigue, headaches, body aches, rhinorrhea, sore throat, conjunctivitis, anosmia, dysgeusia, altered mental status, nausea/vomiting, abdominal pain, and diarrhea. We also evaluated if they were tested for Plus RealAmp Kit, Xpert ® Xpress SARS-CoV2 (running time: 4 hours) by Cepheid and QI-Astat-Dx Respiratory SARS-CoV2 Panel (running time: 8 hours) by Qiagen were available in our hospital to test the KT recipients during the study period. The tests were chosen at the discretion of the ordering providers. The clinical performance of these three PCR platforms is excellent. [16] [17] [18] The total number of outpatient visits from discharge to end of follow-up (5/31/20) was obtained to get a sense of how frequently patients were leaving home and getting potentially exposed to COVID-19 in case they were not following the recommended preventive measures (eg, wearing mask and maintaining social distance). The outpatient visits include appointments with medical providers, appointments for laboratories and imaging studies, outpatient procedures, and emergency department (ED) visits. The telemedicine appointments via ZOOM® went live on 3/30/20 and were also obtained. The charts were reviewed to determine if any of the KT recipients claimed exposure to COVID-19. We evaluated if any of the KT recipients developed COVID-19 during the follow-up period by reviewing their charts to determine if they developed symptoms of COVID-19, tested positive or were diagnosed with COVID-19 at an outside facility. We investigated for readmissions, biopsy-proven rejection, and mortality by the end of the follow-up period. The reasons for readmissions and the treatments used for allograft rejection were also obtained. We also assessed if patients who were readmitted were more likely to be tested for SARS-CoV2 compared with those who were not readmitted. Chi-square test was used to assess bivariate associations between categorical variables; Median was used to assess continuous variables, based on normality of the distributions. A p value < .05 was considered significant. Seventy-six patients received kidney allografts from 57 donors from 3/1/20 to 4/30/20. Forty patients were transplanted in 3/2020 and 36 in 4/2020. The donors and KT recipients were analyzed. (Table 3) . A total of 36 (47.3%) KT recipients were tested for SARS-CoV2 at the time of transplantation by nasopharyngeal PCR; all of these were negative ( Table 3 ). The median length of hospital stay was 6.1 (range: 3.2-20.8) days. All the KT recipients visited the medical center during the follow- tested, 23 (54.8%) were tested once, 12 (28.6%) twice, 4 (9.5%) four times, and 3 (7.1%) six times. All tests came back negative except for one that was inconclusive, but it was repeated and came back negative. Forty (52.6%) KT recipients were readmitted to the hospital during the follow-up period. There were a total of 55 readmissions (Table 4) considerably higher if more people would have been tested. Around half of our KT recipients were readmitted during the follow-up period but none of them were admitted specifically to rule out COVID-19. Interestingly, the KT recipients who were readmitted were more likely to be tested for SARS-CoV2 than patients who were not readmitted. In addition, there were more patients tested for SARS-CoV2 than symptomatic patients. Therefore, it seemed that many asymptomatic KT recipients were screened for SARS-CoV2 during the follow-up period at the discretion of clinicians. have not been reported but they could theoretically occur as viral RNA has been detected in serum in patients with severe COVID-19. 27,28 SARS-CoV2 has also been isolated in urine 29 spots, but it should be investigated. In-hospital COVID-19 transmission has been reported. In a single-center study from Wuhan, 41% patients were thought to have acquired COVID-19 in the hospital. 30 We believe that the in-hospital exposure probability in our center is low given all the preventive measures that were enforced. In-hospital COVID-19 transmission can be easily prevented through basic infection control measures such as wearing surgical masks and performing hand and environmental hygiene. 31 Our study demonstrates that a DDKT program can remain active during the COVID-19 pandemic as long as the COVID-19 preventive measures are followed strictly, and the hospital is not at the maximum capacity. This study has several limitations. First, it is a retrospective study. Therefore, we could have missed clinical data, such as symptoms of COVID-19 among our KT recipients. Second, our sample size was relatively small, and the study follow-up time was not too long. Clinical features of patients infected with 2019 novel coronavirus in Wuhan The COVID-19 pandemic: a comprehensive review of taxonomy, genetics, epidemiology, diagnosis, treatment, and control World Health Organization. Rolling Updates on Coronavirus Disease (COVID-19 Florida's COVID-19 Data and Surveillance Dashboard. 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