key: cord-0727298-5eylgvm9 authors: Manzia, Tommaso M.; Angelico, Roberta; Toti, Luca; Pisani, Gennaro; Vita, Giuseppe; Romano, Francesca; Pirozzi, Brunella M.; Vinci, Danilo; Cacciola, Roberto; Iaria, Giuseppe; Tisone, Giuseppe title: The hamletic dilemma of patients waiting for kidney transplantation during the COVID‐19 pandemic: To accept or not to accept (an organ offer)? date: 2021-01-16 journal: Transpl Infect Dis DOI: 10.1111/tid.13560 sha: 7726dbb0414189313f90dee405e08de9e08621cc doc_id: 727298 cord_uid: 5eylgvm9 The outbreak of COVID‐19 led to a reduction in the number of organ transplant interventions in most Countries. In April 2020, at the Tor Vergata University in Rome, Italy, two patients on the waiting list for kidney transplantation (KT) declined a deceased donor's kidney offer. Therefore, between April 20 and 25, 2020, we conducted a telephone survey among our 247 KT waitlist patients. Our aim was to explore: (a) the COVID‐19 diffusion among them and (b) their current willingness to be transplanted in case of a kidney offer from a deceased donor. Two hundred and forty‐three patients participated in a phone interview. One patient had died from COVID‐19. Eighty‐five (35%) KT candidates would decline any kidney offer, in most cases until the end of the COVID‐19 pandemic. Upon a multivariate analysis, female gender (OR = 2.25, 95% CI = 1.26‐4.03, P = .006), high cardiovascular risk (OR = 2.33, 95% CI = 1.06‐5.08, P = .034), a waiting list time <3 years (OR = 0.375, 95% CI = 0.15‐0.95, P = .04), and the need to be transferred to another hospital for HD (OR = 2.56, 95% CI = 1.10‐5.9, P = .03) were associated with such refusal. The COVID‐19 pandemic led to a fear of transplantation in a third of the KT candidates. Proactive educational webinars could be a useful tool to remove, or at least lessen, any doubts on the part of KT candidates and to avoid losing the opportunity to quit dialysis. Following the initial outbreak in December 2019 in Wuhan, China, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- Organization on March 11, 2020 1 and, by , it has already involved more than 50 million people globally. 2 In Italy, as of , the resulting Coronavirus disease 19 led to 960 373 confirmed cases and 41 750 deaths. 2 The abrupt expansion of the COVID-19 pandemic in Italy had a dramatic effect on the national health system. Many hospitals, both in the North of Country, where the outbreak has been overwhelming, and in Central and South Italy, were converted to predominantly accommodate COVID-19 patients. In the attempt to contain the further spread of the disease, the national government enforced a severe lockdown from March 9 to May 18, 2020, and severe restrictive pandemic. The study included all end-stage renal disease (ESRD) patients waitlisted for KT at our Transplant Center in Rome, as of April 25, 2020. (2), patients were asked (a) if for any reason they had been transferred to another hospital in order to continue their hemodialysis (HD) program (Y/N); (b) if any patients had a diagnosis of COVID-19 in their local Nephrology Unit (Y/N); and (c) whether, in case of an appropriate organ offer, they would give consent to proceed with KT during the current COVID-19 pandemic (Y/N); if patients answered "No", they were asked for how long they would decline the kidney offer (with the following possible answers: "1 month", "3 months", or "up to the end of the pandemic"). All data were initially recorded into an EXCEL database (Microsoft). Continuous variables were reported as medians and interquartile range (IQR); the Mann-Whitney U test was used for comparisons between groups. Categorical variables were reported as numbers and percentages. Comparisons were done using Fisher exact text. Variables with a P value <.05 were considered statistically significant and were used for a multivariate logistic regression analysis (backward conditional methods). The multivariate analysis was fitted in order to identify the characteristics of the patients who would decline the KT during the COVID-19 pandemic. The Odds Ratio (OR) and the 95% confidence interval (95% CI) were reported for significant variables. The SPSS statistical package version 23.0 was used for statistical analyses (SPSS Inc). On April 25, 2020, 247 patients were on the KT waiting list of our [n = 6], or unknown reason [n = 10]) and were candidates to re-transplantation. One-hundred and seventy-nine (72.5%) patients had ESRD with complete anuria. Two-hundred and eleven (85.8%) patients were undergoing HD 3 days per week, while 25 (10.1%) received homebased peritoneal dialysis. Five (2.0%) listed patients were candidates to preemptive KT. In six (4.0%) patients details about the RRT were not available. One-hundred and twenty (48.6%) patients had been on dialysis for more than 5 years. Nineteen (7.7%) were enrolled in the Italian hyperimmune program (PNI 3.0), which is designed for those patients who have been on the waiting list for more than 8 years with maximum PRA > 90%. 7 With regard to comorbidities, 12 (4.9%) patients had a history of chronic obstructive pulmonary disease, 168 (68%) were under medical treatment for hypertension, 24 (9.7%) had IDDM, 35 (14.2%) were obese, and 28 (11.3%) had a history of cancer. One-hundred and ten (44.5%) patients had already received at least one call for KT. Of these, at the time of the previous call, 70 (28.3%) were selected as a backup only, 33 (13.4%) were not transplanted because of organ unsuitability and 7 (2.8%) declined the transplantation. (1) Two-hundred and forty-three (98.4%) patients participated in the telephone questionnaire. Since January 30, 2020, 64 (26.3%) patients reported one or more symptoms, such as fever (n = 23), fatigue (n = 26), dyspnea (n = 4), dry cough (n = 14), sore throat (n = 5), nasal congestion/runny nose (n = 19), or diarrhea (n = 13). Forty-five (18.5%) patients were tested for SARS-CoV-2 with nasopharyngeal swab. Of these, most were asymptomatic (n = 33, 73.3%) while 12 (26.7%) reported having had mild upper respiratory tract symptoms (ie, runny nose, nasal congestion, and dry cough). Only one (0.4%) case of COVID-19 was recorded. The patient was a 71-year-old woman listed for retransplantation, on HD since 2006 after a previously failed KT. At the beginning of February 2020, the patient started to suffer from mild symptoms, such as nasal congestion, diarrhea, and fever. One week later, as a result of an upcoming dyspnea, she was admitted to the Emergency Unit, and then to the ICU of our hospital, where treatment with hydroxychloroquine, datunavir, ritonavir, and antibiotics was started. The patient died of COVID-19 pneumonia 26 days after admission. (2) Twenty-three (9.5%) KT candidates reported that COVID-19 patients were admitted to the Nephrology Unit during their dialysis treatment. Twenty-seven (11.1%) patients reported that because of the COVID-19 pandemic they had been transferred to another local Nephrology Unit in order to continue HD. Eighty-five (35%) KT candidates with a median waiting list time of 24 (IQR = 10-41.5) months reported that, at the time of the survey, they would have declined any kidney offer from a deceased donor. Of these, 11 (12.9%) patients stated that they would not accept a KT for the next month, 22 Bold italic values refers to significant P values (P < .05). a The type of dialysis for two patients was not available. b In one patient the time since the start of dialysis was not available. c Two patients did not answer. It should also be emphasize that there is still a wide gap between the demand for KT and the availability of suitable grafts. World Health Organization. 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