key: cord-0939259-snnh76f4
authors: Jan, Muhammad Y.; Jawed, Areeba T.; Barros, Nicolas; Adebiyi, Oluwafisayo; Diez, Alejandro; Fridell, Jonathan A.; Goggins, William C.; Yaqub, Muhammad S.; Anderson, Melissa D.; Mujtaba, Muhammad A.; Taber, Tim E.; Mishler, Dennis P.; Kumar, Vineeta; Lentine, Krista L.; Sharfuddin, Asif A.
title: A National Survey of Practice Patterns For Accepting Living Kidney Donors With Prior Covid-19.
date: 2021-05-15
journal: Kidney Int Rep
DOI: 10.1016/j.ekir.2021.05.003
sha: 4e8cde0a38069f4948286be5937e08f5653b6d9b
doc_id: 939259
cord_uid: snnh76f4

INTRODUCTION: A critical question facing transplant programs is if, when and how to safely accept living kidney donors (LKD) who have recovered from COVID-19 infection. The purpose of the study is to understand current practices related to accepting these LKDs. METHODS: We surveyed US transplant programs from September 3 through November 3, 2020. Center level and participant level responses were analyzed RESULTS: A total of 174 respondents from 115 unique centers responded, representing 59% of US LKD Programs and 72.4% of 2019 and 72.5% of 2020 LKD volume(1)(Organ Procurement and Transplantation Network-OPTN 2021). 48.6% of responding centers had received inquiries from such LKDs, while 44.3% were currently evaluating. 98 donors were in evaluation phase, while 27.8% centers had approved 42 such donors to proceed with donation. 50.8% of participants preferred to wait > 3 months while 91% would wait at least > 1 month from onset of infection to LD surgery. Most common reason to exclude LDs was evidence of COVID-19 related AKI (59.8%) even if resolved, followed by COVID-19 related Pneumonia (28.7%) and Hospitalization (21.3%). Most common concern in accepting such donors was kidney health post donation (59.2%), followed by risk of transmission to recipient (55.7%),donor perioperative pulmonary risk (41.4%) and donor pulmonary risk in the future (29.9%). CONCLUSIONS: Practice patterns for acceptance of COVID-19 recovered LKD showed considerable variability. Ongoing research and consensus building are needed to guide optimal practices to ensure safety of accepting such donors. Long term close follow up of such donors is warranted.

Introduction: A critical question facing transplant programs is if, when and how to safely accept living kidney donors (LKD) who have recovered from COVID-19 infection. The purpose of the study is to understand current practices related to accepting these LKDs. Hospitalization (21.3%). Most common concern in accepting such donors was kidney health post donation (59.2%), followed by risk of transmission to recipient (55.7%),donor perioperative pulmonary risk (41.4%) and donor pulmonary risk in the future (29.9%). Postponement of elective procedures to provide more beds, resources and personnel to be able to handle COVID- 19 Overall 54.7% percent of participants said their program would consider accepting an LD who has recovered from COVID 19, while 38.9% mentioned doing so on a case-by-case basis. A very small percentage would decline or were unsure about such donors (6.4%). Not un-surprisingly the biggest concern among participants (59%) was related to Donor Kidney Health post donation. This is shown in Figure 2 . Additional concerns expressed by participants included hypercoagulable state, long-term cardiovascular risk, and development of lung disease as a sequala of COVID-19 to the donor.

In consideration of such LDs a significant trend of uncertainly was observed with very few participants actually choosing not to decline such donors however choosing "Unsure". In consideration of accepting such donors an overwhelming majority mentioned that they would only consider donors who had mild disease who were managed as outpatient without requiring any treatment. A smaller but significant percentage of participants stated that their decision to accept a LD would depend on degree of recovery and not the severity of their COVID-19

disease. This is shown in Figure 3 , while reasons for main preferences for exclusion are shown in Timeframe of LD evaluation and Surgery:

If considered, for LD, most participants' preference or opinion was to wait for at least > 1 months after infection and before LD initial evaluation is done, followed by preferring waiting for at least 3 months. Majority of participants would like to wait > 3 months for surgery (50.8%), and overwhelming majority would wait at least > 1 month (91%) after onset of infection. These trends are shown in Figure 5 . Table 4 .

During the survey period, 82.9% percent of the participants were not aware of any former LDs getting infected with COVID-19 while, a total of 44 living donors were reported to programs and known to have had COVID-19.

Our LD Acceptance preferences and concerns among LDKT programs:

We found variability in accepting COVID-19 recovered donors for LD based on preferences related to severity of COVID-19 infection and timeline for initiating evaluation and donor surgery. Not surprising, the most common concern observed in our survey was related to donor kidney health post donation even in the setting of recovered kidney function and a preference was observed to not accept such LDs. While kidney donation does not result in reduced or compromised immunity, the main concern stems from reduced renal reserve from donor nephrectomy which could result in higher likelihood of severe Acute Kidney Injury (AKI) in the case of severe infection. A meta-analysis 9 from November 2020 showed the incidence of AKI to be 22.6% among studies analyzed from North America in all hospitalized patients with COVID-19. Similarly the study showed an overall incidence of acute kidney injury in hospitalized patients with COVID-19 at 10.6% 9 . A study comparing AKI occurrence and outcomes in COVID-19 associated AKI vs Non COVID-19 AKI showed that in the setting of COVID-19, AKI occurred twice as commonly as non-COVID-19 patients (26% vs 12 %) 11 . It also showed that patients with Chronic Kidney Disease (CKD) had higher odds of developing AKI (2.81).

Post donation LDs have lower glomerular filtration rate (GFR) and there is emerging data that shows potentially higher CKD and ESKD risks in patients with lower GFR 12 . However these risks need to be looked at in the context of severity of COVID-19 infection.

Hospitalizations among healthy individuals who constitute the majority of LDs, for mild or asymptomatic COVID-19 is exceedingly rare, and we do not have data on the incidence and severity of AKI in this group. Moreover lack of any abnormal findings on established LD evaluation tools like CT, 24hr creatinine clearance and albuminuria are reassuring in healthy individuals with recovered COVID-19. This combined with the rigorous testing in the LD evaluation process and strict observance of protocols regarding the timing of this testing in relation to timeline of COVID-19 recovery should enable such LD to proceed with donation.

This is especially important for LD who wants to proceed with donation given the long wait times for deceased donor kidney transplants, and high mortality rates ranging from 8.1% in 2017 to 6.8% in 2019 among recipient candidates who were waitlisted in 2014 and 2016 respectively 1 .

Perioperative and post donation pulmonary risk to donors remained the second main concern among participants. An international cohort study 13 reviewed 1128 surgeries among people who were positive for COVID-19 peri-operatively. Out of these 280 were elective surgeries which showed a 30 day mortality of 18.9% with risk of pulmonary complications being 53.1% 13 . This study suggested that consideration should be given for postponing non-urgent procedures 13 .

Currently there is no conclusive evidence to show transmission of COVID-19 via blood borne or urinary route however the concern regarding potential for viral transmission with kidney transplant remains 14 Our survey also showed that majority of participants chose to wait, with a third preferring to wait at least 1 month and a third preferring to wait even further up to at least 90 days from onset of infection to LD evaluation. Similarly most of the participants wanted to wait at least 3 months (85/167) before proceeding with LD surgery. Studies done previously on LD programs nationally 3 and internationally 8 seem to reflect similar practices being reported by participants at their transplant centers.

In the case series by Kute et al the average time from first positive NP-PCR test to first negative NP-PCR test was a median of 24 days, from first negative NP-PCR test to transplant was a median of 25 days and from testing positive with NP-PCR for the first time to surgery was a median of 52 days. In this study donors had to be symptom free for 28 days and needed to have two negative NP-PCR tests with an additional test at the time of surgery. Indeed a similar trend was seen among our study participants who preferred to get COVI9-19 specific testing as part of initial testing before any other evaluation is pursued.

Timing of testing as well timing of surgery for potential LDs is highly intertwined with recipient evaluation and testing. Clearly pre-emptive transplants are superior in most cases, and living donation quite often is the only way to prevent a recipient from need renal replacement therapy.

The variability in testing and timing likely also reflects, a participant's concern balancing the J o u r n a l P r e -p r o o f risks of a recipient medical condition which nowadays also includes higher mortality due to COVID-19.

As the most common practice for testing, a nasopharyngeal swab for COVID-19 NP-PCR was considered to be the standard test by most participants, given that the utility and interpretation of serological testing and its protective ability is unknown at this time 18 . Moreover based on AST recommendations, serological testing is not included as part of the COVID-19 screening process. Similarly in the case of asymptomatic recovered LDs, our study showed that participants mostly preferred to see COVID-19 PCR results with limited decisions based on serological status 16 . This is different than the findings of a previous international survey 8 which showed 21% of LDKT centers choosing serum IgG only. A large number of participants (113/174) preferred to add a Chest CT to standard LD evaluation, closely followed by pulmonary function tests, and transthoracic echocardiogram which reflects the concern for cardiovascular and pulmonary effects from COVID-19 in the short and long term. This reflects the LD community's high concern for this healthy population to ensure their short and long-term safety.

Recipient Immunosuppression regimens and testing: J o u r n a l P r e -p r o o f 

OPTN OPaTN. National Data, Transplants by donor type based on OPTN data as of

Survey of US LIving Kidney Donation and Transplantation Practices in the COVID-19 Era

Trends in US Kidney Transplantation During the COVID-19 Pandemic

The REDCap consortium: Building an international community of software platform partners

Successful Living Kidney Donation After COVID-19 Infection

Is it Safe to Be Transplanted From Living Donors Who Recovered From COVID-19? Experience of 31 Kidney Transplants in a Multicenter Cohort Study From India

An International survey on living kidney donation and transplant practices during the COVID-19 pandemic

Risk factors and prognosis for COVID-19-induced acute kidney injury: a meta-analysis

COVID-19 and Acute Kidney Injury: A Systematic Review and Meta-Analysis

Acute kidney injury associated with COVID-19: A retrospective cohort study

Association of Early Postdonation Renal Function With Subsequent Risk of End-Stage Renal Disease in Living Kidney Donors

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Detection of SARS-CoV-2 in Different Types of Clinical Specimens

6-month consequences of COVID-19 in patients discharged from hospital: a cohort study

COVID-19 Resources for Transplant Community

National Institute for Health and Care Excellence

Interpreting Diagnostic Tests for SARS-CoV-2

CDC COVID-19 Data Tracker

Provisional Death Counts for Coronavirus Disease 2019 (COVID-19)

Table 2: Participants preference in considering COVID-19 recovered LD for Non-Directed, Paired-Kidney Donation, and for High-immunological risk recipients

Non-Directed (altruistic) living donor? 63.1% 29

Consideration for Paired Kidney Donation(KPD)?

Table 4: Preferences related to testing and immunosuppression regimen for recipients of LDKT from COVID-19 recovered LDs

When using LD with recovered COVID 19, would you screen the recipient for COVID 19 post-transplant?

If Yes, Which test would you screen the recipient with?