key: cord-0947974-ao1t80b5 authors: Pascual, Julio title: Kidney transplant after a COVID-19 date: 2021-05-28 journal: Nefrologia (Engl Ed) DOI: 10.1016/j.nefroe.2021.05.004 sha: 62b8a4c95a8d6674cd67ed78d211588aadbf8303 doc_id: 947974 cord_uid: ao1t80b5 nan Since the first months of the pandemic, numerous publications of clinical cases, case series, and registries have described the clinical features of COVID-19 in kidney transplantation (KT) [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] . The incidence and mortality rate are higher than in the general population and it was found that the poor prognosis was associated to similar variables as in the general population, such as advanced age or severe pneumonia. As in the general population, no specific treatment has been shown to be effective, and only general and respiratory support are truly relevant in the therapeutic strategy. The potential benefit of high-dose steroids 30 has not yet been confirmed in renal patients. During the months of March and April 2020, due to the collapse of the intensive care units and the almost exclusive dedication to the care of patients with COVID -19, most organ donation and transplant programs reduced their activity, or even were suspended. Thereafter, the activity progressively recovered, and expert professionals have adapted the programs to the new reality [31] [32] [33] . One of the most important concerns of professionals responsible of kidney transplant (KT) programs the need for a safe KT given the indisputable evidence that there are alternative renal replacement treatment techniques, such as peritoneal dialysis and hemodialysis, that allow transplantation to be deferred and done in maximum safety conditions. The fact that RT is the most favorable option of RRT with the best rehabilitation and greater survival 34 may not justify the risk of reducing safety of the procedure, in an epidemiological pandemic scenario ( Table 1) . As recommended by ONT to guarantee the protection of patients on the waiting list, patients will undergo an exhaustive medical history inquiring about contact with suspected or confirmed cases, or if there is any symptoms compatible with COVID-19 11 . SARS-CoV-2 screening should be performed by RT-PCR in a respiratory tract sample before the procedure of renal implant, antigen testing or virus serology being discouraged as an alternative to RT-PCR for screening. The transplant will not be performed until the result of the PCR is available. At this moment, there is no evidence to recommend the systematic performance of chest CT as a screening test in patients without clinical data suggestive of active infection. Evidently, to avoid aggravation of the infection, if a patient on the KT waiting list is a suspected or confirmed case of COVID-19, he will be excluded from the list and will remain a temporary contraindication for KT until complete cure occurs . This will be established after a minimum period of 14 days since the onset of symptoms, with at least three days free of symptoms and a negative CRP; at this point the patient can be included in kidney transplant list. In this sense, the ONT also recommends the review of informed consents for transplantation, including relevant information about the COVID-19 infection as part of the general process of information to the potential recipient or their legal representative 11 . Based on data from the SEN COVID-19 registry, we have reported a special risk of severe COVID-19 and high mortality in recent KT recipients 16, 17 . Therefore, strategies should be developed whereby the hospital admission time is as short as possible, including intensive telematic monitoring, management strategies as outpatient in hospital facilities with SARS-CoV-2 free circuits, and very early diagnosis of any symptoms potentially related with COVID-19 [32] [33] [34] . The development of non-invasive monitoring tools, that were already relevant, now become essential; and of course, quality research and development in this area should be a priority 35 . There is little published evidence about the safety of KT in patients who have survived a mild 36 or asymptomatic 37 episode of COVID-19. In this issue of the journal, two very interesting experiences are being reported, in which the authors describe the cases of three patients who received a KT after having overcome the disease 38, 39 . The two cases reported from India are unique and constitute original contributions 38 . It is the first patient reported to undergo a transplant after overcoming COVID-19 pneumonia (four weeks after the initial diagnosis), and the first recipient of a kidney from living donor in which both donor and recipient simultaneously presented previous mild symptomatic COVID-19. In both cases, the recipients were negative at the time of renal implantation and presented anti-SARS-CoV-2 IgG antibodies . The case from Spain 39 is the first case reported of advanced age (70 years). On this occasion, COVID-19 was found when the patient did not present symptoms, as a screening immediately prior to a KT from a deceased donor. After several positive PCR tests, alternating with some negative ones, it was decided to put him back on the list and he was transplanted with a negative PCR that was repeated frequently after transplantation. Although the authors acknowledge that there is no supporting evidence, they decided to confirm negativity to the virus with three consecutive PCR tests. It is possible that the specific characteristics of kidney patients, especially those who undergo periodic dialysis treatment, make it advisable to wait at least four weeks after a negative PCR, before proceeding with intense immunosuppression of a KT. In addition, it must not be forgotten that the sensitivity of PCR does not exceed 75-80%, and therefore it is advisable its repetition on at least two to three consecutive occasions. Besides certainty in the negativity of the PCR, it seems pertinent to verify the existence of sufficient titers of anti-SARS-CoV-2 IgG antibodies while the patient is awaiting for a KT. In this patient the disappearance of IgG antibodies was verified after having demonstrated their presence. It seems reasonable to think that the disappearance of IgG antibodies does not contraindicate KT, but with the current state of our knowledge, the documentation of each case should be as exhaustive as possible. This experience reinforces the concept that a past COVID -19 episode does not guarantee adequate long term protection, and in no way should preventive measures against possible infection should be relaxed. Given the high incidence of COVID-19 in dialysis patients, it is very likely that throughout the world , patients with a past COVID-19 infection are being transplanted, especially in countries with very high transplantation activity as in Spain . It is necessary to collect experiences in this regard and to know the evolution with detail, learn whether respiratory or other sequelae are detected, if IgG antibodies are preserved over time and if reinfections occur 40 . Transplant teams must be most careful in the analysis and orderly follow-up of these cases. The authors declare that they have no conflict of interest. . -Intensificar el grado de información que se transmite a los pacientes, especialmente de los riesgos de la COVID-19 postrasplante -Revisar las hojas de información y el consentimiento informado, e incorporar información COVID-19 -En el paciente candidato a TR, descartar infección activa por SARS-CoV-2 con una PCR de exudado nasofaríngeo negativa y ausencia de síntomas durante al menos 72 horas -En cualquier situación de TR electivo (por ejemplo, donante vivo), repetir PCR y confirmar su negatividad -Realizar detección de anticuerpos anti-IgG SARS-CoV-2 en suero; su presencia garantiza mayor seguridad -Limitar indicación y dosis de tratamiento de inducción con anticuerpos policlonales II) Tras el TR -Medidas estrictas de aislamiento durante el primer ingreso -Valorar la retirada precoz del catéter vesical (1-4 días) -Si función inmediata, limitar al máximo la estancia durante el primer ingreso (4-6 días) -Si función retardada, desarrollar programas de manejo en hospital de día, con hemodiálisis a demanda y seguimiento ambulatorio -Instaurar consulta de telemedicina desde el momento del alta, y limitar al máximo la necesidad de visitas presenciales -Desarrollar estrategias de monitorización que no requieran técnicas invasivas (biopsias de protocolo) ni ingresos, ni visitas presenciales no imprescindibles 1 Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy CKD is a key risk factor for COVID-19 mortality Comorbidities and Mortality in Patients With COVID-19 Aged 60 Years and Older in a University Hospital in Spain COVID-19 in Grade 4-5 Chronic Kidney Disease Patients Clinical Profiles in Renal Patients with COVID-19 Outcomes of COVID-19 Among Hospitalized Patients With Non-dialysis CKD Management of the SARS-CoV-2 coronavirus epidemic (COVID-19) in hemodialysis units Recommendations on management of the SARS-CoV-2 coronavirus pandemic (COVID-19) in kidney transplant patients COVID-19 in Spain: Transplantation in the midst of the pandemic SARS-CoV-2 infection in patients on renal replacement therapy. Report of the COVID-19 Registry of the Spanish Society of Respiratory and Gastrointestinal COVID-19 Phenotypes in Kidney Transplant Recipients Use of tocilizumab in kidney transplant recipients with COVID-19 Days After Kidney Transplantation COVID-19 in elderly kidney transplant recipients Clinical characteristics and immunosuppressants management of coronavirus disease 2019 in solid organ transplant recipients Identification of Kidney Transplant Recipients with Coronavirus Disease A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia COVID-19 infection in kidney transplant recipients COVID-19 in kidney transplant recipients Early Description of Coronavirus 2019 Disease in Kidney Transplant Recipients in New York Earliest cases of coronavirus disease 2019 (COVID-19) identified in solid organ transplant recipients in the United States COVID-19 in solid organ transplant recipients: a single-center case series from Spain Covid-19 and Kidney Transplantation COVID-19 in Solid Organ Transplant Recipients: Initial Report from the US Epicenter COVID-19 in kidney transplant recipients Group for the Study of COVID-19 in Transplant Recipients. COVID-19 in transplant recipients: The Spanish experience Corticosteroid use in COVID-19 patients: a systematic review and meta-analysis on clinical outcomes. Crit Care Resetting Healthcare Services During the Coronavirus disease 2019 Pandemic: A Multidisciplinary Team Approach to Delivering Kidney Transplantation Organ donation and transplantation during the COVID-19 pandemic: a summary of the Spanish experience Ethical Issues in the COVID Era: Doing the Right Thing Depends on Location, Resources, and Disease Burden Assessing the Limits in Kidney Transplantation: Use of Extremely Elderly Donors and Outcomes in Elderly Recipients Remote monitoring using donor-derived, cell-free DNA after kidney transplantation during the coronavirus disease 2019 pandemic Successful kidney transplantation after COVID-19 Successful simultaneous pancreas and kidney transplant in a patient post -COVID-19 infection Successful kidney transplantation after COVID-19 infection in two cases Infección por SARS-COV-2 en lista de espera de trasplante renal: ¿se puede trasplantar un paciente con antecedente de COVID-19 Retest positive for SARS-CoV-2 RNA of "recovered" patients with COVID-19: Persistence, sampling issues, or reinfection