key: cord-0953519-4441zfc8
authors: Butt, Fauzia K.; Julian, Kathleen; Kadry, Zakiyah; Jain, Ashokkumar
title: Navigating Kidney Transplantation in the Early Phase of COVID-19: Screening Patients with RT-PCR and Low Radiation Dose Chest CT
date: 2021-01-09
journal: Transplant Proc
DOI: 10.1016/j.transproceed.2021.01.001
sha: fb6024146535ff58b43eca3c5be8beb1a7059429
doc_id: 953519
cord_uid: 4441zfc8

Background The COVID-19 viral pandemic of 2020 changed organ transplantation. All elective cases at our institution were postponed for approximately 3 months. CMS considers organ transplant surgery a Tier 3b case, along with other high acuity procedures, recommending no postponement. Our transplant program collaborated with our transplant infectious disease colleagues to create a protocol that would ensure both patient and staff safety during these unprecedented times Methods The living donor program was electively placed on hold until we had the proper protocols in place. Pre-operative COVID-19 testing was required for all recipients and living donors. All patients underwent a rapid nasopharyngeal (NP) swab test. After testing negative by NP swab, recipients also underwent a low radiation dose CT scan to rule out any radiographic changes suggestive of a COVID-19 infection Results We performed 8 living donor and 9 deceased donor kidney transplants. In comparison, we performed 10 living donor and 4 deceased donor transplants during the same time period in the previous year. Our testing protocol enabled efficient utilization of all suitable organs offered during the viral pandemic. No recipients or living donors tested positive or developed COVID-19 Conclusions Creation of a viral testing protocol, developed in conjunction with our infectious disease team, permitted kidney transplantation to be performed safely and the number of deceased donor transplants increased considerably, without adversely affecting our outcomes.

The Coronavirus Disease 2019 (COVID-19) viral pandemic of 2020 changed the world in countless ways. However, little is known about how organ transplantation was affected and the multiple challenges faced by programs in performing transplants in a manner that was safe for all involved. 1 Our aim was to examine how we handled these challenges at our own center, while maintaining the safety of our patients and staff, yet utilizing all suitable organs for transplantation. All elective cases at our institution were postponed for approximately 3 months. The Centers for Medicare & Medicaid Services (CMS) considers organ transplant surgery to be a Tier 3b case, along with other high acuity procedures, such as trauma, limb-threatening vascular surgery and cardiac surgery for symptomatic patients, and recommends continuation during the COVID-19 viral pandemic. 2 Our transplant program collaborated with our transplant infectious disease colleagues to create a protocol that would ensure patient and staff safety during these unprecedented times.

For deceased donor recipients, we made several changes to the admissions process, including a preliminary telephonic screening for symptoms of an ongoing viral infection. Screening questions included the presence of fevers, respiratory symptoms, recent travel, and contact with an infected person or close contacts with undiagnosed acute respiratory illnesses. After passing the initial screening process, recipients were admitted and tested for COVID-19 infection with a nasopharyngeal (NP) swab. Early in the pandemic, several relatively asymptomatic, non-transplant COVID-19 cases were recognized by computerized tomography (CT) scan findings alone. We also experienced several cases of false-negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR). We developed a two-step testing process (Figure 1 ). After a negative NP swab result, recipients proceeded to have a low radiation dose CT (LDCT) of the chest without contrast to ensure that there was no evidence J o u r n a l P r e -p r o o f 2 of a COVID-19 infection indicated by radiographic changes. We felt that this confirmatory testing was essential in all recipients due to the lower sensitivity of NP swab testing alone. 3, 4, 5, 6 The time required to perform testing and obtain results was considered before the acceptance of any deceased donor organ offers.

Our center also changed the way in which we screened deceased donor offers during this viral pandemic. All deceased donors were required to have a negative COVID-19 NP swab. A bronchoalveolar lavage (BAL) for COVID-19 was also required in the presence of any radiographic changes on chest xray or CT scan that were consistent with infection, including ground glass opacities, infiltrates or consolidation. Any deceased donors that tested positive for COVID-19, or had strong radiographic evidence of infection, were not utilized by our institution for transplantation.

Initially, there was much uncertainty regarding our elective living donor kidney transplant cases.

While these cases technically fell under the CMS Tier 3b category designation, they were also elective and involved a healthy donor undergoing surgery who would now have the added risk of developing an infection with the COVID-19 virus. In addition, there was a risk of donor-derived SARS-CoV-2 infection for the recipient. Resource allocation was another consideration as all recipients are admitted to the ICU at our institution. As a program, we electively chose to postpone all living donor cases until there was a better understanding of the viral pandemic and the hospital infrastructure was ready to support resumption of our caseload. Protocols needed to be in place to ensure the safety of donors, recipients and hospital staff, including residents and medical students. Our living donor program ended its voluntary suspension on May 14, 2020, resulting in about a 2.5 month postponement of living donor cases. The institution, as a whole, resumed non-transplant elective surgical cases on May 26, 2020.

When we resumed our living donor cases, living donors and their recipients were both admitted the day before the scheduled procedure after passing an initial telephonic screening for symptoms and J o u r n a l P r e -p r o o f 3 exposures. This was a departure from our standard process, as patients were typically admitted in the early morning, on the day of surgery. Both living donors and recipients were tested with a COVID-19 NP swab after admission (Figure 1 ), which usually ended up being sometime in the afternoon, due to bed availability. Living donor recipients then proceeded with LDCT of the chest ( Figure 1 ) after testing negative with the NP swab, to rule out any radiographic changes indicative of a COVID-19 infection. We felt that this confirmatory testing was essential due to the lower sensitivity of NP swab testing alone. 3, 4, 5, 6 This new admission protocol was developed with the assistance of our transplant infectious disease team, to ensure that there would be adequate time provided for COVID-19 testing and that the patients would not risk exposure to the virus after initially testing negative. When elective procedures resumed at our institution, patients were required to have a negative COVID-19 NP swab test as an outpatient through a contracted reference lab which had a turnaround time of 2-3 days. We did not feel that this was adequate for patients receiving immunosuppression and we did not want to risk exposure to COVID-19 before their scheduled procedure. We developed a protocol to conduct in-house testing with a 2-4 hour turnaround time, to be completed within 24 hours of the planned transplant operation.

Our transplant program created a special consent form regarding COVID-19 and the possibility of acquiring this viral infection. In general, this consent informed the recipients that despite our testing protocols, they could be infected at any time, before, during or after transplantation. It also stated that the risk of acquiring the infection is reduced if guidelines are followed, including mask wearing, social distancing, hand washing, etc. These guidelines were reinforced by the staff during education prior to discharge. The results of the transplants performed are summarized in Table 1 To date, no recipient or living donor outlined in Table 1 has contracted COVID-19 and they are all doing well. All of the deceased donor recipients have stable allograft function.

We experienced several challenges with the COVID-19 testing. A designated COVID swab team was only available between the hours of 7 am to 11 pm. Patients admitted after 11 pm could not be tested until 7 am the following morning. Recognition of these delays sometimes mandated passing on Donation after Cardiac Death (DCD) donors, or other offers with a time constraint present. Occasionally, these testing limitations also required us to decline the admission of recipients who were backing up a multiorgan recipient, as we could not obtain the NP swab testing in an expedient and timely manner.

Eventually, the COVID-19 swab team was disbanded and charge nurses were individually trained to J o u r n a l P r e -p r o o f 5 perform this testing, which was much more accommodating for our patients. Our laboratory ran the COVID-19 samples as a priority for these patients and produced results in 2 hours, enabling us to accept offers and perform transplants in an expedient manner.

The COVID-19 testing and admission protocol for living donors and their recipients caused some delays when we were involved in a swap or a transplant chain through the National Kidney Registry (NKR). NKR required test results by 3 pm the day before a scheduled transplant and occasionally, the hospital was at a capacity where beds were not immediately available. Admission and subsequent testing were occasionally delayed beyond the 3 pm deadline, much to the dismay of our living donor coordinator and NKR.

Our program's medical students were prohibited from being in the hospital during this 3 month period. Surgical residents were reduced to a skeleton crew with 2 weeks on and 2 weeks off, in case they needed to be quarantined for a suspected COVID-19 infection. Without a surgical resident team specifically assigned to the transplant service, the chief resident would make assignments for individual operative cases daily. Occasionally, two attending surgeons would scrub on a case, as there were no residents available due to the staffing shortage. Resident participation in deceased donor recovery procedures was limited, as they were only allowed to participate in cases at our own institution. The local OPO also requested local surgeons to recover organs for teams outside of our immediate area. When we recovered organs for the OPO at nearby hospitals outside of our system, residents were not allowed to participate and an OPO staff member served as a surgical assistant. The CT chest findings in a patient with an early COVID-19 infection include ground glass opacities, bilateral/multifocal involvement and peripheral distribution. At a later stage, these can develop into crazy paving, consolidation and a reversed halo sign. 9 Figure 2 is a LDCT chest of one of our patients who had a negative RT-PCR upon pre-operative screening for a liver transplant, but CT findings were consistent with a possible COVID-19 infection, including patchy, peripheral groundglass opacities in the anterior lungs.

Inpatient: Post-transplant protocols had to be created regarding the admission of recipients from the operating room. At our center pre-COVID-19, all transplant recipients were admitted to the surgical anesthesia intensive care unit (SAICU). During the viral pandemic, we made a deliberate effort to admit our patients to an ICU that was completely separate from the SAICU, where patients infected with COVID-19 were already located. All transplant recipients were admitted to the HVI (Heart and Vascular Institute) ICU, which was physically located on a different floor, yet staffed by the same anesthesia attending as the SAICU. This physical separation was important in order to prevent accidental transmission of COVID-19 to our freshly transplanted, highly immunosuppressed patients. Anecdotally, J o u r n a l P r e -p r o o f 7 we have heard of cases at another institution where freshly transplanted patients were located in the same ICU as patients infected with COVID-19 and three liver transplant recipients became infected with COVID-19.

Outpatient: Clinic changes took effect almost immediately, with the postponement of all surgical donor and recipient evaluations. In an effort to minimize the unnecessary potential exposure of transplanted patients to COVID-19, a weekly huddle was conducted to review all of the patients scheduled for clinic visits that week. Physical visits were reserved for patients who absolutely needed one for medical issues, or for the removal of drains or staples. The majority of visits were converted to a telehealth platform. These telehealth visits presented their own challenges, as initially, our institution stated that any video platform was acceptable, despite the inability to protect patient's health information, as patient care was the priority. That blanket approval was then revoked, as certain video platforms, such as Doximity and Facetime, did not have the proper security safeguards in place. The OnDemand video platform that our institution eventually adopted also had some limitations, as it was only compatible with the iPhone and not with the Android operating system. Some of our patients had trouble registering for OnDemand, did not have reliable Wi-Fi connectivity or lacked a smartphone. For these patients, visits had to be conducted by telephone. Other unforeseen challenges with the OnDemand video platform included the lack of webcams on the providers' desktops and these had to be installed. Also, if our patient resided in another state, providers had to be licensed in that state in order to utilize the video platform, otherwise we were limited to performing the visit with a phone call.

In response to the COVID-19 pandemic, our transplant program closely collaborated with our infectious disease colleagues to develop a protocol that allowed transplantation to continue, while ensuring the safety of our patients and staff. While initial challenges were experienced in performing timely testing, we were able to perform a total of 17 kidney transplants, including living donors, without the development of any COVID-19 infections. We created a screening protocol during the early phase of M  LURD  --------14  45  F  LURD  --------15  63  F  LURD  --------16  42  M  LRD  --------17  53  F  LURD  ------- 

Challenges in Abdominal Organ Transplantation During the COVID-19 Pandemic

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