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Global Transplantation COVID Report March 2020

2020; Wolters Kluwer; Volume: 104; Issue: 10 Linguagem: Inglês

10.1097/tp.0000000000003258

1534-6080

Chanwoo Ahn, Hala Amer, Dany Anglicheau, N. L. Ascher, Carla C. Baan, G. Battsetset, B. Bat-Ireedui, Thierry Berney, Michiel G.H. Betjes, Shrirang Bichu, Henrik Birn, David Brennan, Jacoline E. C. Bromberg, Sophie Caillard, Robert M. Cannon, Marcelo Cantarovich, Albert C. Y. Chan, Z.S. Chen, Jeremy R. Chapman, Edward Cole, Nathan Cross, Francesca T. Durand, Hiroshi Egawa, Jean C. Emond, Marta Farrero, P Friend, Edward K. Geissler, jung woo Ha, Mehmet Haberal, Macey L. Henderson, Dennis A. Hesselink, Abhinav Humar, Wayel Jassem, Jeon Yu Jeong, Beth Kaplan, Terence Kee, Seungyeon Kim, Deepali Kumar, Christophe Legendre, Kenneth K. C. Man, Bruno Moulin, Elmi Muller, R. Munkhbat, Od-Erdene Lkhaakhuu, Peggy Perrin, Munipraveena Rela, Katsuyuki Tanabe, Hélio Tedesco‐Silva, K.T. Tinckam, Stefan G. Tullius, Gregory Wong,

COVID-19 Impact on Reproduction

The COVID-19 pandemic has hit the entire world in an almost unprecedented way. The crisis has spread rapidly, disease burden and casualties continue to rise, and the impact of the crisis is spreading through developing countries. Social distancing, travel restrictions, and intensified testing have improved the rate of the rise in new cases in some regions; however, it remains unclear when normality will return. Mechanisms of the disease remain largely unclear; treatment, if available, is mostly supportive. As during times of war, the challenges of the coronavirus crisis change our views in almost any aspect. Transplant patients and those with end-stage organ failure are in a particular vulnerable position. Elective surgeries including live donor transplant procedures have paused in many countries. Deceased donor transplants, where the procedure is established, continue in some countries, albeit with modified donor and recipient criteria, in an attempt to reduce the risk of COVID transmission or an infection after transplantation. Those who are immunocompromised are probably at increased risk of severe disease, though the role of immunosuppression is debated and uncertain. Communication of knowledge is a critical component of the current crisis. Responses, experiences, and outcomes have been different around the world as different countries and regions experience different impacts and different rates of infection and death. Sharing how others have coped in practice will assist in planning and managing this most stressful and challenging situation for patients and health workers alike. As a transplant community, many are currently engaged in optimizing our immediate responses. With our actions largely based on epidemiological assessments, there is a critical lack of data on the consequences of COVID on transplant patients or those with end-stage organ disease. This report is designed to assist in understanding the approaches taken in other countries and different phases of the epidemic. There are new opportunities coming to the forefront in these otherwise gloomy days: virtual meetings, clinical visits, increased use of electronic communication, and improved remote monitoring may very well be one of the beneficial legacies of this crisis and our responses. Editors and contributors to Transplantation have shared their thoughts on how they are dealing with the current crisis. While we understand that the information of today may be quite different tomorrow in this fast-moving pandemic, this report will open our forum of an international exchange on COVID for the transplant community. AUSTRALIA Acute transplantation activity has substantively reduced nationally. Living donor kidney transplantation has stopped for the past few days, and deceased donor transplantation, which was being assessed on a case-by-case basis, has also stopped entirely for a period, depending on hospital Intensive Care and Emergency Department capacity. All deceased donors have required COVID testing, but the number of deceased donors has dropped dramatically. We have also slowed down all elective surgery, endoscopies, and bronchoscopies, as well as auxiliary and allied health services. The government has today banned all nonurgent elective surgery. We are committed to ensure the safety and well-being of our transplant recipients, and as a clinical group, we have decided it would be inappropriate to subject high-risk patients to intensive immunosuppression during the COVID-19 pandemic. Reduced expert staff availability and a limited supply of Personal Protective Equipment availability are additional concerns for frontline clinical staff. Chronic transplant recipients are being distributed to consultants' private clinics as well as using telehealth and "apps" for consultations. Laboratory tests are being done outside the hospitals in private pathology laboratories. Clinic rooms have been converted into COVID screening rooms for at-risk and exposed immunosuppressed patients. Transplant recipients are encouraged to use telehealth for their regular clinic visits. A service, while useful for the young and IT literate, is extremely difficult for patients with culturally and linguistically diverse backgrounds. New challenges include broadband availability and connectivity, the lack of personal interactions, difficulty in directly engaging patients and their caregivers, and inability to perform a full physical examination, and the acceptance and willingness to conduct a telehealth conference varies substantially between patients. Our trial-based activity and clinical research have also been affected. We have stopped all trial recruitments and only conduct clinically relevant patient follow-up in trials when necessary. CANADA, MONTREAL We have stopped living donor kidney transplantation and are not accepting offers of deceased donor kidneys for recipients >70 years unless they are highly sensitized. All deceased donor kidney offers have been assessed on a case-by-case basis to assess individual risk/benefits for a transplant at this time, but we have now put a hold on transplants. We are planning to reassess that decision in 2 weeks. All donors must be tested for COVID-19 polymerase chain reaction (PCR) before transplantation. All recipients have been screened by phone by the transplant nephrologist on-call about travel history and fever and respiratory symptoms, but we have not tested the recipients for COVID-19 PCR. Our goal in clinic follow-up is to reduce clinic visits and maximize blood testing as needed by time posttransplant ( 6 mo, delay clinic by 1 mo and reduce laboratory tests). We are aiming to ensure that all blood tests are taken at home for patients >70 years. Transplant coordinators will call patients at home and document their clinical status, blood pressure, heart rate, and weight; this will be followed by the nephrologist via telephone to review the laboratory tests to assess overall management and medications. CANADA, TORONTO Since March 16, 2020, the 2 adult kidney transplant programs in Toronto, Canada, have suspended living donor kidney transplants and all new or ongoing workups to reduce the risk of COVID-19 exposure among recipient and donor candidates. Similarly, deceased donor kidney transplants and workups have been placed on pause except for patients currently active on the waiting list who have been deemed medically urgent (eg, terminal vascular access) or those with calculated panel reactive antibody >99% whose access to kidneys is already very limited. The pancreas transplant program has followed a similar strategy to kidney. The lung transplant program has been suspended to free up beds for critical patients with COVID-19, and this is being regularly reevaluated. Lung transplants in rapidly deteriorating patients continue to be considered on a case-by-case basis. Liver transplantation from deceased donors remains active, with donor after circulatory death (DCD) being restricted to donors 10 people, closure of restaurants, bars, cafes, shopping centers, hair salons, and similar businesses, and an extensive set of guidelines for the public to avoid spreading of the disease. Preparations have been made by national and regional health authorities to accommodate the expected number of patients requiring admission and intensive care, including temporary cessation of all nonessential treatments and interventions. Shortage of ventilators, personal protective equipment, and SARS-CoV-2 test reagents are all of concern. National health authorities have defined transplantations of vital organs as treatments that should not be postponed or canceled. Deceased donor kidney, liver, lung, and heart transplantations are being continued at all Danish centers performing these. Combined kidney-pancreas transplantation has been paused. Organ exchange within the Scandinavian deceased donor exchange program is maintained at present. The number of deceased donors currently appears to be stable. All potential deceased donors are tested for SARS-CoV-2, and to date, no donor has tested positive. Scheduled living donor kidney transplants will proceed at some kidney renal transplant centers, while others have canceled these. No new living donor kidney transplantations are scheduled. A planned match run within the Scandinavian living donor kidney paired donation program has been canceled. All kidney transplant centers have converted almost all follow-ups to telephone visits. Locally, standard letters have been offered to kidney transplant patients to inform their employers of their risk status. There are reports of COVID-19–infected transplant recipients; however, none of these are thought to be among the dead. ENGLAND, LONDON The liver transplant program normally undertakes 250 liver transplants per year and currently has 150 patients on the waiting list. The events are changing rapidly by day. Currently, there are 60 COVID-19–positive patients in general intensive care, 35 ventilated. The general theaters have been converted to intensive care beds with the view of increasing numbers of infected patients requiring intensive therapy unit management. Specialized theaters and Hepatobiliary, Cardiothoracic, Orthopedic, and Neurosurgical theaters are covering general surgery emergencies. With increasing numbers of staff testing positive or in self-isolation, many transplant medical personnel will be helping in intensive care and all clinical academics have been asked to stop research activity and return to full-time clinical work. Surgeons will also be trained in intensive care management. Patients with acute liver failure are still listed and transplanted. We are still proceeding with routine transplantation; however, we believe that it may slow because of an increasing number of COVID-19–positive donors and a lack of intensive care beds. The 16 dedicated liver intensive care beds are increasingly given over to serve general intensive care needs. Admissions for routine transplant assessment have been canceled. Pediatric liver transplant activity may be transferred to another "clean" site; however, it will continue for now. All elective adult and pediatric living donor liver transplants (LDLTs) have been canceled. We are still providing the National Organ Retrieval Service 24-hour on-call team for retrievals, but the number of donors has been declining partly because of COVID-19 positivity. There are no plans to decrease or cease retrieval activities. All elective posttransplant surgical cases have been canceled or postponed. Most of the chronic patients have been managed with virtual clinics and their medications sent to them by post. Primary care physicians are repeating blood tests and seeing patients when required. The UK government has just published guidelines including transplant patients among the extremely vulnerable from COVID-19 and recommended isolation for 12 weeks. Currently, we are in discussion on the matter of providing bloods and support to patients' homes. All transplant patients have access to 24-hour online support. FRANCE, PARIS, LIVER The burden of COVID-19 infection in France is lower than in Italy, but as of March 24 almost 20 000 infected patients have been identified and 860 died, including 5 doctors. The number of infected patients is growing exponentially, but there are disparities between different regions in the country with a higher prevalence in the east of France and a lower prevalence in the west. The government has declared lockdown in the whole country. The hospitals' priority is to create units for patients with COVID-19 infection and educate physicians, nurses, and all caregivers on how to manage these patients and protect themselves. In Paris, about 1000 intensive care beds are available that we are trying to double. Nonurgent medical care and elective surgery have been canceled in all hospitals. To date, the number of medical staff tested positive is relatively limited, but 3 physicians died during the last 48 hours. The national regulatory authority "Agence de la Biomédecine" has decided to continue organ procurement including DCD donors. All donors have to be tested for COVID-19. Because organs are scarce and many patients are at risk of dying on the waiting list, we have decided to continue the program of liver transplantation. However, intensivists will be massively involved by the management of ICU patients with COVID-19 infection, and it can be anticipated that the number of donors will decrease in the next weeks. A dedicated COVID-free ICU where transplant recipients can be admitted may be 1 solution. The ward where liver transplant recipients are transferred or admitted is also COVID free. Only the sickest patients are still active on the waiting list. Several liver transplant recipients have been tested positive in recent days and infection had a benign course except in 1 relatively old patient with comorbidities who had to be transferred to the ICU with severe pneumonia. Chronic transplant patient on site clinics have been canceled to limit traveling and avoid infection risk. Unfortunately, no dedicated telemedicine system exists in France. FRANCE, PARIS, KIDNEY To prevent transplant patients coming to the transplant center, clinics are undertaken through the phone and we have created a file of all 2300 follow-up patients to send them information and new follow-up processes. The role of doctors has been modified to allow each of us to take care of a specific phase of care. Kidney transplantation with deceased and living donors has stopped until further notice. When transplant patients suspected of infection come to the hospital, they are seen in the infectious disease unit, tested by PCR, and then allocated to a COVID-19–positive hospital since ours has been designated COVID negative. In less than a week, 11 patients are positive, 10 tests are awaited, 3 patients are in intensive care, and 2 are in a very bad situation. With COVID-19–positive patients, we stop mycophenolate mofetil and mammalian target of rapamycin inhibitors. In patients with acute respiratory distress syndrome, we also stop tacrolimus so patients remain only on steroids. We call each positive patient every day to monitor progress. The important clinical symptoms include anosmia and ageusia. computerised tomography (CT) scanning is critical to evaluate severity and oximetry to regulate O2 therapy. FRANCE, STRASBOURG All acute living and deceased donor kidney transplantation activity has totally stopped from March 9, 2020, and most of the outpatients are contacted and managed through video or teleconference. A Crisis Coordination Committee involving the manager of each medical unit helps manage the hospital on a day-to-day basis with a daily video conference. Patients are being separated into COVID-19–positive and COVID-19–negative groups when hospitalization is necessary. Medical staff are also separated into dual on-call teams on the nephrology ward, 1 for positive patients and 1 for negative. The telephone is the most important communication tool with the patients both inside and outside the hospital, with lists of the phone numbers of patients' rooms communicated to the medical and nurse staff. Collection of functional signs, interrogation of the patient, and questions and explanations of the clinical situation as well as provision of information for the patient are all undertaken by phone. We have limited the number of doctors in contact with patients. A doctor assesses the respiratory frequency and signs of respiratory distress and performs clinical examination if necessary but retains the same mask and glasses all morning. Phone communication occurs between junior and senior doctors to avoid contact. There is no sharing of computers and evaluation of diets, provision of physiotherapy advice, and psychological support of patients and families are all through the phone. It is important to keep the COVID-19–positive staff team with masks and protected by distance and specific procedures to prevent contagiousness. It is a rapidly evolving and very tense situation requiring transfer to ICU, sedation, and high death rates with essentially no guidelines and little or no basic evidence. GERMANY Throughout Germany, living kidney donor transplant procedures are mostly being postponed. Cadaveric transplantation activities are being performed as normal for the time being. Testing for COVID-19 will be performed on cadaveric donors, but the results will generally not be used to determine if the organ is transplanted; the testing is for the purpose of recording whether the donor was positive or negative for the virus. Standard follow-up visits for transplant recipients will be kept to a minimum, but a higher density of visits will be maintained at our institution for patients with problems or those in the early period after transplantation. Where possible with regard to long-term care, patients will be contacted by telephone, or some sites have the capability of conducting video conferencing with patients; some of these systems will be provided free of charge during the coronavirus pandemic situation. Some additional specific actions are relevant for liver transplantation. High urgency children at our institution are currently planned to receive either deceased or LDLTs without major restrictions. For adults on the waiting list, normal demands for recertification of, for example, model of end stage liver disease (MELD) score will be eased, and the details surrounding this issue are under continuous discussion. Deceased donor liver transplants will still be performed in lower urgency situations on a case-by-case basis, depending on the COVID-19 burden on the system at the time. As with all hospitals at the current time, we are preparing for the expected rapid influx of patients, which might require reprioritization as necessary. Transport of organs across country borders remains active with only some restrictions. The transplantation society in collaboration with other medical societies plans to establish a COVID-19 transplantation registry as part of a larger existing database. HONG KONG As of March 25, 2020, there have been 410 cases of COVID-19 in Hong Kong with a population of just under 8 million. Since the first outbreak in January 2020, we saw an initial surge in the number of infections by mid-February 2020 after the Chinese New Year, followed by a rapid decline in the number of cases from late February to early March (averaging 2–3 cases per d). However, with the recent global increase, we have seen a huge influx of returning local residents to Hong Kong. As a result, we are now witnessing a second surge in the number of new cases with over 100 new cases reported just within 1 week. The liver transplant service at Queen Mary Hospital has seen a 50% reduction in elective LDLTs in response to the hospital's request to optimize the utilization of available personal protective equipment for frontline staff in ICU and isolation wards and to ensure the availability of healthcare providers to fight the infection. LDLT for urgent conditions, however, remained unaffected. On the other hand, deceased donor liver transplantation service was severely affected with an all-time low organ donation rate from brain dead donors and only 2 DDLT occurred in February. Paradoxically, there has been a sharp increment in the number of LDLT, mostly for liver failure. As of today, a total of 12 LDLTs have been performed when compared with 5 LDLTs in the previous year. Both potential living donors and recipients are only screened for COVID infection if they have symptoms or a history of recent travels. For deceased donors, screening is only performed in the presence of clinical symptoms or a recent travel history. INDIA, NORTH WEST India took relatively early steps by stopping air traffic with affected countries and limited the inflow of passengers to only returning Indian citizens together with airlifting of stranded Indian citizens in affected countries with COVID-19 testing before travel or on arrival and with strict quarantine. Initial limitation of kits for testing meant that the test was only offered to the few who were suspected on the basis of symptoms and travel history. Testing is now available in large numbers through private laboratories and a number of private hospitals. We anticipate that the true trend in the number of infected cases will become evident and will assist us to know whether the relatively early intervention by the central government has helped. There is poor adherence to calls for social distancing, though in the past 2 days more people have come to terms with the likely reality and following social distancing with some seriousness. This is mainly because of the lockdown imposed by government—a near curfew not witnessed before even during the religious riots in 1992. However, domestic trains returning migrants to their hometowns in other states were crowded. All international flights, domestic flights, and long-distance railways have stopped. Interstate transport has stopped. People have been asked to work from home. Government offices are working at 20% capacity. All nonessential services have been stopped, and total lockdown has been ordered. Hospitals have been asked to treat only emergency cases, and routine outpatient clinics in hospitals have been put on hold. We have moved to online consultation wherever necessary. We are admitting only patients who need urgent attention or those who will potentially worsen without admission. All nonemergent surgeries have been stopped. Governments particularly in large cities are making huge efforts to take on the situation that will arise with exponential growth in 3 or 4 weeks. In Mumbai, a large hospital with 1200-bed capacity has been earmarked for COVID-19–positive patients. All large private hospitals have been ordered to reserve a certain number of beds for COVID-19 patients. Since the number of known patients is still small, it is too early to understand how things will unfold. We also face hoarding. For example, a large number of N95 masks have been bought by the wealthier members of the general public, leaving a huge deficit preventing protection of healthcare workers. As reports of the possible benefit of chloroquine and hydroxychloroquine started circulating, hydroxychloroquine ran out of stock in most pharmacies. Live donor transplants have stopped across Mumbai, but each hospital is taking its own decision outside Mumbai as of today. Deceased donor kidney transplants have also stopped in Mumbai and the region. There is no national direction from National Organ & Tissue Transplant Organization or from the regional body Regional Organ & Tissue Transplant Organization to stop deceased donor liver and heart transplants yet. All nonemergency work is on hold. Chronic care patients are being encouraged to get blood tests done and then connect on the phone by voice or video call to their physician. We have also instituted zero waiting time for transplant patients if they are compelled to visit the hospital. All patients have been asked to keep a minimum 1 month's medicine stock. The Apex Foundation in Mumbai has resolved to support transplant patients running out of money because of loss of job/wages since many are entering a very difficult economic situation. INDIA, SOUTH Indians stranded across the world have been evacuated, quarantined, tested, and discharged when negative. Southern states such as Kerala and Tamilnadu have shut down domestic borders; temperature tests are done to screen those in cars and trains, and the Government has just ordered a nationwide lockdown. Schools and universities have been shut down and so are swimming pools, gyms, malls, and movie theaters. Weddings and other public gatherings are banned. There has been an increase in the number of the research laboratories approved for testing for coronavirus. Government directives and guidelines have been released to provide for measures and infrastructure changes to hospitals to tackle the expected explosion in cases coming. Private and public sector hospitals are gearing up with stringent screening measures, emergency room triage areas, and dedicated isolated COVID-19 floors with beds and ICU. Healthcare workers are being trained to work efficiently and safely during the crisis. Any optimism needs to be tempered. The sobering thought is that if in fact the low incidence of the disease to date the small number of patients in intensive care and the limited mortality above observed in India to date are wrong, then India with its archaic public health system, one of the lowest per capita ICU bed ratios in the world, lack of adequately trained personnel, and a large impoveri