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Pestana JM, Cristelli MP, Tedesco Silva H. The Challenges of Risk Aversion in Kidney Transplantation: Lessons From the SARS-CoV-2 Pandemic in Brazil. Transplantation 2024; 108:813-818. [PMID: 38526427 DOI: 10.1097/tp.0000000000004890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Affiliation(s)
- José Medina Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Disciplina de Nefrologia, Departamento de Medicina, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil
| | | | - Helio Tedesco Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
- Disciplina de Nefrologia, Departamento de Medicina, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil
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2
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López V, Mazuecos A, Villanego F, López-Oliva M, Alonso A, Beneyto I, Crespo M, Díaz-Corte C, Franco A, González-Roncero F, Guirado L, Jiménez C, Juega J, Llorente S, Paul J, Rodríguez-Benot A, Ruiz JC, Sánchez-Fructuoso A, Torregrosa V, Zárraga S, Rodrigo E, Hernández D. Update of the recommendations on the management of the SARS-CoV-2 coronavirus pandemic (COVID-19) in kidney transplant patients. Nefrologia 2023; 43:531-545. [PMID: 37957107 DOI: 10.1016/j.nefroe.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/15/2023] Open
Abstract
SARS-CoV-2 infection (COVID-19) has had a significant impact on transplant activity in our country. Mortality and the risk of complications associated with COVID-19 in kidney transplant recipients (KT) were expected to be higher due to their immunosuppressed condition and the frequent associated comorbidities. Since the beginning of the pandemic in March 2020 we have rapidly improved our knowledge about the epidemiology, clinical features and management of COVID-19 post-transplant, resulting in a better prognosis for our patients. KT units have been able to adapt their programs to this new reality, normalizing both donation and transplantation activity in our country. This manuscript presents a proposal to update the general recommendations for the prevention and treatment of infection in this highly vulnerable population such as KT.
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Affiliation(s)
- Verónica López
- Unidad de Gestión Clínica de Nefrología, Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), RICORS2040 (RD21/0005/0012), Málaga, Spain.
| | | | | | | | - Angel Alonso
- Servicio de Nefrología, Complejo Hospitalario A Coruña, A Coruña, Spain
| | - Isabel Beneyto
- Servicio de Nefrología, Hospital Universitario Politécnico La Fe, Valencia, Spain
| | - Marta Crespo
- Servicio de Nefrología, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), RD16/0009/0013 (ISCIII FEDER REDinREN), Barcelona, Spain
| | - Carmen Díaz-Corte
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, Spain
| | - Antonio Franco
- Servicio de Nefrología, Hospital de Alicante, Alicante, Spain
| | | | - Luis Guirado
- Servicio de Nefrología, Fundación Puigvert, REDinREN RD16/0009/0019, Barcelona, Spain
| | | | - Javier Juega
- Servicio de Nefrología, Hospital Trias i Pujol, REDinREN RD16/0009/0032, Barcelona, Spain
| | - Santiago Llorente
- Servicio de Nefrología, Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Javier Paul
- Servicio de Nefrología, Hospital Miguel Servet, Zaragoza, Spain
| | - Alberto Rodríguez-Benot
- Servicio de Nefrología, Hospital Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba, Spain
| | - Juan Carlos Ruiz
- Servicio de Nefrología, Hospital Marqués de Valdecilla, IDIVAL, REDinREN RD16/0009/0027, Santander, Cantabria, Spain
| | - Ana Sánchez-Fructuoso
- Servicio de Nefrología, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Sofía Zárraga
- Servicio de Nefrología, Hospital de Cruces, Bilbao, Vizcaya, Spain
| | - Emilio Rodrigo
- Servicio de Nefrología, Hospital Marqués de Valdecilla, IDIVAL, REDinREN RD16/0009/0027, Santander, Cantabria, Spain
| | - Domingo Hernández
- Unidad de Gestión Clínica de Nefrología, Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), RICORS2040 (RD21/0005/0012), Málaga, Spain
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Sever MS, Vanholder R, Oniscu G, Abramowicz D, Van Biesen W, Maggiore U, Watschinger B, Mariat C, Buturovic-Ponikvar J, Crespo M, Mjoen G, Heering P, Peruzzi L, Gandolfini I, Hellemans R, Hilbrands L. Kidney transplantation during mass disasters - from COVID-19 to other catastrophes A Consensus Statement by the DESCARTES Working Group and Ethics Committee of the ERA. Nephrol Dial Transplant 2023; 38:300–308. [PMID: 36066915 PMCID: PMC9923698 DOI: 10.1093/ndt/gfac251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Indexed: 07/23/2023] Open
Abstract
Mass disasters are characterized by a disparity between health care demand and supply, which hampers complex therapies like kidney transplantation. Considering scarcity of publications on previous disasters, we reviewed transplantation practice during the recent COVID-19 pandemic, and dwelled upon this experience for guiding transplantation strategies in the future pandemic and non-pandemic catastrophes. We strongly suggest continuing transplantation programs during mass disasters, if medical and logistic operational circumstances are appropriate. Postponing transplantations from living donors and referral of urgent cases to safe regions or hospitals are justified. Specific preventative measures in anticipated disasters (such as vaccination programs during pandemics or evacuation in case of hurricanes or wars) may be useful to minimize risks. Immunosuppressive therapies should consider stratifying risk status and avoiding heavy immune suppression in patients with a low probability of therapeutic success. Discharging patients at the earliest convenience is justified during pandemics, whereas delaying discharge is reasonable in other disasters, if infrastructural damage results in unhygienic living environments for the patients. In the outpatient setting, telemedicine is a useful approach to reduce the patient load to hospitals, to minimize the risk of nosocomial transmission in pandemics and the need for transport in destructive disasters. If it comes down to save as many lives as possible, some ethical principles may vary in function of disaster circumstances, but elementary ethical rules are non-negotiable. Patient education is essential to minimize disaster-related complications and to allow for an efficient use of health care resources.
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Affiliation(s)
| | - Raymond Vanholder
- European Kidney Health Alliance, Brussels, Belgium; Department of Internal Medicine and Pediatrics, Nephrology Section, Ghent University Hospital, Ghent, Belgium
| | | | | | - Wim Van Biesen
- Department of Internal Medicine and Pediatrics, Nephrology Section, Ghent University Hospital, Ghent, Belgium
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Bruno Watschinger
- Medical University of Vienna, Department of Medicine III, Division of Nephrology and Dialysis, Vienna, Austria
| | - Christophe Mariat
- Service de Néphrologie, Dialyse et Transplantation rénale, Centre Hospitalier Universitaire de Saint Etienne, Hôpital NORD, Université de Lyon, Université Jean Monnet, Saint Etienne, France
| | | | - Marta Crespo
- Hospital del Mar, Department of Nephrology, Barcelona, Spain
| | - Geir Mjoen
- Section of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
| | - Peter Heering
- Klinik für Nephrologie und Allgemeine Innere Medizin, Städtisches Klinikum Solingen, Solingen, Germany
| | | | | | - Rachel Hellemans
- Department of Nephrology and Hypertension, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Luuk Hilbrands
- Radboud university medical center, Department of Nephrology, Nijmegen, The Netherlands
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Shimizu S, Sakamoto S, Yamada M, Funaki T, Fukuda A, Uchida H, Okada N, Nakao T, Kodama T, Komine R, Shoji K, Baba C, Suzuki Y, Nakagawa S, Ogimi C, Kasahara M. Successful pediatric liver transplantation case with a positive SARS-CoV-2 test at the time of transplant. Hepatol Res 2023. [PMID: 36654476 DOI: 10.1111/hepr.13881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/14/2022] [Accepted: 01/12/2023] [Indexed: 01/20/2023]
Abstract
AIM We report a successful liver transplantation (LT) in a child with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. CASE PRESENTATION A 3-year-old female patient with decompensated cirrhosis due to Alagille syndrome underwent a split LT with a left lateral segment graft. She had a history of SARS-CoV-2 infection 4 months before LT. She was exposed to SARS-CoV-2 after the decision for organ acceptance. We repeatedly confirmed the negative SARS-CoV-2 test by polymerase chain reaction (PCR) before LT. Liver transplantation was carried out in the negative pressure operational theater with full airborne, droplet, and contact precautions as the patient was considered to be within the incubation period of SARS-CoV-2. The SARS-CoV-2 PCR test became positive in the nasopharyngeal swab specimen at the operation. Remdesivir, the antiviral treatment, was held off due to potential hepatotoxicity and no exacerbation of COVID-19. She received tacrolimus and low-dose steroids per protocol. She remained SARS-CoV-2 positive on postoperative days (PODs) 1, 2, and 5. The presence of antibodies for SARS-CoV-2 at LT was confirmed later. On POD 53, she was discharged without any symptomatic infection. CONCLUSION This case demonstrated that a positive SARS-CoV-2 result was not an absolute contraindication for a life-saving LT. Liver transplantation could be safely performed in a pediatric patient with asymptomatic COVID-19 and S-immunoglobulin G antibodies for SARS-CoV-2.
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Affiliation(s)
- Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Masaki Yamada
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan.,Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Takanori Funaki
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Noriki Okada
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toshimasa Nakao
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Tasuku Kodama
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Ryuji Komine
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kensuke Shoji
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Chiaki Baba
- Department of Anesthesia and Intensive Care, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuyuki Suzuki
- Department of Anesthesia and Intensive Care, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Chikara Ogimi
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Fabian J, Etheredge HR, Lundgren C, Brannigan L. Practising in a post-truth world: Pandemic ethics can inform patient autonomy and clinical communication. S Afr Med J 2022; 113:5-8. [PMID: 36537542 DOI: 10.7196/SAMJ.2023.v113i1.16746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Indexed: 01/04/2023] Open
Abstract
The COVID-19 pandemic posed an unprecedented challenge to modern bioethical frameworks in the clinical setting. Now, as the pandemic stabilises and we learn to 'live with COVID', the medical community has a duty to evaluate its response to the challenge, and reassess our ethical reasoning, considering how we practise in the future. This article considers a number of clinical and bioethical challenges encountered by the author team and colleagues during the most severe waves of the pandemic. We argue that the changed clinical context may require reframing our ethical thought in such a manner as to adequately accommodate all parties in the clinical interaction. We argue that clinicians have become relatively disempowered by the 'infodemic', and do not necessarily have adequate skills or training to assess the scientific literature being published at an unprecedented rate. Conversely, we acknowledge that patients and families are more empowered by the infodemic, and bring this empowerment to bear on the clinical consultation. Sometimes these interactions can be unpleasant and threatening, and involve inviting clinicians to practise against best evidence or even illegally. Generally, these requests are framed within 'patient autonomy' (which some patients or families perceive to be unlimited), and several factors may prevent clinicians from adequately navigating these requests. In this article, we conclude that embracing a framework of shared decision-making (SDM), which openly acknowledges clinical expertise and in which patient and family autonomy is carefully balanced against other bioethics principles, could serve us well going forward. One such principle is the recognition of clinician expertise as holding weight in the clinical encounter, when framed in terms of non-maleficence and beneficence. Such a framework incorporates much of our learning and experience from advising and treating patients during the pandemic.
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López V, Mazuecos A, Villanego F, López-Oliva M, Alonso A, Beneyto I, Crespo M, Díaz-Corte C, Franco A, González-Roncero F, Guirado L, Jiménez C, Juega J, Llorente S, Paul J, Rodríguez-Benot A, Ruiz JC, Sánchez-Fructuoso A, Torregrosa V, Zárraga S, Rodrigo E, Hernández D. [Update of the recommendations on the management of the SARS-CoV-2 coronavirus pandemic (COVID-19) in kidney transplant patients.]. Nefrologia 2022; 43:S0211-6995(22)00174-6. [PMID: 36405492 PMCID: PMC9664833 DOI: 10.1016/j.nefro.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022] Open
Abstract
SARS-CoV-2 infection (COVID-19) has had a significant impact on transplant activity in our country. Mortality and the risk of complications associated with COVID-19 in kidney transplant recipients (KT) were expected to be higher due to their immunosuppressed condition and the frequent associated comorbidities. Since the beginning of the pandemic in March 2020 we have rapidly improved our knowledge about the epidemiology, clinical features and management of COVID-19 post-transplant, resulting in a better prognosis for our patients. KT units have been able to adapt their programs to this new reality, normalizing both donation and transplantation activity in our country.This manuscript presents a proposal to update the general recommendations for the prevention and treatment of infection in this highly vulnerable population such as KT.
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Affiliation(s)
- Verónica López
- Unidad de Gestión Clínica de Nefrología. Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), RICORS2040 (RD21/0005/0012), Málaga, España
| | | | | | | | - Angel Alonso
- Servicio de Nefrología. Complejo Hospitalario A Coruña, España
| | - Isabel Beneyto
- Servicio de Nefrología. Hospital Universitario Politécnico La Fe, Valencia, España
| | - Marta Crespo
- Servicio de Nefrología. Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, España. RD16/0009/0013 (ISCIII FEDER REDinREN), España
| | - Carmen Díaz-Corte
- Servicio de Nefrología. Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Asturias, España
| | - Antonio Franco
- Servicio de Nefrología. Hospital de Alicante, Alicante, España
| | | | - Luis Guirado
- Servicio de Nefrología. Fundación Puigvert, REDinREN RD16/0009/0019, Barcelona, España
| | | | - Javier Juega
- Servicio de Nefrología. Hospital Trias i Pujol, REDinREN RD16/0009/0032, Barcelona, España
| | - Santiago Llorente
- Servicio de Nefrología. Hospital Virgen de la Arrixaca, Murcia, España
| | - Javier Paul
- Servicio de Nefrología. Hospital Miguel Servet, Zaragoza, España
| | - Alberto Rodríguez-Benot
- Servicio de Nefrología. Hospital Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba, España
| | - Juan Carlos Ruiz
- Servicio de Nefrología. Hospital Marqués de Valdecilla, IDIVAL, REDinREN RD16/0009/0027, Santander, España
| | - Ana Sánchez-Fructuoso
- Serivicio de Nefrología. Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, España
| | | | - Sofía Zárraga
- Servicio de Nefrología. Hospital de Cruces, Bilbao, España
| | - Emilio Rodrigo
- Servicio de Nefrología. Hospital Marqués de Valdecilla, IDIVAL, REDinREN RD16/0009/0027, Santander, España
| | - Domingo Hernández
- Unidad de Gestión Clínica de Nefrología. Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), RICORS2040 (RD21/0005/0012), Málaga, España
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Jemal SS, Alemu BD. Modeling the Transmission Dynamics of COVID-19 Among Five High Burden African Countries. Clin Epidemiol 2022; 14:1013-1029. [PMID: 36051859 PMCID: PMC9426766 DOI: 10.2147/clep.s366142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/21/2022] [Indexed: 12/22/2022] Open
Affiliation(s)
- Sebwedin Surur Jemal
- Department of Statistics, College of Natural and Computational Sciences, Mizan-Tepi University, Tepi, Ethiopia
- Correspondence: Sebwedin Surur Jemal, Department of Statistics, College of Natural and Computational Sciences, Mizan-Tepi University, Tepi, Ethiopia, Tel +251977237466, Email
| | - Bizuwork Derebew Alemu
- Department of Statistics, College of Natural and Computational Sciences, Mizan-Tepi University, Tepi, Ethiopia
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8
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Chow KM, Maggiore U, Dor FJ. Ethical Issues in Kidney Transplant and Donation During COVID-19 Pandemic. Semin Nephrol 2022; 42:151272. [PMID: 36577645 PMCID: PMC9283694 DOI: 10.1016/j.semnephrol.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The coronavirus disease-19 pandemic caused by the severe acute respiratory syndrome coronavirus has faced the transplant community with unprecedented clinical challenges in a highly vulnerable patient category. These were associated with many uncertainties for patients and health care professionals and prompted many ethical debates regarding the safe delivery of kidney transplantation. In this article, we highlight some of the most important ethical questions that were raised during the pandemic and attempt to analyze ethical arguments in light of core principles of medical ethics to either suspend or continue kidney transplantation, and to mandate vaccination in transplant patients, transplant candidates, and, finally, health care providers. We have come up with frameworks to deal responsibly with these ethical challenges, and formulated recommendations to cope with the issues imposed on patients and transplant professionals.
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Affiliation(s)
- Kai-Ming Chow
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Umberto Maggiore
- Dipartimento di Medicina e Chirurgia, Università di Parma, Unita’ Operativa Nefrologia, Azienda Ospedaliera-Universitaria Parma, Parma, Italy
| | - Frank J.M.F. Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom,Department of Surgery and Cancer, Imperial College, London, United Kingdom,Address reprint requests to Frank J.M.F. Dor, MD, PhD, FEBS(Hon), FRCS, Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust, Office 468, Hammersmith House, Hammersmith Hospital, Du Cane Road, W120HS London, United Kingdom
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9
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Kute VB, Tullius SG, Rane H, Chauhan S, Mishra V, Meshram HS. Global Impact of the COVID-19 Pandemic on Solid Organ Transplant. Transplant Proc 2022; 54:1412-1416. [PMID: 35337665 PMCID: PMC8828418 DOI: 10.1016/j.transproceed.2022.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 02/04/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND COVID-19 has drastically affected transplant services, but there is limited understanding of the discrepancy of COVID-19 effects on various regions of the world. METHODS We have explored the Global Observatory for Organ Donation and Transplantation data for assessing the transplant number changes between the calendar year 2019 (n = 157,301) and 2020 (129,681). RESULTS There was a disproportionate impact of COVID-19 on different areas of the world. Globally, there was a decline of 17.5%, in which deceased donation, kidney (20.9%), pancreas (16.2%), lung (12.7%), liver (11.3%), and heart (8%) transplant declined disproportionally in different regions of the world. The pandemic affected almost all geographic regions and nations, but China and the United States were mostly able to recover from the initial halt of the transplant practices by the pandemic so that there was a cumulative increase in transplant numbers. CONCLUSIONS Our data show that developing nations lagged behind, whereas developed nations have been able to recover their transplantation programs during the pandemic. Further policy making and preparedness is required to safeguard the most vulnerable areas of the world to minimize the impact of any future pandemic on transplantation practices.
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Affiliation(s)
- Vivek B Kute
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, India
| | - Stefan G Tullius
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Hemant Rane
- Department of Anaesthesia, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, India
| | - Sanshriti Chauhan
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, India
| | - Vineet Mishra
- Department of Gynaecology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, India
| | - Hari Shankar Meshram
- Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, India.
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10
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Petrini C, Peritore D, Riva L, Floridia G, Gainotti S, Grossi P, Castiglione A, Beretta M, Rea F, Nosotti M, Lombardini L, Cardillo M. POST COVID-19 LUNG TRANSPLANTATION ITALIAN PIVOTAL PROTOCOL: SOME ETHICAL CONSIDERATIONS. Transplant Proc 2022; 54:1524-1527. [PMID: 35863996 PMCID: PMC9156951 DOI: 10.1016/j.transproceed.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/04/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022]
Abstract
SARS‑CoV‑2 mostly affects the respiratory system with clinical patterns ranging from the common cold to fatal pneumonia. During the first wave of the COVID-19 pandemic, owing to the high number of patients who were infected with SARS‑CoV‑2 and subsequently recovered, it has been shown that some patients with post–COVID-19 terminal respiratory failure need lung transplantation for survival. There is increasing evidence coming from worldwide observations that this procedure can be performed successfully in post–COVID-19 patients. However, owing to the scarcity of organs, there is a need to define the safety and efficacy of lung transplant for post–COVID-19 patients as compared to patients waiting for a lung transplant for other pre-existing conditions, in order to ensure that sound ethical criteria are applied in organ allocation. The Milan's Policlinic Lung Transplant Surgery Unit, with the revision of the National Second Opinion for Infectious Diseases and the contribution of the Italian Lung Transplant Centres and the Italian National Transplant Centre, set up a pivotal observational protocol for the lung transplant of patients infected and successively turned negative for SARS‑CoV‑2, albeit with lung consequences such as acute respiratory distress syndrome or some chronic interstitial lung disease. The protocol was revised and approved by the Italian National Institute of Health Ethics Committee. Description of the protocol and some ethical considerations are reported in this article.
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Agnese GA, Federico N, Massimo C, Salvatore G, Giuseppe T, Maria EG, Luciano DC, Renato R, Carlo P, Antonio GP, Mario P. Liver transplantation from active COVID-19 donors: is it ethically justifiable? Transpl Infect Dis 2022; 24:e13846. [PMID: 35579913 PMCID: PMC9348408 DOI: 10.1111/tid.13846] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/11/2022] [Accepted: 04/16/2022] [Indexed: 11/29/2022]
Abstract
The debate on the opportunity to use organs from donors testing positive for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) in recipients with naïve resolved or active COVID‐19 is ongoing. We aim to present the ethical analyses underlying the decision to perform liver transplantation (LT) in selected patients with resolved or active COVID‐19 in Italy. We used Jonsen, Siegler, and Winslade's Four‐Boxes casuistic method, addressing the four topics considered as constitutive of the essential structure of single clinical cases for their ethical analysis (medical indications, patient preferences, quality of life, and contextual features) to enable decision‐making on a case‐by‐case basis. Based on these topics, we elucidate the meaning and balance among the principles of biomedical ethics. Clinical ethics judgment based on the relation between the risk of acquiring SARS‐CoV‐2 along with its potentially negative effects and the expected benefits of transplant lead to consider LT as clinically appropriate. Shared decision‐making allows the integration of clinical options with the patient's subjective preferences and considerations, enabling a valid informed consent specifically tailored to the patients’ individual circumstances. The inclusion of carefully selected SARS‐CoV‐2 positive donors represents an opportunity to offer lifesaving LT to patients who might otherwise have limited opportunities to receive one. COVID‐19 positive donor livers are fairly allocated among equals, and respect for fundamental rights of the individual and the broader community in a context of healthcare rationing is guaranteed.The ethical analysis of the decision to perform LT in selected patients shows that the decision is ethically justifiable.
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Affiliation(s)
- Grossi Alessandra Agnese
- Center for Clinical Ethics, Department of Biotechnologies and Life Sciences, University of Insubria, Varese, Italy.,Department of Human Sciences, Innovation and Territory, University of Insubria, Varese, Italy
| | - Nicoli Federico
- Center for Clinical Ethics, Department of Biotechnologies and Life Sciences, University of Insubria, Varese, Italy.,Clinical Ethics Service, Domus Salutis Clinic, Teresa Camplani Foundation, Brescia, Italy
| | - Cardillo Massimo
- Italian National Transplantation Center (CNT), Italian National Institute of Health, Rome, Italy
| | - Gruttadauria Salvatore
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, UPMC (University of Pittsburgh Medical Center), Palermo, Italy.,Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
| | - Tisone Giuseppe
- Department of Surgical Sciences, University of Rome - Tor Vergata, Rome, Italy
| | - Ettorre Giuseppe Maria
- Department of General and HBP Surgery, Liver Transplantation Service, San Camillo Forlanini Hospital, Rome, Italy
| | - De Carlis Luciano
- General Surgery and Abdominal Transplantation Unit, University of Milano-Bicocca and Niguarda-Cà Granda Hospital, Milan, Italy
| | - Romagnoli Renato
- General Surgery 2U and Liver Transplantation Center, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Petrini Carlo
- Bioethics Unit, Italian National Institute of Health (ISS), Rome, Italy
| | - Grossi Paolo Antonio
- Italian National Transplantation Center (CNT), Italian National Institute of Health, Rome, Italy.,Department of Medicine and Surgery, Infectious Disease Unit, University of Insubria, Varese, Italy
| | - Picozzi Mario
- Center for Clinical Ethics, Department of Biotechnologies and Life Sciences, University of Insubria, Varese, Italy
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12
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Scales NB, Herry CL, van Beinum A, Hogue ML, Hornby L, Shahin J, Dhanani S, Seely AJE. Predicting Time to Death After Withdrawal of Life-Sustaining Measures Using Vital Sign Variability: Derivation and Validation. Crit Care Explor 2022; 4:e0675. [PMID: 35415612 PMCID: PMC8994079 DOI: 10.1097/cce.0000000000000675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
To develop a predictive model using vital sign (heart rate and arterial blood pressure) variability to predict time to death after withdrawal of life-supporting measures.
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13
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Katvan E, Cohen J, Ashkenazi T. Organ donation in the time of COVID-19: the Israeli experience one year into the pandemic—ethical and policy implications. Isr J Health Policy Res 2022; 11:6. [PMID: 35101144 PMCID: PMC8802285 DOI: 10.1186/s13584-022-00519-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 01/17/2022] [Indexed: 12/15/2022] Open
Abstract
Purpose To present the response of the Israel National Transplantation Center (NTC) to the evolving challenge of COVID-19, the impact on deceased organ donation and living organ kidney donation during 2020, and resultant policy and ethical implications. Methods Data collected included (i) for deceased donors, the total number of potential organ donors, if hospitalized in ICU or general ward, cause of death, number of family authorizations and refusals, number of actual donors, number of organs transplanted/donor and total number of transplants performed; (ii) for living-kidney-donors (related or altruistic), the number of procedures performed; and (iii) the number of patients registered on the national organ waiting-list. Results Following the first case (February 2020), deceased organ donation continued uninterrupted. The total number of potential donors was similar to 2019 (181 vs. 189). However, the number of families approached for donation decreased significantly (P = 0.02). This may be attributed to COVID-19-imposed limitations including fewer brain death determinations due to limited possibilities for face-to-face donor coordinator-donor family interactions providing emotional support and visual explanations of the medical situation. Fewer donors were admitted to ICU (P = 0.1) and the number of organs retrieved/donor decreased (3.8/donor to 3.4/donor). The overall result was a decrease of 24.2% in the number of transplant procedures (306 vs. 232). Living kidney donation, initially halted, resumed in May and the total number of procedures increased compared to 2019 due to a significant increase in altruistic donations (P < 0.0001), while the number of related-living donations decreased. Conclusion This study of organ donation during a crisis has informed the introduction of policy changes in the NTC including the necessity to mobilize rapidly a “war room”, the use of innovative virtual tools for contact-less communication, and the importance of cooperation with hospital authorities in allocating scarce health-care resources. Finally, the pandemic highlighted and intensified ethical considerations, such as under what circumstances living kidney donation be continued in the face of uncertainty, and what information to provide to altruistic donors regarding a prospective recipient, in particular whether all options for related living donation have been exhausted. These should be addressed now.
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14
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Sandal S, Massie A, Boyarsky B, Chiang TPY, Thavorn K, Segev DL, Cantarovich M. Impact of the COVID-19 pandemic on transplantation by income level and cumulative COVID-19 incidence: a multinational survey study. BMJ Open 2022; 12:e055367. [PMID: 35022176 PMCID: PMC8756076 DOI: 10.1136/bmjopen-2021-055367] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The COVID-19 pandemic significantly affected the provisions of health services to necessary but deprioritised fields, such as transplantation. Many programmes had to ramp-down their activity, which may significantly affect transplant volumes. We aimed to pragmatically analyse measures of transplant activity and compare them by a country's income level and cumulative COVID-19 incidence (CCI). DESIGN, SETTING AND PARTICIPANTS From June to September 2020, we surveyed transplant physicians identified as key informants in their programmes. Of the 1267 eligible physicians, 40.5% from 71 countries participated. OUTCOME Four pragmatic measures of transplant activity. RESULTS Overall, 46.5% of the programmes from high-income countries anticipate being able to maintain >75% of their transplant volume compared with 31.6% of the programmes from upper-middle-income countries, and with 21.7% from low/lower-middle-income countries (p<0.001). This could be because more programmes in high-income countries reported being able to perform transplantation/s (86.8%%-58.5%-67.9%, p<0.001), maintain prepandemic deceased donor offers (31.0%%-14.2%-26.4%, p<0.01) and avoid a ramp down phase (30.9%%-19.7%-8.3%, p<0.001), respectively. In a multivariable analysis that adjusted for CCI, programmes in upper-middle-income countries (adjusted OR, aOR=0.47, 95% CI 0.27 to 0.81) and low/lower-middle-income countries (aOR 0.33, 95% CI 0.16 to 0.67) had lower odds of being able to maintain >75% of their transplant volume, compared with programmes in high-income countries. Again, this could be attributed to lower-income being associated with 3.3-3.9 higher odds of performing no transplantation/s, 66%-68% lower odds of maintaining prepandemic donor offers and 37%-76% lower odds of avoiding ramp-down of transplantation. Overall, CCI was not associated with these measures. CONCLUSIONS The impact of the pandemic on transplantation was more in lower-income countries, independent of the COVID-19 burden. Given the lag of 1-2 years in objective data being reported by global registries, our findings may inform practice and policy. Transplant programmes in lower-income countries may need more effort to rebuild disrupted services and recuperate from the pandemic even if their COVID-19 burden was low.
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Affiliation(s)
- Shaifali Sandal
- Department of Medicine, Division of Nephrology, Multi-organ Transplant Program, Montreal, Québec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Allan Massie
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Brian Boyarsky
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Kednapa Thavorn
- Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dorry L Segev
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marcelo Cantarovich
- Department of Medicine, Division of Nephrology, Multi-organ Transplant Program, Montreal, Québec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
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15
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Millán DAC, Fajardo-Cediel W, Tobar-Roa V, García-Perdomo HA, Autrán-Gómez AM. Strategies to Mitigate the Impact of COVID 19 Pandemic on Organ Donation and Kidney Transplantation in Latin America. Curr Urol Rep 2021; 22:59. [PMID: 34913144 PMCID: PMC8724642 DOI: 10.1007/s11934-021-01076-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW COVID-19 pandemics have severely affected Latin America. It has resulted in SARS-CoV-2-associated clinical adverse outcomes, but also in social and economic deterioration. Consequently, it generated a significant negative impact on organ donation and kidney transplantation (KTx) activity in our region, leading to a negative impact on these patients' survival and quality of life. For this reason, this article aimed to describe applicable logistics, organizational and clinical strategies to mitigate the effect of the COVID-19 pandemic on kidney donation and transplantation in our region. RECENT FINDINGS Absenteeism to hemodialysis sessions in patients with end-stage renal disease has been described in up to 54% in Latin America. Not surprisingly, there was a reduction in organ donation and transplants between 21 and 59%. Also, there is a higher incidence of COVID-19 positive tests in the waiting list population than KTx recipients (9.9%). However, there was a higher mortality rate in KTx recipients than the waiting list population (32%). Additionally, 59% of living donor kidney transplant programs suspended the evaluation of new donors due to the COVID-19 pandemic. Throughout this manuscript, we summarize some practical tips to resume organ donation and KTx during pandemics in Latin America, such as selecting healthy donors and recipients, universal SARS-CoV-2 screening, implementing COVID-19 accessible pathways, and telehealth as a standard, and postpone all non-urgent visits.
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Affiliation(s)
- David Andrés Castañeda Millán
- Department of Surgery, Urology Unit, Hospital Universitario Nacional de Colombia, Universidad Nacional de Colombia, Bogotá, Colombia.
| | | | - Verónica Tobar-Roa
- Urology Department and Kidney Transplant Unit, Clínica FOSCAL, Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
| | | | - Ana María Autrán-Gómez
- Oficina de Investigación Confederación Americana de Urologia (CAU), Buenos Aires, Argentina
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Fonseca EA, Feier F, Pugliese R, Freitas AF, Porta G, Miura I, Baggio V, Kondo M, Benavides M, Vincenzi R, Roda K, Oliveira CV, Chapchap P, Seda‐Neto J. Pediatric liver transplantation activity in a high-volume program during the COVID-19 pandemic in Brazil. Pediatr Transplant 2021; 25:e14112. [PMID: 34396644 PMCID: PMC8420104 DOI: 10.1111/petr.14112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/15/2021] [Accepted: 07/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The impact of the COVID pandemic on liver transplant (LT) programs varied among countries. Few data are available about that impact in pediatric liver transplant (PLT) programs. This study aimed at comparing the data of our program in Brazil (2019 vs. 2020). METHODS Retrospective cohort study. RESULTS One hundred and seventy-four PLT were performed in the period (93% living donors). Patients were divided into two groups according to the LT date: pre-COVID-19 period (march/2019-February/2020) and COVID-19 period (March/2020-February 2021). In the pre-COVID-19 period, 97 LTs were performed, and 77 LTs were performed in the COVID-19 period. Patients in the COVID-19 period were younger (10.9 months vs. 16 months, p 0.009), had higher PELD scores (15 vs. 14, p 0.04), more ascites (66.2 vs. 51.5%, p 0.03), and more frequently hospitalized before LT (27.3 vs. 17.5%). However, there was no difference in post-LT complications, retransplantation nor survival rates. Six (6.2%) patients from pre-COVID-19 period were COVID positive at a median of 15.5 months (14-17.5), and 6 (7.8%) patients from COVID-19 period were COVID positive at a median of 3 months (20 days-6 months) from LT. There was neither mortality nor complications in those patients. Four (33%) were hospitalized, and one had prolonged intubation. Four (33%) were asymptomatic, 4 (33%) had upper airways symptoms, and the remaining had gastrointestinal symptoms. CONCLUSION Overall, PLT was not affected during COVID-19 period. Even though patients from COVID-19 period were sicker, there was no significant impact in LT outcomes. All the recipients who tested positive for COVID had a favorable outcome.
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Affiliation(s)
- Eduardo A. Fonseca
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Flavia Feier
- Hepatology and Liver TransplantationSanta Casa de Porto AlegrePorto AlegreBrazil
| | - Renata Pugliese
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Aline F. Freitas
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Gilda Porta
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Irene Miura
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Vera Baggio
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Mario Kondo
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Marcel Benavides
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Rodrigo Vincenzi
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Karina Roda
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Caio V. Oliveira
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - Paulo Chapchap
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
| | - João Seda‐Neto
- Hepatology and Liver TransplantationHospital Sírio‐LibanêsSão PauloBrazil,Hepatology and Liver Transplantation A. C. Camargo Cancer CenterSão PauloBrazil
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17
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Ibrahim B, Dawson R, Chandler JA, Goldberg A, Hartell D, Hornby L, Simpson C, Weiss MJ, Wilson LC, Wilson TM, Fortin MC. The COVID-19 pandemic and organ donation and transplantation: ethical issues. BMC Med Ethics 2021; 22:142. [PMID: 34674700 PMCID: PMC8528937 DOI: 10.1186/s12910-021-00711-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 10/13/2021] [Indexed: 12/24/2022] Open
Abstract
Background The COVID-19 pandemic has had a significant impact on the health system worldwide. The organ and tissue donation and transplantation (OTDT) system is no exception and has had to face ethical challenges related to the pandemic, such as risks of infection and resource allocation. In this setting, many Canadian transplant programs halted their activities during the first wave of the pandemic. Method To inform future ethical guidelines related to the COVID-19 pandemic or other public health emergencies of international concern, we conducted a literature review to summarize the ethical issues. Results This literature review identified three categories of ethical challenges. The first one describes the general ethical issues and challenges reported by OTDT organizations and transplantation programs, such as risks of COVID-19 transmission and infection to transplant recipients and healthcare professionals during the transplant process, risk of patient waitlist mortality or further resource strain where transplant procedures have been delayed or halted, and resource allocation. The second category describes ethical challenges related to informed consent in the context of uncertainty and virtual consent. Finally, the third category describes ethical issues related to organ allocation, such as social considerations in selecting transplant candidates. Conclusion This literature review highlights the salient ethical issues related to OTDT during the current COVID-19 pandemic. As medical and scientific knowledge about COVID-19 increases, the uncertainties related to this disease will decrease and the associated ethical issues will continue to evolve.
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Affiliation(s)
| | | | - Jennifer A Chandler
- Faculty of Law, University of Ottawa, Ottawa, ON, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Aviva Goldberg
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.,Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Laura Hornby
- Canadian Blood Services, Ottawa, ON, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Christy Simpson
- Canadian Blood Services, Ottawa, ON, Canada.,Faculty of Medicine, Department of Bioethics, Dalhousie University, Halifax, NS, Canada
| | - Matthew-John Weiss
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.,CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Quebec, QC, Canada.,Transplant Québec, Montreal, QC, Canada
| | | | - T Murray Wilson
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Marie-Chantal Fortin
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada. .,Centre de Recherche du CHUM, Room R12-418, 900 rue St-Denis, Montreal, QC, H2X 0A9, Canada. .,Faculté de Médecine, Université de Montreal, Montreal, QC, Canada.
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18
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Thieme CJ, Anft M, Paniskaki K, Blazquez-Navarro A, Doevelaar A, Seibert FS, Hoelzer B, Justine Konik M, Meister TL, Pfaender S, Steinmann E, Moritz Berger M, Brenner T, Kölsch U, Dolff S, Roch T, Witzke O, Schenker P, Viebahn R, Stervbo U, Westhoff TH, Babel N. The Magnitude and Functionality of SARS-CoV-2 Reactive Cellular and Humoral Immunity in Transplant Population Is Similar to the General Population Despite Immunosuppression. Transplantation 2021; 105:2156-2164. [PMID: 33988334 PMCID: PMC8487706 DOI: 10.1097/tp.0000000000003755] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/26/2021] [Accepted: 02/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The ability of transplant (Tx) patients to generate a protective antiviral response under immunosuppression is pivotal in COVID-19 infection. However, analysis of immunity against SARS-CoV-2 is currently lacking. METHODS Here, we analyzed T cell immunity directed against SARS-CoV-2 spike-, membrane-, and nucleocapsid-protein by flow cytometry and spike-specific neutralizing antibodies in 10 Tx in comparison to 26 nonimmunosuppressed (non-Tx) COVID-19 patients. RESULTS Tx patients (7 renal, 1 lung, and 2 combined pancreas-kidney Txs) were recruited in this study during the acute phase of COVID-19 with a median time after SARS-CoV-2-positivity of 3 and 4 d for non-Tx and Tx patients, respectively. Despite immunosuppression, we detected antiviral CD4+ T cell-response in 90% of Tx patients. SARS-CoV-2-reactive CD4+ T cells produced multiple proinflammatory cytokines, indicating their potential protective capacity. Neutralizing antibody titers did not differ between groups. SARS-CoV-2-reactive CD8+ T cells targeting membrane- and spike-protein were lower in Tx patients, albeit without statistical significance. However, frequencies of anti-nucleocapsid-protein-reactive, and anti-SARS-CoV-2 polyfunctional CD8+ T cells, were similar between patient cohorts. Tx patients showed features of a prematurely aged adaptive immune system, but equal frequencies of SARS-CoV-2-reactive memory T cells. CONCLUSIONS In conclusion, a polyfunctional T cell immunity directed against SARS-CoV-2 proteins as well as neutralizing antibodies can be generated in Tx patients despite immunosuppression. In comparison to nonimmunosuppressed patients, no differences in humoral and cellular antiviral-immunity were found. Our data presenting the ability to generate SARS-CoV-2-specific immunity in immunosuppressed patients have implications for the handling of SARS-CoV-2-infected Tx patients and raise hopes for effective vaccination in this cohort.
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Affiliation(s)
- Constantin J. Thieme
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz, Berlin, Germany
| | - Moritz Anft
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Germany
| | - Krystallenia Paniskaki
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
| | - Arturo Blazquez-Navarro
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz, Berlin, Germany
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Germany
| | - Adrian Doevelaar
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Germany
| | - Felix S. Seibert
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Germany
| | - Bodo Hoelzer
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Germany
| | - Margarethe Justine Konik
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
| | - Toni L. Meister
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
| | - Stephanie Pfaender
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
| | - Eike Steinmann
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
| | - Marc Moritz Berger
- Department of Anesthesiology, University Hospital Essen, University Duisburg-Essen, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, University Hospital Essen, University Duisburg-Essen, Germany
| | - Uwe Kölsch
- Department of Immunology, Labor Berlin GmbH, Berlin, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
| | - Toralf Roch
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz, Berlin, Germany
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Germany
| | - Peter Schenker
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Richard Viebahn
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Ulrik Stervbo
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Germany
| | - Timm H. Westhoff
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Germany
| | - Nina Babel
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz, Berlin, Germany
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Germany
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Ducharlet K, Trivedi M, Gelfand SL, Liew H, McMahon LP, Ashuntantang G, Brennan F, Brown M, Martin DE. Moral Distress and Moral Injury in Nephrology During the COVID-19 Pandemic. Semin Nephrol 2021; 41:253-61. [PMID: 34330365 DOI: 10.1016/j.semnephrol.2021.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Summary: Across the world, challenges for clinicians providing health care during the coronavirus disease 2019 (COVID-19) pandemic are highly prevalent and have been widely reported. Perspectives of provider groups have conveyed wide-ranging experiences of adversity, distress, and resilience. In understanding and responding to the emotional and psychological implications of the pandemic for renal clinicians, it is vital to recognize that many experiences also have been ethically challenging. The COVID-19 pandemic has prompted rapid and extensive transformation of health care systems and widely impacted care provision, heightening the risk of barriers to fulfillment of ethical duties. Given this, it is likely that some clinicians also have experienced moral distress, which can occur if an individual is unable to act in accordance with their moral judgment owing to external barriers. This review presents a global perspective of potential experiences of moral distress in kidney care during the COVID-19 pandemic. Using nephrology cases, we discuss why moral distress may be experienced by health professionals when withholding or withdrawing potentially beneficial treatments owing to resource constraints, when providing care that is inconsistent with local prepandemic best practice standards, and when managing dual professional and personal roles with conflicting responsibilities. We argue that in addition to responsive and appropriate health system supports, resources, and education, it is imperative for health care providers to recognize and prevent moral distress to foster the psychological well-being and moral resilience of clinicians during extended periods of crisis within health systems.
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20
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Kute VB, Meshram HS, Navadiya VV, Chauhan S, Patel DD, Desai SN, Shah N, Dave RB, Banerjee S, Engineer DP, Patel HV, Rizvi SJ, Mishra VV. Consequences of the first and second COVID-19 wave on kidney transplant recipients at a large Indian transplant centre. Nephrology (Carlton) 2021; 27:195-207. [PMID: 34378832 PMCID: PMC8420491 DOI: 10.1111/nep.13961] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 02/06/2023]
Abstract
Background There is a scarcity of data comparing the consequences of first and second COVID‐19 waves on kidney transplant recipients (KTRs) in India. Methods We conducted a single‐centre retrospective study of 259 KTRs with COVID‐19 to compare first wave (March 15–December 31 2020, n = 157) and second wave (April 1–May 31 2021, n = 102). Results KTRs during second wave were younger (43 vs. 40 years; p‐value .04) and also included paediatric patients (0 vs. 5.9%; p‐value .003). Symptoms were milder during the second wave (45 vs. 62.7%; p‐value .007); COVID‐19 positive patients had less frequent cough (32 vs. 13.8%; p‐value .001), fever was less frequent (58 vs. 37%; p‐value .001), and we observed fewer co‐morbidities (11 vs. 20.6%; p‐value .04). The percentages of neutrophils (77 vs. 83%; p‐value .001) and serum ferritin (439 vs. 688; p‐value .0006) were higher during second wave, while lymphocyte counts were reduced (20 vs. 14%; p‐value .0001). Hydroxychloroquine (11 vs. 0%; p‐value .0001) and tocilizumab (7 vs. 0%; p‐value .004) were more frequently prescribed during first wave, while utilization of dexamethasone (6 vs. 27%; p‐value .0001) and remdesivir (47 vs. 65%; p‐value .03) increased during the second wave. Mucormycosis (1.3 vs. 10%; p‐value .01) and ICU admissions (20 vs. 37.2%; p‐value .002) were more frequent during second wave. The 28‐day mortality rate (9.6 vs. 10%; p‐value 1) was not different. Conclusions There has been a different clinical spectrum of COVID‐19 amongst KTR with similar mortality between the two waves at a large Indian transplant centre. A large single centre study from India reporting on the health outcomes of COVID‐19 infected kidney transplant recipients during the two waves of between 2020 and 2021. The rate of intensive care admission was more frequent during the second wave of infection although mortality rates were similar in both waves.
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Affiliation(s)
- Vivek B Kute
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Hari Shankar Meshram
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Vijay V Navadiya
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Sanshriti Chauhan
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Dev D Patel
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Sudeep N Desai
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Nauka Shah
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Ruchir B Dave
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Subho Banerjee
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Divyesh P Engineer
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Himanshu V Patel
- Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center and Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Syed Jamal Rizvi
- Department of Transplantation Surgery, IKDRC-ITS, Ahmedabad, Gujarat, India
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21
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Robertson J, Flint AJ, Blumberger D, Bhat V. Ethical Considerations in Providing Electroconvulsive Therapy during the COVID-19 Pandemic. Can J Psychiatry 2021; 66:701-706. [PMID: 33596695 PMCID: PMC8329900 DOI: 10.1177/0706743721993617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jamie Robertson
- Centre for Clinical Ethics, 10071St Michael's Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, 7938University of Toronto, Ontario, Canada
| | - Alastair J Flint
- Centre for Mental Health, 7989University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, 7938University of Toronto, Ontario, Canada
| | - Daniel Blumberger
- Department of Psychiatry, 7938University of Toronto, Ontario, Canada.,Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Venkat Bhat
- Department of Psychiatry, 7938University of Toronto, Ontario, Canada.,Mental Health and Addictions Service, St. Michael's Hospital, Toronto, Ontario, Canada
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22
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Kute VB, Ray DS, Yadav DK, Pathak V, Bhalla AK, Godara S, Kumar A, Guleria S, Khullar D, Thukral S, Mondal RRS, Jain M, Jha PK, Hegde U, Abraham M A, Dalal S, Patel H, Bahadur MM, Shingare A, Sharma A, Kumar Sharma R, Anandh U, Gulati S, Gumber M, Siddini V, Deshpande R, Kaswan K, Varyani U, Kakde S, Kenwar DB, Shankar Meshram H, Kher V. A Multicenter Cohort Study From India of 75 Kidney Transplants in Recipients Recovered After COVID-19. Transplantation 2021; 105:1423-1432. [PMID: 33724246 DOI: 10.1097/tp.0000000000003740] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND There is limited current knowledge on feasibility and safety of kidney transplantation in coronavirus disease-19 (COVID-19) survivors. METHODS We present a retrospective cohort study of 75 kidney transplants in patients who recovered from polymerase chain reaction (PCR)-confirmed COVID-19 performed across 22 transplant centers in India from July 3, 2020, to January 31, 2021. We detail demographics, clinical manifestations, immunosuppression regimen, laboratory findings, treatment, and outcomes. Patients with a previous diagnosis of COVID-19 were accepted after documenting 2 negative severe acute respiratory syndrome coronavirus 2 PCR tests, normal chest imaging with complete resolution of symptom for at least 28 d and significant social distancing for 14 d before surgery. RESULTS Clinical severity in patients ranged from asymptomatic (n = 17, 22.7%), mild (n = 36.48%), moderate (n = 15.20%), and severe (n = 7.9.3%) disease. Median duration between PCR positive to transplant was 60 d (overall) and increased significantly from asymptomatic, mild, moderate, and severe disease (49, 57, 83, 94 d, P 0.019), respectively. All recipients and donors were asymptomatic with normal creatinine after surgery at a median (interquartile range) follow-up of 81 (56-117) d without any complications relating to surgery or COVID-19. Patient and graft survival was 100%, and acute rejection was reported in 6.6%. CONCLUSIONS Prospective kidney transplant recipients post-COVID-19 can be considered for transplantation after comprehensive donor and recipient screening before surgery using a combination of clinical, radiologic, and laboratory criteria, careful pretransplant evaluation, and individualized risk-benefit analysis. Further large-scale prospective studies with longer follow-up will better clarify our initial findings. To date, this remains the first and the largest study of kidney transplantation in COVID-19 survivors.
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Affiliation(s)
- Vivek B Kute
- Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Deepak S Ray
- Department of Nephrology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
| | - Dinesh Kumar Yadav
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Vivek Pathak
- Department of Nephrology, Kovai Medical Center and Hospital, Coimbatore, Tamil-Nadu, India
| | - Anil K Bhalla
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Suraj Godara
- Department of Nephrology, Mahatma Gandhi Medical College & Hospital, Jaipur, India
| | - Anil Kumar
- Department of Nephrology BGS Global Hospital, Bengaluru, Karnataka, India
| | - Sandeep Guleria
- Department of Transplantation Surgery, Indraprastha Apollo Hospital, New Delhi, India
| | - Dinesh Khullar
- Nephrology and Renal Transplant Medicine, Max Saket Complex, Max Super Speciality Hospital, Saket, Delhi, India
| | - Sharmila Thukral
- Department of Nephrology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
| | - Rabi Ranjan Sow Mondal
- Department of Nephrology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
| | - Manish Jain
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Pranaw Kumar Jha
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Umapati Hegde
- Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Abi Abraham M
- Nephrology and Renal Transplant Services, VPS Lakeshore Hospital, Kochi, India
| | - Sonal Dalal
- Department of Nephrology, Gujarat Kidney Foundation, Ahmedabad, India
| | - Himanshu Patel
- Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Madan M Bahadur
- Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Ashay Shingare
- Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Ashish Sharma
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh (PGIMER), Chandigarh, India
| | - Raj Kumar Sharma
- Nephrology and Kidney Transplant Medicine, Kidney & Urology Institute, Medanta, Lucknow, India
| | - Urmila Anandh
- Department of Nephrology, Yashoda Hospital, Secunderabad, India
| | - Sanjeev Gulati
- Nephrology and Kidney Transplant Fortis Group of Hospitals, New Delhi, India
| | - Manoj Gumber
- Department of Nephrology, Apollo Hospitals International Limited, Gandhi Nagar, Ahmedabad, Gujarat, India
| | | | - Rushi Deshpande
- Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Kamal Kaswan
- Department of Nephrology, Narayana Multispeciality Hospital, Jaipur, India
| | - Umesh Varyani
- Department of Nephrology Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | | | - Deepesh B Kenwar
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh (PGIMER), Chandigarh, India
| | - Hari Shankar Meshram
- Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Vijay Kher
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta-The Medicity, Gurugram, Haryana, India
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23
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Sandal S, Boyarsky BJ, Massie A, Chiang TPY, Segev DL, Cantarovich M. Immunosuppression practices during the COVID-19 pandemic: A multinational survey study of transplant programs. Clin Transplant 2021; 35:e14376. [PMID: 34050961 PMCID: PMC8209940 DOI: 10.1111/ctr.14376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/03/2021] [Accepted: 05/24/2021] [Indexed: 12/17/2022]
Abstract
During the COVID-19 pandemic, there has been wide heterogeneity in the medical management of transplant recipients. We aimed to pragmatically capture immunosuppression practices globally following the early months of the pandemic. From June to September 2020, we surveyed 1267 physicians; 40.5% from 71 countries participated. Management decisions were made on a case-by-case basis by the majority (69.6%) of the programs. Overall, 76.8% performed ≥1 transplantation and many commented on avoiding high-risk transplantations. For induction, 26.5% were less likely to give T-cell depletion and 14.8% were more likely to give non-depleting agents. These practices varied by program-level factors more so than the COVID-19 burden. In patients with mild, moderate and severe COVID-19 symptoms 59.7%, 76.0%, and 79.5% decreased/stopped anti-metabolites, 23.2%, 45.4%, and 68.2% decreased/stopped calcineurin inhibitors, and 25.7%, 43.9%, and 57.7% decreased/stopped mTOR inhibitors, respectively. Also, 2.1%, 30.6%, and 46.0% increased steroids in patients with mild, moderate, and severe COVID-19 symptoms. For prevalent transplant recipients, some programs also reported decreasing/stopping steroids (1.8%), anti-metabolites (10.3%), calcineurin inhibitors (4.1%), and mTOR inhibitors (5.5%). Transplant programs changed immunosuppression practices but also avoided high-risk transplants and increased maintenance steroids. The long-term ramifications of these practices remain to be seen as programs face the aftermath of the pandemic.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Multi-Organ Transplant Program, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada.,Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Brian J Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Allan Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Teresa Po-Yu Chiang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marcelo Cantarovich
- Division of Nephrology, Multi-Organ Transplant Program, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada.,Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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24
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Yamada M, Funaki T, Shoji K, Miyairi I, Fukuda A, Sakamoto S, Imadome KI, Kasahara M. Do Not Delay: Safe Operation for Pediatric Living-donor Liver Transplantation Programs in the COVID-19 Era. Transplantation. 2021;105:e39-e40. [PMID: 33617209 DOI: 10.1097/tp.0000000000003594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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25
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Affiliation(s)
- Julio Pascual
- Servicio de Nefrología, Hospital del Mar, Barcelona, Spain.
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26
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Affiliation(s)
- Julio Pascual
- Servicio de Nefrología, Hospital del Mar, Barcelona, España
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27
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Abstract
Coronavirus disease 2019 (COVID-19) outbreak has significantly upended solid organ transplant (SOT) practice around the world. Early reports confirmed the heavy burden of COVID-19 in SOT recipients with mortality rates reaching up to 35%. Because most transplant recipients harbored multiple comorbidities known to be associated with a severe course of COVID-19, the true impact of immunosuppression by itself remained an unsolved issue. Transplant societies have initially recommended to postpone nonurgent renal transplantations, while trying to maintain life-saving transplant programs, such as heart, lung, and liver transplantations. The pandemic thus resulted in an unprecedented and sudden drop of transplant activity worldwide. Moreover, the best treatment strategy in infected patients was challenging. Both reduction of immunosuppression and use of targeted therapies aiming at counteracting severe acute respiratory syndrome coronavirus 2 infection were the 2 faces of the therapeutic armamentarium. Recent controlled studies have better delineated the basis of mitigating and management strategies to improve patients' outcome. Nevertheless, and given the persistence of circulating virus, evidence-based recommendations in SOT recipients remain unclear. The resumption of transplant activity should be tailored with careful selection of both donors and recipients. Transplant decision should be made on a case-by-case basis after thorough assessment of the risks and benefits.
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28
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Affiliation(s)
| | - Darius F. Mirza
- Address for correspondence: Darius F. Mirza, Consultant HPB and Transplant surgeon, The Liver Unit, 3rd Floor, Nuffield House Queen Elizabeth Hospital, Mindelsohn Way, Brimingham B15 2TH, United Kingdom.
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29
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Abstract
The coronavirus pandemic has significantly impacted solid organ transplantation (SOT). Early in the outbreak period, transplant societies recommended suspending living kidney transplant programs in communities with widespread transmission to avoid exposing recipients to increased risk of immunosuppression, while recommendations were made to reserve deceased-donor kidney transplantation for likely life-saving indications. SOT recipients may be at high risk from COVID-19 disease due to chronic immunosuppressive treatment and other medical comorbidities. Mortality rates reported between 13 to over 30% in SOT recipients. In addition to high rates of complications and mortality attributable to COVID-19 infections, the pandemic has also led to additional complexities in transplantation including new questions regarding screening of donors and recipients, decision making to accept a patient for kidney transplant or wait after pandemic. The clinical implications of COVID-19 infection may also differ depending on the type of the transplanted organ and recipient comorbidities which further impacts decisions on continuing transplantation during the pandemic. Transplant activity during a pandemic should be tailored with careful selection of both donors and recipients. Furthermore, while tremendous strides have been made in treatment strategies and vaccinations, the impact of these in transplant recipients may be attenuated in the setting of their immunosuppression. In this review, we aim to summarize several aspects of COVID-19 in transplantation, including the immune response to SARS-CoV-2, SARS-CoV-2 diagnostics, clinical outcomes in SOT recipients, and end-stage kidney disease patients, transplant activity during the pandemic, and treatment options for COVID-19 disease.
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Affiliation(s)
- Yorg Azzi
- Division of Nephrology, Abdominal Transplant Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Rachel Bartash
- Division of infectious Disease, Montefiore Medical Center Transplant Center, Albert Einstein College of Medicine, Bronx, NY
| | - Joseph Scalea
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD
| | - Pablo Loarte-Campos
- Division of Nephrology, Abdominal Transplant Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Enver Akalin
- Division of Nephrology, Abdominal Transplant Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Abstract
As in the general population with coronavirus 2019 (COVID-19) infection, therapeutic interventions in solid organ transplant (SOT) recipients have evolved over time. The preceding 6 months of the pandemic can be divided into 2 main therapeutic eras: the early era and the later era. The first era was characterized by the widespread use of drugs such as hydroxychloroquine with or without azithromycin, lopinavir-ritonavir, and tocilizumab. More recently, with the publication of larger trials, there has been increasing use of remdesivir, dexamethasone, and convalescent plasma, with the rapid proliferation of clinical trials including a wide variety of investigational and repurposed agents with antiviral or immunomodulatory effects. This overview focuses on what is known about the effects of different therapies in SOT recipients with COVID-19, mainly from case series and, more recently, larger multicenter registries; as well as outlining the information that will be needed to optimize management and outcomes in SOT recipients with COVID-19 in the future.
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Affiliation(s)
- Robin K Avery
- 1 Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD
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31
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Woodside KJ, Singh N, Lentine KL, Pavlakis M, Basu A, Cabeza Rivera FH, Kensinger CD, Parajuli S, Sultan S, Tantisattamo E, Parsons RF, Cooper M. Approach to pancreas transplant during the COVID-19 pandemic. Clin Transplant 2020; 35:e14177. [PMID: 33341985 PMCID: PMC7883274 DOI: 10.1111/ctr.14177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/28/2022]
Affiliation(s)
| | - Neeraj Singh
- John C. McDonald Regional Transplant Center, Shreveport, LA, USA
| | | | | | | | | | | | | | | | | | | | - Matthew Cooper
- Medstar Georgetown Transplant Institute, Washington, DC, USA
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32
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McAdams M, Ostrosky-Frid M, Rajora N, Hedayati S. Effect of COVID-19 on Kidney Disease Incidence and Management. Kidney360 2020; 2:141-153. [PMID: 35368812 PMCID: PMC8785734 DOI: 10.34067/kid.0006362020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/24/2020] [Indexed: 02/04/2023]
Abstract
The COVID-19 outbreak has had substantial effects on the incidence and management of kidney diseases, including AKI, ESKD, GN, and kidney transplantation. Initial reports from China suggested a lower AKI incidence in patients with COVID-19, but more recent studies from North America reveal a much higher incidence, likely due to the higher prevalence of comorbid conditions, such as hypertension, diabetes, and CKD. AKI in this setting is associated with worse outcomes, including the requirement for vasopressors or mechanical ventilation and death. Performing RRT in those with AKI poses challenges, such as limiting exposure of staff, preserving PPE, coagulopathy, and hypoxemia due to acute respiratory distress syndrome. Continuous RRT is the preferred modality, with sustained low-efficiency dialysis also an option, both managed without 1:1 hemodialysis nursing support. Regional citrate is the preferred anticoagulation, but systemic unfractionated heparin may be used in patients with coagulopathy. The ultrafiltration rate has to be set carefully, taking into consideration hypotension, hypoxemia, and responsiveness to presser and ventilatory support. The chance of transmission puts in-center chronic hemodialysis and other immunosuppressed patients at particularly increased risk. Limited data show that patients with CKD are also at increased risk for more severe disease, if infected. Little is known about the virus's effects on immunocompromised patients with glomerular diseases and kidney transplants, which introduces challenges for management of immunosuppressant regimens. Although there are no standardized guidelines regarding the management of immunosuppression, several groups recommend stopping the antimetabolite in hospitalized transplant patients and continuing a reduced dose of calcineurin inhibitors. This comprehensive review critically appraises the best available evidence regarding the effect of COVID-19 on the incidence and management of kidney diseases. Where evidence is lacking, current expert opinion and clinical guidelines are reviewed, and knowledge gaps worth investigation are identified.
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Affiliation(s)
- Meredith McAdams
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Nilum Rajora
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Susan Hedayati
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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33
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Chadban SJ, McDonald M, Wyburn K, Opdam H, Barry L, Coates PT. Significant impact of COVID-19 on organ donation and transplantation in a low-prevalence country: Australia. Kidney Int 2020; 98:1616-1618. [PMID: 33096085 PMCID: PMC7575441 DOI: 10.1016/j.kint.2020.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia; Transplantation Society of Australia and New Zealand, Sydney, Australia.
| | - Mark McDonald
- Australian Organ and Tissue Authority, Canberra, Australia
| | - Kate Wyburn
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia; Transplantation Society of Australia and New Zealand, Sydney, Australia
| | - Helen Opdam
- Australian Organ and Tissue Authority, Canberra, Australia
| | - Lucinda Barry
- Australian Organ and Tissue Authority, Canberra, Australia
| | - P Toby Coates
- Transplantation Society of Australia and New Zealand, Sydney, Australia; Department of Renal Medicine, Royal Adelaide Hospital, Adelaide, Australia
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34
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Mangioni D, Dondossola D, Antonelli B, Alagna L, Invernizzi F, Polli F, Tosetti G, Muscatello A, Gori A, Rossi G. Coronavirus disease 2019 and transplantation: tackling the challenges of SARS-CoV-2 infection in waiting list candidates. Transpl Int 2020; 33:1830-1832. [PMID: 32936963 DOI: 10.1111/tri.13742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Davide Mangioni
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Barbara Antonelli
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Alagna
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Invernizzi
- Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca", Center for the Study of Liver Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Polli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Tosetti
- Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca", Center for the Study of Liver Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Muscatello
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgio Rossi
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Guha C, Tong A, Baumgart A, Scholes-Robertson N, Isbel N, Kanellis J, Campbell S, Coates T, Chadban S. Suspension and resumption of kidney transplant programmes during the COVID-19 pandemic: perspectives from patients, caregivers and potential living donors - a qualitative study. Transpl Int 2020; 33:1481-1490. [PMID: 32640048 PMCID: PMC7361590 DOI: 10.1111/tri.13697] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/26/2020] [Accepted: 07/02/2020] [Indexed: 12/23/2022]
Abstract
Many countries have suspended kidney transplantation programmes during the COVID‐19 pandemic because of concerns for patient safety and the shortage of healthcare resources. This study aimed to describe patient, family member and potential donor perspectives on the suspension and resumption of kidney transplant programmes due to COVID‐19. We conducted seven online focus groups involving 31 adult kidney transplant candidates (n = 22), caregivers (n = 4) and potential donors (n = 5). Transcripts were analysed thematically. We identified five themes: cascading disappointments and devastation (with subthemes of shattering hope, succumbing to defeat, regret and guilt); helplessness and vulnerability (fear of declining health, confronted by the threat of and change in dialysis, disconnected from health care, susceptibility to infective complications); stress from uncertainty (confusion from conflicting information, unable to forward plan), exacerbating burdens (incurring extra financial costs, intensifying caregiver responsibilities), and sustaining health through the delay (protecting eligibility, relying on social support, adapting to emerging modalities of care). During the suspension of kidney transplantation programmes, patients felt medically vulnerable because of declining health, susceptibility to infection and reduced access to care. There is a need to address health vulnerabilities, disappointment, uncertainty and additional burdens arising from the suspension of kidney transplantation programmes.
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Affiliation(s)
- Chandana Guha
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Amanda Baumgart
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Nicole Isbel
- Department of Renal Medicine, The University of Queensland at Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - John Kanellis
- Department of Medicine, Monash University, Clayton, Vic., Australia.,Department of Nephrology, Monash Medical Centre, Clayton, Vic., Australia
| | - Scott Campbell
- Department of Renal Medicine, The University of Queensland at Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Toby Coates
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,Centre Northern Adelaide Renal Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Steven Chadban
- Department of Renal Medicine, Central Clinical School, Royal Prince Alfred Hospital, The University of Sydney, Sydney, NSW, Australia
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