By Grace H. Kim, Research Associate
The American Society of Nephrology (ASN) hosted a webinar on April 23rd to update the kidney community about the current status of transplant programs during the ongoing COVID-19 pandemic. While many transplant programs have temporarily ceased surgeries, as of May 1, 2020, forty-nine kidney transplant programs in the United States remain active and are continuing with emergent transplant procedures and surgeries.1 A full listing of active centers can be found here.
This comes after an announcement by the Centers for Medicare & Medicaid Services (CMS) recommending limiting non-essential planned surgeries and procedures until further notice. As a life-saving treatment, transplant surgeries are considered essential and are classified by CMS as Tier 3b, a designation considered to be “high priority; do not postpone.” 2 Trauma and cardiac procedures and surgeries also fall in this category.
Challenges
While transplant surgeries continue, a few big picture challenges in kidney transplant remain. In deceased donation, more people staying safe at home has created a dramatic decline in deceased donor organ availability due to a reduction in trauma-related deaths nationally. Deceased donor cadavers with eligible kidneys have dropped from about 35 per day to just 7 per day.3 Living donor kidney transplant rates have also decreased as many centers have paused these surgeries, evaluations and routine lab tests in efforts to keep donors and patients safe.
For centers performing both deceased donor and living donor transplants, testing remains a key challenge. Not all centers have consistent access to COVID-19 testing materials, resulting in delays for prospective recipients as well as living donors. Prior to either receiving or donating a kidney, transplant centers administer nasal and/or oral swabs for both living donors and deceased donors to test for COVID-19.4 Living donors who test positive are required to postpone donation 14 to 28 days.5 Deceased donor organs that test positive for COVID-19 are not used in transplant.5
If a patient is experiencing potential COVID-19 symptoms, or if they test positive for COVID-19, they may be temporarily inactivated on the waitlist. This means that organ offers will not be presented to the patient until the temporary inactivation is removed. The transplant center can remove a hold at any time, and patient experiences no change in waitlist priority.6 Temporary inactivations are often designated when a patient experiences a change in health or insurance status. Historically, the most common causes for inactivation were cardiovascular and suspected malignancy and usually resulting in loss of waiting time.7 With limited testing availability at transplant centers, waitlist inactivations are increasing.8
Solutions
Transplant organizations and professionals are working tirelessly to address these challenges. In response to testing challenges, on April 3, 2020, UNOS added COVID-19 testing information to DonorNet, the database that contains donors’ medical information and that executes match runs and makes electronic organ offers. Making COVID-19 testing information available enables accepting transplant centers to see if testing was already performed by another center and the results, thus saving time.9 To address the need for temporary inactivations for waitlisted patients, UNOS added a new category of temporary inactivation of transplant candidates for the reason of “COVID-19 Precaution” with no loss of waiting time.10 In a similar policy modification, UNOS changed waiting time initiation for non-dialysis transplant candidates which enables transplant programs to apply for retroactive waiting time modifications for candidates that were unable to obtain additional testing required for registration due to the pandemic.10
To address concerns about safety for patients and donors visiting the transplant center, centers have expanded their telehealth services to conduct evaluation visits with multidisciplinary team members and regular check-ins with kidney patients for post-transplant care. On April 13, 2020, in a letter to Alex Azar,11 Secretary of the Department of Health and Human Services, ASN encouraged the Trump Administration to temporarily expand Medicare-approved and reimbursed telehealth visits to include transplant candidate and living donor assessments in the list of Medicare-approved telehealth services, which were already broadened on March 17th in response to the pandemic.12 The Trump Administration has not yet approved further expansion of Medicare-approved home lab tests for transplant patients and living donors.
In another letter to the Secretary, ASN requested prioritization of organ donors and transplant recipients for COVID-19 testing.12 According to a preliminary study, no one specific type of immunosuppressive drug regimen makes a patient more susceptible to COVID-19 compared to other regimens.13 Medical professionals have advised kidney patients who are immunocompromised to continue with their immunosuppressive regimens. To ensure that patients have access to their medications, ASN requested Healthcare Management Systems (HMS) insurers to cover 90-day supplies and mail-order delivery of prescription drugs for transplant, diabetic and end stage kidney disease patients.10
Additional preliminary studies have shown that symptoms of COVID-19 do not differ in transplant patients compared to the general population.13 It is not yet known whether the rate of complications due to COVID-19 may be higher among this population. More research is needed before experts can weigh in conclusively on these issues. As with the general population, there are currently no FDA approved therapies for transplant patients, but clinical trials are available to a limited number of patients. Supportive care is the mainstay of treatment at the moment.
If you are experiencing any respiratory symptoms or fevers and are concerned about COVID-19, please contact your medical team. If you are a dialysis or transplant patient, our team of nephrologists, health educators and transplant experts created a guide with tips and FAQs to help you navigate transplant care during the pandemic.
During these times, it is important to continue to shelter-in-place, keep practicing social distancing, and use caution. As the COVID-19 pandemic brings many small- and large- scale changes to the way we navigate and access care, staying up to date with current policies is more important than ever. In response to the challenges in transplantation stemming from the COVID-19 pandemic, at-home-services like telehealth visits, mail-order prescriptions, and home lab visits are becoming standard options that offer more flexible ways to connect with care now, and beyond the pandemic.
Reference List
- Registry NK. Kidney Transplant Centers: Top United States Kidney Transplant Centers. In:2020.
- Services CfMM. CMS Adult Eelective Surgery and Procedures Recommendations: Limit all non-essential planned surgeries and procedures, including dental, until further notice. In:2020.
- Organizations AoOP. Information about COVID-19. In:2020.
- Registry NK. COVID-19 Testing Solutions. In:2020.
- Foundation NK. Transplant & COVID-19. In:2020.
- Foundation NK. UNOS Transplant Waitlist Status. In:2014.
- Shafi S, Zimmerman B, Kalil R. Temporary inactive status on renal transplant waiting list: causes, risk factors, and outcomes. Transplant Proc. 2012;44(5):1236-1240.
- Sharing UNfO. COVID-19 and Solid Organ Transplant. In:2020.
- Sharing UNfO. New donor data collection for COVID-19 testing and results added to DonorNet. In:2020.
- Sharing UNfO. COVID-19 Policy Actions Implemented. In:2020.
- Agarwal A. Letter to Secretary of Department of Health and Human Services. 2020.
- Services CfMM. Additional Background: Sweeping Regulatory Changes to Help U.S. Healthcare System Address COVID-19 Patient Surge. In:2020.
- Columbia UKTP. Early Description of Coronavirus 2019 Disease in Kidney Transplant Recipients in New York. Journal of the American Society of Nephrology: JASN. 2020.