Practicing With Uncertainty: Kidney Transplantation During the COVID-19 Pandemic

Abstract

The coronavirus disease 2019 (COVID-19) pandemic required transplant nephrologists, surgeons, and care teams to make decisions about the full spectrum of transplant program operations and clinical practices in the absence of experience or data. Initially, across the country, there was a reduction in kidney transplant procedures and a striking pause in the conduct of living donation and living-donor transplant surgeries. Aspects of candidate evaluation and follow-up rapidly converted to telehealth. Months into the pandemic, much has been learned from experiences worldwide, yet many questions remain. In this Perspective, we reflect on some of the practice decisions made by the transplant community in the initial response to the pandemic and consider lessons learned, including those related to the risks, benefits, and logistical considerations of proceeding with versus delaying deceased-donor transplantation, living donation, and living-donor transplantation during the pandemic. We review the evolution of therapeutic strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their use in transplant recipients, current consensus related to immunosuppression management in infected transplant recipients, and emerging information on vaccination against SARS-CoV-2. We share our thoughts on research priorities, discuss the areas in which we are still practicing with uncertainty, and look ahead to the next phase of the pandemic response.

Keywords: Coronavirus disease 2019 (COVID-19); allograft rejection; evaluation; follow-up; immunosuppression management; kidney transplantation; living kidney donation; pandemic; screening; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); telehealth; therapeutics; vaccines.

Figure 1

Barriers to LDKT surgery during the COVID-19 pandemic. Original graphic ©2020 International Society of Nephrology; adapted from Lentine et al with permission of the copyright holder.

Figure 2

Impact of the COVID-19 pandemic on US kidney transplant volumes. Cumulative LDKT (A) and DDKT (B) activity based on Organ Procurement and Transplantation Network and Scientific Registry of Transplant Recipients data as of September 2020 (green line) with cumulative volume for 2019 shown for comparison (blue line). Changes in volume of LDKT (C) and DDKT (D) in each US transplant program during the first 6 months of the pandemic (March 1, 2020, through August 31, 2020) compared with the preceding 6 months (September 1, 2019, through February 29, 2020) grouped by prepandemic program volume. For LDKT, the vast majority of US programs had a decrease in volume, which was particularly noticable in high-volume programs. For DDKT activity, even though volume was lower than at baseline at many programs, a substantial number of programs (mostly large and medium-sized, along with few small programs) performed more DDKT procedures than during the prepandemic period.

Figure 3

Currently known and uncertain future impacts of the COVID-19 pandemic across the spectrum of kidney transplantation practice.