Transplant Decisions Complicated by Donor COVID-19 Unknowns

Marcia Frellick

March 23, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Uncertainty about what COVID-19 means for kidney transplantations is quickly eclipsing the concerns related to the major changes in the way kidneys are allocated that are expected by the end of the year.

"We can't test donors and know whether they are COVID-positive," said Alden Doyle, MD, a transplant nephrologist and medical director of the kidney and pancreas transplant program at University of Virginia Health in Charlottesville.

"We can make assumptions, but you can't 100% know, like you could with hepatitis C or flu or any other virus," he told Medscape Medical News. "Imagine you've been on dialysis for 5 years and you get this great offer. I can't tell you for sure that the donor wasn't carrying COVID."

Current limitations in testing mean that COVID-19 test results for deceased kidney donors can take 4 to 5 days, said Doyle, who will discuss changes in the allocation of kidneys at the now-virtual National Kidney Foundation (NKF) 2020 Spring Clinical Meetings.

Decision to Accept Kidneys

Transplant physicians are having new discussions about choice and risk.

"We go through why we think the donor is or is not infected and have that discussion with patients, but we're figuring it out on the fly," said Doyle.

His team recently got offered two kidneys.

"We took one and not the other," he said. "One died of an undiagnosed respiratory illness, probably not COVID, but could be, and we turned that one down, and one died of a totally unrelated reason and we took that one."

Transplant patients are at higher risk of contracting COVID-19 because of their immunosuppression, he pointed out.

Last week, as calls to limit nonessential surgeries of all kinds in the United States became louder, the NKF asked for clarification.

"We are grateful to the Administration for clarifying that transplantations are an essential surgery which can be performed safely if a hospital feels they have the staff and resources available during the COVID-19 crisis," writes Joseph Vassalotti, MD, chief medical officer of the NKF, in a statement.

"While some may think prospective transplant patients can remain on dialysis until the threat of COVID-19 has passed, it is important to recognize that this might not be in the patient's best interest," he adds.

Without that clarification, organizations that facilitate transplants might not have been able to even enter a hospital.

Living Donors Can Start the Process Virtually

Living-donor kidney transplants, in contrast, are considered elective surgery and, under normal circumstances, can be scheduled at the convenience of the donor and recipient, said Mona Doshi, MBBS, director of the live-donor kidney transplant program at Michigan Medicine in Ann Arbor.

However, her hospital and many others are currently "not performing any living-donor kidney transplant surgeries to protect the health of the donor and the recipient," she told Medscape Medical News.

These surgeries will be scheduled once the pandemic is "under control and it is safe for the donor and recipient to be in the hospital. Most of the donor–recipient pairs are understanding and willing to wait until COVID is over," she added.

Evaluation, however, can begin on the phone and over video, said Doshi, who is also scheduled to speak at the virtual conference.

"We will be able to screen out candidates who are not suitable based on medical and social history. This will also give recipients a chance to seek for alternative donors. Once COVID is under control, this leg work will allow us to quickly resume the life-saving surgery of live-donor kidney transplant," she explained.

There are more than 100,000 patients waiting for kidney transplantation in the United States, and only 18,000 underwent the procedure in 2019. The wait for a deceased donor kidney is currently from 4 to 8 years.

There is detailed guidance on disease management, dialysis, and transplantation during the COVID-19 crisis on the NFK website.

System Transformation

Before the emergence of COVID-19, there were already questions about how kidneys from deceased donors would fare when the allocation system changed at the end of this year.

During his virtual presentation, Doyle will describe how the mission to balance justice in transplantation, with the goal of getting more organs transplanted successfully, has evolved since the 1980s.

At the end of this year, the system will no longer give preference to patients on the basis of which of the 58 donor-service areas they live in.

Currently, if you live 2 miles outside a donor-service area, you could have lower priority than someone living much farther away but within that area's boundaries. The new system will give preference to those within 250 nautical miles of the hospital where the donor is listed.

Donor-service areas were eliminated earlier this year for heart and lung transplantation and for liver transplantation, and those systems now use nautical miles.

But for kidneys, the switch means that many organs will have to travel farther, and many will be flown instead of driven, which raises concerns about how much "cold time" each organ will have before transplant, whether more will thus be rejected, and logistical issues related to delivery, said Doyle.

He also noted that 250 nautical miles is very different if the terrain is mountainous or if the route is through Manhattan rather than a sparsely populated area.

Flights are also an issue, with pilot shortages and regional peculiarities. In Alabama, for example, the airports are so jammed on days surrounding University of Alabama football games that it would be difficult to fly kidneys, he explained.

The modeling for the new system gets closer to the balance between justice and utility and is a step in the right direction, but the process still needs to evolve, he said.

The talk in the transplant community, Doyle reported, is that eventually the 250 nautical mile threshold will be phased out, and that there won't be any single number but a complex equation that gives a score that takes into account organ quality, how an organ travels, how sick a patient waiting for a kidney is, the recipient's distance from the donor, and a number of other factors.

National Kidney Foundation (NKF) 2020 Spring Clinical Meetings. To be presented March 26, 2020.

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