Survey of US Living Kidney Donation and Transplantation Practices in the COVID-19 Era

Abstract

Introduction: The scope of the impact of the COVID-19 pandemic on living donor kidney transplantation (LDKT) practices is not well defined. Methods: We surveyed US transplant programs to assess practices, strategies, and barriers to living LDKT during the COVID-19 pandemic. After institutional review board approval, the survey was distributed from 9 May 2020 to 30 May 2020 by e-mail and postings to professional society list-servs. Responses were stratified based on state COVID-19 cumulative incidence levels. Results: Staff at 118 unique centers responded, representing 61% of US living donor recovery programs and 75% of LKDT volume in the prepandemic year. Overall, 66% reported that LDKT surgery was on hold (81% in "high" vs. 49% in "low" COVID-19 cumulative incidence states). A total of 36% reported that evaluation of new donor candidates had paused, 27% reported that evaluations were very much decreased (>0% to <25% typical), and 23% reported that evaluations were moderately decreased (25% to <50% typical). Barriers to LDKT surgery included program concerns for donor (85%) and recipient (75%) safety, patient concerns (56%), elective case restrictions (47%), and hospital administrative restrictions (48%). Programs with higher local COVID-19 cumulative incidence reported more barriers related to staff and resource diversion. Most centers continuing donor evaluations used remote strategies (video, 82%; telephone, 43%). As LDKT resumes, all programs will screen for COVID-19, although timeframe and modalities will vary. Recommendations for presurgical self-quarantine are also variable. Conclusion: The COVID-19 pandemic has had broad impacts on LDKT practice. Ongoing research and consensus building are needed to reduce barriers, to guide optimal practices, and to support safe restoration of LDKT across centers.

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

“…A survey of U.S. programs in May 2020 identified multiple barriers to living donation and LDKT surgery during the early phase of the pandemic, including program concerns for donor (85%) and recipient (75%) safety, patient concerns (56%), elective case restrictions (47%), and hospital administrative restrictions (48%). 7 Programs with higher local COVID-19 cumulative incidence reported more barriers related to staff and resource diversion.…”

“…5,6 The rationale for the dramatic disruption of practices early on included categorizing LDKT as 'elective' (i.e., distinct from some 'essential' DDKT) and possible to safely delay, especially in locations with strained resources including the availability of ventilators (Figure 1). 7 Further, LDKT has additional complexity related to safety concerns both for the recipient, as early reports suggested that transplant recipients face substantially increased mortality risks following severe acute respiratory syndrome coronavirus 2 (SARS CoV 2) infection, 8,9 and also for the living donor. A by-proxy effort to synthesize consensus based on 19 professional society bulletins published in March J o u r n a l P r e -p r o o f 2020 offered strong agreement (14/19) for reduction to a minimum, if not complete postponement, of 'elective' transplantation, in particular LDKT, during the pandemic.…”

“…17 Recent surveys show wide variation in adoption of these recommendations. 6,7 In July 2020, the AST modified recommendations to suggest that while self-quarantine is recommended as a preventive strategy, it should not be mandatory. 16 Given the widespread nature of the pandemic, individuals who have recovered from COVID-19 may present for living donor candidate evaluation.…”

“…A recent survey of U.S. programs found less than half counsel donors that the risk of contracting COVID-19 is not impacted by donation, less than a third counsel that the risk of complications is not impacted by donation, while 57% educate donors about associations of COVID-19 and acute kidney injury (AKI). 7…”

Health Care Policy and Regulatory Challenges for Adoption of Telemedicine in Kidney Transplantation

“…1 Telemedicine has allowed transplant centers to sustain pretransplant evaluations of kidney failure patients and potential live kidney donors and post-transplant continuity of care for both the recipient and donor. 13 Moreover, telemedicine provides prompt and safe approach to transplant patients with COVID-19. We have developed a practical workflow process using telemedicine to manage kidney transplant patients with COVID-19 while avoiding emergency room or clinic visit, which is especially important for such immunosuppressed patients who may have prolonged viral shedding.…”