Telemedicine Services for Living Kidney Donation: A U.S. Survey of Multidisciplinary Providers

Purpose: Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine has the potential to facilitate care delivery/ coordination for donors. We aimed to understand center practices and provider attitudes and perceived barriers of telemedicine services for living kidney donation. Method(s): We conducted a national survey of multidisciplinary providers from 194 U.S. active adult living donor kidney transplant centers in 2020. The survey was distributed with an online link from 2/18/2021 to 5/13/2021, and up to two reminders were provided. The target population included nephrologists, surgeons, nurse coordinators, social workers or independent living donor advocates, and psychiatrists or psychologists. We used descriptive statistics and analysis of variance. Result(s): Two hundred ninety-three providers from 128 unique centers responded to the survey, a center representation rate of 66.0%, reflecting 82.9% of U.S. practice by donor volume and 91.5% of U.S. states/territories. Most centers (70.3%) will continue using telemedicine beyond the COVID-19 pandemic. Video only was mostly used for donor evaluation by nephrologists, surgeons, psychiatrists or psychologists. Telephone and video were mostly used by social workers, while no mutual modality was used by coordinators. Vital signs and weight were obtained largely using self-reported measures or a local provider/primary care physician, and a physical exam was mostly completed at a subsequent in-person visit to the transplant center. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation for potential donors. These attitudes were consistent across provider roles (p>0.05). Providers were favorably disposed to use telemedicine beyond the pandemic for donor evaluation and followup care. Out-of-state licensing and reimbursements were key regulatory barriers. Conclusion(s): These findings help inform clinical practice and policy expanding telemedicine services to enhance access to living donation and may be extended to other medical specialties.

Nurse and nurse practitioner-lead monoclonal antibody initiative for solid organ transplant (SOT) recipients with COVID-19

Purpose: Monoclonal antibody (mAB) infusion (bamlanivimab or casirivimab/ imdevimab) for symptomatic, non-hypoxemic, high-risk outpatients with COVID-19 infection, is an available early intervention for COVID-19+ SOT recipients. We aimed to assess efficiency in time from diagnosis to treatment, and outcomes in a retrospective cohort of SOT recipients with COVID-19 who received mAB. Methods: We developed a Nurse Coordinator-led initiative to screen, refer, and facilitate mAB infusion for COVID-19+ SOT recipients within 10 days of symptom onset. SOT recipients received electronic messaging to promptly report potential COVID-19 symptoms to the transplant team. Data were collected on time from symptom onset to diagnosis, mAB infusion, and follow-up > 21 days, and hospital admissions, disease severity, mortality, and rejection. Results: 34 out of 36 referred SOT recipients with symptomatic COVID-19 disease without hypoxia received mAB therapy (3 heart, 8 lung, 16 kidney, 2 Liver-Kidney, 2 Pancreas-Kidney, 3 Kidney-Heart). Median time from symptom onset to diagnosis was 2 days and from date of diagnosis to mAB infusion was 4 days. Of those 34, 88% did not require hospitalization and recovered uneventfully. 12% required hospitalization for COVID disease progression, two on the same day as mAB infusion, and the other 2, more than 26 days post infusion. Of these, 2 patients had mild-moderate hypoxia, and 2 had critical disease. Only 1 patient died from COVID-19 complications and no episodes of rejection or graft loss were observed. Conclusions: The Nurse Coordinator-led initiative efficiently facilitated mAB therapy for COVID-19+ SOT recipients and was associated with excellent outcomes. Compared to prior published COVID-19 outcomes in SOT recipients, patients who received mAB may have reduce hospitalization and low mortality. As mAB therapy may be underutilized in the general population, these results support efforts to educate transplant centers to implement efficient interventions for the screening and referral of COVID+ SOT recipients for mAB therapy.

Telemedicine in the care of kidney transplant recipients with COVID-19

Introduction: Kidney transplant (KT) recipients with COVID-19 symptoms are bringing challenges to providers given the risk of COVID-19 exposure to health care workers, patients, and the public. Case Description: Three KT recipients with COVID-19 were managed using telemedicine via synchronous video visits integrated with an electronic medical records system, from home to inpatient settings (Figure 1-2). Patient 1 is a 53-year-old male s/p KT in 2012;Patient 2 is a 56-year-old female s/p KT in 2019;and Patient 3 is a 53-yearold female s/p simultaneous liver-kidney transplant in 2014. Patients 1 and 3 had followup COVID-19 NAT testing: Patient 1 converted to be negative at 24 & 28 days, whereas Patient 2 converted to be negative at 45 & 48 days. Discussion: Telemedicine helped assess, diagnose, triage, and treat patients with COVID-19 while avoiding an ER or outpatient clinic visit. We highlight the value of telemedicine in the maintenance of uninterrupted follow-up care for immunosupressed patients with prolong viral shedding.