Ethical analysis examining the prioritisation of living donor transplantation in times of healthcare rationing.

The transplant community has faced unprecedented challenges balancing risks of performing living donor transplants during the COVID-19 pandemic with harms of temporarily suspending these procedures. Decisions regarding postponement of living donation stem from its designation as an elective procedure, this despite that the Centers for Medicare and Medicaid Services categorise transplant procedures as tier 3b (high medical urgency-do not postpone). In times of severe resource constraints, health systems may be operating under crisis or contingency standards of care. In this manuscript, the United Network for Organ Sharing Ethics Workgroup explores prioritisation of living donation where health systems operate under contingency standards of care and provide a framework with recommendations to the transplant community on how to approach living donation in these circumstances.To guide the transplant community in future decisions, this analysis suggests that: (1) living donor transplants represent an important option for individuals with end-stage liver and kidney disease and should not be suspended uniformly under contingency standards, (2) exposure risk to SARS-CoV-2 should be balanced with other risks, such as exposure risks at dialysis centres. Because many of these risks are not quantifiable, donors and recipients should be included in discussions on what constitutes acceptable risk, (3) transplant hospitals should strive to maintain a critical transplant workforce and avoid diverting expertise, which could negatively impact patient preparedness for transplant, (4) transplant hospitals should consider implementing protocols to ensure early detection of SARS-CoV-2 infections and discuss these measures with donors and recipients in a process of shared decision-making.

Efficacy of remdesivir for hospitalized COVID-19 patients with end stage renal disease.

BACKGROUND: Since the beginning of corona virus disease 2019 (COVID-19) pandemic, there has been a widespread use of remdesivir in adults and children. There is little known information about its outcomes in patients with end stage renal disease who are on dialysis. AIM: To assess the clinical outcomes with use of remdesivir in adult patients with end stage kidney failure on hemodialysis. METHODS: A retrospective, multicenter study was conducted on patients with end stage renal disease on hemodialysis that were discharged after treatment for COVID-19 between April 1, 2020 and December 31, 2020. Primary endpoints were oxygen requirements, time to mortality and escalation of care needing mechanical ventilation. RESULTS: A total of 45 patients were included in the study. Twenty patients received remdesivir, and 25 patients did not receive remdesivir. Most patients were caucasian, females with diabetes mellitus and hypertension being the commonest comorbidities. There was a trend towards reduced oxygen requirement (beta = -25.93, X 2 (1) = 6.65, P = 0.0099, probability of requiring mechanical ventilation (beta = -28.52, X 2 (1) = 22.98, P < 0.0001) and mortality (beta = -5.03, X 2 (1) = 7.41, P = 0.0065) in patients that received remdesivir compared to the control group. CONCLUSION: Larger studies are justified to study the effects of remdesivir in this high-risk population with end stage kidney disease on dialysis.

Coronavirus Disease 2019 in Kidney Transplant Recipients: Single-Center Experience and Case-Control Study.

BACKGROUND: Kidney transplant recipients (KTR) are considered high-risk for morbidity and mortality from coronavirus disease 2019 (COVID-19). However, some studies did not show worse outcomes compared to non-transplant patients and there is little data about immunosuppressant drug levels and secondary infections in KTR with COVID-19. Herein, we describe our single-center experience with COVID-19 in KTR. METHODS: We captured KTR diagnosed with COVID-19 between March 1, 2020 and May 18, 2020. After exclusion of KTR on hemodialysis and off immunosuppression, we compared the clinical course of COVID-19 between hospitalized KTR and non-transplant patients, matched by age and sex (controls). RESULTS: Eleven KTR were hospitalized and matched with 44 controls. One KTR and 4 controls died (case fatality rate: 9.1%). There were no significant differences in length of stay or clinical outcomes between KTR and controls. Tacrolimus or sirolimus levels were >10 ng/mL in 6 out of 9 KTR (67%). Bacterial infections were more frequent in KTR (36.3%), compared with controls (6.8%, P = .02). CONCLUSIONS: In our small case series, unlike earlier reports from the pandemic epicenters, the clinical outcomes of KTR with COVID-19 were comparable to those of non-transplant patients. Calcineurin or mammalian target of rapamycin inhibitor (mTOR) levels were high. Bacterial infections were more common in KTR, compared with controls.

Inpatient Dialysis Planning During the COVID-19 Pandemic: A Single-Center Experience and Review of the Literature.

BACKGROUND: COVID-19 has created havoc in healthcare systems worldwide, including shortages in equipment and supplies for dialysis in the acute setting. METHODS: We compared our planning and experience at a tertiary care academic medical center to recommendations in the literature. RESULTS: Published literature and our experience underscored the need to plan for adequate dialysis equipment, particularly for continuous renal replacement therapy in the ICU setting, adequate nursing, and flexible scheduling of chronic patients to accommodate the surge in acute patients. We discovered other "shortages" not mentioned in the literature: shortages in the number of portable reverse osmosis (RO) machines needed to prepare dialysis water, inadequate number of rooms in units designated for COVID-19 patients with plumbing for dialysis, and lack of temperature blending valves on sinks that necessitated using cold water only, and damaging the RO membranes. We identified the need for cooperation between nephrology and critical care medicine, hospital-based and community nephrologists and community dialysis units as well as nephrologists at other hospitals in the region. We turned to guidance from the hospital ethics committee. CONCLUSION: Planning for an expected surge in hospitalized patients requiring RRT demands coordination between critical care, dialysis and nursing services as well as community and hospital providers to make certain there are adequate dialysis resources. Our experience suggests that continuous dialysis is in greatest demand early in the illness, and that plans to increase supplies should be put in place. But, planning should also focus on unforeseen hospital-specific infrastructure shortages that can develop over time and hamper intermittent dialysis delivery to all patients who require treatment.

Successful recovery from COVID-19 in three kidney transplant recipients who received convalescent plasma therapy.

Novel coronavirus disease 2019 (COVID-19) is a highly infectious, rapidly spreading viral disease that typically presents with greater severity in patients with underlying medical conditions or those who are immunosuppressed. We present a novel case series of three kidney transplant recipients with COVID-19 who recovered after receiving COVID-19 convalescent plasma (CCP) therapy. Physicians should be aware of this potentially useful treatment option. Larger clinical registries and randomized clinical trials should be conducted to further explore the clinical and allograft outcomes associated with CCP use in this population.