The deceased organ donor rate in Canada in 2018 (including Quebec) was 20.6 donors per million population, an increase of 42% since 2009.*
In 2018, a total of 2,782 transplant procedures (all organs) were performed in Canada (including Quebec), an increase of 33% since 2009.*
At the end of 2018, there were 4,351 people on a waiting list for an organ transplant, including 2,890 who were active on the list.*
We decided this because the recipient of a kidney receives a higher dose of immunosuppressive medicines around the operation. These patients may be extra vulnerable to (and side) infections. The safety of our patients is a priority. That is why we do not want to take extra risk, as long as the exact impact is still unclear at this time.
Recommend avoiding grouping of patients for education or clinical activities.
Ensure that all wait-listed or transplanted patients can adhere to social distance protocols in clinics or hospital.
Recommend temperature screening of all patients seen in clinic.
Recommend screening and self-isolation after travel as per local practice and protocols.
Recently transplanted patients should follow respiratory principle and wear a mask when available.
Recommend developing guidance for candidates and recipients about risk mitigation, including but not limiting exposure to large crowds, hand hygiene and avoidance of sick exposures.
Recommend screening and self-isolation after travel as per local practice and protocols.
Consider postponement of routine visits and surveillance.
Postpone all non-essential surveillance of wait-listed patients.
Recommend only seeing critical patients and defer routine surveillance visits.
Develop messaging for candidates and recipients abut how and when to contact the transplant centre in case of illness.
Encourage working from home (and supporting medical justification if needed), eliminate non-essential travel, hand hygiene, general social distancing.
Consider postponement of routine visits and surveillance.
Limit all non-essential contact and recommend increased use of distance consultation.
Detailed recommendations on how to favour remote evaluation (telephone or videoconferencing).
Follow-up with various means like mobile and email.
Determine approaches to minimize exposure to healthcare setting by considering: reduced frequency of clinic visits and lab tests, deferral of elective procedures (i.e. protocol biopsies) in stable patients, delaying pre-transplant evaluations for patients who do not require immediate evaluation. Telephonic follow-up when possible.
1) Postponing routine surveillance heart biopsies and bronchoscopies in patients that are more than 3-6 months from transplantation. 2) Increased importance of home as opposed to hospital based spirometry. 3) for heart recipients, suggest considering the use of non-invasive methods for rejection surveillance, as available such as gene expression profiling.
Potential and actual transplant recipients are by definition an at-risk population.
Acknowledge that exact risk is unknown but very likely increased compared to general population.
At risk of developing severe COVID-19; counsel recipient and family as high-risk.
Recommend a combination of tele-practice, pre-visit screening calls and limiting visits further if patient has COVID-19 consistent symptoms ISHLT.
Consider airborne precautions for recipient if donor had negative testing but epidemiological risk factors.
Should be housed in single rooms with an attached bathroom and all staff attending to them should be in full PPE until infection with COVID-19 is ruled out.
Suspended need for post-transplant follow-up reporting back dated to March 13 declaration of emergency. Also have created new data fields for COVID-19 related refusals of organs.
Recommend confirmation of blood product supply, ventilators and PPE prior to acceptance.
In geographically confined outbreaks, transplant authorities may consider putting transplant candidates on the waiting list at alternative centres for transplantation.
Centre should not be earmarked for the treatment of COVID-19 patients and needs to have protocols for patient movement around the hospital to prevent nosocomial acquisition of COVID.
Apply restrictions in travel for procurement and shipment of organs according to the policies decided by public authorities in the different ET member countries during the epidemic.
Whenever possible, recover organs locally and ship them. For those centres that cannot recover organs locally, the decision to send a surgical team can be assessed on case-by-case basis, relative to recipient urgency.
Screen and test.
Procurement activity has to be planned depending on the locally available resources and ideally by identifying at least one recipient for the organs to be procured ahead of the procedure. Programs should avoid procurement procedures for which subsequently no recipient is found.
All programs assess program specific risk/benefit analyses in devising their own unique additions for the benefit of their staff and patients.
With all this, the benefit of transplantation as compared to the risk of severe COVID infection is therefore difficult to assess and likely to evolve to the detriment of transplantation in the course of a worsening epidemic.
Must consider all resources for entirety of transplant pathway.
The transplant team must evaluate each organ offer for the specific potential recipient in light of resource availability and total course, prior to deciding whether to proceed with transplant. Specific mention of likely shortage of blood and blood products.
Consideration for all donors that have – COVID-19 screening test. ICU capacity to maintain donor or treat recipient is at discretion of ICU consultant (most responsible physician).
State that all transplantation should be done on a case by case balancing ICU resources, risk to patient and risk of immunosuppression.
Recommendations must balance the incidence trends in provinces and territories, the risk posed to potential recipients who will become immunocompromised, and the risks of suspending or delaying transplantation.
If donor had inconclusive or unavailable testing results, informed consent with potential recipient on unknown risk of transmission and lack of currently approved therapies.
Recommend informing all parties of risks during “uncertain times”.
| Separate consent recommendations: https://bts.org.uk/information-resources/covid-19-information/ |
If living donation from a COVID-19 + donor deemed medically necessary, explicit informed consent required for both donor and recipient. Deceased donation: If a graft from a donor with unknown COVID-19 status used, must have explicit informed consent from recipient.
For emergency lifesaving transplantation: appropriate counselling of both the donor and recipient as well as their families should be done, and a high-risk informed consent taken before proceeding with the transplant.
If transplantation is required as a life-saving procedure, it can be conducted with appropriate assessment of infection in door and recipient and with appropriate informed consent.
Regardless of donor screening, the centre should have a discussion of risk-benefit with the recipient.
Recipients of solid organ transplants should be fully informed at time of organ offer of the potential risk of severe complications should they contract the virus at the time of transplant, during the hospital stay, or once discharged from the hospital while being immunosuppressed. This informed consent should be clearly documented in the hospital chart.
Recommend diminishing or eliminating need for hospital presence for providers at higher risk (e.g. over 65, immuncompromised, underlying conditions).
| We recommend strict application of protective measures in transplant patients. |
To the extent feasible off-site, remote working and social distancing is prudent.
Recommend limiting face-to-face interactions as much as possible, including on patient rounds post-transplant.
Increased number of vehicles for transport to increase distance between staff. Masks to be worn when social distancing impossible. Anticipate absenteeism for various reasons.
Encourage videoconferencing even within the same building and alterations in catering practices.
Staff involved in care of transplant patients may not be involved in case of other patients.
Determine who can work remotely and ensure they have the resources to do so.
If surgical recovery teams travel, the teams should be as small as possible. Every effort should also be made to minimize the team’s potential exposure to COVID-19. For example, upon arrival in locality, teams should go directly to the OR, they should avoid the emergency department whenever possible, and they should return directly to the plane as soon as they are able.
Respiratory caution for all of us and respiratory barrier protection for healthcare workers should be incorporated into ALL transplant program protocols.
Recommend continuing with hospital procedures for OR PPE use for COVID-19 negative patients (all donors screened).
Bronchoscopy in cases of suspected COVID-19 or in areas where community transmission is occurring should be done using airborne isolation precautions.
N95 masks should be required for all ICU and OR staff, when deemed appropriate by
hospital safety protocols (e.g., procedures that may lead to aerosolization of the virus such
as intubation, bronchoscopy, surgical cautery, bone saw).
Surgical mask.
We suggest all health care professionals deploy routine universal precautions (surgical masks, gloves) during the care of COVID-negative donors and recipients.” “acknowledged that there is regional and institutional variability with respect to: i) COVID-specific PPE ii) Universal precautions iii) No routine precautions.
Strict isolation precautions should be followed for anyone with suspected SARS-CoV2.
It is important to follow local protocols for suspected patient infections.
Staff who have returned from countries with >10 infected patients or have been exposed to a confirmed or suspected case of COVID-19 within the last 14 days should follow hospital policies, but should likely not care for transplant patients.
CDC has recommended use of airborne precautions and N95 masks for healthcare workers while they remain available.
Use airborne and contact precautions with face shield when entering the patient room with suspected + case.
Strong recommendation to follow national guidance adapted to local conditions.
Adhere to local protocols.
During the donation process medical staff should apply appropriate and hygiene and use personal protective
equipment in accordance with national public health guidelines [61,62]. Personal protective measures in the
donation area of a SoHO establishment which is not located in a hospital environment should not be as
stringent as in settings where staff take care of infected or potentially infected patients. Infection control
practices and measures should be in line with the national public health recommendations for COVID-19
[63].
Unless COVID-19 is suspected on epidemiological or clinical grounds, additional precautions to those usually employed for acquiring respiratory samples in standard, non-COVID-19 ICU patients is NOT required. Specifically, there is no need for patient isolation or the use of non-standard ICU PPE in ongoing care of these patients.
…”has to be adequate availability of PPE for care of these patients”
“Full PPE” as per local protocol when in contact with confirmed or suspected COVID-19 + patient.
General hygiene ( frequent hand washing, disinfect surfaces, avoid hand-face contact), avoidance, N95 and eye protection when in close contact.
Adhere to the CDC’s recommendations on PPE.
Suspension of all living donation.
Intention to withdraw the April matching run.
All living-donor kidney transplantation and deceased donor transplantation in patients that are stable on dialysis are put on hold until the end of the COVID-19 epidemic.
Minimum of 6 weeks (effective Mar 16).
Advised to practice social distancing and not travel 14 days prior to surgery.
Recommend 28 days past resolution of symptoms and negative testing prior to consideration for use.
Two negative tests before being considered for donation and another negative test at the time of donation.
Possibly not low risk donor candidates, but currently few patients would be considered low risk.
Same as for deceased donors. PCR diagnostics must have been carried out on all living donors prior to organ removal to exclude the possibility of COVID-19 infection. If the PCR test on the living donor is positive, the organ removal must not be carried out.
Testing no longer than 7 days before donation.
Exclude if testing positive.
Where available, testing of upper and lower airway specimens by PCR/NAT of donors with concern for COVID-19 should be considered.
Testing occurring as close as possible prior to donation (within 24–48 hours). Current data suggests the optimal test type in this ambulatory setting is a nasopharyngeal swab.
Delay for 14 days.
21 days from travel to endemic area or contact with confirmed case.
At least 14 days after contact with COVID-19 positive or travel to region with sustained community transmission.
Exclusion if international travel in last 14 days or contact in last 14 days with confirmed case of COVID-19.
Should not be performed on either a donor or recipient who has returned from countries with >10 infected patients or who have been exposed to a patient with confirmed or suspected COVID-19 within 14 days.
If donor has been within an endemic area, wait at least 14 days (presumed incubation period) for symptom development.
The living donor transplant programme may be temporarily suspended…all elective live living kidney and liver transplant should be postponed.
14 days after international travel.
Living donors are classified into high, intermediate and low risk based on testing, clinical signs and epidemiological factors.
| Donors who are at risk of COVID-19 or are self- isolating are not to be considered for organ donation. |
Defer regardless of symptoms.
Question all potential donors for potential febrile respiratory symptoms or contact with COVID-19 suspected persons in 28 days prior to donation.
Donors should not be utilized if they have fever and/or respiratory symptoms unless SARS-CoV-2 is excluded.
Exclude if history of fever or acute respiratory infection (eg. Shortness of breath, cough, sore throat) with or without fever.
Donors should not be utilized if they have fever and/or respiratory symptoms unless SARS-COV-2 is excluded.
Any donor with compatible symptoms should be deferred but should also be tested to allow for future planning.
Temporary suspension may need to be considered.
Except for medical emergencies (e.g. pediatric acute liver failure).
Except for medical emergencies (e.g. pediatric acute liver failure).
In countries with widespread community transmission, temporary suspension of the living-donor kidney and liver transplant programs should be considered when donation can safely be deferred to a later date.
In countries with widespread community transmission, temporary suspension of the living-donor kidney and liver transplant programs should be considered when donation can safely be deferred to a later date.
Carries greater urgency…should continue on a case-by-case basis, taking into account recipient medical need and hospital resource utilization.
Temporary suspension may need to be considered.
Recommend suspension until COVID-19 epidemiology better understood in US.
Evaluated on a case by case basis.
Program was suspended but the decision now is to start the program in phases.
Maintenance of activity for COVID-19 negative donors and recipients.
In countries with widespread community transmission, temporary suspension of the living-donor kidney and liver transplant programs should be considered when donation can safely be deferred to a later date.
All living-donor kidney transplantation and deceased donor transplantation in patients that are stable on dialysis are put on hold until the end of the COVID-19 epidemic.
The living donor transplant programme may be temporarily suspended…all elective live living kidney and liver transplant should be postponed.
In countries with widespread community transmission, temporary suspension of the living-donor kidney and liver transplant programs should be considered when donation can safely be deferred to a later date.
Recommend restart in 3 phases:
1. The first priority will be to resolve the donation and transplantation chains affected the suspension of the program on March 16, 2020. The goal is to complete or collapse all affected chains by August 2020.
2. With an anticipated start date of June 2020, match runs will take place every month, as opposed to three times per year. The purpose of this change is to better accommodate provincial programs, as it is expected they will incrementally return to normal operations. The greater frequency of match runs will also help to identify as many matches as possible, given the limited number of opportunities for matches that are anticipated going forward. Programs will also be encouraged to ship and receive kidneys, instead of asking donors to travel, with some local travel by donors taking place at the discretion of programs.
3. It is expected that most provincial programs will have returned to normal operations by Fall 2020. The KPD program will work with provincial programs to identify opportunities for innovation and adapt for the new environment.
Recommend continued life-saving transplantation on case-by-case basis.
Centres continue to transplant all in-patient recipients on case by case evaluation.
The hospitals that transplant hearts and lungs strive to carry out heart and lung transplants.
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered, especially when resources at the transplant centre may be constrained. There is no clear reason to suspend deceased donor transplants in countries only experiencing sporadic cases of COVID-19 cases.
Liver, heart, and lung transplantation programs continue. As a general guideline, priority should be given to hyper-urgent and urgent transplants.
No transplantation of lungs from COVID-19 + donors.
Recommend continued life-saving transplantation on case-by-case basis.
Centres continue to transplant all in-patient recipients on case by case evaluation.
The hospitals that transplant hearts and lungs strive to carry out heart and lung transplants.
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered, especially when resources at the transplant centre may be constrained. There is no clear reason to suspend deceased donor transplants in countries only experiencing sporadic cases of COVID-19 cases.
Liver, heart, and lung transplantation programs continue. As a general guideline, priority should be given to hyper-urgent and urgent transplants.
Recommend continued life-saving transplantation on case-by-case basis.
Consider transplantation from COVID-19 + donors on case by case basis, continue donation as usual if COVID-19 negative.
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered, especially when resources at the transplant centre may be constrained. There is no clear reason to suspend deceased donor transplants in countries only experiencing sporadic cases of COVID-19 cases.
Liver, heart, and lung transplantation programs continue. As a general guideline, priority should be given to hyper-urgent and urgent transplants.
Decision must be made on case by case basis considering local resources and transmission risk.
Recommend continued life-saving transplantation on case-by-case basis.
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered, especially when resources at the transplant centre may be constrained. There is no clear reason to suspend deceased donor transplants in countries only experiencing sporadic cases of COVID-19 cases.
As a general guideline, transplantation that are not lifesaving in the short term should be delayed until the end of the COVID epidemic. Liver, heart, and lung transplantation programs continue. As a general guideline, priority should be given to hyper-urgent and urgent transplants.
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered, especially when resources at the transplant centre may be constrained.
We do not recommend a general cessation of all transplant or VAD activity due to the COVID-19 pandemic solely to liberate resources for treating COVID-19 patients.
As a general guideline, transplantation that are not lifesaving in the short term should be delayed until the end of the COVID epidemic. At that stage, liver, heart, and lung transplantation programs continue. As a general guideline, priority should be given to hyper-urgent and urgent transplants.
Recommend continued life-saving transplantation on case-by-case basis.
Recommend continuing with cases after case-by-case evaluation considering local ICU and OR resource realities.
Transplantation to continue based on case by case assessment and individual transplantation programs, but have restricted criteria for potential DCD donors.
Consider transplantation from COVID-19 + donors on case by case basis, continue donation as usual if COVID-19 negative.
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered, especially when resources at the transplant centre may be constrained. There is no clear reason to suspend deceased donor transplants in countries only experiencing sporadic cases of COVID-19 cases.
All living-donor kidney transplantations and deceased donor transplantations in patients that are stable on dialysis are put on hold until the end of the COVID-19 epidemic.
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered, especially when resources at the transplant centre may be constrained.
Recommend continued life-saving transplantation on case-by-case basis.
Transplantation to continue based on case by case assessment and individual transplantation programs, but have restricted criteria for potential DCD donors; pancreas programs are closed.
| At this time, the joint transplant centers have decided to postpone almost all renal transplant operations. This therefore applies to both kidney transplants with a kidney from a living and a deceased donor and pancreatic / islet transplants. |
Consider transplantation from COVID-19 + donors on case by case basis, continue donation as usual if COVID-19 negative. COVID-19 screening results of donor must be available prior to organ recovery.
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered, especially when resources at the transplant centre may be constrained. There is no clear reason to suspend deceased donor transplants in countries only experiencing sporadic cases of COVID-19 cases.
All deceased donor transplantation in patients that are stable on dialysis are put on hold until the end of the COVID-19 epidemic. Centres can perform kidney transplantation in patients with Eurotransplant high urgency HU) status. Renal transplantation in highly immunized patients with long waiting times can be envisioned in case a well-matched donor kidney against which the patient has no preformed donor-specific antibodies becomes available and the transplant centre considers that the risk-benefit ratio is beneficial and that the necessary resources for successful transplantation are available. Pediatric renal transplantation can therefore be performed in case treating physicians consider the benefit outweighs the potential risks related to COVID-19 infection under high dose immunosuppression. The decision should be taken after discussion with the patient’s caregivers and eventually the patient her- or himself. Kidney-pancreas transplantation is to be suspended except for high urgency transplants or in highly immunized patients according the definition given above for renal transplantation.
Islet transplantation is suspended.
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered, especially when resources at the transplant centre may be constrained.
All transplant programs should consider suspending deceased kidney transplants, except for highly sensitized recipients (PRA>=99%) or because of an urgent medical need due to a lack of access to dialysis.
Should report all post-transplant patients with suspected or confirmed COVID-19 to local infection control. Contact ODO and/or UNOS if suspected transmission through donated organ.
Separated systems will keep the infected from the uninfected.
Cohort patients with COVID from non-infected inpatients.
Prudent to limit visitors.
Severe limitations recommended such as only for hospice patients or at time of discharge instructions.
RIVM advises the vulnerable group to stay at home, to receive as little visitors as possible, to keep 1.5 meters away, to wash hands often and to allow contact with others to take place by telephone as much as possible.
| Consider suspending non-essential clinic visits. |
Limit all non-essential contact and recommend increased use of distance consultation. Ensure at least 90 day supply of medications.
Recommend distance consultation as much as possible. Limit lab or radiology that requires transfers within or between hospitals. Patients should be given 90 day medication supplies.
Recommend against coming to hospital if symptomatic unless advised by transplant team, encourage phone or video conference visits.
Transplant patients with fever and/or respiratory symptoms should be instructed to call the transplant centre and avoid presenting to the clinic without notifying the centre in advance to avoid inadvertent exposures.
Mention possible increased risk to shed and transmit virus among immunocompromised patients that have COVID-19.
Transplant units advised to consider ways to limit hospital attendance for patients such as (rescheduling on urgent out patient appts, virtual or tele-medicine or telephonic appts, home delivery of immmunosuppression if feasible). Patients with stable graft function and adequate drug supply can avoid routine follow-up visits to transplant hospitals.
Limit hospital visits, attempt to find alternative means to obtain routine lab work and other needed tests. Implement procedures to screen patients coming to clinic for fever and respiratory symptoms.
Contact transplant program if develop fever and/or respiratory symptoms, GI symptoms and other COVID related symptoms.
Recommend all symptomatic patients contact transplant teams and avoid general hospital areas.
When should I contact my medical specialist in the hospital?
• If you have a fever above 38 degrees
• If you feel feverish and have a cold like coughing, sore throat or cough
Increased risk of infection and severity among immunocompromised likely though unproven.
Fever, cough, difficulty breathing; immediately call respective transplant centre.
Any patient with fever or respiratory symptoms should call transplant centre and avoid presenting to clinic without notifying centre in advance to avoid inadvertent exposures. Telephone follow-up when possible.
CDC is recommending masks when in public for everyone.
Recently transplanted patients should follow respiratory principle and wear a mask when available.
Prudent to limit visitors.
Severe limitations recommended such as only for hospice patients or at time of discharge instructions.
RIVM advises the vulnerable group to stay at home, to receive as little visitors as possible, to keep 1.5 meters away, to wash hands often and to allow contact with others to take place by telephone as much as possible.
Current risk is unknown but that severe disease have been reported.
One should assume that it is likely to acquire COVID-19 disease from a blood entry pathway.
State that evidence from SARS and MERS does not suggest increased mortality for post-transplant patients. Immunosuppression may decrease severity of disease but likely increases viral shedding.
Transplants are probably just as likely to get the COVID-19 virus as people without a transplant. It is much more important to properly follow the guidelines of the RIVM. This will reduce your chance of getting a Corona virus infection.
Mention possible increased risk to shed and transmit virus among immunocompromised patients that have COVID-19.
We recommend strict application of protective measures in transplant patients and in case of even mild clinical signs suggestive of COVID-19, a lower threshold for screening since they represent a higher risk population for infection and contagion.
Strict adherence to social distancing and hand hygiene.
Recommend strict adherence to social distancing recommendations.
Limit travel and respect social distancing recommendations (including advocating for patients to work from home).
Follow the advice of RIVM. RIVM advises the vulnerable group to stay at home, to receive as little visitors as possible, to keep 1.5 meters away, to wash hands often and to allow contact with others to take place by telephone as much as possible.
Strictly follow travel advisories and take extra precautions.
Adhere to travel advisories issued by their respective health authorities/govt bodies. This may necessitate postponing travel to countries with >10 infected patients. Recipients should avoid travel to all locations where COVID is currently circulating. Transplant recipients should avoid all cruise ship travel.
Take respiratory precautions and wash hands frequently and thoroughly.
CDC is recommending masks or face covering when in public.
Mask any patient with suspected COVID-19.
Patients with suspected COVID-19 or who require testing to rule out COVID-19 should wear a surgical mask, be placed in isolation and have evaluation and testing coordinated with infection control or Transplant ID team, consistent with local policies.
We recommend strict application of protective measures in transplant patients.
Wear mask.
Any symptomatic transplant recipient should wear mask during any hospital or clinic visit, be placed in isolation, and have ID consult for management consistent with local policies.
Recommend adherence to CDC guidelines of avoidance of non-essential travel, including by caregivers or close contacts. Ensure adequate supply of medications if travel necessary. Community spread should be assumed in Canada and US.
Follow national recommendations.
Teams should follow local health department guidelines for isolating, quarantining, testing, and monitoring returned travellers from endemic areas.
14 days after international travel
| Teams should follow local health dept guidelines for isolating, quarantining, testing and monitoring returned travellers from endemic areas. All patients who have returned from countries with >10 infected patients or have been exposed to a confirmed or suspected case of COVID-19 within the previous 14 days should avoid elective clinic visits and surgical procedures (including bronchoscopies in lung transplant patients). Plans should be in place to get required lab testing of such patients during 14 days done in such a way to avoid potential exposure of other patients. |
14 days
We recommend against the use of lopinavir/ritonavir for first line therapy given early data that it lacks efficacy and the potential for severe drug-drug interactions.
Consider remdesivir for the treatment of hospitalized patients with severe COVID-19 under the FDA’s EUA.
The use should be considered in conjunction with local practice or as part of clinical trial.
Specifically told not to change therapy unless advised by physician.
Consider reducing high dose steroids (careful to avoid aderenal insufficiency). Consider reducing calcineurin inhibitor dosage and azathioprine or mycophenolate dosages in the setting of lymphopenia.
Stop antiproliferative agents (MMF/azathioprine), review total burden of immunosuppression, high does steroid can be counterproductive, minimise calcineurin inhibitors in early disease.
Consider holding mycophenolate mofetil or azathioprine while admitted with moderate/ severe illness (with close monitoring for rejection).
Drug-drug interactions with immunosuppressant medications need to be evaluated and managed.
There is overall agreement of stopping antimetabolite drugs and decrease calcineurin inhibitors by 50%. Steroid should be continued on same doses (based on Mass General recommendations).
Decreasing immunosuppression should be considered for infected recipients, if no recent rejection episodes.
Not for asymptomatic patients.
It is very important that patients do not stop taking immunosuppressive medicines.
There is a paucity of data, however, for safety we recommend limited use of induction therapy during this COVID-19 surge. Lymphocyte depletion should be used with great caution.
Current experience does not suggest a change in induction protocols with ongoing use of lymphocyte depleting agents if indicated, but it should be noted that COVID-19 is frequently associated with lymphopenia.
Current experience does not suggest a change in induction protocols with ongoing use of lymphocyte depleting agents if indicated, but it should be noted that COVID-19 is frequently associated with lymphopenia.
Also to the Vigilance and Surveillance Expert Advisory Committee (VSEAC) of the Organ and Tissue Authority (OTA) in addition to any immediate state and territory reporting requirements.
Test as soon as patient arrives at hospital, especially if they show symptoms.
Lung transplant specifically for COVID-19 related lung disease should be considered with grave caution in carefully selected cases following two negative PCR based tests as noted above. Recent data indicate that myocarditis may occur at this stage, and thorough cardiac evaluation is warranted.
Await full symptom resolution and then have at least 2 negative screens (PCR).
Recipients with active COVID-19 or recovering from an acute COVID-19 infection should not undergo transplantation.
RT-PCR testing.
Should not be performed on either a donor or recipient who has returned from countries with >10 infected patients or who have been exposed to a patient with confirmed or suspected COVID-19 within 14 days.
We recommend waiting at least 14 days after initial diagnosis AND two successive negative PCR-based tests at least 48 hours apart PRIOR to transplantation if possible.
Recommend waiting 14 days if candidate travelled through endemic area. Clinical prudence paramount.
Chest imaging should be considered.
CT thorax to screen for typical COVID-associated lung lesions is also recommended at admission to the hospital for transplantation.
14 days.
Does not specify if recommendations are only for DD recipients.
Screen all potential recipients for symptoms prior to calling in from home. Test all patients (depending on availability) with preference for bronchial secretions > nasopharygeal swab > oropharyngeal swab.
Symptom screening and chest assessment. Recipients with active COVID-19 or recovering from an acute COVID-19 infection should not undergo transplantation; NHS advice is for NP and OP swabs for all those admitted to hospital.
Screen all patients as close as possible to transplant surgery, especially if clinical or epidemiological risk factors.
A patient receiving a transplant is tested for COVID19. If the patient is infected with the coronavirus himself, transplantation cannot proceed.
All patients who have returned from countries with >10 infected patients or have been exposed to a confirmed or suspected case of COVID-19 within the previous 14 days should avoid elective clinic visits and surgical procedures (including bronchoscopies in lung transplant patients). Plans should be in place to get required laboratory testing of such patients during the 14 days in such way as to avoid potential exposure of other patients.
NP swab in the 24–48 hours prior to surgery and should not proceed if positive.
Test all symptomatic patients and defer transplantation of COVID-19 + patients. Unclear on utility of screening asymptomatic patients.
We assume that general hospital protocols will stress that all clinics screen people for fever (with protocols to assess those for source of fever).
Screen all potential recipients for symptoms prior to calling in from home. Test all patients (depending on availability) with preference for bronchial secretions > nasopharygeal swab > oropharyngeal swab.
Symptom screening and chest assessment. Recipients with active COVID-19 or recovering from an acute COVID-19 infection should not undergo transplantation; NHS advice is for NP and OP swabs for all those admitted to hospital.
Screen all patients as close as possible to transplant surgery, especially if clinical or epidemiological risk factors.
A patient receiving a transplant is tested for COVID19. If the patient is infected with the coronavirus himself, transplantation cannot proceed.
All patients who have returned from countries with >10 infected patients or have been exposed to a confirmed or suspected case of COVID-19 within the previous 14 days should avoid elective clinic visits and surgical procedures (including bronchoscopies in lung transplant patients). Plans should be in place to get required laboratory testing of such patients during the 14 days in such way as to avoid potential exposure of other patients.
All potential recipients should be screened prior to transplantation.
All potential recipients have to be screened by naso-pharyngeal COVID-19 NAT ahead of the planned donation procedure.
Those that have been exposed to a confirmed case or suspected COVID-19 patient within last 14 days or who have returned from nations with COVID-19 outbreaks should be tested; anyone with fever, cough or difficulty breathing should call their transplant centre who will specify if testing required.
If available, we suggest PCR-based testing for SARS-CoV-2 by nasopharyngeal/ oropharyngeal swab prior to transplant assuming rapid turn-around. Recommend against transplanting into positive patients if no therapy availabl.
NP swab…positive symptom screen should be deferred.
Recommend 28 days past resolution of symptoms and negative testing prior to consideration for use.
Await 28 days after resolution of symptoms.
Can be re-assessed if greater than 21 days post recovery.
Deferred at least 14 days after symptom resolution and negative results of repeat testing.
Negative PCR test.
2 negative NP PCR swabs that are 24 hours apart.
The Ontario Ministry of Health criteria for when to discharge someone from isolation outlines scenarios for home isolation, hospital, and healthcare workers.
a. For hospitalized patients, isolate in hospital until two negative tests (single NP swab), obtained at least 24 hours apart.
b. If discharged home within 14 days of symptom onset, follow advice for individuals at home where viral clearance swabs are not required.
c. If discharged to a long-term care home/retirement home, maintain isolation (droplet and contact precautions) until two consecutive negative tests, obtained at least 24 hours apart. If testing for clearance is not feasible, maintain isolation until at least 14 days from symptom onset
Foreign offers are primarily evaluated by the Medical Director in close collaboration with the international partner organizations. Swisstransplant retains the right to suspend certain services until further notice.
Organs form other Eurotransplant member countries are acceptable for transplantation in Belgium in case donors were screened for COVID-19 by NAT on naso-pharyngeal swabs or broncho-alveolar lavage fluids.
All organ offers from programs such as in the United States where testing of donors may not have reliably occurred, should not be accepted.
No, if someone is infected, he can no longer be a donor. This is possible if the donor was previously infected and has gotten better.
Living donation should not be performed on either a donor or recipient who has returned from countries with >10 infected patients or who have been exposed to a patient with confirmed or suspected COVID-19 within 14 days. Donors should not be utilized if they have fever and/or respiratory symptoms unless SARS-CoV-2 is excluded.
Exclude deceased donor if COVID-19 is suspected due to presence of severe bilateral community-acquired pneumonia and no other cause is identified (irrespective of COVID-19 PCR test results.
Exclude patients with unexplained respiratory failure as cause of death, history of fever or acute respiratory infection (ie. shortness of breath, cough, sore throat) with or without fever, severe bilateral community-acquired pneumonia without any other cause.
If test results not available and judged to be intermediate risk: do not use for lungs or intestinal transplant. Other organs on a case-by-case basis.
All donors with inconclusive tests or risk factors (clinical or epidemiologic) should be excluded.
Exclude deceased donors if probable case of COVID-19. A person with fever (>38C) or history of fever (eg. Night sweats, chills) OR acute respiratory infection (eg. Cough, shortness of breath, sore throat) AND who is a household contact of a confirmed case of COVID-19, where testing has not yet been conducted.
Active infection or positive test.
Prudence suggests that organs from positive donors not be accepted.
If the PCR test is positive, organs must not be allocated.
Only if not recovered; if recovered, carefully assessed.
Case by case after a min of 21 days following resolution of symptoms.
No, if someone is infected, he can no longer be a donor.
Use of organs from COVID-19 + donors to be considered on case by case basis and depends on organ.
Implied; not explicitly stated.
Exclude deceased donor if confirmed COVID-19 positive.
“Organs from donors with active COVID-19 should not be used.”
Recommend storage of blood for future testing as it becomes available.
Testing of blood is being proposed, but it’s utility is also unknown.
Blood and serum stored for future testing when reliable viral or antibody tests are available.
Not recommended to use rapid tests (antigenic or serologic).
Acknowledge that not currently available.
…blood (serology clotted) tube (for retrospective serology testing).
Potential donors have to be screened by naso-pharyngeal NAT and CT thorax ahead of the planned donation procedure.
May show signs of SARS-CoV-2 infection even before development of symptoms or positive PCR and hence may be useful in donor assessment. If CT imaging is suggestive of a viral pneumonitis, we recommend avoiding the donor offer.
These donors are considered high or intermediate risk. Blood samples are to be collected.
At risk potential donors defined as exposure to a COVID-19 patient (including sharing a unit with) or travel to endemic area within 21 days.
Persons who returned from countries with >10 infected patients or who have been exposed to a patient with confirmed or suspected COVID-19 within 14 days should not be accepted as a donor. Likewise donors with unexplained respiratory failure leading to death should be excluded.
Deceased donors without symptoms or diagnosis of COVID-19 in an area with sustained transmission should be tested for the presence of SARS-CoV-2 in the bronchoalveolar lavage (BAL) specimens collected 72 hours before organ procurement.
| If prior infection (e.g. >28 days since COVID-19 diagnosed and clinical features fully resolved), it may be safe to procced with donation although information is limited at present. Consider only after the discussion with an Infectious Disease physician and when the need for transplantation is urgent. Clearance of infection is defined currently on the basis of European Centre for Disease Prevention and Control Technical Report (2020) Novel Coronavirus. The definition of an infected person is using at least two upper respiratory tract samples negative for SARS CoV2 RNA testing collected >24 hrs. apart. There are collected >7 days following symptoms of >3 days following fever resolution or >14 days if asymptomatic illness (ECDC 2020). |
No acceptance of donors with international travel in last 14 days or contact with confirmed case of COVID-19 within last 14 days.
Avoid donors who returned from countries with >10 infected patients or who have been exposed to a patient with confirmed, or suspected COVID-19 within 14 days. Avoid donors with unexplained respiratory failure leading to death.
| Recommend avoidance of such donors if testing not available. |
Should be considered higher risk and caution should be exercised. Negative testing is essential before proceeding. More than one sample type may be needed (eg.NP swab and BAL).
No preference stated between NP, OP and bronchial secretion testing.
BAL or an oro- or nasopharyngeal swab.
Recommended for all deceased donors. Avoid bronchoscopy for risk of aerosolization.
Recommended BAL or bronquial apsirate, particularly in lung and/or small bowel donation.
Where available, testing of upper and lower airway specimens by PCR/NAT of donors with concern for COVID-19 should be considered.
Organs form other Eurotransplant member countries are acceptable for transplantation in Belgium in case donors were screened for COVID-19 by NAT on naso-pharyngeal swabs or broncho-alveolar lavage fluids.
Bronchoaleveolar lavage is not currently recommended owing to the higher risk of aerosol generation and the need to conserve ICU bronchoscopes.
As sampling by nasopharyngeal/ oropharyngeal swabs has been reported to have a lower sensitivity, bronchoalveolar lavage fluid or deep tracheal aspiration may be preferable.
“greater sensitivity in cases of pneumonitis…Concerns about aerosolization with bronchoscopic BAL sampling should also be taken into account”
No preference stated between NP, OP and bronchial secretion testing.
BAL or an oro- or nasopharyngeal swab.
Does not replace endotracheal aspirate, but often done prior to donation consideration.
Done as close as possible to organ recovery.
“Where available, testing of upper and lower airway specimens by PCR/NAT of donors with concern for COVID-19 should be considered”.
…endotracheal aspirate (PCR test) only if it can be done safely, as per ICU policies.
“likely has less sensitivity (than nasopharyngeal)”
No preference stated between NP, OP and bronchial secretion testing.
BAL or an oro- or nasopharyngeal swab
| Does not replace endotracheal aspirate, but often done prior to donation consideration. |
Done as close as possible to organ recovery.
Having confirmed COVID-19 or returning form a country with sustained COVID-19 transmission. If organ
transplant procedure cannot be delayed, the donor’s nasopharyngeal swab specimens should be tested for the presence of the viral RNA no longer than seven days before donation
Potential donors have to be screened by naso-pharyngeal NAT and CT thorax ahead of the planned donation procedure.
combined nose and throat swab (PCR test)
“nasopharyngeal PCR assay is reasonably sensitive in most settings, although there is no clear gold standard for comparison of swab efficacy.”
avoid retrieval of deceased organs from donors within endemic/high prevalence areas
PCR diagnostics must have been carried out on all potential donors to exclude the possibility of COVID-19 infection (preferably using BAL or an oro- or nasopharyngeal swab) and recorded in the SOAS. The test result must be available before the organs can be transplanted. If a PCR test is already available, it cannot be more than 72 hours old when entry of the donor is first made in the SOAS. A repeat test is required if the time window exceeds 72 hours.
All + patients excluded, await results for patients already screened.
Only with epidemiologic or clinical risk factors or all donors for small bowel or lung transplant
All patients who may be donors and who are in intensive care are now first tested for corona.
Routine screening should only be performed in areas with significant ongoing community transmission to minimize the risk of false positive testing and organ wastage.
Deceased donors without symptoms or diagnosis of COVID-19 in an area with sustained transmission should be tested for the presence of SARS-CoV-2 in the bronchoalveolar lavage (BAL) specimens collected 72 hours before organ procurement.
Routine COVID-19 virus testing should be undertaken in all deceased donors, within 72 hours of donation.
..”within 72 hours prior to donation”.
Where available, testing of upper and lower airway specimens by PCR/NAT of donors with concern for COVID-19 should be considered. …should only be performed in areas with significant ongoing community transmission to minimize the risk of false positive testing and organ wastage.
Where available, testing of upper and lower airway specimens by PCR/NAT of donors with concern for COVID-19 should be considered. …should only be performed in areas with significant ongoing community transmission to minimize the risk of false positive testing and organ wastage.
