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Programme de recherche en don et de transplantation du Canada
Room 6002, Li Ka Shing Centre for Health Research Innovation
University of Alberta
Edmonton, AB, Canada T6G 2E1
Recommends to avoid all travels.
For some patients, medical leave or temporary reassignment to non-public facing work in order to minimize possible exposure may be necessary. Basic precautions for patients and their caregivers include staying at home and reducing contact with other people as much as possible. Stringent hand hygiene with soap and water or hand sanitizer should be reinforced. Avoid non-essential travel. Physical distancing of > 1m, routine face mask use, and eye protection independently reduce the risk of developing viral respiratory infections. (10) We recommend mask use when physical distancing is not feasible, such as attending indoor areas, public transportation, and crowded outdoor spaces for all patients to reduce the risk of developing COVID-19.
Mandatory for all potential donors.
All patients in regions where SARS-CoV-2 is circulating should be tested for virus prior to transplantation, even if asymptomatic.
Candidates should be educated about preventive strategies such as social distancing, masking when in proximity to non-household contacts and frequent hand washing.
Temporary suspension of elective living donor transplantation may need to be considered.
They recommend use of face masks, eye protection and and N95 masks (for professionals who enter the room of a patient with known or suspected COVID-19 or as specified by institutional policies) and while they remain available.
Must be thoroughly screened; more manageable with living donor.
As with the live donor, a negative COVID-19 PCR, self-isolation for 7-14 days followed by a pre-procedure negative PCR, CXR, and normal exam will provide support that the transplant procedure is performed on an uninfected individual.
We would propose that a medically suitable, COVID-19 PCR- donor with no history of cough or exposures go into self-isolation for a minimum of 7 days, but preferably 7-14 days. Two days prior to proposed donation, another COVID-PCR should be negative, and on the day of surgery a rapid COVID-19 PCR, temperature check, and CXR should be normal.
Acknowledges that significant false negative rate, so must use all information at disposal when making a decision.
Regardless of test outcome, serisously consider not accepting from donor with « recent history of suspicious febrile or respiratory illness and/or chest CT with ground glass infiltrates ».
Other countries not mentioned. However, strongly encouraged local retrieval and shipment to recipient team. Highly recommend against travel.
Must consider recent symptoms and environment.
PCR test on BAL is preference, though must consider risk of aerosols.
Second best to BAL.
Consider notifying patients that the COVID-19 pandemic may impact their waiting time on the transplant list; Notify patients that family and visitor access to them during their hospital stay may be limited or prohibited.
SARS-CoV-2-positive transplant candidates may be considered for transplantation at least 14-21 days after symptom resolution and 1 or 2 negative SARS-CoV-2 diagnostic tests.
Document does not delineate b/w deceased and living donors, but certainly recommends screening all potential donors for COVID symptoms, as the test can provide false negatives.
Recommend limiting face-to-face interactions as much as possible, including on patient rounds post-transplant; only include trainees and fellows when adequate PPE available.
The American Gastroenterological Association recommend healthcare workers involved with endoscopy wear a full set of PPE, including N95 masks and double gloves.
Duration of enhanced social distancing pre- and post-donation must be in line with national guidance.
Both recipient and live donor are tested at time of assessment and prior to surgery via swab (must test negative 48-72 hours before planned procedure).
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 telemedicine, home delivery of immunosuppression, and rescheduling of non-urgent appointments.
Only if not recovered; if recovered, carefully assessed after 28 days or be subject to clinical assessment and multidisciplinary discussion.
Some units have used chest CT to screen potential transplant recipients, but have been largely replaced by nose and throat swabs due to false negative and false positive results concerns.
Unfortunately, no more than one visitor at a time may come to the hospital per patient.
Patients will be tested for COVID-19 just before the transplant. They must take medicines immediately after a transplant to prevent their body from rejecting the new organ. The immune system is therefore much less, and they can become seriously ill from the coronavirus.
The operation team only goes to a hospital where patients with corona are in isolation.
Liver donation programs have been maintained since the beginning of COVID-19.
Use of organs from COVID-19+ donors to be considered on case by case basis and depends on organ.
All potential donors tested by PCR. Paediatric transplantation continue without restriction.
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.
Consider reduced frequencies of clinic visits and laboratory testing.
Have a plan for physician and staff absences or furloughs due exposure to patients with or team member illness with 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.
Serology assays (IgG and IgM) are becoming available. They have higher sensitivity later in
the course of disease. Their potential utility in donor screening has not been evaluated.
All potential donors must be tested for COVID-19.
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.
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.
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.
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.
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.
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 ».
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.
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.
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.
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).
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).
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.
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
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.
Suspension of all living donation.
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.
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.
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.
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.
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.
All potential living donors should undergo a symptom screen prior to donation. Any donor with compatible symptoms should be deferred but should also be tested to allow for future planning.
During periods of local transmission, temporary suspension of elective living donor Tx may need to be considered to protect the potential donor as well as the recipient.
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.
« Liver donor liver transplantation caries greater urgency…should continue on a case-by-case basis, taking into account recipient medical need and hospital resource utilization depending on the severity of the pandemic in the local jurisdiction. »
Recommend suspension until COVID-19 epidemiology better understood in US.
Normal, careful activity for COVID-19 negative donors and recipients. Caution kidney transplant resumption.
« All living donor kidney transplant programs in Canada should consider postponing living
donor transplants on a case-by-case basis and/or until this issue has resolved. »
Recommend continued life-saving transplantation on case-by-case basis.
All pulmonary centres are open, though some patients are concerned and have « self suspended ».
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.
All heart centres are open and operating similarly to pre-COVID-19 numbers.
Consider transplantation from COVID-19 + donors on case by case basis, continue donation as usual if COVID-19 negative.
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.
Consider suspending living donor liver transplant programs during the pandemic, except for pediatric patients with acute liver failure.
All centres are open with DBD nearing normal numbers and DCD increasing.
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.
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.
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.
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.
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.
Determine approaches to minimize exposure to the healthcare setting.
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.
Implement procedures to screen patients coming to clinic for fever and respiratory symptoms.
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.
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.
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.
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.
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.
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
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; recommends against lopinavir-ritonavir…Hydroxychloroquine with or without azithromycin is not routinely recommended.
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.
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.