COVID-19 Makes Kidney Donation and Transplants Complicated

Uncertainty about what COVID-19 means for kidney transplantations is quickly eclipsing the concerns related to the major changes in the way kidneys are allocated that are expected by the end of the year.

MARCH 26, 2020 -- Uncertainty about what COVID-19 means for kidney transplantations is quickly eclipsing the concerns related to the major changes in the way kidneys are allocated that are expected by the end of the year.

"We can't test donors and know whether they are COVID-positive," said Alden Doyle, MD, a transplant nephrologist and medical director of the kidney and pancreas transplant program at University of Virginia Health in Charlottesville.

"We can make assumptions, but you can't 100% know, like you could with hepatitis C or flu or any other virus," he told Medscape Medical News. "Imagine you've been on dialysis for 5 years and you get this great offer. I can't tell you for sure that the donor wasn't carrying COVID."

Decision to Accept Kidneys

Transplant physicians are having new discussions about choice and risk.

"We go through why we think the donor is or is not infected and have that discussion with patients, but we're figuring it out on the fly," said Doyle.

His team recently got offered two kidneys.

"We took one and not the other," he said. "One died of an undiagnosed respiratory illness, probably not COVID, but could be, and we turned that one down, and one died of a totally unrelated reason and we took that one."

Transplant patients are at higher risk of contracting COVID-19 because of their immunosuppression, he pointed out.

Last week, as calls to limit nonessential surgeries of all kinds in the United States became louder, the NKF asked for clarification.

"We are grateful to the Administration for clarifying that transplantations are an essential surgery which can be performed safely if a hospital feels they have the staff and resources available during the COVID-19 crisis," writes Joseph Vassalotti, MD, chief medical officer of the NKF, in a statement.

"While some may think prospective transplant patients can remain on dialysis until the threat of COVID-19 has passed, it is important to recognize that this might not be in the patient's best interest," he adds.

Without that clarification, organizations that facilitate transplants might not have been able to even enter a hospital.

Living Donors Can Start the Process Virtually

Living-donor kidney transplants, in contrast, are considered elective surgery and, under normal circumstances, can be scheduled at the convenience of the donor and recipient, said Mona Doshi, MBBS, director of the live-donor kidney transplant program at Michigan Medicine in Ann Arbor.

At the end of this year, the system will no longer give preference to patients on the basis of which of the 58 donor-service areas they live in.

Currently, if you live 2 miles outside a donor-service area, you could have lower priority than someone living much farther away but within that area's boundaries. The new system will give preference to those within 250 nautical miles of the hospital where the donor is listed.

Donor-service areas were eliminated earlier this year for heart and lung transplantation and for liver transplantation, and those systems now use nautical miles.

But for kidneys, the switch means that many organs will have to travel farther, and many will be flown instead of driven, which raises concerns about how much "cold time" each organ will have before transplant, whether more will thus be rejected, and logistical issues related to delivery, said Doyle.

He also noted that 250 nautical miles is very different if the terrain is mountainous or if the route is through Manhattan rather than a sparsely populated area.

Flights are also an issue, with pilot shortages and regional peculiarities. In Alabama, for example, the airports are so jammed on days surrounding University of Alabama football games that it would be difficult to fly kidneys, he explained.

The modeling for the new system gets closer to the balance between justice and utility and is a step in the right direction, but the process still needs to evolve, he said.

The talk in the transplant community, Doyle reported, is that eventually the 250 nautical mile threshold will be phased out, and that there won't be any single number but a complex equation that gives a score that takes into account organ quality, how an organ travels, how sick a patient waiting for a kidney is, the recipient's distance from the donor, and a number of other factors.

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References
Sources: National Kidney Foundation (NKF) 2020 Spring Clinical Meetings. To be presented March 26, 2020.

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