Organ transplants drop dramatically during pandemic

Many transplant centers have temporarily shut down their living donor kidney transplant programs “to ease pressure on hospitals and protect donors and recipients from COVID-19” 1. These actions make sense given the current pandemic. At the same time, pre-emptive renal transplantation with a living donor remains the optimal therapy for endstage renal disease 2. Without this being an available therapeutic option, patients are being exposed to more dialysis and its associated risks (including increased risk of COVID-19). For example, based on registry data from France, the COVID-19 mortality rate was 30% among waitlisted hemodialysis patients compared to 13% in the kidney transplant population 3. As of may 6, 2020, the ERA-EDTA COVID-19 database has reported mortality rates of 20% and 18% for dialysis and kidney transplant patients, respectively 4.

With this data in mind, workup of living donors must continue. Yet, strategies that minimize visits to hospital, address donor COVID-19-related anxiety and provide proper follow up are essential. How can this be achieved?

First, in-person donor evaluations will be necessary in dedicated “cold zones” of the hospital. Testing must also be condensed (if possible) into a period of 1-2 days so that repeated trips to the hospital can be minimized. Furthermore, the peri-operative period is generally a stressful time for the living donor. In the era of SARS-Cov-2, this anxiety is likely to be increased. Mandatory SARS-CoV-2 testing, a 14-day self-quarantine period pre-nephrectomy and hospitalisation in a COVID-19-free zone will all be the “new normal”. Lastly, given that history taking, blood pressure measurement and labs encompass the bulk of living donor surveillance, most long- term follow up can effectively be done virtually rather than in-person.

For those living donors who are either ABO or HLA incompatible with their recipient, paired exchange programs have provided excellent opportunities to proceed with transplantation. In Canada’s kidney paired donation program, living donors have traditionally traveled to the recipient’s transplant center (often in a different province). Donor travel, particularly to a different province, can be a source of apprehension and a reason for refusal to participate (due to perceived expense and-or lack of familiarity with the city and/or language). With the emergence of COVID-19, donors can now add another reason to refuse participation. Given the above, transplant programs in Canada should adopt ways to efficiently ship kidneys (while minimizing cold ischemic time and delayed graft function) 5.

In summary, as both a lifesaving and cost effective therapy, hospitals and health care systems must strive to return to safely performing living donor kidney transplantation. With donor anxiety and stress further inflamed by COVID-19, measures that financially and medically protect the living donor are more important than ever before.