Operational challenges in the COVID era: Asymptomatic infections and vaccination timing

Transition of Care of Stable Kidney Transplant Patients to Referring Nephrologists: A Survey of U.S. Transplant Program Staff

BACKGROUND AND OBJECTIVES

We conducted a national survey to assess the opinions and experiences of transplant center staff related to processes of care graduation.

METHODS

Following IRB approval, medical staff at U.S. adult kidney transplant programs were surveyed using the Qualtrics survey platform (4/5/2022-10/05/2022). Respondents were invited via email and listservs of professional societies. If > 1 survey was submitted for a program, a selection hierarchy was utilized (e.g., prioritizing nephrologists' responses).

RESULTS

Respondents provided data from 46.7% of active programs (N = 92), representing 67% of the national kidney transplant volume. Most respondents (70%) were nephrologists. Full graduation to referring nephrologists was reported by 39% of transplant programs, with an additional 48% reporting partial graduation with ongoing co-management. Rationales for graduation were multifactorial, most commonly including patient travel distance (64%), maintenance of referral base (58%), continuity of care (58%), and center and/or patient burden (54%). Common reasons cited by programs for postgraduation return of care to the transplant center included worsening renal function (82%), malignancy (66%), opportunistic infection (63%), limited local nephrologist availability (60%), and pregnancy planning (57%). Additional coordinators and clinic staff were cited as needed to make transplant center perpetual care feasible by 78% of programs, with 71% stating that more clinicians are needed, while half thought more physical space or telemedicine are required.

CONCLUSIONS

Graduation of kidney transplant patients is common, with half of programs using a joint-care approach and another third reporting full return of care to the referring nephrologist. Expanded opportunities related to transplant care for the broad nephrology community are essential.

Indications, Techniques, and Barriers for Pancreas Transplant Biopsy: A Consensus Perspective From a Survey of US Centers

BACKGROUND

Pancreas transplant biopsy practices for the diagnosis of rejection or other pathologies are not well described.

METHODS

We conducted a survey of staff at US pancreas transplant programs (March 22, 2022, to August 22, 2022) to assess current program practices and perceptions about the utility and challenges in the performance and interpretation of pancreas allograft biopsies.

RESULTS

Respondents represented 65% (76/117) of active adult pancreas transplant programs, capturing 66% of recent pancreas transplant volume in the United States. Participants were most often nephrologists (52%), followed by surgeons (46%), and other staff (4%). Pancreas allograft biopsies were performed mostly by interventional radiologists (74%), followed by surgeons (11%), nephrologists (8%), and gastroenterologists (1%). Limitations in the radiologist's or biopsy performer's comfort level or expertise to safely perform a biopsy, or to obtain sufficient/adequate samples were the two most common challenges with pancreas transplant biopsies. Pancreas transplant biopsies were read by local pathologists at a majority (86%) of centers. Challenges reported with pancreas biopsy interpretation included poor reliability, lack of reporting of C4d staining, lack of reporting of rejection grading, and inconclusive interpretation of the biopsy. Staff at a third of responding programs (34%) stated that they rarely or never perform pancreas allograft biopsies and treat presumed rejection empirically.

CONCLUSIONS

This national survey identified significant variation in clinical practices related to pancreas allograft biopsies and potential barriers to pancreas transplant utilization across the United States. Consideration of strategies to improve program experience with percutaneous pancreas biopsy and to support optimal management of pancreas allograft rejection informed by histology is warranted.

Factors Associated With Prolonged Respiratory Virus Detection From Polymerase Chain Reaction of Nasal Specimens Collected Longitudinally in Healthy Children in a US Birth Cohort

BACKGROUND

Respiratory viral shedding is incompletely characterized by existing studies due to the lack of longitudinal nasal sampling and limited inclusion of healthy/asymptomatic children. We describe characteristics associated with prolonged virus detection by polymerase chain reaction (PCR) in a community-based birth cohort.

METHODS

Children were followed from birth to 2 years of age in the PREVAIL cohort. Weekly nasal swabs were collected and tested using the Luminex Respiratory Pathogen Panel. Weekly text surveys were administered to ascertain the presence of acute respiratory illnesses defined as fever and/or cough. Maternal reports and medical chart abstractions identified healthcare utilization. Prolonged virus detection was defined as a persistently positive test lasting ≥4 weeks. Factors associated with prolonged virus detection were assessed using mixed effects multivariable logistic regression.

RESULTS

From a sub-cohort of 101 children with ≥70% weekly swabs collected, a total of 1489 viral infections were detected. Prolonged virus detection was found in 23.4% of viral infections overall, 39% of bocavirus infections, 33% of rhinovirus/enterovirus infections, 14% of respiratory syncytial virus (RSV) A infections, and 7% of RSV B infections. No prolonged detection was found for influenza virus A or B, coronavirus 229E or HKU1, and parainfluenza virus 2 or 4 infections. First-lifetime infection with each virus, and co-detection of another respiratory virus were significantly associated with prolonged detection, while symptom status, child sex, and child age were not.

CONCLUSIONS

Prolonged virus detection was observed in 1 in 4 viral infections in this cohort of healthy children and varied by pathogen, occurring most often for bocavirus and rhinovirus/enterovirus. Evaluating the immunological basis of how viral co-detections and recurrent viral infections impact duration of virus detection by PCR is needed to better understand the dynamics of prolonged viral shedding.

When you need to dive in the deep end-Transplanting SARS-CoV-2 PCR+ recipients

There is an ongoing need to understand whether transplantation during acute Coronavirus disease 2019 (COVID-19) can be performed safely, especially when urgent transplant is required. We collected retrospective data of all consecutive non-lung transplant recipients who had a positive SARS-CoV-2 polymerase chain reaction (PCR) on the day of planned deceased donor organ implantation. Data were collected from two large transplant centers from 01/01/2022 to 02/01/2023. Demographics, details regarding COVID-19 infection, waitlist priority, and details regarding transplantation were obtained. A descriptive analysis was performed. A total of 12 patients were identified: 7 renal, 4 liver, and 1 heart transplant recipient. All 12 patients were vaccinated for COVID-19. Ten were asymptomatic outpatients found positive on admission and transplanted immediately. Two were in-patients with mild COVID-19 symptoms and were reactivated on the waitlist following 3 days of remdesivir when no progression to severe COVID-19 occurred. Most patients (10/12) received remdesivir posttransplant. No complications attributed to COVID-19 were noted nor were any secondary family or healthcare worker infections observed. All recipients were managed with special isolation precautions befitting their potentially infectious state. Standard induction therapy was used in all recipients. After a median follow up period of 143 days (interquartile range: 96-201 days), 3 episodes of rejection were documented, 2/7 renal recipients experienced delayed graft function, and 2/4 liver recipients required renal replacement therapy. Graft and patient survival were 100%. Transplantation can safely proceed in select, minimally symptomatic, non-lung recipients with a positive SARS-CoV-2 PCR at the time of transplant.

An Observational Study on Patients With COVID-19 Infection Admitted to the Intensive Care Unit With Respect to Their Vaccination Status

Background SARS-CoV-2 (COVID-19) created unprecedented recurrent waves of pandemic globally. Apart from COVID-19-appropriate behavior, vaccinating the population was proposed to be the most effective measure to control these outbreaks. However, the outcomes of vaccinated patients admitted to the intensive care unit (ICU) and their comparison with unvaccinated counterparts, especially in developing countries, have not been extensively studied. Materials and methods Our study examined consecutive patients with positive RT-PCR for COVID-19 admitted to the ICU from August 1, 2021, to July 31, 2022. Prior vaccination status and its relation to demographics, disease severity, mortality, and length of stay were analyzed. Results Among 436 patients admitted to the ICU, 76 (15.4%) were unvaccinated and 369 (84.6%) were vaccinated against COVID-19. Vaccinated patients were significantly older and hypertensive, and had comparatively less severity of illness than unvaccinated patients. Crude ICU and hospital mortality were significantly lower among vaccinated patients than unvaccinated patients (15.2% versus 25.4% and 16% versus 22.3%, respectively; P<0.05). Furthermore, risk-adjusted multivariate analysis demonstrated a strong but statistically nonsignificant inverse association between vaccination status and ICU mortality (odds ratio (OR)=0.540, 95% confidence interval (CI)=0.290-1.006, P=0.052). Conclusion In severe COVID-19-infected patients who required admission to the ICU, the majority were vaccinated. However, the severity of illness and hospital mortality was significantly lower among vaccinated patients with breakthrough infections.

Transplantation Amid a Pandemic: The Fall and Rise of Kidney Transplantation in the United States

Following the outbreak of coronavirus disease 2019 (COVID-19) in the United States, the number of kidney waitlist additions and living-donor and deceased-donor kidney transplants (LDKT/DDKT) decreased substantially but began recovering within a few months. Since then, there have been several additional waves of infection, most notably, the Delta and Omicron surges beginning in August and December 2021, respectively.

Methods

Using SRTR data, we compared observed waitlist registrations, waitlist mortality, waitlist removal due to deteriorating condition, LDKT, and DDKT over 5 distinct pandemic periods to expected events based on calculations from preepidemic data while accounting for seasonality and secular trends.

Results

Although the number of daily waitlist additions has been increasing since May 2020, the size of the active waitlist has consistently declined, reaching a minimum of 52 556 on February 27, 2022. The recent Omicron surge knocked LDKT from 25% below baseline (incidence rate ratio [IRR] = 0.690.750.81) during the Delta wave to 38% below baseline (IRR = 0.580.620.67). DDKT, however, was less affected by the Omicron wave (IRR = 0.850.890.93 and 0.880.920.96 during the Delta and Omicron waves, respectively). Waitlist death decreased from 56% above baseline (IRR = 1.431.561.70) during Delta to 41% above baseline during Omicron, whereas waitlist removal due to deteriorating condition remained at baseline/expected levels during the Delta wave (IRR = 0.931.021.12) and the Omicron wave (IRR = 0.991.071.16).

Conclusions

Despite exceptionally high COVID-19 incidence during the Omicron wave, the transplant system responded similarly to prior waves that imposed a lesser disease burden, demonstrating the transplant system's growing adaptations and resilience to this now endemic disease.

International Practices on COVID-19 Vaccine Mandates for Transplant Candidates

Background

The coronavirus disease 2019 (COVID-19) pandemic created unprecedented challenges for solid organ transplant centers worldwide. We sought to assess an international perspective on COVID-19 vaccine mandates and rationales for or against mandate policies.

Methods

We administered an electronic survey to staff at transplant centers outside the United States (October 14, 2021-January 28, 2022) assessing the reasons cited by transplant centers for or against implementing a COVID-19 vaccine mandate. Each responding center was represented once in the analysis.

Results

Respondents (N=90) represented 27 countries on five continents. Half (51%) of responding transplant center representatives reported implementing a COVID-19 vaccine mandate, 38% did not, and 12% were unsure. Staff at centers implementing a vaccine mandate cited efficacy of pretransplant vaccination versus post-transplant vaccination, importance for public health, and minimizing exposure of other patients as rationale for the mandate. Of centers with a mandate, the majority (81%) of the centers mandate vaccination regardless of prior SARS-CoV-2 infection status and regardless of prevaccination spike-protein antibody titer or other markers of prior infection. Only 27% of centers with a vaccine mandate for transplant candidates also extended a vaccine requirement to living donor candidates. Centers not implementing a vaccine mandate cited concerns for undue pressure on transplant candidates, insufficient evidence to support vaccine mandates, equity, and legal considerations.

Conclusions

The approach to pretransplant COVID-19 vaccination mandate policies at international transplant centers is heterogeneous. International transplant centers with a vaccine mandate were more willing to extend vaccine requirements to candidates' support persons, cohabitants, and living donors. Broader stakeholder engagement to overcome vaccine hesitancy across the world is needed to increase the acceptance of pretransplant COVID-19 vaccination to protect the health of transplant patients.

The effect of COVID 19 vaccination on kidney recipients

BACKGROUND

Nearly one year from the onset of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, safe and effective vaccines began distribution around the world. This study aimed to assess the rate of COVID-19 disease among vaccinated kidney transplant patients and the types of symptoms found within them.

DESIGN

This cross-sectional study was performed at the transplant ward and Organ Procurement Unit of Sina Hospital, Tehran, Iran. As a sample size, 159 cadavers' kidney recipients received two doses of the Sinopharm SARS-CoV-2 vaccine. The required data were collected using a checklist via conducting a face-to-face interview.

RESULTS

The mean age of the vaccinated participants was 49.44 ± 13.87 years old. There were 73 (45.91%) vaccinated cases of SARS-CoV-2 infection during the study period, 18 cases (12.6%) occurred among fully vaccinated individuals, and 53 cases (33.3%) were among individuals who had received only one dose of vaccine. 45% of the fully vaccinated patients (received 2 doses vaccine) contracted SARS-CoV-2 from their families; 35% were infected through participation in social events (35%). There was a significant difference in disease severity levels between the fully vaccinated group and the one-dose vaccinated (p < 0.023). The severe disease occurred in 2 patients after vaccination, who were subsequently admitted to the hospital. There was a significant difference between the number of kidney transplant days and infection with SARS-CoV-2 before (P = 0.15) and after vaccination (p < 0.015).

CONCLUSION

Even after vaccination, kidney recipients are still at the risk of contracting SARS-CoV-2. In addition to these results, the efficacy of vaccination in preventing death caused by SARS-CoV-2 was confirmed.

Survey of current transplant center practices regarding COVID-19 vaccine mandates in the United States

An electronic survey canvassing current policies of transplant centers regarding a COVID-19 vaccine mandate for transplant candidates and living donors was distributed to clinicians at US solid organ transplant centers performing transplants from October 14, 2021-November 15, 2021. Responses were received from staff at 141 unique transplant centers. These respondents represented 56.4% of US transplant centers, and responding centers performed 78.5% of kidney transplants and 82.4% of liver transplants in the year prior to survey administration. Only 35.7% of centers reported implementing a vaccine mandate, while 60.7% reported that vaccination was not required. A minority (42%) of responding centers with a vaccine mandate for transplant candidates also mandated vaccination for living organ donors. Centers with a vaccine mandate most frequently cited clinical evidence supporting the efficacy of pre-transplant vaccination (82%) and stewardship obligations to ensure organs were transplanted into the lowest risk patients (64%). Centers without a vaccine mandate cited a variety of reasons including administrative, equity, and legal considerations for their decision. Transplant centers in the United States exhibit significant heterogeneity in COVID-19 vaccination mandate policies for transplant candidates. While all centers encourage vaccination, most centers have not mandated COVID-19 vaccination for candidates and living donors, citing administrative opposition, legal prohibitions, and concern about equity in access to transplants.

An overview of COVID-19 in solid organ transplantation

BACKGROUND

The COVID-19 pandemic has influenced the field of solid organ transplantation (SOT) in many ways. COVID-19 has led to programmatic impacts and changes in donor and recipient selection. Several studies have evaluated the course, optimal treatment, and prevention of COVID-19 in SOT recipients.

OBJECTIVES

To review the literature on COVID-19 in SOT recipients.

SOURCES

PubMed, Web of Science, and Google Scholar were searched. The search was restricted to articles published between January 1, 2019 and December 1, 2021.

CONTENT

The COVID-19 pandemic initially led to a decreased volume of solid organ transplants. However, transplant volumes at most centres have rebounded. Donor selection remains an incompletely defined issue. Several reports suggest that donor-derived SARS-CoV-2 infections occur only in lung transplant recipients and that other organs from SARS-CoV-2 PCR-positive donors could potentially be safely used. However, these data are limited to case series. Transplantation for end-stage lung disease after COVID-19 infection is increasingly common and has been performed with acceptable outcomes. In acute COVID-19 in a transplant candidate, transplantation should be delayed when feasible. After adjustment, mortality after COVID-19 appear similar in SOT recipients compared to the general population, with notable increased use of antiviral and anti-inflammatory treatment options. Prevention of COVID-19 is key in SOT recipients. Vaccination of SOT recipients and anyone who is in contact with SOT recipients is one of the cornerstones of prevention. Nonpharmacological interventions such as face coverings, hand hygiene, and physical distancing remain ever important as well.

IMPLICATIONS

The COVID-19 pandemic continues to have an important impact on SOT candidates and recipients. Prevention of infection is the most important measure and requires careful attention to approaches to vaccination and messaging of the ongoing need for face coverings, physical distancing, and hand hygiene.

Deceased Donor Procurement Biopsy Practices, Interpretation, and Histology-Based Decision Making: A Survey of U.S. Transplant Centers

Introduction

Methods

Results

Conclusion

Considering a COVID-19 vaccine mandate for pediatric kidney transplant candidates

The world continues to face the effects of the SARS-CoV-2 pandemic. COVID-19 vaccines are safe and effective in protecting recipients, decreasing the risk of COVID-19 acquisition, transmission, hospitalization, and death. Transplant recipients may be at greater risk for severe SARS-CoV-2 infection. As a result, transplant programs have begun instituting mandates for COVID-19 vaccine for transplant candidacy. While the question of mandating COVID-19 vaccine for adult transplant candidates has garnered attention in the lay and academic press, these discussions have not explicitly addressed children who may be otherwise eligible for kidney transplants. In this paper we seek to examine the potential ethical justifications of a COVID-19 vaccine mandate for pediatric kidney transplant candidacy through an examination of relevant ethical principles, analogous cases of the use of mandates, differences between adult and pediatric kidney transplant candidates, and the role of gatekeeping in transplant vaccine mandates. At present, it does not appear that pediatric kidney transplant centers are justified to institute a COVID-19 vaccine mandate for candidates. Finally, we will offer suggestions to be considered prior to the implementation of a COVID-19 vaccine mandate.

Use of Organs from SARS-CoV-2 Infected Donors: Is It Safe? A Contemporary Review

PURPOSE OF REVIEW

As the prevalence of individuals with recovered coronavirus disease 2019 (COVID-19) increases, determining if and when organs from these donors can be safely used is an important priority. We examined current knowledge of outcomes of transplant using donors with recovered COVID-19.

RECENT FINDINGS

A literature search of PubMed and Google scholar databases was conducted to identify articles with terms "SARS-CoV2," "COVID-19," "donor recovered," and "transplantation" published through 08/10/2021. We identified 25 reports detailing 94 recipients of both abdominal and thoracic transplants from donors with both prior and active COVID-19 infection. Rates of transmission to the recipient and of transplanted organ dysfunction were low among reports of donors with prior COVID-19 infection. End organ dysfunction and transmission were more common with active infection, although few reports are available. Standardized reporting is needed to better assess the impact of donor symptomatology, cycle thresholds, and individual recipient risk factors on postoperative outcomes.

SUMMARY

Available reports suggest that transplantation from COVID-19 donors may be feasible and safe, at least in short term follow-up. Nevertheless, there is a need for standardized testing and management protocols which should be tailored for available resources. While increased availability of COVID-19 vaccinations will mitigate risks of donor-derived COVID-19 and simplify management, continued vigilance is warranted during the ongoing public health emergency.