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Renal Transplantation in COVID 19 Pandemic

-Dr. Santosh Chhetri

The exact scenario of renal diseases in Nepal has not been well studied. It is assumed that more than 3000 cases of end stage renal disease are diagnosed throughout the country who require significant medical assistance for continuing their life. Renal replacement therapy either in the form of dialysis (Hemodialysis or Peritoneal Dialysis) or renal transplantation are the options available. Renal transplantation is the best option available for those patients.

Renal transplantation has been an established and successful program run by a number of centres in Nepal. Notably, Tribhuvan University Teaching Hospital (TUTH) and Human Organ Transplant Centre (HOTC) are conducting the majority of the cases. Cadaveric transplantation has been a major talk of the town since couple of years, yet to be materialized. So, transplant programs are basically living donors directed in Nepal. Every year hundreds of patients are being benefitted with the services inside the country.

Year 2020 started with the rise of new SARS- CoV-2 infection causing COVID-19. This has been a pandemic and a major threat to the human health services. Nepal has seen a steep rise in number of cases since last week. The numbers has crossed above 400 with a couple of mortality. 

The transplant centres can understand the fear and anxiety among the wait listed candidates. We get notable number of phone calls from them enquiring when surgery will restart.

Since the month of Chaitra 2076, majority of the elective procedures including transplantation surgeries has been cancelled in all the hospitals of Nepal. Although the importance of kidney transplants for dialysis patients is well recognised, we cannot ignore the potential safety issues during this pandemic.

Being already very poor in medical logistics, the best available resources has to be directed towards the care of COVID 19 pandemic. Nepal faces scarce medical logistics (medics, nurses, paramedical staffs, beds, operation theatres and so on). Medical professionals including Nephrologist and Transplant Surgeon are standing in the frontline in the war with COVID conducting fever clinics and doing 24 hours call in isolation wards. This is a call for need to divert all our focuses and energies to end this pandemic. As the number of patients requiring critical care will rise, we will face a dreaded situation ahead.

Renal transplantation requires intense immunosuppression in first few months of surgery and this degree of immunosuppression will increase the risk of developing severe COVID status. Studies from China and Italy among transplant recipients reported mortality rates of above 30 percent, quite alarming.

RT-PCR test for SARS-CoV-2 has limited accuracy and might lead to under-diagnosis. This limited accuracy is may be due to errors in collection, handling, transport, storage or timing of test or may be due to errors in analytical phase. The sensitivity and specificity of Rapid Diagnostic Test among renal failure patients is much poorer than general population. Hence, it is very difficult to rule out patients and their potential living donors for asymptomatic COVID infection with available tests.

Statement from the American Society of Transplantation: The risk of acquiring COVID-19 from organ donation is low. Donors are screened for COVID-19 symptoms and exposure history. Living donors who have been to high-risk areas or exposed to someone diagnosed or being evaluated for COVID-19 infection are generally being asked to postpone donation for 14 to 28 days after returning. Some organ procurement organizations are testing some or all donors for COVID-19. 

The Center for Disease Control (CDC) made recommendations about elective surgeries and non-essential procedures that include transplantation. Transplants should not be postponed in “high acuity/unhealthy patients.” Some centres may still need to look at temporarily putting elective living donor transplantation or non-urgent deceased donor transplants on hold. Transplant centres will base these decisions on issues such as the level of circulating COVID-19 infection in their areas and/or operational issues (such as testing availability, bed space, availability of basic supplies and equipment, including personal protective equipment).

There is insufficient evidence to consider kidney transplantation as a safe procedure in COVID-19 pandemic areas. Medical services has largely been diverted towards the pandemic issues, besides providing care to medical emergencies. ESRD patients need to continue their maintenance dialysis and medications as previously and follow the instruction to avoid the possible transmission of virus as the general public. In present scenario worldwide, transplant services using living donors seems to be at halt till the pandemic remains. More research and discussions are underway worldwide.

-(Dr Chhetri is consultant nephrologist in Department of Nephrology and Transplant medicine, TUTH)

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