Journal of Clinical Medicine Review Kidney Transplantation in COVID Pandemic—A Review of Guidelines Gabriela Gut 1 , Agata Góral 1 , Zofia Dal Canton 1 , Paweł Pozna ´nski 2 , Magdalena Krajewska 2 and Mariusz Kusztal 2,* 1 Faculty of Medicine, Wroclaw Medical University, 50-556 Wroclaw, Poland; [email protected] (G.G.); [email protected] (A.G.); zofi[email protected] (Z.D.C.) 2 Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; [email protected] (P.P.); [email protected] (M.K.) * Correspondence: [email protected]; Tel.: +48-71-733-25-00 Abstract: The paper describes problems with the transplantation process during the COVID-19 pandemic. Transplantation procedures and programs have been impacted by COVID-19. The number of transplants has fallen noticeably. The first part of the paper points out changes in service organization, in particular donor and recipient pre-transplant and peri-transplant management. If the patients during pre-transplant evaluation need to attend face-to-face appointments, such as blood testing or other investigations, the risk of contracting or spreading COVID-19 should be minimized. “Clear green areas”, which are COVID-19-free pathways, are highly recommended in hospitals during transplant procedures. Diagnostic procedures concerning donors, including CT scans and coronavirus testing (nasopharyngeal swab), are necessary before transplant surgery. COVID-19 symptoms and risks of the transplant population are described. Detailed guidelines from Citation: Gut, G.; Góral, A.; Dal transplant societies concerning changes in immunosuppression in infected recipients are discussed. Canton, Z.; Pozna´nski,P.; Krajewska, Management of infected or suspected medical staff is mentioned. The paper ends with guidelines M.; Kusztal, M. Kidney concerning vaccination against COVID-19 in transplant recipients. Transplantation in COVID Pandemic—A Review of Guidelines. Keywords: COVID-19; renal transplantation guidelines; SARS-CoV-2; solid organ transplanta- J. Clin. Med. 2021, 10, 2877. https:// tion guidelines doi.org/10.3390/jcm10132877 Academic Editors: Madhav C. Menon, Klemens Budde and Michael Duerr 1. Introduction Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, was first diagnosed Received: 18 April 2021 during the outbreak in Wuhan, People’s Republic of China, in December 2019. The virus Accepted: 19 June 2021 Published: 29 June 2021 spread worldwide and on 11 March 2020, the World Health Organization declared a COVID-19 pandemic. The virus transmits between infected people through respiratory droplets and aerosols (breathing it in air, having it on eyes, nose, mouth or touching face Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in with hands that have virus on them) [1]. According to data from the Center for Systems published maps and institutional affil- Science and Engineering at John Hopkins University, on 31 May 2021, more than 170 million iations. positive cases have been confirmed with more than 3.55 million fatalities [2]. Transplant programs and all procedures related to transplantation have been impacted by the COVID-19 pandemic. Worldwide data concerning activities in organ donation and transplantation, derived from official sources, show that in 2020, the number of transplants from both deceased and living donors has fallen by 39% in Europe and by 35% in America, Copyright: © 2021 by the authors. compared with 2019 (Table1)[ 3,4]. Transplantations from deceased donors declined by Licensee MDPI, Basel, Switzerland. This article is an open access article 90% in France and by 51% in the USA. This mostly pertains to kidney transplantation, distributed under the terms and but the effect was also seen for heart, lung and liver, all of which provide a meaningful conditions of the Creative Commons improvement in survival probability [5]. Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). J. Clin. Med. 2021, 10, 2877. https://doi.org/10.3390/jcm10132877 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 2877 2 of 10 Table 1. Kidney transplant statistics in Europe, America and Poland for 2019 and 2020. Total Kidney Transplants Deceased Kidney Transplants Living Kidney Transplants Region/Year 2020 2019 2020 2019 2020 2019 Global 42,948 105,231 33,348 64,514 9264 40,720 America 25,582 39,515 19,515 28,035 6047 11,480 Europe 17,366 28,329 13,833 20,476 3217 7853 Poland 751 983 720 931 31 52 The challenge is to prevent the transmission of disease between patients and medical staff. Vaccination of the staff and/or patients can reduce the risk but does not fully guarantee safety against infection, especially with new mutated strains of SARS-Cov2. Transplantation organizations have established various procedures for how to proceed before a planned transplantation. These recommendations refer to the types of tests and examinations that should be carried out on recipients and living donors, organization of hospitals, qualification process and the situations when healthcare workers should be tested. Recommendations pointed out that there is an opportunity to contact the clinic via online communicators or phone, to minimize the risk of infection, which would be increased during face-to-face contact. The purpose of this review is policy analysis of guidance/recommendation of different societies for transplantation procedures during the COVID-19 pandemic. 2. Methodology A systematic search for guidelines for renal transplantation during the COVID-19 pandemic was performed from December 2020 to May 2021. We analysed recommendations with the latest publication date. Only English and Polish papers (position papers in journals and on websites) were reviewed. Guidelines from major organizations/societies were reviewed in terms of service organization, communication and risk management, transplant recipients and donors, qualification for transplantation, healthcare workers and treatment against COVID-19. Data were compiled in a table and compared for similarities and differences between the guidelines. The following society/organizations addressed the problem: American Society of Transplantation (AST), American Society of Transplant Surgeons (ASTS), European Renal Association (ERA-EDTA), British Transplant Society (BTS), Canadian Society of Transplan- tation (CST), National Institute for Health and Care Excellence (NICE), Centers for Disease Control and Prevention (CDC), European Association of Urology (EAU) and Poltransplant (Polish Transplant Coordinating Centre). 3. Service Organization, Communication and Risk Management The decision about limiting a transplant service or reopening it must consider patient wellbeing, prevalence of infection within the local community and the capability of a particular centre to manage the workload while maintaining infection control procedures and respecting recipient and donor autonomy [6]. The EAU guidelines recommend classification of kidney transplant patients into groups of priority for transplantation. Low priority patients are deferred if postpone- ment by six months results in no clinical harm. Intermediate priority category needs case-by-case discussion. High priority and emergency category patients are defined as combined transplantation recipients or permanent lack/dysfunction of dialysis-access patients, respectively, and require renal transplantation urgently [7]. Transplant personnel should re-evaluate donors and patients on the waiting list. It is required to estimate the risks and benefits for them in the context of COVID-19. Decisions should be made by a multidisciplinary team [8]. It is crucial to ensure that there are COVID-19-secure sites or areas for pretransplant patients, donor assessment, donation and J. Clin. Med. 2021, 10, 2877 3 of 10 transplantation surgery, post-transplantation follow-up and ongoing care for all transplant recipients. Centres should be confident that they have the option of rapid turnaround testing for SARS-CoV-2 [8]. Poltransplant also recommends sectionalising “Clear green areas”, which are COVID- free pathways. Selection of living and deceased donors as well as organ harvesting procedures should be stopped in multi-specialized hospitals. Organ procurement can exceptionally be performed in those parts of a hospital where the area with non-infected COVID-19 patients is clearly defined and separated [9]. It is very important to minimize face-to-face contact with patients before and after transplantation. Before admission to hospital, there should be a medical interview, per- formed by means of distance communication, to ensure that patients have no COVID-19 signs or symptoms and that there is no evidence that patients should be quarantined [8]. For all stable patients with overall good general health and stable transplant function, visits to the hospital should be limited or postponed if possible. Contact with patients by telephone, video or email consultations is recommended whenever possible [7–9]. It is preferable to use different digital or remote methods to deliver prescriptions and medicine, for example, electronic prescription, pharmacy deliveries, postal services, drive- through medicine pick-up points. Most stable transplant outpatients are encouraged to take laboratory tests at home [5]. It is important to note that there are limitations of telehealth as well. Underserved patients without resources necessary for the effective use of telemedicine, such as