Restarting Transplant Programme in COVID era
COVID-19 outbreak has been a double whammy for healthcare. The novel Coronavirus has been unique due to its highly variable clinical manifestation as well as highly unpredictable course. At one end, healthcare systems are collapsing due to sheer bulk of COVID patients; the other extreme is a glaring lacuna in care of non-COVID patients. The transplant programme was one of the worst casualties – fear of highly infectious disease in immunocompromised transplant patients as well as risk of infection in donors. Prior to COVID, we were doing close to 20 – 25 renal transplants per month. With onset of lockdown and government advisory on elective procedures, transplant programmes were closed down across the country. At the same time, there were concerns regarding fate of chronic kidney disease (CKD) patients on maintenance haemodialysis (MHD), who were willing for transplant. Repeated visits to haemodialysis centre would also risk the immunocompromised CKD patient to COVID infection. Many transplant surgeons voiced their concerns regarding stopping of transplant programmes as knee jerk reactions.
A willing family of a brain-dead patient initiated the process of restarting the transplant programme in our centre. At the same time there was a need for an urgent liver. We thought of retrieving both kidneys also. As head of the team, the first challenge was to motivate my team. Everybody was scared. I led from the front and discharged my clinical duties, in spite of being on the wrong side of age. The hospital management pitched in to provide PPE kits to all team members, and commitment to treat any team member, who inadvertently got infected, free of cost. All the healthcare workers were insured for Coronavirus infection. With free and frank discussion with my team members, I was successful in mitigating their fears and instilled confidence and motivation in them. Then, I had discussions with other stakeholders – Nephrologists, Anaesthesiologists, ICU teams - addressed their concerns and motivated them.
Next, I had to discuss multiple times with National Organ and Tissue Transplant Organization (NOTTO) and government authorities to convince them for going ahead with kidney transplantation. NOTTO agreed for liver transplantation but had reservations for kidney transplantation due to government advisory. The risk of infection to transplant recipients had to be weighed against risk of losing precious organs, a scarcity in our part of the country. Finally, NOTTO agreed with conditions – testing of both donor and recipients, screening of the whole transplant team, including doctors, co-ordinators, OT and ward nursing staff and front office/secretarial staff who would be coming in contact with the patients.
The final part was to convince the patients, explaining them the risk of MHD versus transplant in COVID times. Finally, five patients agreed to come for assessment. They all were called as per priority list and assessed regarding fitness for surgery. At the same time, NOTTO called up other stakeholder hospitals regarding availability of a cadaver kidney; however, no other transplant team agreed. With time ticking away, I decided to volunteer to take the second kidney also. NOTTO generously permitted for the same. Thankfully, the first two transplants were successful.
To take these further, green corridors were created in the hospital. Segregated areas were earmarked for transplant patients; with strict movement restriction of staff. Our nephrology team actively participated in convincing the waiting patients to go ahead for transplant. At the same time, seven international patients were waiting for kidney transplants. Their work-up was complete and authorisation committee clearance was already done. Due to lockdown and government advisory, we postponed their transplants. These patients kept on pleading for an early transplant. They could not go back to their country and they were losing money while waiting. They were ready to sign any consent and had understood the possibility of contracting COVID infection and its consequences. Unfortunately, over the last three months, many of my team members – senior consultants, DNB trainees, nursing staff and secretarial staff got infected with COVID-19 infection. However, the hospital honoured its commitment of providing free hospitalisation and treatment to one and all. Luckily, all of them recovered. Since the lockdown from 24th March to 30th June 2020, we have done 19 renal transplants including two cadaveric transplants, two paediatric transplants (one with neurogenic bladder), two ABO incompatible, one pair of swap transplant and two Robot assisted transplants. Apart from screening both donors and recipients for COVID-19 by RT-PCR, no other change in routine protocol was made.
All patients were explained the possibility of contracting COVID-19 infection and its consequences. All patients signed a detailed consent. During follow up, until absolutely necessary, recipients and donors were managed by telephonic/video consultations and home collection of samples. All 19 of our recipients are doing well, none of them has got COVID infection. Seven international patients did very well and went back home when their flights were available. Assessing the current situation of COVID-19 pandemic in India, this disease is not fading away anytime soon. We understand the need for treatment of COVID patients. At the same time, we must take care of our non-COVID patients, lest they suffer from lack of medical care. From our initial experience, we can strongly say that transplant programmes should be re-started after taking due precautions and care to prevent infection in patients and donors. Protocols can be made at local level with infection control committee of concerned hospital. The Indian Society of Organ Transplantation (ISOT) and NOTTO have also laid down new guidelines to start organ transplantation during this ongoing COVID-19 pandemic.
- Copyright © 2021. Published by MOHAN Foundation
- Keywords: Renal transplant, Immunocompromised transplant Patients, Rrobot assisted Ttransplants, Risk of MHD versus transplant in COVID times, COVID-19 pandemic, swap transplant, ABO incompatible transplant