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Transplant & COVID-19

Are transplant recipients at higher risk of getting COVID-19?

Because transplant recipients take immunosuppressive drugs, they have a higher risk of infection from viruses such as cold or flu. To lower the chance of getting the coronavirus that causes COVID-19, transplant patients should follow the CDC’s guidance on how to avoid catching or spreading germs, and contact their health care professional if they develop symptoms of COVID-19.

Statement from the American Society of Transplantation (AST):
We do not have specific information on whether COVID-19 infection will be more severe in transplant recipients compared to healthy people; however, other viruses often cause more severe disease in people whose immune system is low, such as transplant recipients.

Are young transplant recipients at increased risk from COVID-19?

" The idea that COVID-19 is sparing of young people is just false. Parents need to continue to take the virus seriously."
Lawrence C Kleinman, MD, MPH
Professor and Vice Chair for Academic Development/
Chief, Division of Population Health, Quality, and Implementation Sciences
Department of Pediatrics at Rutgers Robert Wood Johnson Medical School

Recent reports indicate that children, teens, and young adults are at greater risk for severe complications from COVID-19 and most of the children admitted to pediatric intensive care units have underlying conditions, such as kidney transplant recipients who are immunosuppressant medication.

Published findings -
A newly published study followed 48 children and young adults (newborns to 21 years old) who were admitted to pediatric intensive care units (PICUs) in the United States and Canada for COVID-19 in March and April. Over 80% of the patients had chronic underlying conditions.

During the 3-week study period, over 20% of these patients experienced failure of 2 or more organ systems due to COVID-19, and nearly 40% required a breathing tube and ventilator. At the end of the follow-up period, nearly 33% of the children were still hospitalized due to COVID-19, with 3 still needing ventilator support, 1 child on life support, and 2 children died.

New developments -
Even more recently, a growing number of children have been identified who appear to have a different response to COVID-19, which doctors are calling Pediatric Multi-System Inflammatory Syndrome. The symptoms of Pediatric Multi-System Inflammatory Syndrome include a persistent fever, rash, as well as gastrointestinal symptoms such as vomiting and diarrhea. Patients can also suffer from cardiac inflammation. In the coming days, the CDC is expected to issue guidance with information for treatment.

Are people born with one kidney at higher risk for COVID-19?

No specific information exists about there being a higher risk for COVID-19 in people who have a single kidney as compared with the general population.

Should transplant recipients be worried about living with loved ones who go out in public or work outside the home?

A person who is living with a loved one who has contracted COVID-19 is at risk of also becoming infected. This is especially true for posttransplant patients.

Therefore, it is important for anyone to limit going into the public, especially if there is an active and expanding outbreak in their area, or if local and state authorities recommend remaining in place in an effort to maintain social distancing to help control the spread of the virus.

If people need to go into public, then they should take certain precautions, including limiting the time spent outside as much as possible, avoiding large crowds, and maintaining social distances (at least 6 feet). People with a kidney transplant should also consult with their healthcare team to find out what precautions should be taken by them and their caregivers. This might include additional hand washing/sanitizing, face coverings, or other measures.

How can COVID-19 affect transplant surgeries?

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 centers may still need to look at temporarily putting elective living donor transplantation or non-urgent deceased donor transplants on hold. Transplant centers 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).

Also, living donors are being asked to not travel to high-risk areas for at least 14 days before donation and monitor for symptoms. Information about recent travel and possible exposure is also asked about deceased donors to help determine if it is safe to use them for organ and tissue donation.

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 centers may still need to look at temporarily putting elective living donor transplantation or non-urgent deceased donor transplants on hold. Transplant centers 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).

Can I still get evaluated for transplant if I've had COVID-19?

Yes, but your healthcare team will need to tell you when you will be free from infection. Also, depending on your current health status and the impact of COVID-19 on hospital staff and supplies, your transplant may be delayed or postponed. You should discuss this with your transplant center.

Click here for the list of transplant centers and their contact information.

If I have COVID-19, can that delay my transplant evaluation?

Yes, if you or your living donor are still infectious.

How can I find a kidney donor now?

Check out NKF’s THE BIG ASK: THE BIG GIVE resources for tips on sharing your story to find a living kidney donor.

Check with your transplant center about whether they are currently evaluating potential living donors in light of COVID-19.

Are those who pass due to COVID-19 eligible organ donors?

The risk of acquiring COVID-19 from organ donation is low. Donated kidneys are screened for COVID-19. If a kidney tests positive for COVID-19, the organ cannot be used for transplantation.

Are those on immunosuppressants at risk of a false negative COVID-19 diagnosis?

There have been reports of possible false negative COVID-19 test results in the general public. There is also the potential for false negative COVID-19 test results among kidney transplant recipients on immunosuppression. However, research is ongoing to confirm or determine the extent of false negative test results.

Can transplant patients recover from COVID-19?

Post-transplant or other high-risk patients may be at higher risk for severe disease from COVID-19. For severe cases, recovery may take 6 weeks or more. About 1% of infected people worldwide will die from the disease.

Are transplant surgeries delayed by 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 centers may still need to look at temporarily putting elective living donor transplantation or non-urgent deceased donor transplants on hold.

Transplant centers 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).

How does COVID-19 affect rejection treatment?

Most rejection episodes do not have symptoms and are usually found through routine bloodwork.

However, if symptoms do occur the most common signs of rejection are:

  • Flu-like symptoms
  • Fever of 101° or greater
  • Decreased urine output
  • Weight gain
  • Pain or tenderness over transplant
  • Fatigue

If you have signs or symptoms of kidney transplant rejection, contact your transplant team immediately. Your transplant team will decide what other tests and treatments you may need.

What should I know about miracle cures and treatments?

" The FDA considers the sale and promotion of fraudulent COVID-19 products to be a threat to the public health.”"

Stephen H Hahn, MD, FDA Commissioner

Unfortunately, in times of uncertainty, there are people who look to prey upon those who are vulnerable. The US Food and Drug Administration (FDA) reports there are unscrupulous companies and individuals looking to fraudulently profit by scamming people who want to prevent and/or treat COVID-19.

Knowledge is power

The best way to avoid becoming a victim of fraud is to know the facts. According to the latest guidance from the CDC, there no vaccines or drugs approved to treat or prevent COVID-19. And, while there are investigational COVID-19 vaccines and treatments in development, these investigational products are still in the early stages of development and have not yet been fully tested for safety or effectiveness.

Beware of false promises

Products that claim to cure, mitigate, treat, or prevent disease, but are not proven safe and effective for those purposes, defraud consumers of money and can place consumers at risk for serious harm. Fraudulent COVID-19 products may come in many varieties, including dietary supplements, such as vitamins and minerals, foods (garlic), as well as questionable products purporting to be drugs, herbal remedies, immune boosters, medical devices, or vaccines. Using these products may lead to delays in getting proper diagnosis and treatment for COVID-19.

The FDA urges consumers and patients to talk to their healthcare providers and to follow the advice from federal public health agencies about how to prevent the spread and treatment options for people with COVID-19.

How can I protect myself if I need a blood test or other labs?

" Keep in mind that you may need a new “order” from your doctor if you use a new lab."

For routine blood draws or other kinds of labs, contact your healthcare provider to determine if the test can be postponed. If your doctor feels the test is necessary to do now, contact your lab to see if it can be done at home. Check if your lab is accepting urine samples dropped off at their site or sent through the mail. Sterile specimen cups can be purchased online or may be in stock at a local pharmacy.

If home testing is not an option, you should ask your lab, doctor, or transplant coordinator if there are any local labs that can provide in-home testing services. Not all health insurance plans cover lab visits at home, so you should contact your insurance provider to learn about your coverage.

Staying safe at the lab

If the test cannot be postponed or done in your home, you should know that medical facilities are taking precautions to keep you healthy. Hospitals, labs, doctors’ offices, and dialysis centers are evaluating patients and staff, such as checking temperatures and asking questions, to assess each person for active COVID-I9. If it is suspected that someone has the virus, then those people are kept isolated from all healthy people.

Prevention tips

It is also important that you take measures to help keep yourself safe and reduce the chance of getting COVID-19. Be sure to wear a mask when you go outside your home. Keep at least 6 feet distance between you and other people. Remember to wash your hands frequently and use hand sanitizer if there are no washing facilities. Avoid touching your eyes, mouth, and nose.

Be well prepared

Have extra supplies on hand, including surgical masks, hand sanitizer, and disposable gloves, so that if you come into contact with someone at a medical facility or if a technician comes to your home, you are both well protected. For in-home visits be sure to disinfect any surfaces that another person may have touched, such as doorknobs and countertops.

For National home testing programs click here:
CareDx
Natera

Ordering take-out with confidence

Many restaurants are now closed to enforce social distancing, but take-out is still available from many eateries. Here are some ideas for making ordering take-out easy even with your special kidney diet. Start by knowing your diet well and asking your dietitian for any tips or advice. If you have sodium, potassium, phosphorus, or protein restrictions, this information will help you make good decisions based on your specific dietary needs.

Plan ahead

Choose a restaurant where it will be easiest to select foods best suited for your diet. Restaurants where food is made to order are the best choice.

Making your selections

Look over the menu carefully. Ask for more details about items you do not know about. When you place your order explain that you are following a special diet. Make special requests about the way your food is prepared as follows:

Entrées:

  • Portions served in restaurants may be much larger than what you eat at home. When ordering take-out, estimate an amount close to what you normally have. (3 ounces of cooked meat, fish, or poultry is about the size of a deck of cards). Plan to have leftovers or split the meal with another person.
  • Grilled items are good choices.
  • Request that salt not be added when cooking.
  • Request that gravies or sauces be served in a separate container.
  • Avoid mixed dishes or casseroles. They are usually higher in sodium and phosphorus.
  • Remove the skin from poultry and any crusts from fried foods to decrease sodium content.
  • It is best NOT to add steak sauce, Worcestershire sauce, soy sauce, or hot sauce because of the high sodium content.
  • Lemon or lime juice and vinegar make good sauces and will bring out a lot of the natural flavor of foods. Black pepper will add zest to the food without making you thirsty.

Side dishes:

  • If you need to restrict potassium, choose starches and vegetables that are lower in potassium, such as rice, noodles and green beans.
  • If your meal does not include a good choice for your diet, request a substitute.
  • Ask that sauces be omitted or served in a separate container.

Stay safe

Ask the delivery person to leave the bag outside your door or be sure to keep your distance from them, especially if you need to pay them directly. If you have to pay them directly, consider wearing gloves. You can also wipe down the bag with a disinfectant wipe. Make sure food is well heated and reconsider the use of uncooked foods that aren't prepackaged. Of course, wash your hands before eating. Other tips on Safe Food Handling can be found at the FDA website.

What kind of foods should I have in my house?

If there is a virus outbreak in your area and you need to decrease your risk of getting sick, it’s important that you have food in your home. This will help reduce your risk of infection by allowing you to avoid crowded spaces like grocery stores and drug stores.

It's important for you to have shelf stable food choices to help you follow your kidney diet. Shelf stable means foods that last a long time without spoiling, such as canned foods. It’s important to prepare now by stocking up 2-3 weeks’ worth of healthy, kidney friendly foods, fresh water, and medicines. Check with your healthcare professional if you have any questions about your medications.

What are some kidney friendly low-sodium items (no potassium or phosphorus restriction)?

Includes all dialysis friendly foods as well as foods listed below.

Fruits (2-3 servings/day)

  • No sugar added canned fruits
  • Dried fruit
  • Fruit Juice

Vegetables (2-3 servings/day)

  • No salt added or low-sodium canned vegetables

Protein

  • Low-Sodium canned meat
  • Tuna
  • Salmon
  • Meat
  • Turkey
  • Chicken
  • Dried beans and peas
  • No sodium added or low-sodium canned beans
  • Shelf stable Tofu
  • Unsalted Nut butter
  • Unsalted Nuts and Seeds

Dairy (2-3 cups/day)

  • Dry Milk Solids
  • Evaporated milk
  • Shelf stable milk alternative (refrigeration required after opened)
  • Rice, soy, almond

Grain

  • Whole grain breads and pastas
  • White or brown rice
  • Unsalted crackers
  • Dry cereals: Low sodium
  • Cooked Cereals
  • Cream of wheat or rice
  • Grits
  • Rolled or steel cut oats

Fats

  • Unsalted butter or margarine
  • Low-sodium mayonnaise (single packets)
  • Salad or cooking oil

Sweets

  • Animal crackers
  • Chewing gum
  • Graham crackers
  • Hard candy
  • Jellybeans
  • Vanilla Wafers

Other

  • Low-sodium Soups and Broths
  • Honey
  • Jelly
  • Jam

Key points for patients with kidney disease

COVID-19 is a new virus, and therefore research on it has only just begun. Some hypotheses — ideas based on very little evidence — have been made about the effects of certain drugs on COVID-19, but nothing has been proven. In fact, leading health organizations such as the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have not recommended that patients stop any particular drug in order to decrease the chance of getting COVID-19 or to make it less severe. Some common drugs that have been highlighted in the news are discussed below.

Blood pressure medications called angiotensin converting enzyme inhibitors (ACEs) and angiotensin receptor blockers (ARBs) should NOT be stopped, unless recommended by a healthcare professional. These drugs are key to controlling blood pressure in patients with kidney disease. Stopping them could lead to a heart attack, stroke, or decreased kidney function. Learn more from the American College of Cardiology.

Patients with kidney transplants should not stop taking their immunosuppressants or lower their dose, unless their healthcare team tells them to. Stopping your immunosuppressants will most likely lead to the loss of your donated kidney. Contact your transplant team for any questions or concerns. Follow precautions as recommended by the American Society for Transplant located here.

Patients with kidney disease are usually told to avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. In general, kidney experts recommend acetaminophen for pain relief and reducing fever. But if you’re told by your healthcare team to take an NSAID for a specific reason, then you shouldn’t stop taking it because of COVID-19. Always talk with your healthcare team before making any changes in the drugs you take. Find the WHO's statement here.

Will there be drug shortages?

Since people with kidney disease depend on medicine to stay healthy it is important to understand issues related to potential drug shortages due to COVID-19. It’s hard to know which drugs will be affected, but it’s best not to panic. Hoarding and stockpiling drugs will only cause drug shortages to happen faster. Call your healthcare provider if you have a problem getting any of your medicines.

  • Only take medicines that are prescribed by your healthcare provider
  • Do NOT change the medicines you’re taking without speaking to your healthcare provider

The Food and Drug Administration (FDA) keeps a close watch on the drug supply chain.

This includes the availability of active pharmaceutical ingredients (API) which are often made in other countries, and any other parts of the supply chain that may be impacted by COVID-19. You can find more information about drug shortages related to COVID-19 on the Food and Drug Administration (FDA) website.

Feeling stress and depression?

"It’s common for people who have been diagnosed with chronic kidney disease, patients on dialysis, and those who have received kidney transplants to feel sad and depressed. In fact, studies show that 20% to 40% of people with kidney failure may also have depression. While the risk of severe illness due to COVID-19 remains low in the general population, people who have a chronic illness or who are taking immunosuppressant drugs are at an increased risk of becoming very ill. These fears are real – and the worry and stress can lead to an even greater bout of depression. If you are feeling more depressed than usual, The Centers for Disease Control has some great tips for helping you to manage your stress and anxiety.

Coping strategies

If you are feeling more depressed than usual, The Centers for Disease Control has some great tips for helping you to manage your stress and anxiety.

It is true -- the coming days are going to be unlike any we’ve ever had to face before – however, there are ways to help manage stress and depression and to help you cope when you feel sad and overwhelmed.

For more information

What should I know about shelf stable foods?

It’s important to keep shelf stable foods on hand to avoid getting sick if an outbreak happens in your area.

Reminders:

  • Throw away cans that are opened, dented, or past their expiration date to avoid food poisoning.
  • Avoid using salt (and salt substitutes if you have a potassium restriction)
  • Keep distilled water on hand (bottles or jugs).

Do immunosuppressive medications increase the risk of complications from COVID-19?

Yes – according to the CDC, taking immunosuppressive drugs does increase your risk for developing severe disease from the coronavirus due to an underlying medical condition.

Kidney transplant recipients

Doctors at a New York City hospital have reported that kidney transplant recipients are at significantly higher risk for developing serious, life-threatening COVID-19 illness due to taking chronic immunosuppression drugs and having co-existing medical conditions. While their sample size was small (36 transplant recipients), their results showed that kidney transplant recipients had a COVID-19 mortality rate of close to 30% as compared to 1% to 5% mortality in the general population and 8% to 15% mortality in patients with COVID-19 who are 70 years of age or older.

Continue taking your medication

Kidney transplant recipients should not stop taking immunosuppressant medication or lower their dose, unless instructed by their kidney doctor or transplant team. Stopping your immunosuppressants will most likely lead to the loss of your donated kidney. Contact your transplant team for any questions or concerns.

Follow precautions as recommended by the American Society for Transplant located here.

What about other underlying medical conditions?

There are other underlying medical conditions that people may have in addition to having undergone a kidney transplant recipient or dialysis treatment.

Some of these conditions are:

  • Chronic lung disease or moderate-to-severe asthma
  • Serious heart conditions
  • Immunocompromised due to cancer treatment, smoking, bone marrow transplantation, immune deficiencies, HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications
  • Severe obesity (body mass index [BMI] of 40 or higher)
  • Diabetes
  • Liver disease

What parents of young transplant recipients can do?

The best way to keep children on immunosuppressant treatment well is to prevent their exposure to the virus. Continue to practice everyday preventive actions to help reduce your risk of getting sick and infecting your child and

  • Avoid close contact with people who are sick
  • Stay home when you are sick, except to get medical care
  • Cover your coughs and sneezes with a tissue and throw the tissue in the trash
  • Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food
  • Use an alcohol-based hand sanitizer with at least 60% alcohol, if you’re unable to wash your hands (eg, using a gas pump)
  • Clean and disinfect frequently touched surfaces and objects (eg, tables, countertops, light switches, doorknobs, and cabinet handles)
  • Wear a cloth mask when around your child

Contact your child’s transplant center for more information.

Reference: Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units. JAMA Pediatr. Published online May 11, 2020. doi:10.1001/jamapediatrics.2020.1948.

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