• Letter to the Editor
  • Vol. 51 No. 2, 119–121
  • 23 February 2022

Paediatric living-donor liver and kidney transplantation during COVID-19

Vidyadhar Padmakar Mali, Marion Aw, Kar-Hui Ng, Sivaramakrishnan Venkatesh Karthik, Michelle Tan, Sharon Teo, Perry Yew-Weng Lau, Yoke Lin Nyo, Dale Ser Kheng Lincoln Loh, Ho Yee Tiong, Seng Hock Quak, Hui-Kim Yap

Dear Editor,

The coronavirus disease 2019 (COVID-19) pandemic has impacted global healthcare including paediatric solid organ transplantation (SOT). We report our experience of resuming paediatric living-donor SOT during COVID-19, which took into account safety considerations for living donors, paediatric recipients and the transplant healthcare team. The US Centers for Disease Control and Prevention has categorised SOT recipients at high-risk for COVID-19.1 During this period, transplantation programmes worldwide were either suspended or curtailed.2,3 In Singapore, all non-urgent deceased-donor transplants were temporarily suspended; living-donor transplants could only proceed if medically urgent.4,5

The paediatric solid organ transplant programme at the National University Centre for Organ Transplantation is a small but essential one. Since the start of the paediatric liver and kidney transplant programmes in 1991 and 1989, respectively, a total of 140 liver and 98 kidney transplants have been performed. Living-donor transplantations account for nearly 86% of the paediatric liver transplants and 58% of the paediatric kidney transplants.6 In the early years, the wait-list mortality for paediatric liver transplant was 15%.7 However, with increasing availability of living donors, the wait-list mortality in the last decade is nearly zero. Particularly for children with acute liver failure or chronic end-stage liver disease, there would be no option for survival without liver transplant, unlike children with renal failure where dialysis is an option. At the time of the nationwide partial lockdown in Singapore known as the circuit breaker (7 April–1 June 2020), there were 22 paediatric patients with kidney failure on long-term dialysis, of whom 4 were on the waiting list for a deceased donor kidney transplant. However, unlike the severe acute respiratory syndrome in 2003, the COVID-19 pandemic was prolonged.8 As the paediatric dialysis programme had only 4 dialysis nurses running the national programme, this was almost at full capacity. The mandatory requirement to split medical teams into 2 groups further aggravated the manpower shortage. Therefore, deferring fully worked-up living-related-donor kidney transplants for a prolonged duration would have added to the strain on the dialysis services. Further to the gradual and tiered re-opening of healthcare services after the circuit breaker, we resumed our paediatric SOT activity from June 2020 with a living-donor kidney transplant. With the transition to phase 2 of gradual re-opening, the paediatric living-donor liver transplants were resumed from August 2020 (Fig. S1 of Supplementary Material in the online version of this article).

In order to safely resume the solid organ transplant programme, a number of measures (including established protocols in Fig. S1 of Supplementary Material) were put in place to ensure safety of living donors, paediatric recipients as well as the healthcare team. These included:

  1. Requiring donors and recipients to restrict their movement and contact with other people in the 30 days preceding the scheduled transplant date. They were not allowed to travel out of the country, to come into contact with a COVID-19 positive or suspect patient, or come into contact with people considered at “high-risk” in the preceding 14 days.
  2. Pre-admission COVID-19 nasopharyngeal swab testing using reverse transcription-polymerase chain reaction (RT-PCR) 7days and 48 hours prior to the transplant date.
  3. Mandatory full vaccination for the entire healthcare team once the COVID-19 vaccine became available.

The transplantation proceeded only if the donors and recipients were clinically well, adherent to (1) and tested negative in (2).

Prior to transplant, outpatient transplant candidates and caregivers were seen in separate isolation bays in case of any respiratory symptoms or exposure to confirmed COVID-19 cases; with the healthcare personnel having to wear full personal protective equipment (PPE) (comprising N95 mask, gown, gloves, shoe covers and goggles). Transplants would be deferred to beyond 3 weeks post-resolution of respiratory symptoms.

None of the donors or recipients received COVID-19 vaccines because the vaccination efforts in Singapore were initially focused on the elderly and personnel in high-risk occupations.

We performed a total of 8 paediatric transplants (5 kidneys and 3 livers between June 2020 and May 2021), all from living donors only (Table 1).

Table 1

Intraoperative measures included the use of PPE whereas the immediate post-transplant protocols were not altered. In the immediate post-transplant period, we did not see an increase in ventilation need or respiratory infections. This meant that the precautions taken pre-transplant coupled with the negative PCR testing prior to transplant were sufficient measures until the immediate post-transplant period.

Following discharge, in addition to standard post-transplant advice, recipients were instructed to report respiratory symptoms or any symptoms attributable to COVID-19. They were also advised to mostly stay at home, wear mask when going out and avoid crowded places for 3–6 months in the post-transplant period. At a median follow-up of 11.5 months (range 4–15 months), all patients are alive and well with good graft function. Screening for COVID-19 was not routine. However, there was a low threshold for testing for COVID-19 using the SARS-CoV-2 PCR based on clinical indications. While it is possible that asymptomatic COVID-19 could have been missed, there was no evidence of increased respiratory or other morbidity attributable to COVID-19 in the immediate post-transplant period and for the duration of the follow-up.

Living-donor organ transplantation allows for directed organ donation. During a pandemic, the transplants could be scheduled, balancing the clinical acuity of the transplant candidates with the resource constraints on the healthcare system. Furthermore, the patients and their families could adhere to the safe-management measures in place.

Going forward, we have made pre-transplant COVID-19 vaccination mandatory for age-eligible transplant candidates.9 Pre-transplant COVID-19 vaccines are administered 2–4 weeks apart from other live vaccines; based on common paediatric practice to separate live vaccines from other vaccines. For the eligible organ recipients, COVID-19 vaccination is being mandated 3–6 months after their transplantation.10

In the course of the past 15 months, we have demonstrated that paediatric living-donor liver and kidney transplantation could be resumed safely during COVID-19 under strict pre-transplant isolation and screening protocols, peri-transplant infectious precautions and standard post-transplant immunosuppression and management.

Acknowledgment

We would like to thank Ms Dimple Rajgor for helping with formatting and submission of the manuscript.

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SUPPLEMENTARY MATERIALS

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REFERENCES

  1. Centers for Disease Control and Prevention. People with Certain Medical Conditions, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html. Accessed on 30 July 2021
  2. Charnaya O, Chiang TP, Wang R, et al. Effects of COVID-19 pandemic on pediatric kidney transplant in the United States. Pediatr Nephrol 2021;36:143-51.
  3. Doná D, Torres Canizales J, Benetti E, et al. Pediatric transplantation in Europe during the COVID‐19 pandemic: early impact on activity and healthcare. Clin Transplant 2020;34:e14063.
  4. Kee T, Gan VHL, Chung JS, et al. Managing a Renal Transplant Programme During the COVID-19 Pandemic: Practical Experience from a Singapore Transplant Centre. Ann Acad Med Singap 2020;49:652-60.
  5. Chung SJ, Tan EK, Kee T, et al. Practical Considerations for Solid Organ Transplantation During the COVID-19 Global Outbreak: The Experience from Singapore. Transplant Direct 2020;6:e554.6.
  6. Kee T, Ganpathi IS, Sivathasan C, et al. Solid organ transplantation in Singapore. Transplantation 2018;102:1397-400.
  7. Lim SG, Wai CT, Da Costa M, et al. Referral patterns and waiting times for liver transplantation in Singapore. Singapore Med J 2006;47:599-603.
  8. Wilder-Smith A, Chiew CJ, Lee VJ. Can we contain the COVID-19 outbreak with the same measures as for SARS? Lancet Infect Dis 2020;20:e102-7.
  9. Grupper A, Katchman E, Ben-Yehoyada M, et al. Kidney transplant recipients vaccinated before transplantation maintain superior humoral response to SARS-CoV-2 vaccine. Clin Transplant 2021;10:e14478.
  10. Ministry of Health, Singapore. Updates to eligibility for COVID-19 vaccination, 28 July 2021. Available at: https://www.moh.gov.sg/news-highlights/details/updates-to-eligibility-for-covid-19-vaccination-28jul2021. Accessed on 23 September 2021.