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Renal transplantation: COVID-19 NICE rapid guideline summary

This guideline covers people of all ages who need or have had a kidney transplant and those who are donating a kidney.

It also provides advice for transplant and referral centres on how best to run services during the COVID-19 pandemic and to protect staff and patients from infection.

Service organisation
NG178 suggests that renal networks collaborate to manage renal pathways during the pandemic to ensure that sites are COVID secure for both transplant and recipient assessment and follow-up after transplantation. It is recommended that alternative sites are used for parts of the pathway following human tissue authority guidance.

Prior to re-opening or expanding transplant services, centres are required to be confident that they have appropriate governance arrangements in place for data collection and that they are able to meet all the service specification requirements and have the capability for rapid COVID-19 testing and COVID-19 secure areas for recipients and donors.
Centres need to also discuss re-opening plans with the NHS blood and transplant and take account of the NHS Blood and Kidney advisory group guidance as well as NHS commissioners and other associated non-transplanting centres and local transplant centres if appropriate. They also need to communicate their re-opening plans with patients and their families and discuss the risks and benefits in the current pandemic.

NG178 also suggests that transplant and non-transplant centres use remote phlebotomy services as a way of minimising face-to-face contact and consider COVID-19 testing for both patients on the waiting list in line with any local polices and frontline staff.

Transplant recipients
Among patients who have had a new kidney, NG178 advices that health professionals review the UK government advice on shielding for patients and their families and explain any current risks. It is also important that patients and families are given advice on attending appointments and how to seek help if they become unwell. Staff should ensure that patients are added to their GP shielding list and that when being cared for, staff follow the UK government guidance on infection prevention and control. NG178 advises that staff assess whether patients taking immunosuppressants can have less frequent blood tests for routine monitoring.

NG178 notes that if patients taking immunosuppressants become unwell with respiratory symptoms, COVID-19 should not be automatically considered as the first diagnosis as other infective and non-infective causes may lead to symptoms and immunosuppressant treatment can result in atypical COVID-19 symptoms. However, if COVID-19 is diagnosed then immunosuppressant therapy can be modified following guidance from the British Transplantation Society and Renal Association.

Transplant donors
In the case of deceased donors, NG178 signposts clinical staff to advice on COVID-19 screening by the NHS Blood and Transplant Kidney Advisory group.

For living donors, it is advised that patients are fully informed of the implications of kidney donation in the context of COVID-19 and how risks can be managed. Transplantation should be delayed if patients develop COVID-19 until at least 28 days after becoming symptom-free and after a negative nasopharyngeal swab test for COVID-19. NG178 makes reference to the British Transplantation Society guidance for clinicians on consent for solid organ transplantation in the context of COVID-19.

Donation should not be undertaken until both the donor and recipient have tested negative for COVID-19.

Patients considered for kidney transplant
NG178 discusses the importance of informing patients of the risks and benefits of transplantation in the context of COVID-19. While this advice should be tailored to the individual needs of the patient, it should follow the advice provided to transplant recipients as described above.

Care at the time of the transplant
It is strongly advised in NG178 that transplant centres review induction and immunosuppression regimes to assess an individual’s immunosuppression burden in relation to COVID-19. All patients should be admitted earlier than usual to minimise cold ischaemia time and to allow for checking their history of social distancing and swab testing for COVID-19 performed together with a respiratory assessment.

A CT chest scan is not routinely required for patients without COVID-19 symptoms and the transplant or immunosuppression should not begin until the patient has tested negative for COVID-19. It is also vital that for those who require dialysis after transplantation this should be done in a COVID-19 secure area.

Patient communication and minimising infection risk
NG178 discusses the importance of communicating with patients, their families and carers to support their mental wellbeing during the COVID-19 pandemic to alleviate any anxieties or concerns they might have about the virus. The guideline suggests signposting patients to relevant sources of information such as Kidney Care UK coronavirus guidance, the National Kidney Federation, give a kidney, the UK government guidance mental health and wellbeing aspects of COVID-19, the NHS Blood and Transplant service and any relevant local kidney patient organisations.

NG178 advises staff to remind all patients not to change their current medication unless advised to do so by their specialist team and to keep a current list of their medicines in case they become unwell, in which case they should contact their specialist team.

NG178 recommends minimising face-to-face consultations and to make use of either telephone/video or to contact patients via email or text messaging and to issue electronic rather than paper prescriptions. However, if face-to-face appointments are necessary, staff should minimise the time patients spend in the waiting area through careful scheduling of appointments, discouraging early attendance and by asking patients to remain in their transport vehicle until they receive a text message informing them that they are ready to be seen. NG178 strongly recommends a “clean route” through the hospital and that treatments and prescriptions are delivered and dispensed rapidly.

Patients should be advised to contact both their renal teams and the NHS111 online coronavirus service if they believe that they are infected with COVID-19, but if seriously ill to contact 999.

Patients known or suspected of having COVID-19
Where a patient is known or suspected of having COVID-19, NG178 advises staff to follow the UK government guidance on infection prevention and control. However, if COVID-19 is detected at a later stage and the patient was not initially isolated, the NG178 suggests following the IK government guidance on the management of exposed healthcare workers and patients.

In contrast, if a patient not known to be infected displays COVID-19 symptoms when first presenting, NG176 advises staff to follow the UK government guidance on investigation and initial clinical management of possible cases.

Healthcare workers
In cases where staff are known/suspected of having COVID-19, or live in a household where another person is known/suspected of having the virus, they should self-isolate and only return to work in accordance with the UK government guidance on stay at home for households with possible COVID-19 infection. If self-isolating staff are still able to work, recommended roles include undertaking telephone or video consultations and participation in virtual multidisciplinary meetings, helping to identify patients who can be monitored remotely and those who might require more support as well as performing any routine tasks which can be done remotely.

NG178 is available online and interested readers should check this version for further updates.