[Downloaded free from http://www.ijtonline.in on Monday, July 6, 2020, IP: 10.232.74.

22]

Special Article

NOTTO Transplant Specific Guidelines with reference to

COVID-19
Introduction a) Safety of health care professionals (doctors, nurses,
coordinators, tech nicians, hospital at tendants,
Novel corona virus (SARS-CoV-2) infection starting since
housekeeping staffs, ambulance drivers) by providing
December 2019 has resulted in pandemic within few weeks’ required PPE as per their risk stratification
time. In addition to elderly and patients with associated b) Prevention of transmission of COVID-19 from patients
comorbidities, organ transplant recipients are at a risk for more (recipients & donors) to HCWs and vice-versa by having
severe COVID-19 if they get SARS CoV-2 viral infection. proper facilities for universal precaution including
Further, there is potential risk of infection transmission from the isolation in pre and post- transplant period.
donor to recipient through organ transplantation. Also, there are c) Prevention of cross infection of COVID-19 from these
issues in recipient and donor selection for transplant. In view of patients (recipients& donors) to other non-transplant
these issues, organ transplant at the time of COVID-19 pandemic patients
should be undertaken with caution. The optimal approach to
corona virus disease (COVID-19) screening in organ recipients
and donors may change over time as more data accumulate [1-3].
General Precautions
1. Before restarting transplant program in the era of
Organ transplantation for end stage organ failure can be a COVID-19, we recommend that each transplant hospital
lifesaving intervention in patients with organ failure and mostly does a detailed assessment of epidemiology, current
can be performed electively with few exceptions. Patients trends, surge capacity and impact of COVID-19 as
with acute liver failure, acute on chronic liver failure and well as assessment of ICU facility and team in respective
those with hepatocellular cancer need an urgent transplant. hospitals. Only after that, transplant can proceed with
Some countries have stopped living donor organ transplants caution if the above concerns have been addressed.
(with exception for life saving measures) while some continue 2. Before transplanting new patient, we suggest to initiate
with deceased donor organ transplantation. However, due assessment of existing transplant recipients for their
to risk of COVID-19 related morbidity and mortality in the access to drugs. Patients transplanted in COVID-19
recipient and living donor and cross infection of COVID-19 pandemic should have the same stringent follow up as
among other patients and health care workers (HCW), there they would have got prior to it.
is need for assessing the overall risk v/s benefit of organ 3. We suggest a team of HCW (transplant coordinators
transplantation. If in certain organs the risk of death is higher and transplant team members) should be designated to
due to waiting then that patient should be considered for organ care EXCLUSIVELY for transplant cases (COVID
transplantation. As the situation improves, there may need to FREE safe transplant pathway) to reduce the risk of
be a phased increment in transplantation services. It may be transmission. When feasible all transplant units should
prudent to limit transplants to those who are struggling with define two teams which are separate and not working
non-transplant modalities of treatment. together and which should have independent transplant
surgeon, physician and intensivist so that all surgical
The risk-benefit ratio should be the key point to be exercised and medical problems can be handled if one team gets
in deciding the need for transplantation as post-transplant these quarantined or exposed. The teams can alternate for each
patients will be kept on immunosuppressive drugs which will patient. Transplant teams should reserve personnel at
make them prone to acquiring covid-19 infection. all levels so that in case a member needs quarantine on
All transplant teams can quickly build up a database and account of COVID-19 infection, the care of the patient
assess regarding number of patients currently contactable, should not suffer. Alternatively, an informal understanding
their ability to procure medicines in the current lockdown should take place between transplant centres in the same
and connectivity with their doctors, number of patients who city to provide cross over in such an eventuality
developed COVID-19 and their outcome. This will help each 4. We recommend all transplant recipients and donors
should sign the fully documented written informed
of the regions to set up support systems not only for already
CONSENT accepting a potential risk of COVID-19
transplanted patients but also for the new transplants.
infection during hospital stay and after transplant. It
While recommending organ transplantation during COVID-19 should include risk and benefit of transplantation vs
pandemic, following general safeguards have to be ensured available alternative treatment such as dialysis in case of
by each hospital: renal failure.

© 2020 Indian Journal of Transplantation | Published by Wolters Kluwer ‑ Medknow 85

[Downloaded free from http://www.ijtonline.in on Monday, July 6, 2020, IP: 10.232.74.22]

Kute, et al.: Transplantation in COVID pandemic

5. We recommend adequate availability of personal 6. We recommend routine training of HCW on use and
protective equipment (PPE) (i.e., triple layer masks, disposal of PPE [1, 2] [Table 1, 2].
N95 respirators (preferably without valves), gloves, 7. We recommend ensuring HCW should receive adequate required
gowns, goggles, face shields, shoes/ shoe covers) as per training on various components of “universal precautions” (hand
GOVERNMENT guidelines [1, 2]. hygiene, respiratory etiquette, and social distancing etc.) [1, 2]

Transplant unit preparedness checklist developed to deliver safe transplant during and after COVID-19 pandemic

TABLE 1 CHECKLIST FOR TRANSPLANTATION

DONOR RECIPIENT HCW CARE GIVERS
1) SOCIAL DISTANCING: Practicing social distancing for 14 days prior to Yes/No Yes/No Yes/No Yes/No
surgery to avoid unnecessary exposure
2)HEALTH EDUCATION on COVID-19 prevention Yes/No Yes/No Yes/No Yes/No
3) COVID-19 DIAGNOSIS
EPIDEMIOLOGICAL screening for travel and potential exposures
Travel to or residing in an area in the preceding 21 days, where local Yes/No Yes/No Yes/No Yes/No
COVID-19 transmission is occurring
Direct contact with known or suspected case of COVID-19 in the Yes/No Yes/No Yes/No Yes/No
preceding 21 days
Confirmed Diagnosis of COVID 19 in the last 28 days Yes/No Yes/No Yes/No Yes/No
Travel to or residing in an area which has been designated as a containment Yes/No Yes/No Yes/No Yes/No
zone in the last 28 days
Any suspicion to conceal history of exposure to COVID-19 in patient and Yes/No Yes/No NA NA
donor in order to receive transplant
CLINICAL screening for COVID-19 symptoms
History of fever (>38ºC or 100.3ºF ) and or Yes/No Yes/No Yes/No Yes/No
Respiratory symptoms: Cough shortness of breath, wheezing or chest Yes/No Yes/No Yes/No Yes/No
tightness, sore throat, flu like symptoms. Consider excluding symptoms
attributable to other causes and allergies
Temperature (thermal screening) Yes/No Yes/No Yes/No Yes/No
LABORATORY screeningwithCOVID-19 RT-PCR test of airway specimen If required or hospital is a COVID facility
(1-3 days before transplant)
Date and time
Specimen used: nasopharyngeal, oropharyngeal swab, bronchoalveolar lavage,
endotracheal aspirate or a combination
Results +ve/ -ve +ve/ -ve +ve/ -ve +ve/ -ve
4) Potential risk of COVID-19 consent: have transplant recipient and donor NA
signed an informed consent accepting a potential risk of COVID-19 infection
in hospital and after transplant?
5) OTHER OPTIONAL TESTS IF SUGGESTED BY THE TRANSPLANT TEAM
CT chest
Date and time
Results : normal /suspicious of COVID-19
LABORATORY screening(COVID-19 RT-PCR test of airway specimen)
(second test such as in hot spot)
Date and time
Specimen used
Results
PCR every week during their stay and before discharge
COVID-19 IgM/IgG antibody rapid test if approved by the government
Pro-calcitonin
Highly reactive C reactive protein
Complete blood count: lymphocyte count
6) COVID-19 assessment ACCEPTABLE TO PROCEED for surgery Yes/No Yes/No Yes/No Yes/No
Date and time of proposed surgery
Is laboratory testing compatible with proposed transplant date and time? Yes/No Yes/No Yes/No Yes/No
Remark
Date: Name /Signature
This checklist should be used in conjunction with policies and official guidance from local health authorities or hospitals

86 Indian Journal of Transplantation  ¦  Volume 14  ¦  Issue 2  ¦  April‑June 2020

[Downloaded free from http://www.ijtonline.in on Monday, July 6, 2020, IP: 10.232.74.22]

Kute, et al.: Transplantation in COVID pandemic

TABLE 2: CHECK LIST FOR TRANSPLANT UNIT

Is there enough stock of PPE and drugs? Yes/No
Are all HCW patients, attendants and caregivers wearing a three-layer surgical facemask inside the pre and post-transplant area? Yes/No
Is training for use of PPE including donning, doffing and proper disposal is completed for HCW? Yes/No
HaveHCW received training in updated clinical knowledge of COVID-19 & guidelines from government, academic society, and hospital Yes/No
authority, cough etiquette, hand hygiene, social distancing, PPE and universal precautions?
HaveHCW received trainingfor clinical, epidemiology, laboratory screening of patients, donors, care takers and COVID consent Yes/No
process?
HaveHCW self-monitored their symptoms and informed transplant program head in case they or their family members develop Yes/No
symptom(s) suggestive of COVID-19?
Is list of staff recorded and be retained by transplant team head? Yes/No
Have HCW had meals at different times after washinghands with flowing water? Yes/No
COVID FREE SAFE PATHWAY FOR TRANSPLANT Yes/No
Is there a designated entry and exit for patients and HCW involved in transplant? Yes/No
Is there a dedicated area for pre-transplant evaluation to maintain distance between patients, donors and health workers, and is it cleaned Yes/No
between sessions?
Is cleaning and disinfection time table of pre-transplant area displayed at entry gate? Yes/No
PRE AND POST-TRANSPLANT OPD AND WARD
Is there an alcohol-based hand sanitizer at entry? Yes/No
Are the following equipment either used separately for each patient OR disinfect between the shifts? Yes/No
Stethoscopes (diaphragms and tubing cleaned with an alcohol based disinfectant) Yes/No
BP cuffs (NIBP cuffs can be cleaned by alcohol or 1% sodium hypochlorite) Yes/No
Oxygen saturation probes Yes/No
No sharing of thermometers Yes/No
Are posters displayed on education and preventions of COVID-19 (hand hygiene, social distancing, COVID-19 symptoms and testing Yes/No
and universal precautions)?
Transplant infectious disease assessment if required Yes/No
Transplant psychiatry assessment if required Yes/No
Are disinfection, environmental cleanliness, and good air conditioning & ventilation conditions instituted? Yes/No
Is social distancing followed? Yes/No
Are all frequently touched surfaces inside the transplant unit, cleaned and disinfected frequently and duty list maintained? Yes/No
Transplant OT
Is there dedicated transplant OT and HCW for surgery? Yes/No
Is there cleaning and disinfection of OT and timetable? Yes/No
POST-TRANSPLANT
Post-transplant patient and donor in separate rooms with an attached bathroom Yes/No
Are visitors limited to one visitor for 10 minutes with social distancing (2 meter), wearing a surgical mask and a gown? Yes/No
Determine approaches to minimize exposure to the healthcare setting for non-essential services Yes/No
Is telemedicine and emergency consultation contact number available? Yes/No
Recipients should avoid travel to area with COVID-19 cases Yes/No
Can patients find information about the latest developments regarding COVID-19 on the hospital and government website? visit https:// Yes/No
www.mohfw.gov.in/
Remark :
Date: Name /Signature

Recipient and donor related b. EPIDEMIOLOGICAL:

i. Travel to or residing in an area in the preceding
8. We recommend haemodialysis unit preparedness and 21 days, where localCOVID-19 transmission is
safe dialysis delivery based on the Government of India occurring
guidelines for dialysis before transplant [4, 5]. ii.  Confirmed diagnosis of COVID-19 in the last 28 days
9. W e r e c o m m e n d r o u t i n e C L I N I C A L a n d iii. Direct contact with known or suspected case of
EPIDEMIOLOGICA L screening for COVID -19 COVID-19 in the preceding 21 days.
in donors, recipients, HCW and care takers [6 -8] iv.  Travel to or residing in an area which has been
(Table1,2). designated as a containment zone in the last 28
a. CLINICAL screening: fever (>38ºC or 100.3ºF) and/ days
or respiratory symptoms (cough, shortness of breath, 10. We recommend routine LABORATORY screening with
wheezing or chest tightness), anosmia, sore throat, flu COVID-19 real time polymerase chain reaction (RT-PCR)
like symptoms. test of airway specimen for both donor and recipient

Indian Journal of Transplantation   ¦  Volume 14  ¦  Issue 2  ¦  April‑June 2020 87

[Downloaded free from http://www.ijtonline.in on Monday, July 6, 2020, IP: 10.232.74.22]

Kute, et al.: Transplantation in COVID pandemic

with the testing occurring as close as possible prior to 21. We suggest telemedicine for encouraging social
surgery within 24–72 hours in both living and deceased distancing when feasible. Telemedicine consultation is
donor organ transplants. Chest CT scan of the donor is not a substitute to in-person consultation where clinical
mandatory prior to lung transplantation, and may also be examination is required.
required in other transplants for donor and / or recipient 22. We suggest using AarogyaSetuApp, taking extra care of
if suggested by the transplant team [9,10]. the elderly, healthy lifestyle for all, and strict adherence to
11. Living donor with positive COVID-19 test should not universal precautions all the time to mitigate the spread
donate for at least 3-6months until the long-term outcome of COVID-19.
of cured COVID-19 becomes clear. However, in case of 23. We recommend these guidelines and checklist should
life saving transplants, we suggest accepting donor with be used in conjunction with local policies and official
a previous diagnosis of COVID-19 with documented guidance from health authorities or hospitals as per
two negative COVID-19 tests and complete symptom changing situation.
resolution for 28 days and another negative test at the 24. We recommend that all infection prevention and control
time of donation. measures shall be implemented.
12. We suggest practicing social distancing for 14 days prior 25. In order to ensure monitoring the compliance to
to surgery for both living donor and recipient and using guidelines, State appropriate authority, concerned
surgical facemask when going out in public SOTTO and ROTTO should monitor compliance to
13. We recommend minimizing the use of energy devices the guidelines through seeking detailed data from the
during procedures when possible. When energy is needed, hospitals in this regard and sharing the same with NOTTO
we recommend avoiding the ultrasonic scalpel and lower on regular basis.
energy settings to minimize surgical smoke. Futuristic approach for COVID-19 testing protocol for planned
14. We suggest use of induction and other immunosuppressive surgery - The patients should get admitted in isolation 24 hours
drugs based on recipient’s own immune risk stratification before planned surgery.[11]
as being practised before COVID-19.
15. We suggest restricting movement of recipient to other RTPCR IgM IgG Action proposed
hospital areas. Use designated portable X-ray equipment Negative Positive May be taken for transplantation,
no testing during hospital stay and
and/or other designated diagnostic equipment. If transport
exit test
is mandatory, use predetermined transport routes to Negative Negative Negative No infection- Go for
minimize exposure to staff, other patients, and visitors, transplantation, PCR testing every
and patient must use surgical mask. Ensure that HCWs 6-7 days of stay and exit PCR test
who are transporting patients perform hand hygiene and Positive Negative Defer transplantation till PCR
use surgical mask. negative &IgG appears
assumed IgG is universally protective and specificity of the antibody test
16. We recommend limiting visitors to those essential for
is 100% or  close to it
patient support and visitors use surgical mask and keep
social distancing. Visitor’s records should be maintained At present, there is no recommendation for prophylactic
for contact tracing if required in future. medications such as hydroxychloroquine for transplant patients.
17. We suggest managing laboratory specimens, laundry,
food service utensils, and medical waste following safe Conclusion
routine procedures according to infection prevention Given that the epidemiological situation is constantly evolving,
control guidelines. it is recommended that each transplant team assess the current
18. We recommend use of disposable equipments as far scenario that best describes their local situation [6,12].Any
as possible or if equipments (e.g., stethoscopes, blood transplant program should make a CASE BY CASE evaluation
pressure cuffs, thermometers, food trays) need to be when assessing the convenience of carrying out a transplant
re-used, then clean and disinfect between use for each based on availability of health care resources including ICU;
patient (e.g., by cleaning with ethyl alcohol 70% or 1% risk/benefit of exposing an immunosuppressed patient to
sodium hypochlorite). the potential risk of COVID-19 (according to the number of
19. We recommend routine cleaning and disinfecting
cases and the possibility of admission under ideal isolation
surfaces with which the patient is in contact with 1%
conditions) versus the urgent medical need for transplantation
sodium hypochlorite solution.
(clinical situation of the patient).
20. If recipient and /or donor become COVID-19 positive,
we suggest treatment as per local authority guidelines Acknowdegements
as currently there is no standard accepted treatment NOTTO wishes to thank other members of the Indian
guidelines. There is no consensus regarding modification Society of Transplantation (ISOT), Liver Transplant Society
in immunosuppressive regimen. Transplant team should of India(LTSI) and the Indian Society for Heart and Lung
make a case by case evaluation for dose adjustment to Transplantation (INSHLT) for their expert input, critical review
balance infection control & rejection. and approval of this statement. The authors have not received

88 Indian Journal of Transplantation  ¦  Volume 14  ¦  Issue 2  ¦  April‑June 2020

[Downloaded free from http://www.ijtonline.in on Monday, July 6, 2020, IP: 10.232.74.22]

Kute, et al.: Transplantation in COVID pandemic

any funding or grants in support of the presented research or for References

the preparation of this work and have no potential declarations 1. Available from: https://www.mohfw.gov.in/. [Last Accessed on 2020
of interest. Apr 19].
2. WHO. Available from: https://www.who.int/emergencies/diseases/
Disclaimer novel-coronavirus-2019. [Last accessed on 2020 Jun 01].
3. ECDC. Available from: https://www.ecdc.europa.eu/en/publications-
These recommendations/suggestions may require regular data/risk-assessment-outbreak-acute-respiratory-syndrome-associated-
updating to account for the changing epidemiology and new novel-1. [Last accessed on 2020 Jun 01].
information regarding treatment and testing. Updated 18th 4. Available from: https://www.mohfw.gov.in/pdf/
May 2020. GuidelinesforDialysisofCovid19Patients.pdf. [Last accessed on 2020
Jun 01].
Note: This special article is being published simultaneously 5. Available from: https://cdn.georgeinstitute.org/sites/default/files/covid-
19-hemodialysis-unit-preparedness-checklist.pdf. [Last accessed on
in the Indian Journal of Transplantation and the Indian Journal
2020 Jun 01].
of Nephrology, as per the decision of Editor-In-Chiefs of both 6. Ahn C, Amer H, Anglicheau D, Ascher N, Baan C, Bat-Ireedui, et al.
these journals. Global Transplantation COVID Report March 2020. Transplantation
2020. doi: 10.1097/TP.0000000000003258
Vivek Kute, Sandeep Guleria1, Jai Prakash2, Sunil Shroff3, Narayan Prasad4, 7. Available from: https://notto.gov.in/WriteReadData/Portal/
Sanjay K Agarwal5, Santosh Varughese6, Subhash Gupta7, AGK Gokhale8, News/711_1_FINAL_GUIDANCE_COVID-19_31.03.2020.pdf. [Last
Manisha Sahay9, Ashish Sharma10, Prem Varma11, Anil Bhalla12, accessed on 2020 Apr 01].
Harsh Vardhan13, Manish Balwani14, Shruti Dave15, Dhamendra Bhadauria16, 8. SanjivSaigal, Subash Gupta, Sudhindran S, Neerav Goyal, Amit
Manish Rathi17, Dhananjay Agarwal18, Pankaj Shah19, Rastogi, Mathew Jacob, et al. Liver transplantation and COVID-19
Vasanthi R20, Rajiv Garg21 (Coronavirus) infection: guidelines of the liver transplant Society of
India (LTSI). Hepatol Int. 2020:1-3.doi: 10.1007/s12072-020-10041-1.
Department of Nephrology, Institute of Kidney Diseases and Research Center
9. D’Andrea A, Di Giannuario G, Marrazzo G, Riegler L, Mele D, Rizzo
and Dr. H. L. Trivedi Institute of Transplantation Sciences (IKDRC-ITS),
M, et al. The role of multimodality imaging in COVID-19 patients: from
Ahmedabad, Gujarat, 1Department of Transplantation Surgery, Indraprastha
diagnosis to clinical monitoring and prognosis]. G ItalCardiol (Rome).
Apollo Hospital, New Delhi, 2Former Professor and Head, Nephrology,
Italian 2020;21:345-53.
Benarus Hindu University, Varanasi, Uttar Pradesh, 3Managing Trustee, Mohan
10. Zhou S, Wang Y, Zhu T, Xia L. CT Features of Coronavirus Disease
Foundation, Chennai, 4Department of Nephrology, Sanjay Gandhi Post Graduate
2019(COVID-19) Pneumonia in 62 Patients in Wuhan, China. AJR Am
Institute of Medical Sciences, Lucknow , Uttar Pradesh, 5Department of
J Roentgenol. 2020:1-8. doi: 10.2214/AJR.20.22975.
Nephrology, All India Institute of Medical Sciences, New Delhi, 6Department
11. Al-Muharraqi MA. Testing recommendation for COVID-19 (SARS-
of Nephrology, Christian Medical College, Vellore, Tamilnadu, 7Department
CoV-2) in patients planned for surgery - continuing the service and
of Liver Transplant Surgery, Max Center of Liver and Biliary Sciences, Max
‘suppressing’ the pandemic. Br J Oral Maxillofac Surg. 2020. pii:
Hospital, Saket, New Delhi, 8Department of Heart and Lung Transplant, Apollo
S0266-4356(20)30164-9. doi: 10.1016/j.bjoms.2020.04.014.
Hospital, Jubilee Hills, Hyderabad, Telengana, 9Department of Nephrology,
12. Martino F, Plebani M, Ronco C. Kidney transplant programmes during
Osmania Medical College, Hyderabad, Telengana, 10Department of Transplant
the COVID-19 pandemic. Lancet Respir Med. 2020.
Surgery, The Post Graduate Institute of Medical Education and Research
(PGIMER), Chandigarh, 11Department of Nephrology, Venkateshwar Hospital,
This is an open access journal, and articles are distributed under the terms of the Creative
New Delhi, 12Department of Nephrology, Sir Ganga Ram Hospital, New Delhi,
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
13
Department of Nephrology, Jawaharlal Nehru Medical College, Sawangi, remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
Wardha, Maharashtra, 14Department of Nephrology, Indira Gandhi Institute of is given and the new creations are licensed under the identical terms.
Medical Sciences, Patna, Bihar, 15Department of Pathology, IKDRC-ITS,Gujarat,
Ahmedabad, Gujarat, 16Department of Nephrology, SGPGI, Lucknow, Uttar
Pradesh,17Department of Nephrology, PGIMER, Chandigarh, 18Department Access this article online
of Nephrology, SMS Medical College, Jaipur, Rajasthan, 19Department of Quick Response Code:
Nephrology, IKDRC-ITS, Ahmedabad, Gujarat, 20Director, Department of Surgery, Website:
National Organ and Tissue Transplant Organisation, VMMC and Safdarjung www.ijtonline.in
Hospital, New Delhi, 21Director General of Health Services, Nirman Bhawan,
New Delhi, India
DOI:
10.4103/ijot.ijot_62_20
Corresponding Author: Dr. Vasanthi R,
Director, National Organ and Tissue Transplant Organization, NIOP Building,
Safdarjung Hospital campus, Delhi.
Email: [email protected] How to cite this article:Kute V, Guleria S, Prakash J, Shroff S, Prasad N,
Agarwal SK, et al. NOTTO transplant specific guidelines with reference
Received: 22 June 2020; Accepted: 25 June 2020; Published: 06 July 2020 to COVID-19. Indian J Transplant 2020;14:85-9.

Indian Journal of Transplantation   ¦  Volume 14  ¦  Issue 2  ¦  April‑June 2020 89