Critical Care Protocols and Teamwork Help Emory Kidney Transplant Program Meet Pandemic-Related Challenges

 

Although now fully operational, the COVID-19 pandemic created significant challenges for Emory Transplant Center’s Kidney Transplant team. These included the suspension of kidney transplants during the Spring 2020 lockdown, severe hospital bed shortages during surges, and most notably, the heightened risk and impact of infection on the immunocompromised transplant patient.

Case Background

A 47-year-old patient was diagnosed with glomerulonephritis of unknown etiology as a child and had received two previous kidney transplants. Neither of the previous transplants took place at Emory. When his second donor kidney began to fail, he sought care at Emory Transplant Center.

The Emory Kidney Transplant Program team evaluated the patient for transplant in February 2020, and a deceased donor kidney became available in August. Following protocols established by the transplant team, the recipient and donor were tested for COVID-19. Both tested negative and the kidney transplant surgery took place with no complications.

Post Transplant Follow-up

As is often the case with patients who receive a deceased donor kidney, this patient experienced delayed graft function (DGF) needing dialysis support while awaiting transplanted kidney recovery. He was released from the hospital on dialysis and returned to Emory Transplant Center for follow-up care, including protocol biopsies for DGF.

To maintain social distancing in the outpatient clinic and minimize risk of exposure to our immunocompromised transplant patients, the Emory Kidney Transplant team has adopted a hybrid care model where stable kidney transplant patients can receive transplant follow-up care via telemedicine. Given the complexities associated with managing DGF, this patient required in-person appointments.

In October 2020, the patient was readmitted to Emory after testing positive for rhinovirus and pneumonia. A PCR test was negative for COVID-19. He continued to have DGF requiring dialysis and had 3 protocol kidney biopsies to assess for cause. The biopsies did not show evidence of rejection.

COVID-19 Diagnosis

On December 31, the patient presented to Emory University Hospital’s Emergency Department with symptoms including cough, shortness of breath, fever and fatigue requiring a hospital admission. He tested negative for multiple viruses, including SARS-CoV-2. Given that COVID-19 tests are not 100% reliable, the care team kept open the possibility that he had COVID-19 and managed him accordingly by keeping him in isolation. On January 7, his condition deteriorated requiring an ICU transfer, where he was intubated and placed on a ventilator. At that time, the care team ordered another COVID-19 test, which came back positive.

Critical Care Management

Critical care providers, in conjunction with the transplant nephrologist and infectious disease specialists, managed the patient’s care during his three-week ICU stay. While the critical care providers focused on his pulmonary and ventilation needs, transplant nephrologists were utilized for the management of his dialysis, immunosuppression therapy and other renal care needs. To allow for his recovery from COVID pneumonia, his immunosuppression therapy was reduced by closely monitoring renal function to prevent any possibility of kidney rejection.

Transplant infectious disease specialists considered experimental therapies (such as remdesivir) to treat the patient’s COVID symptoms; however, with a glomerular filtration rate greater than 30/mL/min, he did not qualify.

With continued multidisciplinary care, the patient’s condition improved slowly. After a challenging vent weaning course and subsequent tracheostomy, he was discharged to Emory Decatur Hospital Inpatient Rehabilitation Center on February 2, 2021.

Care Coordination with Emory Decatur Hospital Rehabilitation

The transplant team continued to follow the patient closely during his inpatient rehabilitation stay. They maintained an ongoing dialogue with the center’s clinical team and reviewed the patient’s lab results on a regular basis while assisting with management of his immunosuppression. This type of close communication is critical for inpatients who are on dialysis for acute kidney injury.

Ultimately, the patient began to show signs of renal recovery during the rehabilitation stay. Dialysis was discontinued before discharge from rehab and the patient returned home later in February not needing dialysis. At his most recent appointment with the Emory Kidney Transplant team, lab results indicated marked improvement in kidney function and the patient reported increased stamina and strength. The care team anticipates continued renal recovery as his condition continues to improve.

For more information about the Emory Kidney Transplant Program or to refer a patient, call1-855-EMORY-TX (366-7989) or visit emoryhealthcare.org/txrefer.

Emory Transplant Center is committed to the continued health and safety of all patients. During this time, we are taking all necessary precautions to screen for coronavirus (COVID-19) and to prevent its potential spread. We continue to monitor the evolving COVID-19 pandemic and are working with experts throughout Emory Healthcare to keep your patients safe. For the most up-to-date information for our referring partners, click here.