Table 4.
Recommendations From National and International Transplantation Societies
| Society/Reference | Origin | Date | Guideline | Recommendation |
|---|---|---|---|---|
| British Transplantation Society [188] | UK | January 2021 | Guidance on the management of transplant recipients diagnosed as having or suspected of having COVID-19 | Outpatients: - Stop antiproliferative agents (MMF/azathioprine) - Review total burden of immunosuppression and consider reduction of CNIs - High or increased dose steroid is NOT recommended at this stage Hospitalized patients: - Stop antiproliferative agents (MMF/azathioprine) Consider reducing or stopping CNIs - Dexamethasone 6 mg daily for 10 d Patients requiring ventilatory support: - Stop antiproliferative agents (MMF/azathioprine) - Dramatically reduce or stop CNIs - Consider dexamethasone, as above |
| International Society of Heart and Lung Transplantation [189] | International | February 2021 | Guidance from the International Society of Heart and Lung Transplantation regarding the SARS-CoV-2 pandemic | - For transplant recipients, consider holding MMF, mTOR inhibitors, or azathioprine while admitted with moderate/severe illness. |
| Transplantation Society [190] | International | March 2021 | Guidance on Coronavirus Disease 2019 (COVID-19 for Transplant Clinicians | - Dexamethasone 6 mg daily for up to 10 d can be considered in patients who require supplemental oxygen or are mechanically ventilated. - Attention should be paid to the potential drug interactions with current immunosuppression and the potential for increased risk of infectious complications when immunomodulatory agents are added to existing immunosuppressive therapy. |
| American Association for the Study of Liver Diseases [191] | US | March 2021 | Clinical Best Practice Advice for Hepatology and Liver transplant Providers During the COVID-19 Pandemic: AASLD Expert Panel Consensus Statement | - Consider lowering the overall level of immunosuppression, particularly antimetabolite dosages (eg, azathioprine or MMF) based on general principles for managing infections in transplant recipients and to decrease the risk of superinfection. - Monitor kidney function and CNI levels. - Adjust immunosuppressive medications based on severity of COVID-19 and risk of graft rejection and renal injury. |
| Canadian Society of Transplantation [192] | Canada | April 2021 | Consensus guidance and recommendations for organ donation and transplantation services during COVID-19 pandemic | - Based on current evidence, we suggest a temporary adjustment of maintenance immune suppression for hospitalized patients with severe COVID-19. - Data on optimal immune-suppression adjustment in patients with COVID-19 are lacking, may vary, and may not be required depending on disease severity and physician judgment. |
| American Society of Transplantation [193] | US | June 2021 | 2019-nCoV (Coronavirus): FAQs for Organ Transplantation | - The impact of immunosuppression on COVID-19 is not currently known but decreasing immunosuppression may be considered for infected recipients who have not had recent rejection episodes. - Many providers have decreased or discontinued cell cycle inhibitors or reduced CNI levels, but comparative data regarding these interventions are not yet available. - Whether adjunctive corticosteroid therapy for patients with severe ARDS may be beneficial is also unknown. |
AASLD, American Association for the Study of Liver Diseases; ARDS, acute respiratory distress syndrome; CNI, calcineurin inhibitor; COVID-19, coronavirus disease 2019; FAQs, frequently asked questions; MMF, mycophenolate mofetil; mTOR, mammalian target of rapamycin; UK, United Kingdom; US, United States of America; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.