COVID-19

COVID-19 and Pediatric Lung Transplant

  • 1.  COVID-19 and Pediatric Lung Transplant

    Posted 03-19-2020 12:31
    Several of us in the Pediatric Lung Transplant Community started an e-mail discussion about COVID-19 in our recipients.  I've copied the discussion here so that the broader community can participate.  In this post I've copied (edited lightly) the key comments in our e-mail discussion.
    We welcome your input!

    From: Schecter, Marc (Marc) <Marc.Schecter@cchmc.org>
    Sent: Wednesday, March 18, 2020 2:52 PM

    Dear All,

    Has anyone seen COVID in their post-transplant patients?  If so, did you treat with hydroxychloroquine?  Do you have any treatment protocols for immune suppression alterations, use of pulse steroids, oral steroids, steroids tapers?  We are working on finalizing our treatment protocol.

    Marc Schecter, MD

    From: Melicoff-Portillo, Ernestina <portillo@bcm.edu>
    Sent: Wednesday, March 18, 2020 3:02 PM
    We have not seen it in our patients. Flor Munoz put together a guideline on how to assess and treat SOT patients with COVID-19. We are finalizing it and would be glad to share with you.

    We have the luxury of having 3 very stable kids on the list (two of which are status 7), so we decided to be selective with donors. We will request all donors to be tested for SARS-Cov2 - regardless of epidemiological or clinical history. Of course we will continue to review each case and discuss.

    Regarding bronchoscopies, I am concerned that asymptomatic pediatric donors could expose the pulmonary providers if they are not tested. Are you asking your local OPO to test patients being assessed for donation prior to doing a bronchoscopy for evaluation?

    Also, are you performing ALL / some / any bronchoscopy in a negative pressure room? 

    Tina

    From: Sweet, Stuart
    Sent: Wednesday, March 18, 2020 3:31 PM

    ISHLT has convened a working group on COVID-19 that is trying to pull together guidance for transplant centers and others caring for an patients with end stage heart and lung disease.  We have created a COVID-19 community on ISHLT Connect that will be open to anyone interested in viewing or participating in a discussion.  I've attached the most recent version of what is intended to be a dynamic document.  At this point, none of the group could provide clear evidence based guidance on altering immunosuppression or treatment.  I suspect those recommendations will evolve as experience from China, Europe and elsewhere trickles in.  One of the key pieces of information appears to be that the morbidity related to COVID-19 is more the robust immune response rather than the infection itself.

    There is also a robust discussion about COVID-19 in the AST COP discussion board which includes specific treatment recommendations for which the mixture of evidence base and expert opinion isn't entirely clear.  There are also references to the experience in China that I couldn't immediately find in the thread.

    At this time, if we have patients with COVID-19 we're planning to not change immunosuppression immediately, use hydroxychloroquine (if we can get it) and consider IL-6 inhibitors if patients develop ARDS.  I suspect this will be a moving target as well.

    We're going to be very cautious about donors and do our best to have testing performed on any one we consider.  We'll be extremely cautious about taking organs for an ambulatory candidate but will still pursue transplant in our hospitalized kids.

    We're going to defer as much of our surveillance as we can get away with.

    Stuart

    From: Christian Benden <christian_benden@yahoo.de>
    Sent: Wednesday, March 18, 2020 3:48 PM

    Dear All,

    Here in Switzerland, there has been to date only one (adult) lung transplant recipient with COVID-19 according to my knowledge. She actually presented with fever and GI symptoms rather than respiratory symptoms, but she was tested for COVID-19 anyhow and found positive. The patient is hospitalised, not requiring ICU care and receiving IVIG but not altered immunosuppression plus symptomatic therapy. But more lung transplant patients to come our way, that's for sure…

    Regarding donors: since early March, all donors in Switzerland - even without respiratory symptoms - undergo testing to rule out COVID-19 by PCR (either by NPA or bronchoscopy). Organs get allocated only if PCR is negative. We have already detected COVID-19 in asymptomatic donors.

    Chris

    From: Schwerk.Nicolaus@mh-hannover.de <Schwerk.Nicolaus@mh-hannover.de>
    Sent: Wednesday, March 18, 2020 3:49 PM
    Marc,

    until now we only have a close contact case without symptoms. Test result pending. Jens Gottlieb, our adult pulmonologist, is aware of 9 cases with only mild symptoms. We do not have a standardized  treatment protocol yet. I would consider the following steps (just a brain storming)

    1. infected no symptoms: no further action, close follow ups
    2. mild symptoms, lung function stable: like 1
    3. FEV1 decline from baseline >10<20, no tachypnea/diffucult breathing/fever: stop MMF, increase Prednisolon (2 mg/kg), continue Tac, ask our virologist about his opinion regarding antivirals (I think I will do this tomorrow anyway;-)
    4. FEV1<20% and/or tachypnea/difficult breathing/fever: 
    5. a) chest X-ray,  consider CT when diffuse lung disease is suspected
    6. Lab
    7. Consider Bronchoscopy
    8. Consider steroid pulse (Methylpred, 15-20 mg/kg/d od for three days
    9. In case of clinical improvement I would taper Prednisolon individually but  generally slowly. Would prefer Pred 2 mg/kg/d at least for 14 days, as disease activity seems to be quiet long..
    10. No improvement or detoriation: consider hydroxychloroquin 6-10 mg/d after exclusion of contraindications
    11. Ad antibiotics in case of any suspicion of bacterial superinfection 

    As stated above, just short thoughts. Happy to hear your opinion

    Best wishes

    Stay healthy

    Nico

    From: Christian Benden <christian_benden@yahoo.de>
    Sent: Wednesday, March 18, 2020 4:03 PM

    Dear Nico,

     Thank you for your list of considerations provided, always helpful even if "just a brain storming".

     As far as I've learned talking to Italian colleagues, CXR is rather less helpful, so I'd rather go for a CT chest imaging straight away if lung function drops.

     With regards to bronchoscopy, I would rather be cautious.

     Reduction of immunosuppression is not recommended in mild disease as far as I know.

     Further, I would use antibiotics early in the course of the disease rather to prevent a bacterial superinfection.

     Best regards and keep safe!

     Chris

    From: Schecter, Marc (Marc) <Marc.Schecter@cchmc.org>
    Sent: Wednesday, March 18, 2020 4:12 PM 

    We are working on our inpatient treatment guidelines and hope to have them completed tomorrow.  We will be using hydroxychloroquine in our high risk patients.  From the transplant standpoint, we are not planning to augment immune suppression but are considering pulse steroids and considering antibiotics.  We will share what we develop as well.

    Will look at the ISHLT community – thanks for sharing the info Stuart.  It is hard to sift through all of the AST COP emails.

    As for donors, we do not have anyone actively listed at this time. But we would require negative testing before proceeding.

    For bronchoscopies – we are only performing if they are clinically needed,  We have postponed all elective cases.  If they are sick, we are required to be in a negative pressure room and wear N95. 

    As I was writing this UC asked for labs to donate materials for the medium need to run the testing…another obstacle in getting people tested.

    Marc Schecter, MD

    From: Sweet, Stuart
    Sent: Wednesday, March 18, 2020 4:17 PM

    One more thing:

    This document from Belgium provides a pretty comprehensive summary of treatment options and algorithms for the general population (although it doesn't touch on managing immunosuppression in the transplant population). 





    ------------------------------
    Stuart Sweet
    ------------------------------


  • 2.  RE: COVID-19 and Pediatric Lung Transplant

    Posted 03-19-2020 12:40
    Nico,

    Some thoughts about your suggestions:
    1) Agree with holding tight on asymptomatic patients.
    2) I'd be cautious about reducing immunosuppression.  This is an actively moving target and I've seen recommendations in both directions.  In the absence of clear data and the feedback that the morbidity of COVID-19 is largely related to the inflammatory response we're probably going to avoid empirically reducing immunosuppression at this time.
    3) We'll do hydroxychloroquine and consider other experimental treatments (including IL-6 inhibitors and antivirals if we can get them) before empiric increase in steroids.
    4) I suspect that people are going to be very nervous about doing bronchoscopy in a COVID-19 patient (in fact I suspect many PFT labs are going to push back on getting PFTs in a COVID-19 infected patient).  So we may have to rely on home spirometry if we can get it and imaging.
    5) I agree with Chris that early empiric antibiotics is reasonable.

    Let's keep talking!


    ------------------------------
    Stuart Sweet
    ------------------------------