Introduction: In the early period of the COVID-19 Pandemic, many transplant programs in Asia reduced or stopped transplantation activities but later resumed transplantation. In Singapore, living kidney donor transplantation (LKDTX) were suspended for 2 periods (April to June 2020 and May 2021). This study reports on the clinical outcomes of LKDTX performed when transplantation resumed at the Singapore General Hospital. It also report on the effectiveness of peri-transplant protocols to prevent and detect COVID-19 infections in the perioperative period.

Methods: During the COVID-19 Pandemic, all donors and recipients were advised to complete at least 2 doses of COVID-19 mRNA vaccine, adhere to 2 week of social distancing at home before admission for transplant surgery and undertake nasopharyngeal swab for COVID-19 PCR at D-7, D-2 and D-1 prior to LKDTX and weekly thereafter. All donors and recipients were advised to continue social distancing for the first 3 months after transplant surgery and to perform home antigen rapid testing if symptomatic or informed of being a close contact to a COVID-19 infected person. Processes were developed to arrange for infected LKDTX to be directly admitted to COVID-19 wards or receive outpatient SARS-CoV-2 therapeutics with subsequent telemedicine monitoring for 14 to 21 days. Immunosuppression protocols remained unchanged during the Pandemic and high immunological risk kidney transplants with lymphocyte depleting agents and plasma exchange/plasmaphresis proceeded as routine.

Results: A total of 31 LKDTX were performed (10 in 2020 and 21 in 2021), of which 7  (22.6%) were ABO incompatible and 1(3.2%) were HLA incompatible, all requiring lymphocyte depleting agents and plasmaphresis. The rates of return to operating theatre, intensive care unit admission, delayed graft function and rejection rate was low at 3.2% (n=1/31), 6.4% (n=2/31), 3.2% (n=1/31) and 6.4% (n=2/31) respectively. Prior to transplantation, no recipient or donor was diagnosed with COVID-19 infection but after transplantation, 6 patients were diagnosed with COVID-19 at a median time of 149 days (range 97 to 386 days) after transplantation, of which all except 1 had received 3 doses of mRNA COVID-19 vaccine. Anti-SARS CoV-2 antibodies were not detected in 50% (n=3/6) and required sotroviumab infusions. Fortunately, the median 4C Mortality Score was 2 (range 2-3) and none of these patients developed pneumonia. Patient and graft survival of all 31 patients remained at 100% as of last follow-up.

Conclusions: LKDTX can be performed safely during the COVID-19 Pandemic provided there are protocols set in place for screening donors and recipients for COVID-19 prior to transplantation and during the hospital admission. It is also important for patients to be educated on the importance of home ART surveillance for COVID-19 and to promptly inform the transplant program so that early intervention can be provided to prevent progression to severe COVID-19.