Identifying scenarios of benefit or harm from kidney transplantation during the COVID-19 pandemic: A simulation study

Background: Clinical decision-making in kidney transplantation (KT) during the COVID-19 pandemic is a challenge: both candidates and recipients may face increased acquisition risks and case fatality rates (CFRs) Given our poor understanding of these risks, many centers have paused or reduced KT activity, yet data to inform such decisions are lacking Methods: To quantify the benefit/harm of KT in this context, we conducted a Markov simulation study of immediate-KT vs delay-until-after-pandemic for different patient phenotypes under a variety of potential COVID-19 scenarios (Figure 1), simulating expected life-months gained from transplant over 5 years A calculator was implemented (http://www transplantmodels com/covid-sim), and machine learning approaches were used to evaluate the important aspects of our modeling Results: Characteristics of the pandemic (acquisition risk, CFR) and length of delay (length of pandemic, waitlist priority for DDKT) had greatest influence on benefit/ harm (Figure 2) In most scenarios of COVID-19 dynamics and patient characteristics, immediate-KT provided survival benefit;KT only began showing evidence of harm in scenarios where CFRs were substantially higher for KT recipients (e g ≥50% fatality) than for waitlist registrants Conclusions: Our simulations suggest that KT remains beneficial under COVID-19 in many scenarios Our calculator can help identify patients who would benefit most As the pandemic evolves, our calculator can update these predictions