Kidney Transplantation during the SARS-CoV-2 Pandemic in Israel: Experience from a Large-Volume Center

Round 1

Reviewer 1 Report

The paper is reporting a single center experience in the management of kidney transplant candidates and recipients during COVID-19 pandemic in Israel.

The topic is of interest and despite the data are not adding much to the current data reported so far , it is well written and recap most of the main problems that every center faced and still facing during the pandemic. Her are my concerns: 1) when the authors talk about visitors, they stated that visitors should have been vaccinated to access to the transplant ward, do the authors think that they should be screened by NPS (nasopharyngeal swab) too before entering the hospital?  2) the authors reported a molecular screening for deceased donor: do they perform BAL or just NPS? 3) the authors stated that thymo are aggressive immunomodulatory agents, I would replace it with lymphodepleting or strong immunosuppressive. 4) the authors define high immunological risk patients, therefore treated with thymo,  in case of a positive PRA, can the authors specify what is the cutoff of definition? 5) the authors reported an adjustment of thymo according to lymphocyte count, can the authors specify?

Author Response

Response to the reviewer 1 comments:

1.  Screening by NPS (nasopharyngeal swab) was a requirement for visitors prior to the vaccination era, thereafter, we thought that NPS screening is no longer necessary for visitors who received 2 doses of the vaccine and were asymptomatic.
2.  Molecular screening was based upon NPS only.
3.  Agree, the term aggressive should be replaced as proposed.
4. Patients with any positive PRA were considered as high risk  (1% and above, class I or II).
5. We monitored the overall lymphocyte count with daily CBC post-operatively, we looked specifically at the absolute lymphocyte count - when >=0.2 K/micl patients were eligible for second or third TMG dose (1 mg/Kg), the first dose was given intra-operatively.

Reviewer 2 Report

This is well written manuscript. This review aims to describe a single transplant center experience with kidney transplantation during the COVID-19 pandemic. In addition, to review the national and institutional measures and restrictions undertaken in different phases of the ongoing event as well as the outcomes. This review is quite a bit interest. However, some of main important issues need to be verified to improve your work as following.

1. Systematic reviews and meta-analyses are considered to be the highest quality evidence on a research topic because their study design reduces bias and produces more reliable findings. Please add evidence from recent systematic review and meta-analysis.
2. Please add and summarize the results of recent studies in 2021.
3. Finally, since I am not a native English user, I did not check for grammatical errors thoroughly. This should be done by an appropriate language reviewer.

Author Response

1. A systemic review and meta-analysis of COVID-19 in kidney transplant recipients was recently published by Kremer et al. The study included 5559 kidney transplant recipients with COVID-19 and found a risk of mortality of 23%, regardless of sex, age and comorbidities. (Kremer D, Pieters TT, Verhaar MC, Berger SP, Bakker SJL, van Zuilen AD, Joles JA, Vernooij RWM, van Balkom BWM. A systematic review and meta-analysis of COVID-19 in kidney transplant recipients: Lessons to be learned. Am J Transplant. 2021 Jul 1. doi: 10.1111/ajt.16742. Epub ahead of print. PMID: 34212499.)
2. Several studies analyzed the risk of severe Covid‐19 and related mortality between kidney transplant recipients and non-transplant patients, those studies showed results with opposite tendency (1. Chavarot N wt al. A; Critical COVID-19 France Investigators. COVID-19 severity in kidney transplant recipients is similar to nontransplant patients with similar comorbidities. Am J Transplant. 2021 Mar;21(3):1285-1294. doi: 10.1111/ajt.16416. Epub 2021 Jan 4. PMID: 33252201; PMCID: PMC7753406.    2. Caillard S et al. French SOT COVID Registry. Is COVID-19 infection more severe in kidney transplant recipients? Am J Transplant. 2021 Mar;21(3):1295-1303. doi: 10.1111/ajt.16424. Epub 2021 Jan 28. PMID: 33259686; PMCID: PMC7753418)                                                     Panish et al. compared the outcomes of kidney transplant patients with COVID-19 to that of dialysis and waitlisted patients, showing significantly lower proportion of transplanted patients who contracted COVID-19 compared with waitlisted and dialysis patients and comparable fatality ratio (Phanish M, Ster IC, Ghazanfar A, Cole N, Quan V, Hull R, Banerjee D. Systematic Review and Meta-analysis of COVID-19 and Kidney Transplant Recipients, the South West London Kidney Transplant Network Experience. Kidney Int Rep. 2021 Mar;6(3):574-585. doi: 10.1016/j.ekir.2020.12.013. Epub 2020 Dec 19. PMID: 33363263; PMCID: PMC7748968).
3. English language and grammatical errors will be reviewed.
4. thank you

 

Round 2

Reviewer 2 Report

The authors addressed all my previous concerns and significantly improved quality of the manuscript. I have no additional comment.