key: cord-0868320-xnf389bd authors: Tavares, Marcelo de Sousa; Penido, Maria Goretti Moreira Guimarães; de Andrade, Olberes Vitor Braga; Koch, Vera Hermina Kalika; Bernardes, Rejane de Paula; Garcia, Clotilde Druck; Moura-Neto, José A.; Nascimento, Marcelo Mazza; Palma, Lilian Monteiro Pereira title: Recommendations Of The Brazilian Society Of Nephrology Regarding Pediatric Patients On Renal Replacement Therapy During The Covid-19 Pandemic date: 2020-08-26 journal: J Bras Nefrol DOI: 10.1590/2175-8239-jbn-2020-s108 sha: 088f4bbed7d3f52effe6d814066d9593480fec7e doc_id: 868320 cord_uid: xnf389bd INTRODUCTION: The impact of the new coronavirus (SARS-COV-2) and its worldwide clinical manifestations (COVID-19) imposed specific regional recommendations for populations in need of specialized care, such as children and adolescents with kidney diseases, particularly in renal replacement therapies (RRT). We present the recommendations of the Brazilian Society of Nephrology regarding the treatment of pediatric patients with kidney diseases during the COVID-19 pandemic. METHODS: Articles and documents from medical societies and government agencies on specific recommendations for children on RRT in relation to COVID-19 as well as those focused on epidemiological aspects of this condition in Brazil Were evaluated and analyzed. RESULTS: We present recommendations on outpatient care, transportation to dialysis centers, peritoneal dialysis, hemodialysis, and kidney transplantation in children and adolescents during the COVID-19 pandemic in Brazil. DISCUSSION: Despite initial observations of higher mortality rates in specific age groups (the elderly) and with comorbidities (obese, diabetics, and those with cardiovascular diseases), patients with chronic kidney disease (CKD) on RRT are particularly prone to develop COVID-19. Specific measures must be taken to reduce the risk of contracting SARS-CoV-2 and developing COVID-19, especially during transport to dialysis facilities, as well as on arrival and in contact with other patients. Introduction: The impact of the new coronavirus (SARS-COV-2) and its worldwide clinical manifestations (COVID-19) imposed specific regional recommendations for populations in need of specialized care, such as children and adolescents with kidney diseases, particularly in renal replacement therapies (RRT). We present the recommendations of the Brazilian Society of Nephrology regarding the treatment of pediatric patients with kidney diseases during the COVID-19 pandemic. Methods: Articles and documents from medical societies and government agencies on specific recommendations for children on RRT in relation to COVID-19 as well as those focused on epidemiological aspects of this condition in Brazil Were evaluated and analyzed. Results: We present recommendations on outpatient care, transportation to dialysis centers, peritoneal dialysis, hemodialysis, and kidney transplantation in children and adolescents during the COVID-19 pandemic in Brazil. Discussion: Despite initial observations of higher mortality rates in specific age groups (the elderly) and with comorbidities (obese, diabetics, and those with cardiovascular diseases), patients with chronic kidney disease (CKD) on RRT are particularly prone to develop COVID-19. Specific measures must be taken to reduce the risk of contracting SARS-CoV-2 and developing COVID-19, especially during transport to dialysis facilities, as well as on arrival and in contact with other patients. The pandemic involving the new coronavirus SARS-CoV-2 and its clinical manifestations (COVID-19) to the World Health Organization recommending procedures in order to limit the spread as well as minimize the sudden and increasing lethality in distinct population groups. The Department of Pediatric Nephrology of the Brazilian Society of Nephrology (SBN in Portuguese) prepared this manuscript regarding recommendations for children and adolescents with kidney diseases and their respective families to mitigate the risk of acquiring and spreading the disease in Brazil. In Brazil, different profiles of children with chronic kidney disease (CKD) were described by Konstantiner et al 1 (2015) emphasizing that areas with lower social and economic indexes have unsatisfactory access to medical facilities, which is corroborated by a higher proportion of patients with undefined etiology for CKD in such areas. Fernandes et al 2 (2010) have reported that as much as 30% of patients live more than 50 km away from the referral Nephrology center. Each country has its own particularities regarding the management of COVID-19 in children and adolescents with kidney diseases. Nephrology Societies around the globe have adapted WHO recommendations 3 to local conditions and realities, such as the Sociedad Española de Nefrología 4 , the British Association for Paediatric Nephrology 5 , the EUDIAL Working Group of ERA-EDTA 6 , the Chinese Society of Pediatric Nephrology 7 , and the National Kidney The care for pediatric patients involves many family and social aspects that should be considered by the Nephrology Center, which, in turn, must also be a center for continuing education regarding knowledge in all aspects of the COVID-19 pandemic, including isolation, prevention, and waste disposal at home. Transport to dialysis facilities by bus or other mode provided by health authorities (with other patients) is a common practice by children and their families. 1. Transportation to dialysis facilities should be provided by health authorities when not possible by the patient/family; standing patients during transport should not be allowed. The following procedures are recommended during transport to dialysis facilities 10,11 : At the present time, Brazil is under quarantine and the urge for kidney transplantation must be evaluated on an individual basis, according to the Brazilian Association of Organ Transplantation recommendations. Donor and recipient must be considered at risk. In order to minimize the exposure to the virus, nonemergency consultations and hospital visits should be avoided. Use of a surgical mask when at hospitals or for blood sampling is advisable. In case of respiratory symptoms and/or fever, the transplantation center must be communicated. In confirmed cases, the same procedures as for children with COVID-19 on dialysis should be followed: health professionals should wear N95 or FFP2 masks preferably (or disposable surgical masks), eye protection (goggles or face shield), gloves, and gown. Immunosuppression therapy will be changed according to the Center's preferences. The most common approach is stopping the antimetabolite drug. In vitro studies showed that calcineurin inhibitors may play a protective role in coronavirus infections 12 . Clinical evidence of this approach for COVID-19 remains to be defined. Hospital admission is advisable in specific cases. Children and adolescents on PD with fever and/or respiratory symptoms must notify the referral center. The patient's condition must be reviewed and the dialysate aspect has to be evaluated (fever can be the only initial sign of peritonitis). Social isolation for at least 14 days is recommended (including from house contacts). Dyspnea should be promptly evaluated in the dialysis facility, and the health staff should be notified of the patient's arrival in order to minimize contamination risks at the unit. The delivery team (for dialysis materials) should be warned in order to minimize contact (avoid entering the patient's house, use of surgical mask, and handwashing by the driver/ delivery team is strictly recommended). Considering the continental proportion of Brazil, regional differences will demand emphasis on specific aspects of nephrology care of pediatric patients, mainly outpatient dialysis units (such as during transport). The interface between the health team and patients on any form of RRT should be maintained and strengthened during the pandemic. The present recommendations will need to be updated in the future as more research on COVID-19 is conducted. Pediatric chronic dialysis in Brazil: Epidemiology and regional inequalities Geography of peritoneal dialysis in Brazil: analysis of a cohort of 5,819 patients (BRAZPD) Rational use of personal protective equipment for coronavirus disease 2019 (Covid-19) en representación de la Sociedad Española de Nefrología. Protocol against coronavirus diseases in patients on renal replacement therapy: Dialysis and kidney transplant COVID-19): Information and Guidance for Children on Haemodialysis, Peritoneal Dialysis and Immune suppression (including Renal Transplants Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (Covid-19) pandemic in haemodialysis centres Chinese Society of Pediatric Nephrology and Chinese Medical Doctor Association of Pediatric Nephrology. Consensus recommendations for the care of children receiving chronic dialysis in association with the Covid-19 epidemic Novo Coronavírus -SARS-COV-2. Recomendações no Cenário de Transplantes de Órgãos Sólidos Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Covid-19 in Outpatient Hemodialysis Facilities Mitigating Risk of Covid-19 in Dialysis Facilities Covid-19 and Calcineurin Inhibitors: Should They Get Left Out in the Storm?