Recommendations Of The Brazilian Society Of Nephrology Regarding Pediatric Patients On Renal Replacement Therapy During The Covid-19 Pandemic



# Abstract
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.

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# Introduction
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 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 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 Espanola de Nefrologia 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

## Recommendations
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.

## Patients on hemodialysis
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 :

## Patients with chronic kidney disease under evaluation for a kidney transplant
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.

## Pediatric kidney transplant recipients
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 [bib_ref] Covid-19 and Calcineurin Inhibitors: Should They Get Left Out in the Storm?, Willicombe [/bib_ref]. Clinical evidence of this approach for COVID-19 remains to be defined. Hospital admission is advisable in specific cases.

## Pediatric patients on peritoneal dialysis (pd)
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).

# Conclusions
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.
[fig] Foundation 8: The Brazilian Society of Nephrology is the main medical society involved in the care of this pediatric population on dialysis and nephrology care. The present article summarizes the main recommendations for specific care and management of children and adolescents with chronic kidney disease, dialysis, transplantation, and under immunosuppression during the COVID-19 pandemic.The present recommendations are based on documents of the Brazilian Society of Nephrology and Brazilian Association of Organ Transplantation (ABTO)9 , both dated March 16 th , 2020, and are in accordance with the Technical Note of the Brazilian Agency of Sanitation Surveillance (ANVISA) n.04/2020 from March 21st, 2020, and based on a brief review of medical literature and recommendations of other medical societies. [/fig]
[fig] Figure 1: Flow chart of management of suspect and confirmed cases of COVID-19 in pediatric patients on hemodialysis facilities. [/fig]