During an acute and rapidly evolving pandemic crisis such as the COVID-19 pandemic, it may appear impossible to generate evidence for recommendation of the management of specific patient groups within short periods of time using standard methodologies. Thus, current recommendations are mostly derived from the reported Chinese experience (and focus on high-incidence groups with high risk). [12,13,14,15,16,17,18,19,20,21] This lack of targeted clinical evidence will likely not change within highly specialized fields, such as all pediatric subspecialties. For example, in the recently published pediatric COVID-19 case series (almost exclusively based on Chinese data), no cases of children with kidney transplantation or on dialysis were reported. [5, 8,9,10,11]
In this context, expert knowledge, experience, and guidance may provide the best available “evidence”. Since COVID-19-specific reports of children with kidney disease, kidney transplantation, or dialysis were unavailable, as was guidance from respective professional societies, we conducted a Delphi exercise among experts in pediatric nephrology, representing 13 centers in 11 European countries (including two Italian centers). The urgency of the situation prompted us to conduct our Delphi exercise with a mixed method qualitative approach within 5 days, with four answer rounds of 24 h each.
Current advice for COVID-19 testing strategies relevant to the EPDWG depends on the stage of the outbreak in different areas, according to the European Centre for Disease Prevention and Control (ECDC).  Guidelines for COVID-19 testing of patients and HCP are issued by national authorities, but might be adapted by individual centers depending on local regulations and resources. [30, 31] For example, testing of symptomatic patients was uniformly performed in all centers as mandated by health authorities. However, testing of asymptomatic patients and asymptomatic HCP with varying risk factors markedly varied among EPDWG centers, likely reflecting decisions of individual expert teams responsible for clinical care, thus influenced by local expert attitudes and hospital policies. It is important to stress that criteria and strategies for COVID-19 testing are changing rapidly as the geographic spread of COVID-19 expands, as are physician attitudes and hospital policies. In accordance with current literature [5, 8,9,10,11], our study found no cases of confirmed COVID-19 in children with dialysis. However, we identified the first case of confirmed COVID-19 in a child with kidney transplantation in Spain. This child was doing well at the time of manuscript submission.
Guidance on management of immunosuppressive therapy in adult patients with kidney transplantation and COVID-19 has been recently issued. [32,33,34,35,36] Furthermore, arisen speculations on exacerbation of COVID-19 disease by concurrent treatment with ACE-I or ARB have been addressed by the European Society of Cardiology (ESC) and the American Heart Association (AHA), both strongly recommending continuation of these widely used drugs. [37, 38] Although no such guidance has been published for children, all 13 EPDWG centers were in complete consensus for continuation of these established therapies, while alert to appearance of additional data (for rapid dissemination across the network).
Strategies are emerging to counter acceleration of the COVID-19 pandemic in the face of shortages of resources and personal protective equipment.  Concerns about transmission of SARS-CoV-2 to HCP are also emerging more frequently. These might be even more relevant in the pediatric setting, as infected children appear to suffer fewer complications than do their adult HCP. Indeed, up to 20% of Italian HCP have been infected.  KDIGO has recently published guidelines, synthesized from the Chinese and Taiwanese Societies of Nephrology, that recommend separation of HCP and individual patients by location and time, in addition to entrance control, self-monitoring for symptoms, and use of appropriate protective equipment.  The EPDWG pattern of responses for prevention and management of SARS-CoV-2 demonstrated varying degrees of implementation of these recommendations across the 13 centers, primarily dependent on available resources, in addition to on local or regional governmental guidelines.
The COVID-19 pandemic led to suspensions of LRD and/or DD pediatric kidney transplantation programs in most EDPWG centers. These changes in transplantation policies were local decisions within the EPDWG centers and their hospitals, as no health authority regulations were available at the time of the study, and as European and US scientific societies recommended consideration of temporary suspension depending on local circumstances. [32, 39] Implementation of reduction in provision of non-urgent care similarly relied on local practices. Routine checkups and non-urgent appointments were being canceled in most EPDWG centers, whereas routine visits of stable kidney transplant patients and elective were suspended in about 25% of centers, resulting in significant reduction in direct patient contacts, as recently proposed by the Transplant Society in order to keep transplantation centers operational.  Among the EPDWG centers, remote clinical work measures implemented included phone- and video calls, online clinics, and telemonitoring for peritoneal dialysis patients.
Taken together, pediatric nephrology provider response patterns to the challenge of the COVID-19 pandemic have been diverse, as expectable from a multi-country European network in a federalized governmental environment. Responses concerning changes in current treatment were in consensus with recommendations from scientific bodies. However, state-of-the-art tends to be conservative, suggesting change to the status quo only upon presentation of clear evidence of the need for change. Some responses, such as those concerning testing strategies, prevention, and changes in routine care during the COVID-19 pandemic, varied widely among the EPDWG centers, reflecting in part rapid dynamic changes in the responses of national or local health authorities to escalation of the pandemic. Local hospital policies, physicians’ attitudes, and available resources also significantly influenced the diverse patterns of responses among EPDWG centers. Future studies, performing detailed longitudinal assessments of these interdependent variables will be needed to obtain a deeper understanding of determinants of individual response patterns. Such studies should be able to compare the efficacy of any country-specific responses to the COVID-19 pandemic.
The strengths of this Delphi exercise lie in the rapid response and communication of 13 expert centers across Europe, with consecutive qualitative data analysis in a thematic field for which no evidence and no guidance from international societies currently exist. The concise description of multi-country European response patterns may allow experts in other countries affected by this pandemic to base their own responses on an improved level of evidence for recommendations unavailable for the time being through standard methodologies. The COVID-19 pandemic is expanding in the United States with a lag of about 2 weeks compared to continental Europe.  This lag may provide crucial opportunities for US experts to learn from the European areas enduring a more advanced state of the pandemic.
Limitations of this study are inherent in the rapidly evolving pandemic and corresponding dynamics of changing regulations—thus the specific information on response patterns in this study is valid through the date of manuscript submission, and recommendations may change quickly thereafter. However, the consensus identification of specific COVID-19 topics of greatest relevance to a multi-country European expert group working in the midst of the pandemic should be generalizable and may facilitate development of relevant local guidance from other national expert groups or health authorities, supporting individual pediatric nephrology experts in their clinical decision making in a time of extreme uncertainty.