Pediatric Nephrology (2020) 35:1669–1678 https://doi.org/10.1007/s00467-020-04584-6 ORIGINAL ARTICLE Rapid response in the COVID-19 pandemic: a Delphi study from the European Pediatric Dialysis Working Group Fabian Eibensteiner 1 & Valentin Ritschl 2 & Gema Ariceta 3 & Augustina Jankauskiene 4 & Günter Klaus 5 & Fabio Paglialonga 6 & Alberto Edefonti 6 & Bruno Ranchin 7 & Claus Peter Schmitt 8 & Rukshana Shroff 9 & Constantinos J. Stefanidis 10 & Johan Vande Walle 11 & Enrico Verrina 12 & Karel Vondrak 13 & Aleksandra Zurowska 14 & Tanja Stamm 2 & Christoph Aufricht 1 & On behalf of the European Pediatric Dialysis Working Group Received: 14 April 2020 / Revised: 16 April 2020 / Accepted: 22 April 2020 / Published online: 17 May 2020 # The Author(s) 2020 Abstract Background COVID-19 was declared a global health emergency. Since children are less than 1% of reported cases, there is limited information to develop evidence-based practice recommendations. The objective of this study was to rapidly gather expert knowledge and experience to guide the care of children with chronic kidney disease during the COVID-19 pandemic. Methods A four-round multi-center Delphi exercise was conducted among 13 centers in 11 European countries of the European Pediatric Dialysis Working Group (EPDWG) between March, 16th and 20th 2020. Results were analyzed using a mixed methods qualitative approach and descriptive statistics. Results Thirteen COVID-19 specific topics of particular need for guidance were identified. Main themes encompassed testing strategies and results (n = 4), changes in use of current therapeutics (n = 3), preventive measurements of transmission and management of COVID-19 (n = 3), and changes in standard clinical care (n = 3). Patterns of center-specific responses varied according to regulations and to availability of guidelines. Conclusions As limited quantitative evidence is available in real time during the rapid spread of the COVID-19 pandemic, qualitative expert knowledge and experience represent the best evidence available. This Delphi exercise demonstrates that use of mixed methodologies embedded in an established network of experts allowed prompt analysis of pediatric nephrologists’ response to COVID-19 during this fast-emerging public health crisis. Such rapid sharing of knowledge and local practices is Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00467-020-04584-6) contains supplementary material, which is available to authorized users. * Christoph Aufricht 7 Department of Pediatric Nephrology, Hôpital Femme Mère Enfant, christoph.aufricht@meduniwien.ac.at Hospices Civils de Lyon, Lyon, France 8 1 Pediatric Nephrology, Center for Child and Adolescent Medicine, Division of Pediatric Nephrology and Gastroenterology, Heidelberg, Germany Comprehensive Center for Pediatrics, Medical University of Vienna, 9 Waehringer Guertel 18-20, 1090 Vienna, Austria Renal Unit, UCL Great Ormond Street Hospital for Children NHS 2 Foundation Trust, and Institute of Child Health, London, UK Section for Outcomes Research, Center for Medical Statistics, 10 Informatics, and Intelligent Systems, Medical University of Vienna, Department of Pediatric Nephrology, Mitera Children’s Hospital, Vienna, Austria Athens, Greece 3 11 Department of Pediatric Nephrology, University Hospital Vall d’ Department of Pediatric Nephrology, Utoped, Universitair Hebron, Barcelona, Spain Ziekenhuis Gent, Ghent, Belgium 4 12 Pediatric Center, Institute of Clinical Medicine, Vilnius University, Dialysis Unit, Department of Pediatrics, IRCCS Giannina Gaslini, Vilnius, Lithuania Genoa, Italy 5 13 Department of Pediatric Nephrology, KfH Children’s Kidney Center, Department of Pediatric Nephrology, University Hospital Motol, Marburg, Germany Prague, Czech Republic 6 14 Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Department of Pediatric Nephrology, Medical University of Gdansk, IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy Gdansk, Poland 1670 Pediatr Nephrol (2020) 35:1669–1678 essential to timely and optimal guidance for medical management of specific patient groups in multi-country health care systems such as those of Europe and the US. Keywords COVID-19 . Pandemic . Delphi . Dialysis . Transplantation Abbreviations such guidance is especially challenging in highly specialized SARS-CoV-2 Severe-acute-respiratory-syndrome- fields with small target populations, such as pediatric nephrol- coronavirus-2 ogists caring for children with kidney transplants, receiving COVID-19 SARS-CoV-2-related-disease dialysis, or being treated with immunosuppressive therapy for US United States (of America) kidney disease. There is significant concern that such patients EPDWG European Pediatric Dialysis Working Group are more likely to develop severe disease due to SARS-CoV-2 HCP Health care personnel infection; yet, they may have an increased risk of exposure aHUS atypical hemolytic uremic syndrome due to the need to have ongoing clinical care, including dial- LRD living-related donor ysis and laboratory monitoring. The current pandemic pro- DD deceased donor vides a challenge to the international community to develop ECDC European Centre for Disease new approaches for rapid analysis and dissemination of infor- Prevention and Control mation to guide the management of patients with unique ACE-I Angiotensin-converting-enzyme inhibitors healthcare needs. ARB Angiotensin II-receptor-blockers We hypothesized that application of a mixed method qual- ESC European Society of Cardiology itative approach among established international networks of AHA American Heart Association expert groups could very rapidly assess relevant knowledge KDIGO Kidney Disease: gaps and retrieve current and evolving evidence of clinical Improving Global Outcomes response patterns. [22, 23] To rapidly gather this expert HD hemodialysis knowledge for the care of children with kidney disease, dial- ICU intensive-care units ysis, and kidney transplantation during the emerging COVID- KTx kidney transplantation 19 pandemic in Europe, a Delphi exercise was conducted among the European Pediatric Dialysis Working Group (EPDWG). Introduction In December 2019, an outbreak of pneumonia of un- Methods known etiology emerged in Wuhan, Hubei province, China. [1–3] The rapid worldwide spread of severe- We conducted a four-round Delphi exercise among the acute-respiratory-syndrome-coronavirus-2 (SARS-CoV- Pediatric Nephrology experts from the European 2)-related disease (COVID-19) has led to its designation Pediatric Dialysis Working Group (EPDWG) using an as a global health emergency. [2] By early March 2020, email survey. The Delphi process provides structured more than 100,000 infections and more than 4000 deaths communication, iteration with controlled feedback, and worldwide were attributable to COVID-19. [4, 5] Most informed input, [24–26] thereby facilitating rapid synthe- available information on COVID-19 currently stems from sis of expert knowledge. The emerging COVID-19 pan- the Chinese experience, ultimately characterized by ag- demic is creating all over Europe a quickly changing and gressive and uniform public health responses. [6, 7] In ever more challenging setting in which to provide pediat- contrast, the federalized European states have not intro- ric nephrology care. This Delphi exercise was conducted duced uniform countermeasures, which may render their within the 5 days from March, 16th, to March 20th, 2020, responses more comparable to the US than to the more during the first week of statutory public curfews imposed centralized Chinese public health response. [6, 7] by local governments across Europe in response to emerg- As fewer than 1% of reported COVID-19 cases have been ing hotspots of SARS-CoV-2. children, information about COVID-19 in the pediatric popu- lation is sparse. [5, 8–11] The majority of available informa- Participants tion concerns the major risk populations, including adults with significant comorbidities and the elderly. [12–21] All active EPDWG members representing 16 centers from 13 Consequently, there is an urgent need for information to guide European countries were asked to participate. At the time of the management of other patient populations. Development of initiation of this Delphi exercise, COVID-19 cases in varying Pediatr Nephrol (2020) 35:1669–1678 1671 numbers had been reported by local authorities in all EPDWG Results countries. Participants and response rates Data collection and qualitative analysis The invitation to participate was sent out via email to 16 cen- A Delphi exercise uses a series of questionnaires to collect ters from 13 European countries, all active members of the data from multiple panelists. In contrast to other data- EPDWG. Thirteen centers (81%) from 11 European countries gathering techniques, Delphi studies use feedback processes of the EPDWG (85%) participated in this Delphi exercise. The (iterations), to develop a consensus concerning a specific top- participating centers were from Austria, Belgium, ic. This allows participants to reassess their initial judgments Czech Republic, France, Germany, Greece, Italy, Lithuania, at a later time based on information provided earlier. [24] The Poland, Spain, and the United Kingdom. Each participant first Delphi round started with an open email invitation to all completed all four rounds of the Delphi process. EPDWG members to share their current knowledge, experi- ence, information, and guidance for COVID-19 prevention, Themes diagnostics, and management in their target population. Replies were gathered for 24 h. Information provided by the During the first round of the Delphi exercise, 13 clustered EPDWG members was analyzed using a modified form of themes were identified. All themes were included in the sec- meaning condensation analysis. [27, 28] Email replies were ond and third rounds of the Delphi exercise. No new themes first read through to gain an overview of the collected data, emerged after the second round, and data saturation was after which themes were extracted and clustered according to achieved. Among the 13 identified themes, two included test- common meanings. Clustered themes and corresponding quo- ing for COVID-19, two included confirmed COVID-19 cases, tations for each center were synthesized in a summary of find- three included changes in current therapies, three included ing table sent to all participants. Thus, participants could see preventive and preparatory measures of transmission and the findings for each theme and center, including their own. management of COVID-19, and three included changes in The goal of the second Delphi round was to edit the wording, routine clinical care due to COVID-19. propose amendments, and check correctness of the summaries extracted from the experts’ statements. A summary of findings Statements of current practice containing the final version of clustered themes and partici- pants’ quotations for each center was created. In the third For the final Delphi round, 13 thematic questions and a vary- Delphi round, participants were asked to complete informa- ing number of accompanying answer statements were formu- tion on existing themes they had not addressed previously. lated from the gathered data by use of modified meaning con- Replies from rounds 2 and 3 were collected within 48 h. densation analysis. [27, 28] Due to data saturation and clarity After the third Delphi round, no new information emerged of statements from the first three Delphi rounds, only six the- and data saturation was achieved. Modified meaning conden- matic questions and their corresponding answer statements sation analysis [27, 28] was further utilized to formulate the- were included in the fourth round. Qualitative and quantitative matic questions and accompanying answer statements to sys- results are, respectively, displayed in Table 1, Online Resource tematically categorize the whole range of the specific, gath- 1, and in Figs. 1, 2, and 3. ered knowledge. A set of clustered thematic questions and answer statements was created (Table 1). For the fourth Testing for COVID-19 at the centers of the EPDWG Delphi round, this thematic question and answer statement set was circulated, and experts were asked to rate each state- Testing asymptomatic patients with increased risk (immuno- ment with “total agreement” or “no agreement” in accordance compromised or dialysis patients) and epidemiologic risk was with their local practice. We did not aim at consensus due to reported by 46% (6/13). Testing of patients with other or no the descriptive character of our Delphi exercise, but rather chronic disease and epidemiologic risk was reported in 28% aimed for rapid sharing of knowledge and practices to allow (5/13) and 23% (3/13), respectively. At the time of the study, improved guidance of local management. no asymptomatic patients without epidemiologic risks were Descriptive statistics and appropriate graphs were utilized routinely tested in the centers of the EPDWG. Regular screen- to analyze frequencies and differences in local preparation and ing of all asymptomatic health care personnel (HCP) was per- practice of pediatric nephrologists for emerging COVID-19. formed in one center. Screening of asymptomatic HCP upon The draft of the manuscript was sent to all participants for their unprotected contact with suspected or confirmed COVID-19 comments, which were addressed in the revised manuscript. cases was, respectively, performed in 23% (3/13) and 62% The manuscript was submitted after final approval by the (8/13). Testing of symptomatic HCP for COVID-19 regard- EPDWG. less of contact, after unprotected contact with suspected, or 1672 Pediatr Nephrol (2020) 35:1669–1678 Table 1 Summary of the 13 identified thematic questions, with corresponding frequencies for preformed answer statements among the 13 EPDWG centers Thematic questions and answer statements Number (%) I. Which patients are tested for COVID-19? Symptomatic patients 13 (100) Asymptomatic patients with kidney transplantation and epidemiologic risk 6 (46) Asymptomatic patients with dialysis and epidemiologic risk 6 (46) Asymptomatic patients with immunosuppression and epidemiologic risk 6 (46) Asymptomatic patients with chronic disease and epidemiologic risk 5 (28) Other asymptomatic patients with epidemiologic risk 3 (23) Screening of asymptomatic patients without epidemiologic risk 0 (0) II. Testing of Health Care Personnel for COVID-19? Screening of all asymptomatic staff members 1 (8) Screening of asymptomatic staff members upon unprotected contact with suspected 3 (23) COVID-19 case Screening of asymptomatic staff members upon unprotected contact with confirmed COVID-19 case 8 (62) Screening of symptomatic staff members 9 (69) Screening of symptomatic staff members with history of unprotected contact with suspected COVID-19 case 10 (77) Screening of symptomatic staff members with history of unprotected contact with confirmed COVID-19 case 11 (85) Sent home for quarantine and home office after possible contact 9 (69) III. Patients with kidney transplantation and confirmed COVID-19? 1 (8) IV. Patients with dialysis and confirmed COVID-19? 0 (0) V. Continuation of immunosuppressive therapy? 13 (100) VI. Discontinuation of ACE-I or ARB therapy? 0 (0) VII. Discontinuation of Eculizumab therapy? 0 (0) VIII. Dialysis ward triage system? Information to parents to call when child has COVID-19 symptoms 10 (77 Screening of patients upon entering the dialysis ward 7 (54) Screening of patients upon entering the hospital 5 (38) IX. Measures for prevention of SARS-CoV-2 transmission? Zero visitors or chaperons (including parents) 6 (46) Only 1 chaperon allowed 10 (77) Reduction of patient chaperons 10 (77) Structural isolation via curtains, rooms, … 6 (46) Laminar flow rooms 1 (8) Separate transportation of patients to the dialysis center 5 (38) Separation of physicians and nurses for each patient (with registry) 3 (23) Spreading in different time slots with different teams to avoid coinfection 3 (23) Face masks for patients 6 (46) Face masks for physicians 8 (62) Face masks and high protective gear (suits, face shields, …) for physicians 0 (0) Face masks for nurses 9 (69) Face masks and high protective gear (suits, face shields, …) for nurses 2 (15) X. Preparations/provisions for dialysis of SARS-CoV-2-infected patients? Isolated rooms within own dialysis unit 8 (62) Isolated rooms within pediatric hospital (e.g. PICU) 5 (38) Isolated rooms at adult units 4 (31) Isolated by separate time slots 4 (31) Separation of medical staff (“COVID-19 teams”, physician and nurses) 5 (38) XI. Changes of Pediatric Kidney Transplantation Program due to COVID-19? Discontinuation of living-related donor kidney transplantation 7 (54) Pediatr Nephrol (2020) 35:1669–1678 1673 Table 1 (continued) Thematic questions and answer statements Number (%) Discontinuation of deceased donor kidney transplantation 2 (15) XII. Suspension of non-urgent care? Canceling of routine check ups 9 (69) Canceling of elective procedures (e.g. elective surgery) 3 (23) Suspension of routine visits of stable kidney transplant patients 3 (23) Suspension of non-urgent appointments 7 (54) XIII. Implementation of remote clinical work? Telephone calls with patients 12 (92) Video calls with patients 4 (31) E-Mails with patients 9 (69) Telemonitoring of patients 5 (38) Virtual online clinics for patients 4 (31) No remote clinical work, but reduction of patients 4 (31) Other, for example: home office with online tutoring and learning 5 (38) EPDWG European Pediatric Dialysis Working Group, COVID-19 SARS-CoV-2-related-disease, SARS-CoV-2 severe-acute-respiratory-syndrome-co- ronavirus-2, ACE-I angiotensin-converting-enzyme inhibitors, ARB angiotensin II-receptor-blockers, PICU pediatric intensive-care unit confirmed cases was conducted in 69% (9/13), 77% (10/13), Confirmed COVID-19 cases at EPDWG centers and 85% (11/13), respectively. Home quarantine with home office after possible contact of HCP with COVID-19 cases is Among 13 centers from 11 European countries, there have performed in 69% (9/13). been no confirmed cases of COVID-19 in a pediatric dialysis Fig. 1 Local COVID-19 testing a practices at the centers of the EPDWG b 1674 Pediatr Nephrol (2020) 35:1669–1678 Fig. 2 Preventive and preparatory a measures of transmission and management of confirmed and suspected COVID-19 cases among EPDWG centers b c patient and only one in a child with kidney transplant. The Preventive and preparatory measures of transmission latter case occurred in Spain, with the second highest infection and management of COVID-19 and mortality rate for COVID-19 among the 13 centers at the time. The two Italian centers reported no cases of SARS-CoV- Seventy-seven percent (10/13) of EPDWG centers are 2-positive children, despite Italy’s status as having the highest providing recommendations to parents to contact their pe- COVID-19 infection rate. diatric nephrology providers when their child has COVID-19-related symptoms. Thirty-eight percent (5/13) and 54% (7/13) of centers, respectively, perform active Changes in current therapies among the EPDWG screening of patients upon entering the hospital or dialysis ward. Whereas some EPDWG dialysis units can provide All 13 centers of the EPDWG were in consensus for continu- isolated rooms for each patient and even laminar flow ation of immunosuppressive therapy. Statements regarding rooms, others rely on purely organizational measures. prophylactic or post-COVID-19 diagnosis discontinuation of The Italian centers of the EPDWG issued guidance that ACE-I or ARB therapy in children with renal disease all sup- all medical staff and sanitary professionals need to be ported continuation of established therapies. Within the first organized in teams and efficiently protected to avoid co- round of our Delphi exercise, questions arose regarding dis- infection. German centers implemented strategies to be continuation of Eculizumab maintenance therapy for prepared for upcoming delivery shortages, whereas the complement-mediated kidney disease, such as atypical hemo- Czech Republic prescribed during the third Delphi round lytic uremic syndrome (aHUS). During the second and third that face masks were obligatory in public sites. Delphi rounds, this question was addressed, with consensus Frequencies for measures of prevention of SARS-CoV-2 toward continuation of therapy. transmission are given in Table 1. Isolation of cases in Pediatr Nephrol (2020) 35:1669–1678 1675 Fig. 3 Changes in routine clinical a care due to COVID-19 among EPDWG centers b c segregated structures within dialysis units, within the pe- Discussion diatric hospitals (e.g., Intensive Care Units) or within adult units was conducted in 62% (8/13), 38% (5/13), During an acute and rapidly evolving pandemic crisis such as and 31% (4/13) of centers, respectively. Isolation by as- the COVID-19 pandemic, it may appear impossible to gener- signment of cases to different time slots was implemented ate evidence for recommendation of the management of spe- in 31% of centers (4/13), and separation of medical staff cific patient groups within short periods of time using standard was achieved in 38% (5/13). methodologies. Thus, current recommendations are mostly derived from the reported Chinese experience (and focus on high-incidence groups with high risk). [12–21] This lack of Changes in routine clinical care due to COVID-19 targeted clinical evidence will likely not change within highly specialized fields, such as all pediatric subspecialties. For ex- Fifty-four percent (7/13) of EPDWG centers suspended ample, in the recently published pediatric COVID-19 case living-related donor (LRD) transplantation. Deceased do- series (almost exclusively based on Chinese data), no cases nor (DD) kidney transplantation was discontinued in 15% of children with kidney transplantation or on dialysis were of centers (2/13). At two centers, both LRD and DD trans- reported. [5, 8–11] plantation were suspended during the last week of the In this context, expert knowledge, experience, and guid- Delphi exercise. Routine checkups and non-urgent ap- ance may provide the best available “evidence”. Since pointments were canceled in 69% (9/13) and 54% (7/13) COVID-19-specific reports of children with kidney disease, of centers, respectively. Routine visits for stable pediatric kidney transplantation, or dialysis were unavailable, as was kidney transplant patients were suspended in 23% of cen- guidance from respective professional societies, we conducted ters (3/13). Cancelation of elective procedures and/or sur- a Delphi exercise among experts in pediatric nephrology, gery was reported in 23% of centers (3/13). Figure 3 pre- representing 13 centers in 11 European countries (including sents specific measures of remote clinical work two Italian centers). The urgency of the situation prompted us implemented. to conduct our Delphi exercise with a mixed method 1676 Pediatr Nephrol (2020) 35:1669–1678 qualitative approach within 5 days, with four answer rounds of recommendations across the 13 centers, primarily dependent 24 h each. on available resources, in addition to on local or regional Current advice for COVID-19 testing strategies rele- governmental guidelines. vant to the EPDWG depends on the stage of the outbreak The COVID-19 pandemic led to suspensions of LRD and/ in different areas, according to the European Centre for or DD pediatric kidney transplantation programs in most Disease Prevention and Control (ECDC). [29] Guidelines EDPWG centers. These changes in transplantation policies for COVID-19 testing of patients and HCP are issued by were local decisions within the EPDWG centers and their national authorities, but might be adapted by individual hospitals, as no health authority regulations were available at centers depending on local regulations and resources. the time of the study, and as European and US scientific soci- [30, 31] For example, testing of symptomatic patients eties recommended consideration of temporary suspension was uniformly performed in all centers as mandated by depending on local circumstances. [32, 39] Implementation health authorities. However, testing of asymptomatic pa- of reduction in provision of non-urgent care similarly relied tients and asymptomatic HCP with varying risk factors on local practices. Routine checkups and non-urgent appoint- markedly varied among EPDWG centers, likely reflecting ments were being canceled in most EPDWG centers, whereas decisions of individual expert teams responsible for clin- routine visits of stable kidney transplant patients and elective ical care, thus influenced by local expert attitudes and were suspended in about 25% of centers, resulting in signifi- hospital policies. It is important to stress that criteria cant reduction in direct patient contacts, as recently proposed and strategies for COVID-19 testing are changing rapidly by the Transplant Society in order to keep transplantation as the geographic spread of COVID-19 expands, as are centers operational. [35] Among the EPDWG centers, remote physician attitudes and hospital policies. In accordance clinical work measures implemented included phone- and vid- with current literature [5, 8–11], our study found no cases eo calls, online clinics, and telemonitoring for peritoneal dial- of confirmed COVID-19 in children with dialysis. ysis patients. However, we identified the first case of confirmed Taken together, pediatric nephrology provider response COVID-19 in a child with kidney transplantation in patterns to the challenge of the COVID-19 pandemic have Spain. This child was doing well at the time of manuscript been diverse, as expectable from a multi-country European submission. network in a federalized governmental environment. Guidance on management of immunosuppressive therapy Responses concerning changes in current treatment were in in adult patients with kidney transplantation and COVID-19 consensus with recommendations from scientific bodies. has been recently issued. [32–36] Furthermore, arisen specu- However, state-of-the-art tends to be conservative, suggesting lations on exacerbation of COVID-19 disease by concurrent change to the status quo only upon presentation of clear evi- treatment with ACE-I or ARB have been addressed by the dence of the need for change. Some responses, such as those European Society of Cardiology (ESC) and the American concerning testing strategies, prevention, and changes in rou- Heart Association (AHA), both strongly recommending con- tine care during the COVID-19 pandemic, varied widely tinuation of these widely used drugs. [37, 38] Although no among the EPDWG centers, reflecting in part rapid dynamic such guidance has been published for children, all 13 EPDWG changes in the responses of national or local health authorities centers were in complete consensus for continuation of these to escalation of the pandemic. Local hospital policies, physi- established therapies, while alert to appearance of additional cians’ attitudes, and available resources also significantly in- data (for rapid dissemination across the network). fluenced the diverse patterns of responses among EPDWG Strategies are emerging to counter acceleration of the centers. Future studies, performing detailed longitudinal as- COVID-19 pandemic in the face of shortages of resources sessments of these interdependent variables will be needed and personal protective equipment. [31] Concerns about trans- to obtain a deeper understanding of determinants of individual mission of SARS-CoV-2 to HCP are also emerging more fre- response patterns. Such studies should be able to compare the quently. These might be even more relevant in the pediatric efficacy of any country-specific responses to the COVID-19 setting, as infected children appear to suffer fewer complica- pandemic. tions than do their adult HCP. Indeed, up to 20% of Italian The strengths of this Delphi exercise lie in the rapid re- HCP have been infected. [31] KDIGO has recently published sponse and communication of 13 expert centers across guidelines, synthesized from the Chinese and Taiwanese Europe, with consecutive qualitative data analysis in a themat- Societies of Nephrology, that recommend separation of HCP ic field for which no evidence and no guidance from interna- and individual patients by location and time, in addition to tional societies currently exist. The concise description of entrance control, self-monitoring for symptoms, and use of multi-country European response patterns may allow experts appropriate protective equipment. [34] The EPDWG pattern in other countries affected by this pandemic to base their own of responses for prevention and management of SARS-CoV-2 responses on an improved level of evidence for recommenda- demonstrated varying degrees of implementation of these tions unavailable for the time being through standard Pediatr Nephrol (2020) 35:1669–1678 1677 methodologies. The COVID-19 pandemic is expanding in the Ethics approval Not applicable. United States with a lag of about 2 weeks compared to conti- Consent to participate Consent was obtained from all individual par- nental Europe. [4] This lag may provide crucial opportunities ticipants included in the study. for US experts to learn from the European areas enduring a more advanced state of the pandemic. Consent for publication Consent for publication was given by each Limitations of this study are inherent in the rapidly evolving author. pandemic and corresponding dynamics of changing regulations—thus the specific information on response patterns Code availability No custom codes were used for this study. in this study is valid through the date of manuscript submission, Open Access This article is licensed under a Creative Commons and recommendations may change quickly thereafter. However, Attribution 4.0 International License, which permits use, sharing, the consensus identification of specific COVID-19 topics of adaptation, distribution and reproduction in any medium or format, as greatest relevance to a multi-country European expert group long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if working in the midst of the pandemic should be generalizable changes were made. The images or other third party material in this article and may facilitate development of relevant local guidance from are included in the article's Creative Commons licence, unless indicated other national expert groups or health authorities, supporting otherwise in a credit line to the material. If material is not included in the individual pediatric nephrology experts in their clinical decision article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will making in a time of extreme uncertainty. need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Conclusion In conclusion, this Delphi exercise exemplifies international References cooperation and communication of experts during a rapidly emerging pandemic crisis. The use of a mixed method quali- 1. 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