Organ transplant recipients may not mount an adequate immune response to COVID‐19 infection and therefore may benefit greatly from passive immunization with anti‐spike monoclonal antibodies (mAbs), which have been shown to decrease hospitalization rates in the general outpatient population. We evaluated the efficacy of mAb therapy in decreasing hospitalizations or emergency room (ER) visits among kidney transplant recipients (KTR) with COVID‐19. We identified KTR with COVID‐19 between March 1, 2020 and April 30, 2021. Patients were excluded if they had multi‐organ transplant or hospital‐acquired COVID‐19. We studied 95 KTR; 20 received mAb. mAb administration was associated with a significant decrease in hospitalizations or ER visits (15% vs. 76%, p < 0.001). This association remained significant after adjustment for potential confounders, and analysis of mAb administration as a time‐dependent variable, with day of symptom onset as day 1 (adjusted HR 0.216, p = 0.04). Black or Hispanic patients were less likely to receive mAb and more likely to be admitted to the hospital or visit the ER. In our KTR population, mAb therapy for COVID‐19 may have helped decrease hospitalizations and ER visits. Healthcare inequities, including access to investigational treatments, have been exacerbated by the COVID‐19 pandemic. Antiviral mAbs are a promising therapeutic modality, especially for immunocompromised patients.

Background In order for healthcare systems to prepare for future waves of COVID-19, an in-depth understanding of clinical predictors is essential for efficient triage of hospitalized patients. Methods We performed a retrospective cohort study of 259 patients admitted to our hospitals in Rhode Island to examine differences in baseline characteristics (demographics and comorbidities) as well as presenting symptoms, signs, labs, and imaging findings that predicted disease progression and in-hospital mortality. Results Patients with severe COVID-19 were more likely to be older (p = 0.02), Black (47.2% vs. 32.0%, p = 0.04), admitted from a nursing facility (33.0% vs. 17.9%, p = 0.006), have diabetes (53.9% vs. 30.4%, p<0.001), or have COPD (15.4% vs. 6.6%, p = 0.02). In multivariate regression, Black race (adjusted odds ratio [aOR] 2.0, 95% confidence interval [CI]: 1.1–3.9) and diabetes (aOR 2.2, 95%CI: 1.3–3.9) were independent predictors of severe disease, while older age (aOR 1.04, 95% CI: 1.01–1.07), admission from a nursing facility (aOR 2.7, 95% CI 1.1–6.7), and hematological co-morbidities predicted mortality (aOR 3.4, 95% CI 1.1–10.0). In the first 24 hours, respiratory symptoms (aOR 7.0, 95% CI: 1.4–34.1), hypoxia (aOR 19.9, 95% CI: 2.6–152.5), and hypotension (aOR 2.7, 95% CI) predicted progression to severe disease, while tachypnea (aOR 8.7, 95% CI: 1.1–71.7) and hypotension (aOR 9.0, 95% CI: 3.1–26.1) were associated with increased in-hospital mortality. Conclusions Certain patient characteristics and clinical features can help clinicians with early identification and triage of high-risk patients during subsequent waves of COVID-19.

Objective We aimed to externally validate the predictive performance of two recently developed COVID‐19‐specific prognostic tools, the COVID‐GRAM and CALL scores, and prior prognostic scores for community‐acquired pneumonia (CURB‐65), viral pneumonia (MuBLSTA) and H1N1 influenza pneumonia (Influenza risk score) in a contemporary US cohort. Methods We included 257 hospitalised patients with laboratory‐confirmed COVID‐19 pneumonia from three teaching hospitals in Rhode Island. We extracted data from within the first 24 hours of admission. Variables were excluded if values were missing in >20% of cases, otherwise, missing values were imputed. One hundred and fifteen patients with complete data after imputation were used for the primary analysis. Sensitivity analysis was performed after the exclusion of one variable (LDH) in the complete dataset (n = 257). Primary and secondary outcomes were in‐hospital mortality and critical illness (mechanical ventilation or death), respectively. Results Only the areas under the receiver‐operating characteristic curves (RO‐AUC) of COVID‐GRAM (RO‐AUC = 0.775, 95% CI 0.525‐0.915) for in‐hospital death, and CURB65 for in‐hospital death (RO‐AUC = 0.842, 95% CI 0.674‐0.932) or critical illness (RO‐AUC = 0.766, 95% CI 0.584‐0.884) were significantly better than random. Sensitivity analysis yielded similar trends. Calibration plots showed better agreement between the estimated and observed probability of in‐hospital death for CURB65, compared with COVID‐GRAM. The negative predictive value (NPV) of CURB65 ≥2 was 97.2% for in‐hospital death and 88.1% for critical illness. Conclusions The COVID‐GRAM score demonstrated acceptable predictive performance for in‐hospital death. The CURB65 score had better prognostic utility for in‐hospital death and critical illness. The high NPV of CURB65 values ≥2 may be useful in triaging and allocation of resources.

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Background Organ transplant recipients (OTR) are considered high-risk for morbidity and mortality from COVID-19. Case-fatality rates (CFR) vary significantly in different case series, and some patients were still hospitalized at the time of analyses. To our knowledge, no case-control study of COVID-19 in OTR has been published to-date. Methods We captured kidney transplant recipients (KTR) diagnosed with COVID-19 between 3/1 and 5/18/2020. After exclusion of KTR on hemodialysis and off immunosuppression (IS), we compared the clinical course of COVID-19 between hospitalized KTR and non-transplant patients, matched by sex and age (controls). All patients were discharged from the hospital or died. Results 16 KTR had COVID-19. All 3 KTR off IS, who were excluded from further analyses, survived. Median age was 54 (range: 34–65) years; 5/13 KTR (38.4%) were men. Median time from transplant was 41 (range: 1–203) months. Two KTR, both transplanted &gt;10 years ago, were managed as outpatients. IS was reduced in 12/13 (92.3%), most often by discontinuation of the antimetabolite. IL6 levels were &gt;1,000 (normal: &lt; 5) pg/mL in 3 KTR. Tacrolimus or sirolimus levels were &gt;10 ng/mL in 6/9 KTR (67%) (Table 1). Eleven KTR were hospitalized (84.6%) and matched with 44 controls. One KTR, the only one treated with hydroxychloroquine, died (CFR 5.8%; 7.6% in KTR on IS; 9% in hospitalized KTR on IS). Four controls died (CFR: 9%; state CFR: 5.2%; inpatient CFR: 16.6%). There were no significant differences in length of stay or worst oxygenation status between hospitalized KTR and controls. Four KTR (30.7%), received remdesivir, 4 convalescent plasma, 3 (23%) tocilizumab. KTR received more often broad-spectrum antibiotics, convalescent plasma or tocilizumab, compared to controls (Table 2). Table 1 Table 2 Conclusion Unlike early reports from the pandemic epicenters, the clinical course and outcomes of KTR with COVID-19 in our small case series were comparable to those of non-transplant patients. Calcineurin or mTOR inhibitor levels were high, likely due to diarrhea and COVID-19-related hepatic dysfunction. Extremely high IL6 levels were common. The role of IS and potential benefits from investigational treatments remain to be elucidated. A larger multi-institutional study is underway. Disclosures All Authors: No reported disclosures

Background: The effect of COVID-19 on immunosuppressant drug levels in organ transplant recipients (OTRs) has not been adequately studied. Objective: To study the effect of COVID-19 on tacrolimus trough levels (primary outcome) in OTRs and the association of the later with acute kidney injury, bacterial infection, and oxygen requirements. Methods: We studied adult (>18-year-old) hospitalized OTRs with COVID-19, who were receiving tacrolimus between 3/1 and 12/16/2020. Results: Among 30 OTRs, 67% were men, 90% had a kidney transplant. Median age was 60.5 (interquartile range [IQR]: 45-68) years, median time from transplant 36 (IQR: 20-84) months. Tacrolimus troughs were higher on admission for COVID-19 than baseline (average over 6 months prior) ( P = .001). Eighteen patients (60%) had admission tacrolimus trough >10, 5 (17%) >20 ng/mL. Patients with diarrhea had borderline higher tacrolimus troughs, compared to those without diarrhea ( P = .09). Organ transplant recipients with a tacrolimus trough >10 ng/mL were more likely to have elevated aspartate aminotransferase on admission ( P = .01) and require supplemental oxygen. ( P = .026). Conclusion and Relevance: Tacrolimus trough levels were elevated in most OTRs with COVID-19 at the time of hospital admission, compared to baseline. Potential mechanisms are diarrhea and hepatic involvement in COVID-19. In OTRs with COVID-19, including outpatients, immunosuppressant drug levels should be closely followed; management of immunosuppression should be individualized.

Background The COVID-19 pandemic has devastated the global community with nearly 4.9 million deaths as of October 2021. While organ transplant (OT) recipients (OTr) may be at increased risk for severe COVID-19 due to their chronic immunocompromised state, outcomes for OTr with COVID-19 remain disputed in the literature. This review will examine whether OTr with COVID-19 are at higher risk for severe illness and death than non-immunocompromised individuals. Methods MEDLINE (via Ovid and PubMed) and EMBASE (via Embase.com) will be searched from December 2019 to October 2021 for observational studies (including cohort and case-control) that compare COVID-19 clinical outcomes in OTr to those in individuals without history of OT. The primary outcome of interest will be mortality as defined in each study, with possible further analyses of in-hospital mortality, 28 or 30-day mortality, and all-cause mortality versus mortality attributable to COVID-19. The secondary outcome of interest will be the severity of COVID-19 disease, most frequently defined as requiring intensive care unit admission or mechanical ventilation. Two reviewers will independently screen all abstracts and full-text articles. Potential conflicts will be resolved by a third reviewer and potentially discussion among all investigators. Methodological quality will be appraised using the Newcastle-Ottawa Scale. If data permit, we will perform random-effects meta-analysis with the Sidik-Jonkman estimator and the Hartung-Knapp adjustment for confidence intervals to estimate a summary measure of association between histories of transplant with each outcome. Potential sources of heterogeneity will be explored using meta-regression. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., subgroup analysis) considering least minimal adjustment for confounders. Discussion This rapid review will assess the available evidence on whether OTr diagnosed with COVID-19 are at higher risk for severe illness and death compared to non-immunocompromised individuals. Such knowledge is clinically relevant and may impact risk stratification, allocation of organs and healthcare resources, and organ transplantation protocols during this, and future, pandemics. Systematic review registration Open Science Framework (OSF) registration DOI: 10.17605/osf.io/4n9d7.

CASE PRESENTATIONA 34-year-old man with history of Crohn's disease, complicated by intestinal fistulas presented with dyspnea on exertion. He reported that over three days prior to presentation he developed a new dry cough that was worsened with exertion. His cough was associated with bilateral pleuritic chest pain. Other symptoms included rhinorrhea, sore throat, fatigue, night sweats and unintentional weight loss (fifteen pounds in the previous three weeks). He denied fever, chills, headaches, nausea, vomiting, dysuria, hematuria, rashes, sick contacts, or recent travel. He was not vaccinated against SARS-CoV-2. He was undergoing treatment with infliximab for Crohn's disease management; having received the most recent dose one month prior to presentation.His medical history included Crohn's disease with intestinal fistula formation, hypertension, diabetes mellitus, and obstructive sleep apnea. His medications included amlodipine, infliximab, lisinopril, metformin, metoprolol, and trazodone. He lived with his parents and siblings and was previously employed as an interstate tractor-trailer truck driver. He denied alcohol intake, tobacco use and recreational drug use. He reported a history of diabetes mellitus and hypertension in his family.Upon physical examination, temperature was 97.6 ℉, heart rate 106 beats per minute, respiration rate 18 per minute, blood pressure was 128/86 mmHg, oxygen saturation of 88% while breathing ambient air. The patient appeared chronically ill. He was alert and awake. Moist mucous membranes without other lesions were noted in the oral cavity. Cardiac examination was notable for regular tachycardia without cardiac murmurs or extra heart sounds. Pulmonary auscultation was significant for fine inspiratory rales in mid-lung and bases bilaterally. Abdominal examination was unremarkable. No lower extremity edema was noted. Skin and neurological examinations were unremarkable. See Table for relevant laboratory data. See Figure for plain radiograph and computed tomography (CT) of the chest.