Background: In the current coronavirus 2019 (COVID-19) pandemic, hemodialysis patients are at increased risk of acquiring COVID-19 infection. Many patients awaiting transplant may have already contracted COVID-19 infection. Hence, deciding the "right time" to transplant is important. Methods: We describe the first case report of a patient who recovered from severe COVID-19 infection and later successfully underwent living donor ABO incompatible (ABOi) kidney transplant (KT). Results: A 46-year-old man on hemodialysis was planned for ABOi KT, with mother as prospective donor. Unfortunately, the patient developed COVID-19 pneumonia on May 11, 2020 and required intensive care unit care with noninvasive ventilator support in the second week of infection. He recovered clinically and nasopharyngeal swab was negative on June 14, 2020. However, due to persistently high C-reactive protein (CRP) and D-dimer, we waited for additional 2 months after COVID-19 negative report till markers had settled. By this time, markers had decreased from peak CRP 67.55 mg/L and D-dimer 3,970 ng/mL to nadir CRP 6.9 mg/L and D-dimer 881 ng/mL. high. Baseline anti-B titers were IgM 1:64 and IgG 1:2048. Three plasma exchange sessions and one session of 7.5 hours of double filtration plasmapheresis were done. Anti-B antibody titers decreased to IgM nil and IgG 1:4 and he underwent B to O blood group ABOi KT on August 14, 2020. Surgery and post-transplant period were uneventful. At 1-month post-transplant, his serum creatinine was 1.03 mg/dL. Conclusions: In recent COVID-19 recovered patients undergoing KT, ongoing inflammatory and procoagulatory states are additional risk factors for rejection and acute tubular injury. We suggest monitoring of inflammatory and procoagulatory markers in post-COVID-19 infection period and to plan KT only after these markers have settled. In high risk ABOi transplant, the use of anti-blood group immunoadsorption column offers selective removal of anti-blood group antibodies and would theoretically preserve the protective anti-COVID-19 antibodies.
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