Background Kidney graft recipients receiving immunosuppressive therapy may be at heightened risk for coronavirus disease 2019 (Covid-19) and adverse outcomes. It is therefore important to characterize the clinical course and outcome of Covid-19 in this population and identify safe therapeutic strategies. Methods We performed a retrospective chart review of 73 adult kidney graft recipients evaluated for Covid-19 from 13 March to 20 April 2020. Primary outcomes included recovery from symptoms, acute kidney injury, graft failure and case fatality rate. Results Of the 73 patients screened, 54 tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)—39 with moderate to severe symptoms requiring hospital admission and 15 with mild symptoms managed in the ambulatory setting. Hospitalized patients were more likely to be male, of Hispanic ethnicity and to have cardiovascular disease. In the hospitalized group, tacrolimus dosage was reduced in 46% of patients and mycophenolate mofetil (MMF) therapy was stopped in 61% of patients. None of the ambulatory patients had tacrolimus reduction or discontinuation of MMF. Azithromycin or doxycycline was prescribed at a similar rate among hospitalized and ambulatory patients (38% versus 40%). Hydroxychloroquine was prescribed in 79% of hospitalized patients. Graft failure requiring hemodialysis occurred in 3 of 39 hospitalized patients (8%) and 7 patients died, resulting in a case fatality rate of 13% among Covid-19-positive patients and 18% among hospitalized Covid-19-positive patients. Conclusions Data from our study suggest that a strategy of systematic triage to outpatient or inpatient care, early management of concurrent bacterial infections and judicious adjustment of immunosuppressive drugs rather than cessation is feasible in kidney transplant recipients with Covid-19.

OBJECTIVEThe objective of this study was to compare pre‐dialysis and post‐dialysis hemoglobin (Hgb) and ultrafiltration in hemodialysis patients. Factors influencing Hgb are not well understood.METHODSPre‐dialysis and post‐dialysis Hgb and weight were measured in 133 hemodialysis patients. Absolute and percentage change in Hgb (%ΔHgb) and percent change in body weight (%ΔBW) were determined for that treatment. Patients were divided into 2 groups, those with post‐dialysis Hgb < 13 g/dL (group 1) and those with post‐dialysis Hgb ≥13 g/dL (group 2); the differences in %ΔBW were compared between the 2 groups.RESULTSThe mean pre‐dialysis Hgb was 11.9 ± 1.4 g/dL, the mean post‐dialysis Hgb level was 12.8 ± 1.8 g/dL. The %ΔHgb was 3.9 ± 6.6 in group 1 and 10.8 ± 7.8 in group 2. The %ΔBW was 3.1 ± 1.4 in group 1 and 3.9 ± 1.7 in group 2 (p < .001 for all comparisons). We found that although both groups had a rise in Hgb level post‐dialysis, group 2 patients had a rise in %ΔHgb that was greater than the relatively small difference in %ΔBW between the 2 groups. In addition, we found only a modest correlation between %ΔBW and %ΔHgb in both groups. The r2 of 0.24 suggests that only 25% of the variability found in %ΔHgb can be related to %ΔBW.CONCLUSIONSPatients with post‐dialysis Hgb ≥13 g/dL had a greater increase in %ΔHgb that was out of proportion to %ΔBW. Factors other than %ΔBW may play a role in determining post‐dialysis Hgb.

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The response of the immune system to COVID-19 in end stage kidney disease patients who undergo kidney transplantation has yet to be described. We report data on 72 patients who underwent SARS-CoV-2 antibody testing both before and after kidney transplantation and were followed for a median of 186 days (range 83, 277). Of the 25 patients with a positive antibody test at the time of transplant, 17 (68%) remained positive after transplantation. Patients were significantly more likely to have a persistently positive test if they reported a symptomatic COVID-19 infection prior to transplant (p=0.01). SARS-CoV-2 IgG index values were measured in a subset of kidney transplant recipients and compared to wait -listed dialysis patients. These assays demonstrated a more significant decline in IgG (58% versus 14% p = 0.008) in transplant recipients when compared to dialysis patients tested during the same time period. Additional analysis of the quality of the immune response measuring the binding of SARS-CoV-2 antibodies to the receptor-binding domain (RBD binding), the antibody neutralizing capability, and the antibody avidity demonstrated a more pronounced effect when comparing pre-transplant values to post-induction therapy/post transplant values. The attenuated IgG response seen in transplant patients compared to dialysis patients after induction therapy requires further study. These data have important implications for post-transplant management of vaccinated dialysis patients.