A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia

Abstract

The outcome of SARS-CoV2 infection in patients who have received a kidney allograft and are being treated with immunosuppression is unclear. We describe 20 kidney transplant recipients (median age 59 years [inter quartile range 51-64 years], median age of transplant 13 years [9-20 years], baseline eGFR 36.5 [23-47.5]) with SARS-CoV2 induced pneumonia. At admission, all had immunosuppression withdrawn and were started on methylprednisolone 16 mg/day, all but one was commenced on antiviral therapy and hydroxychloroquine with doses adjusted for kidney function. At baseline, all patients presented fever but only one complained of difficulty in breathing. Half of patients showed chest radiographic evidence of bilateral infiltrates while the other half showed unilateral changes or no infiltrates. During a median follow-up of seven days, 87% experienced a radiological progression and among those 73% required escalation of oxygen therapy. Six patients developed acute kidney injury with one requiring hemodialysis. Six of 12 patients were treated with tocilizumab, a humanized monoclonal antibody to the IL-6 receptor. Overall, five kidney transplant recipients died after a median period of 15 days [15][16][17][18][19] from symptom onset. These preliminary findings describe a rapid clinical deterioration associated with chest radiographic deterioration and escalating oxygen requirement in renal transplant recipients with SARS-Cov2 pneumonia. Thus, in this limited cohort of long-term kidney transplant patients, SARS-CoV-2 induced pneumonia is characterized by high risk of progression and significant mortality.

Managing COVID‐19 in Renal Transplant Recipients: A Review of Recent Literature and Case Supporting Corticosteroid‐sparing Immunosuppression

“…Recipients described were between 1 month and 22 years post‐transplant with most patients presenting with severe respiratory symptoms requiring oxygen. Immunosuppressant management in 30 patients consisted of complete cessation of calcineurin inhibitor and antiproliferative therapy with reliance on corticosteroid monotherapy, typically with intravenous methylprednisolone 4,7‐17 . Only three patients were managed without making any change in their baseline immunosuppressive regimen, and one of these patients was receiving a steroid‐sparing regimen at baseline.…”

“…Additionally, broad‐spectrum antibiotic therapy was administered to 34 patients. The average duration of symptoms from those who reported was 21 days, with 18% of patients progressing to respiratory failure requiring mechanical ventilation 4,7‐17 . Eight patients who had presented with severe or critical oxygen needs had died by the time of case publication; all eight patients had immunosuppressant therapy converted to corticosteroid monotherapy while hospitalized 8,11,15,16 …”

“…At this time, supportive care is paramount to combating this virus in solid organ transplant recipients. Very little data are currently available regarding the optimal medical management of renal transplant patients testing positive for SARS‐CoV‐2 including strategies for reducing or modifying immunosuppression 4,7‐17 . Corticosteroids are a cornerstone of many immunosuppressive regimens; however, their use in SARS‐CoV‐2 is controversial 18‐22 .…”

Tocilizumab and Thromboembolism in COVID-19: A Retrospective Hospital-based Cohort Analysis

“…Currently, there are two recombinant humanized monoclonal antibodies targeting the IL-6 receptor, that are FDA approved in the USA, they are Sirukumab and Tocilizumab. There are multiple case reports and observational studies reporting use of Tocilizumab in patients with COVID-19 from around the world [5][6][7].…”

Molecular epidemiology of the first wave of severe acute respiratory syndrome coronavirus 2 infection in Thailand in 2020

“…In the current study no speci c clinical signs were signi cantly associated with any speci c SARS-CoV-2 types. Upper respiratory infection, fever, coughing, sore throat, and runny nose were the most common symptoms in COVID-19 patients, as has been frequently previously reported [25][26][27][28]. Clinical outcomes may associated with host factors such as age, lymphocytopenia, and cytokine responsiveness rather than SARS-CoV-2 genetic factors [29].…”