ABO incompatible kidney transplant after recovery from severe COVID-19 pneumonia

Abstract

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.

Solid Organ Transplantation in SARS-CoV-2 Recovered Transplant Candidates: a Comprehensive Review of Recent Literature

“…Over followup of 45 days, the authors reported no complications in the donor-recipient pair. Similar case reports followed from different areas of the world [12]. But the most comprehensive insight into this topic was documented in an Indian study that reported 75 LDKT in recipients who had recovered from COVID-19 [13 •].…”

“…* = Cases which were RT-PCR positive at the time of transplant surgery. Abbreviations: COVID-19 , coronavirus disease; CKD , chronic kidney disease; CT , cycle threshold; DM , diabetes mellitus; DD , deceased donation; ESKD , end-stage kidney disease; F , female; HD , hemodialysis; IS : immunosuppression; LD , living donation; M , male; m, months; MMF , mycophenolate; nRT-PCR , real-time polymerase chain test through nasopharyngeal specimen; MN , membranous nephropathy; TIN , tubulointerstitial nephritis; TCR , T cell rejection Authors n Type Age/sex Cause of ESKD COVID-19 severity Negative nRT-PCR prior to transplant Waiting time after a negative RT-PCR IgG antibody test Pre-Transplant Donor’s COVID-19 status IS regimen Outcome Follow-up Singh N et al, Sept 2020 [ 20 ] 1 DD 66/F DM Mild (home) 2 negatives (24 h apart) 3 mos Done (positive) Negative No change Uneventful 7 wks Varotti et al, Oct 2020 [ 16 ] 1 DD 28/F MN- CKD Mild 2 negative (48 h apart) 2 wks Done (positive) Negative No change E. coli infection 60 d Waghmare I et al, Dec 2020 [ 12 ] 1 LD 46/M Not reported Severe …”

“…While most reports required normal chest imaging before transplant, owing to high likelihood of residual radiographic changes for months following infection, we suggest the transplant should proceed even in cases of underlying residual damage. There is a report of an ABO kidney transplant where the team waited for inflammatory markers to resolve despite being RT-PCR negative and asymptomatic [ 60 ]. However, normalization of inflammatory markers before transplant should not be a mandatory prerequisite.…”

ISOT consensus statement for the kidney transplant recipient and living donor with a previous diagnosis of COVID-19

“…[ 2 3 4 5 ] With the resumption of kidney transplant program in various parts of India, new issues are expected to arise. There is uncertainty regarding the safety of performing kidney,[ 6 7 8 ] liver,[ 9 10 11 12 ] or lung[ 13 ] transplantation in a recipient recently recovered from COVID-19. At present, we have limited evidence-based information about the safety and feasibility of kidney transplantation from living donors who have recovered from COVID-19.…”

Successful ABO-incompatible kidney transplantation and SARS-CoV-2–specific immune monitoring in a patient recovered from coronavirus infection

“…There are approximately four previous case reports of successful transplantation in patients with a mild disease course of COVID-19 and two case reports of such patients with a severe disease course [ 4 - 8 ]. No previous case report or cohort study showed adaptive immunity in both precise humoral and cellular patterns.…”