Coronavirus Disease 2019 in Solid Organ Transplant: A Multicenter Cohort Study

Abstract

Background The COVID-19 pandemic has led to significant reductions in transplantation, motivated in part by concerns of disproportionately more severe disease among solid organ transplant (SOT) recipients. However, clinical features, outcomes, and predictors of mortality in SOT recipients are not well-described. Methods We performed a multi-center cohort study of SOT recipients with laboratory-confirmed COVID-19. Data were collected using standardized intake and 28-day follow-up electronic case report forms. Multivariable logistic regression was used to identify risk factors for the primary endpoint, 28-day mortality, among hospitalized patients. Results Four hundred eighty-two SOT recipients from >50 transplant centers were included: 318 (66%) kidney or kidney/pancreas, 73 (15.1%) liver, 57 (11.8%) heart, and 30 (6.2%) lung. Median age was 58 (IQR 46-57), median time post-transplant was 5 years (IQR 2-10), 61% were male, and 92% had ≥1 underlying comorbidity. Among those hospitalized (376 [78%]), 117 (31%) required mechanical ventilation, and 77 (20.5%) died by 28 days after diagnosis. Specific underlying comorbidities (age >65 [aOR 3.0, 95%CI 1.7-5.5, p<0.001], congestive heart failure [aOR 3.2, 95%CI 1.4-7.0, p=0.004], chronic lung disease [aOR 2.5, 95%CI 1.2-5.2, p=0.018], obesity [aOR 1.9, 95% CI 1.0-3.4, p=0.039]) and presenting findings (lymphopenia [aOR 1.9, 95%CI 1.1-3.5, p=0.033], abnormal chest imaging [aOR 2.9, 95%CI 1.1-7.5, p=0.027]) were independently associated with mortality. Multiple measures of immunosuppression intensity were not associated with mortality. Conclusions Mortality among SOT recipients hospitalized for COVID-19 was 20.5%. Age and underlying comorbidities rather than immunosuppression intensity-related measures were major drivers of mortality.

Liver Injury in Liver Transplant Recipients With Coronavirus Disease 2019 (COVID‐19): U.S. Multicenter Experience

“…United States. (19) The Centers for Disease Control and Prevention reports that the general U.S. population has a COVID-19 mortality rate of 5%. (20) However, the median age of LT recipients who acquire COVID-19 is higher at 60.1 years compared to the reported median age of 48 years in the general population.…”

“…This racially and ethnically diverse study cohort was 39.3% (n = 44) Hispanic, 27.7% (n = 31) non-Hispanic White, and 25.9% (n = 29) non-Hispanic African American. The median follow-up period for the cohort was 20.0 (IQR, 19)…”

“…LT cohort and the control group were matched for median age (63[IQR,14] vs. 60[IQR,19]; P = 0.10), sex (males, 52.4% vs. 56.9%; P = 0.669), and incidence of comorbidities like DM (47.6% vs. 47.1%; P = 1.000), HTN (57.3% vs. 59.3%; P = 0.804), and obesity (26.8% vs. 37.5%; P = 0.075). At baseline, before the diagnosis of COVID-19, LT recipients and nontransplant patients with CLD had similar median ALT(23 [IQR,22] vs. 25[IQR,24]; P = 0.380).…”

Infectious Complications in Lung Transplant Recipients

“…The authors noted that cell cycle inhibitors were withheld in all ten patients, while calcineurin inhibitors and corticosteroids were continued at the same dose [48]. Finally, a multi-center cohort study of 482 solid organ transplant recipients, including 30 lung transplant patients, showed an overall 28-day mortality rate of 20.5% [49]. Optimal management of immunosuppression in patients with COVID-19 remains unclear.…”

Tocilizumab for severe COVID-19 in solid organ transplant recipients: a matched cohort study

“…Although early case series indicated SOT recipients may be at increased risk of severe disease and mortality, subsequent studies have suggested that outcomes may be similar to the general population. [1][2][3][4][5][6][7] While data on the antiviral remdesivir have shown a clinical benefit in patients with COVID-19, the optimal management of patients who progress to severe disease after several days of mild symptoms remains less clear. 8,9 The hypothesis that this delayed progression may be attributable to a deleterious hyperinflammatory process or cytokine storm led to a significant interest in immunomodulatory agents such as corticosteroids and tocilizumab, a humanized monoclonal antibody to the IL-6 receptor.…”