COVID-19 and Solid Organ Transplantation: Role of Anti-SARS-CoV-2 Monoclonal Antibodies

Abstract

Purpose of Review Solid organ transplant recipients (SOTRs) are ideal candidates for early treatment or prevention of coronavirus disease 2019 (COVID-19) using anti-SARS-CoV-2 monoclonal antibodies because of multiple underlying medical conditions, chronic immune-suppression, sub-optimal immunogenic response to vaccination, and evolving epidemiological risks. In this article, we review pertinent challenges regarding the management of COVID-19 in SOTRs, describe the role of active and passive immunity in the treatment and prevention of COVID-19, and review real-world data regarding the use of anti-SARS-CoV-2 monoclonal antibodies in SOTRs. Recent Findings The use of an anti-SARS-CoV-2 monoclonal antibody in high-risk solid organ transplant recipients is associated with a reduction in the risk of hospitalization, need for intensive care, and death related to COVID-19. Overall, the early experiences from a diverse population of solid organ transplant recipients who were treated with anti-spike monoclonal antibodies are encouraging with no reported acute graft injury, severe adverse events, or deaths related to COVID-19. Summary Anti-SARS-CoV-2 antibodies are currently authorized for treatment of mild-moderate COVID-19 and post-exposure prophylaxis, including in SOTRs. Potential future uses include pre-exposure prophylaxis in certain high-risk persons and synergistic use along with emerging oral treatment options. Successful timely administration of anti-SARS-CoV-2 monoclonal antibodies requires a multidisciplinary team approach, effective communication between patients and providers, awareness of circulating viral variants, acknowledgement of various biases affecting treatment, and close monitoring for efficacy and tolerability.

Update on COVID-19 Therapeutics for Solid Organ Transplant Recipients, Including the Omicron Surge

“…Although the original clinical trials of these agents did not include many immunocompromised patients, it is likely that this group benefits the most from mAb therapy, given their immunocompromise and suboptimal responses to COVID vaccines. 11 Retrospective studie summarized below suggest that mAb treatment in SOT recipients is associated with reduced risk of hospitalization, reduced likelihood of progression to severe infection, and probably reduced mortality. 11 However, with the constantly evolving landscape of the pandemic, and a succession of new dominant variants, the utility of each monoclonal has changed over time.…”

“… 11 Retrospective studie summarized below suggest that mAb treatment in SOT recipients is associated with reduced risk of hospitalization, reduced likelihood of progression to severe infection, and probably reduced mortality. 11 However, with the constantly evolving landscape of the pandemic, and a succession of new dominant variants, the utility of each monoclonal has changed over time. For example, bamlanivimab was originally administered by itself, then later when it was no longer effective as a single agent, was given together with etesevimab, and ultimately was not used at all.…”

“…By contrast, the real revolution has been in early COVID-19 treatment, starting in late 2020 with the introduction of SARS-CoV-2 monoclonal antibodies (mAbs) for treatment of mild-to-moderate COVID-19. 11 Two oral drugs (nirmeltravir/ritonavir and molnupiravir), 12 - 13 as well as a 3-d outpatient protocol for remdesivir, 14 and a randomized trial of high-titer convalescent plasma in outpatients, 15 have expanded the options for treatment of early COVID. This review will examine what we know about each of these newer therapies in terms of clinical utility, risks, and benefits in SOT recipients.…”

Sotrovimab for Treatment of COVID-19 in Solid Organ Transplant Recipients

“… 1 Early use of anti–severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) monoclonal antibody in SOTRs provides a safe outpatient treatment option to reduce COVID-19–related risk of hospitalization and death. 2 Sotrovimab is a recombinant human immunoglobulin-G1-kappa monoclonal antibody that binds to a conserved epitope on the spike protein receptor-binding domain of SARS-CoV and SARS-CoV-2. Sotrovimab contains a 2 amino acid Fc-modification that is designed to improve bioavailability in the respiratory mucosa and increase half-life with a projected human median elimination half-life of 49 d. 3 Based on clinical studies, in which immunocompromised patients were excluded, it received Emergency Use Authorization by the Food and Drug Administration for the treatment of mild to moderate COVID-19 in May 2021.…”

How COVID-19 Affects Lung Transplantation: A Comprehensive Review

“…The subcutaneous administration of casivirimab-imdevimab (REGEN-COV) was shown to prevent COVID-19 in previously uninfected household contacts in the general population, and, therefore, might be of importance in the prevention of COVID-19 [ 96 ]. A study by Dhand et al evaluated 25 COVID-19-infected SOT recipients receiving REGEN-COV, and demonstrated neither COVID-19 progressions nor hospitalizations in the study participants [ 97 ]. Nevertheless, observational studies evaluating the pre-exposure prophylactic administration of mAbs in LuTx recipients are awaited.…”