Kidney transplant patients with SARS-CoV-2 infection: The Brescia Renal COVID task force experience

Abstract

The outcome of kidney transplant patients with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is still unclear. Here we describe the clinical characteristics, disease outcome, and risk factors for acute respiratory distress syndrome (ARDS) and death of a cohort of 53 kidney transplant patients with coronavirus disease 2019 (COVID‐19). Eight of 53 have been handled as outpatients because of mild disease, on average with immunosuppression reduction and the addition of hydroxychloroquine and azithromycin; no patients required admission, developed ARDS, or died. Because of severe symptoms, 45/53 required admission: this cohort has been managed with immunosuppression withdrawal, methylprednisolone 16 mg/d, hydroxychloroquine, and antiviral drugs. Dexamethasone and tocilizumab were considered in case of ARDS. About 33% of the patients developed acute kidney injury, 60% ARDS, and 33% died. In this group, thrombocytopenia was associated to ARDS whereas lymphopenia at the baseline, higher D‐dimer, and lack of C‐reactive protein reduction were associated with risk of death. In the overall population, dyspnea was associated with the risk of ARDS and age older than 60 years and dyspnea were associated with the risk of death with only a trend toward an increased risk of death for patients on tacrolimus. In conclusion, SARS‐CoV‐2 infection may have a variable outcome in renal transplant patients, with higher risk of ARDS and death in the ones requiring admission.

A Systematic Review of COVID-19 and Kidney Transplantation

“…From left to right, quality items were starred black if they fulfilled pre-defined criteria: selection was starred on representativeness of patients with the exposure of interest (kidney transplant), selection of the non-exposed group, ascertainment of exposure, and demonstration that outcome of interest (death) was not present at start of the study; comparability was starred on the study controlling for the exposure of interest, and any additional factor; outcome was starred on how the outcome was assessed, whether follow-up was long enough for the outcome to occur, and whether loss to follow-up was adequate enough to be unlikely to introduce bias. Study design Selection Comparability Outcome Manganaro et al 16 Single-centre case series ☆☆★★ ☆☆ ☆☆☆ Boyarksy et al 18 Cross-sectional national survey ☆☆☆★ ☆☆ ☆☆☆ Pereira et al 21 Two-centre case series ★☆★★ ☆☆ ★☆☆ Sánchez-Álvarez et al 12 National registry cohort ★★☆★ ★☆ ☆★☆ Vistoli et al 19 Cross-sectional national survey ★☆☆★ ☆☆ ☆☆☆ Rodriguez-Cubillo et al 23 Single-centre case series ★☆★★ ☆☆ ★★★ Pascual et al 13 National registry case series ★☆★★ ☆☆ ★☆☆ Chen et al 27 Single-centre case series ★☆★★ ☆☆ ★★★ Mehta et al 28 Single-centre case series ★☆★★ ☆☆ ★★★ Bossini et al 25 Multi-centre case series ★☆★★ ☆☆ ★★★ Cravedi ...…”

“…Of the studies with available patient demographic data, average age ranged from 45 years in Demir et al to 66 years in Rodriguez-Cubillo et al 23 , 24 The percentage of male patients ranged from 46% in Pascual et al to 79% in Bossini et al 13 , 25 …”

“…10 , 17 Of other studies from which inpatient mortality could be calculated, it was 7/39 patients (18%) in Lubetzky et al across New York, 22 6/29 patients (21%) in both Rodriguez-Cubillo et al in Madrid and Chen et al in New York City, 23 , 27 15/42 patients (36%) in Bossini et al in Brescia and 9/25 patients (36%) Mohamed et al in London. 20 , 25 …”

An initial report from the French SOT COVID Registry suggests high mortality due to COVID-19 in recipients of kidney transplants

“…We also demonstrate that some immunocompromised patients with Covid-19 were manageable at home with favorable outcome as described in an Italian cohort from Brescia. 23 This decision was taken on a case-basis and was chiefly implemented for young patients without dyspnea and high fever. This patient subgroup was offered daily teleconsultation surveillance until disease resolution, a strategy that has been successfully implemented in a recent report from the United States.…”

Handling immune-suppressive therapies during SARS-CoV-2 pandemic: insights from pediatric datasets

“…SARS-Cov-2 infection has had a relevant impact, in terms of incidence and disease severity, on adult kidney transplant recipients. A study from Brescia, Lombardy, the Italian region with one of the highest rates of SARS-CoV-2 worldwide, reported an incidence of COVID-19 of 4.6% among a population of 1200 kidney transplant recipients and a mortality rate of 27% (15/55), which is higher than the rates reported in the general population [ 3 ]. A more recent survey, involving a population of 9845 kidney transplant recipients across 14 centers worldwide (TANGO consortium), confirmed the Italian data and reported an incidence of infection of 1.5%, with a mortality rate of 32% (44/144) during a median follow-up of 52 days [ 4 ].…”