Management of immunosuppression in kidney transplant recipients with COVID‐19 pneumonia: A summary of 41 confirmed cases reported worldwide

Abstract

There is no consensus on immunosuppression management for kidney transplant recipients (KTRs) with SARS‐CoV‐2 pneumonia. Therefore, we conducted a search in English database from October 2019 to July 2020 and extracted data from cases with treatment details worldwide, and total of 41 recipients with a median age of 50 years were enrolled in this study. Most of them were males (75.8%). The most common presenting symptoms were fever (80.5%), cough (63.4%) and fatigue (41.5%). Patients were classified into three catalogs according to severity of pneumonia, 17 (41.5%) were mild, 15 (36.6%) severe and 9 (21.9%) critical disease. Laboratory tests revealed that serum creatinine of critical patients was significantly higher than that of mild or severe patients. 68.3% received oxygen support; all patients received antiviral therapy, 15 (36.6%) recipients were additionally treated with intravenous immunoglobulin and interferon‐α. 19.5% patients maintained immunosuppressive therapy; 36.6% suspended antimetabolite; 43.9% only treated with corticosteroid. 6 (14.6%) patients died (severe: 2, critical: 4); high creatinine with low lymphocyte count was the biggest challenge of immunosuppression management. In all, it is necessary to pay close attention to renal function and lymphocyte count in KTRs infected with COVID‐19, and choose appropriate medication programs according to the specific situations.

The Management of Immunosuppression in Kidney Transplant Recipients with COVID-19 Disease: An Update and Systematic Review of the Literature

“…For KT recipients with mild symptoms, the “wait and see approach” was the most commonly used [ 44 , 90 ]. This conservative clinical practice is in line with the recommendation of the Developing Education Science and Care for Renal Transplantation in European States (DESCARTES) Working Group, an expert panel of the ERA-EDTA [ 8 ].…”

Immunomodulatory Therapies for COVID-19 in Solid Organ Transplant Recipients

“…In addition to the nonrandomized design of these studies and the lack of details on the regimen administered (i.e., type of corticosteroid and relative potency, low-to-moderate daily courses versus high-dose pulses for few days), the analysis is hampered by the large heterogeneity observed in the adjustment of baseline immunosuppression. A literature review pooling data for 41 KT recipients described three separate basic schemes (no changes in immunosuppression, only antimetabolites were suspended, or only maintained on corticosteroids), which greatly differed according to the severity of SARS-CoV-2 infection, pointing to confounding by indication [75]. Consistent with this notion, as much as 25.7% of LT recipients with severe COVID-19 reported from a large Spanish multicenter study received corticosteroid boluses, compared to only 4.9% of those with mild or moderate infection [76•].…”

Tratamiento de COVID-19 en receptores de trasplante renal

“…7 Respecto al manejo de inmunosupresión de mantenimiento durante la infección por SARS-CoV-2 ha sido muy heterogéneo, se realiza principalmente basado en opinión de expertos y traslapando la conducta que se toma frente a infecciones sistémicas graves. 1,[8][9][10][11] Al inicio y ante la incertidumbre de cómo se comportaría en inmunosuprimidos, se llegó a suspender tanto el inhibidor de calcineurina como el antiproliferativo, pero pronto surgieron propuestas basadas en la gravedad de la enfermedad como el esquema que utilizamos en el Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», que se muestra en la Figura 1. 10,12 El manejo de infecciones como virus BK, CMV, SARS-CoV, MERS, entre otros, nos han mostrado el beneficio de tener como primer paso la suspensión del antiproliferativo en casos moderados a graves, manteniendo el inhibidor de calcineurina, logrando reducir el número de rechazos comparado a la interrupción del inhibidor de calcineurina manteniendo el antiproliferativo.…”