Outcomes of Renal Transplant Recipients With SARS-CoV-2 Infection in the Eye of the Storm: A Comparative Study With Waitlisted Patients

Abstract

Background. Patients with chronic kidney disease stage 5 and those on immunosuppression are particularly vulnerable and are shielded as per public health strategy. We present our experience of coronavirus disease 2019 (COVID-19) transplant patients in one of the most affected parts of the UK with direct comparison to waitlisted patients. Methods. A single-center prospective study of symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive waitlisted and transplant patients was undertaken to compare these groups and assess clinical outcomes. Results. A total of 60 consecutive symptomatic SARS-CoV-2 positive patients were identified with 32 active waitlisted patients and 28 functioning renal transplants. Demographics were similar. The incidence of symptomatic COVID-19 in the waitlisted group was 9.9% compared to 1.9% in renal transplant patients (P < 0.001). Immunosuppression did not influence initial symptomology. Fifteen percent of patients in the waitlisted and 32% in the transplant groups died (P = 0.726). Mortality as proportion of total waitlisted (321 patients) and transplant population (1434 patients) of our centre was 1.5% and 0.6% (P < 0.001), respectively. C-reactive protein (CRP) at 48 h and peak CRP were associated with mortality in both groups while quick sequential organ failure assessment score at 48 h (P = 0.036) was associated with mortality for transplant patients. Conclusions. Incidence of COVID-19 is higher in the waitlisted population but transplant patients have more severe disease, reflected by higher mortality. CRP at 48 h can be used as a predictive tool. In the absence of effective treatments, the current strategy of shielding is arguably the most important factor in protecting patients while resuming transplantation.

Risks and Benefits of Kidney Transplantation during the COVID-19 Pandemic: Transplant or Not Transplant?

“…Such studies are of interest as they would help make better informed decisions regarding whether to proceed with transplantation during the pandemic versus having the patient accrue time on the waiting list. We summarized the studies comparing transplant patients to wait-listed patients with COVID-19 disease in Table 3 9,11,[30][31][32][33][34][35] .…”

“…Another explanation is the increased exposure of waitlisted patients to virus while receiving in-center hemodialysis. Most studies, which were done in Europe, identified a much higher COVID-19 related mortality in transplant recipients versus waitlisted patients, ranging 20-37% vs 5-16%, respectively 9,11,[31][32][33][34][35] . The largest series came from France for the period March 1st through June 1, 2020 that identified 275 deaths among the 42,812 kidney transplant recipients and 144 deaths among the 16,210 candidates 35 .…”

COVID-19 and the Response of Transplant Centers: the Global Response with an Emphasis on the Kidney Recipient

“…In particular, the T cell response is significantly suppressed in this population [ 1 ••, 2 •, 3 , 4 ]. At the outset of the pandemic, when the natural history of COVID-19 infection could only be conjectured, there was bona fide concern that immunosuppressed patients would be at increased risk for infection with SARS-CoV-2 and would experience unacceptably high mortality rates [ 3 – 7 ]. Faced with this hypothesis, solid organ transplant programs needed to make important decisions about very practical matters [ 7 , 8 ].…”

“…Around the world, transplant centers made individualized decisions about the conduct of their programs, though several themes were mostly consistent: pre-operative testing of recipients and donors for COVID-19 infection, minimizing immunosuppression, rigorous limited recipient selection, and the use of telemedicine in the outpatient setting when possible [ 1 ••, 3 , 5 , 8 , 9 ••]. In this paper, we explore the variations on these management strategies, to demonstrate that the transplant center response to the COVID-19 pandemic developed to address the individual needs of the centers, but ultimately reflected the desire to protect patients from any modifiable excessive harm.…”

Reply letter to: Inhibition of SARS‐CoV‐2 replication using calcineurin inhibitors: Are concentrations required clinically achievable?

“…Since we know neither the actual SARS-CoV-2 viral load in these COVID-19 patients nor the differences in viral load across tissues and cell types, we think that when used at the recommended clinical doses, an antiviral effect of CsA or tacrolimus could not be ruled out. Interestingly, and unexpectedly, a recent study in the UK showed that SARS-CoV-2 infections were less frequent in transplanted patients receiving immunosuppressive therapy (mainly tacrolimus, cyclosporine and steroids) compared with those on a transplant waiting list, with no immunosuppression [7]. Similarly, an international, multicentric study showed that only 144 out of 9845 patients with kidney transplants and immunosuppressive therapy were hospitalized with COVID-19, and most of them, with comorbidities [8], suggest possible protection by tacrolimus or CsA, acting upon undetermined mechanisms.…”