Experience with SARS-CoV-2 Infection Early After Renal Transplantation
Paul Morrissey1, Dimitrios Farmakiotis2, Ralph Rogers2, Adena Osband1, Basma Merhi3, George Bayliss3, Krista Mecadon4, Reginald Gohh3
1Surgery, Rhode Island Hospital, Providence, Rhode Island, United States, 2Infectious Disease, Rhode Island Hospital, Providence, Rhode Island, United States, 3Nephrology, Rhode Island Hospital, Providence, Rhode Island, United States, 4Pharmacy, Rhode Island Hospital, Providence, Rhode Island, United States
Objectives: To prevent early acute rejection, kidney transplant recipients (KTR) are administered augmented immunosuppression during the initial period after transplant. Since March 2020, these patients have been at risk for severe SARS-CoV-2 infection (COVID-19). However, outcomes of COVID-19 during this period of intense immunosuppression have not been well-studied. Design: We reviewed 124 KTR at risk of COVID-19 within six months after transplant (period of highest immunosuppression). Setting: Academic transplant center. Patients: Consecutive recipients (n=124) of kidney transplant from September 2019 - February 2022. Interventions: All received antibody induction followed by tacrolimus, mycophenolate, and steroids. Patients were tested for COVID-19 on admission for transplant surgery and whenever symptoms were suggestive of COVID-19 per CDC guidelines. Main Outcome Measures: Development of COVID-19 infection after renal transplantation. Secondary outcomes were need for hospitalization along with patient and allograft survival. Results: Overall, 27 (22%) developed COVID-19 at a mean of 345 days after transplant. Eight had SARS-CoV-2 detected by nasopharyngeal swab PCR within 6 months (0, 14, 27, 54, 71, 113, 126, 163 days) after transplant. Of those eight patients, five required hospitalizations, including one asymptomatic patient with PCR positive for SARS-CoV-2 on the day of transplant. Mean age was 46 years. All received treatment with reduced immunosuppression, anti-spike monoclonal antibodies, and/or remdesivir. Two of 27 COVID-19 positive patients died: one 12 months after transplant from pneumonia and one of the eight early cases due to massive CVA in the setting of severe COVID-19 disease (d-dimer 3,300). All others are alive and well, with good allograft function (mean creatinine 1.3 mg/dL, range 0.6-2.2 mg/dL). Time to recovery was not prolonged compared to other transplant recipients with COVID-19. COVID-19-related mortality among 232 organ transplant recipients (mean age: 57 years) diagnosed with COVID-19 at our institution to-date is 12%. Conclusions: Despite heightened immunosuppression early after renal transplant, patients with COVID-19 had similar outcomes to those of organ transplant recipients who acquired COVID-19 >6 months after transplant. In view of expanded vaccination practices, including additional doses, and the availability of new antiviral agents, these results favor the benefits over the risks of renal transplantation during the pandemic.
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