COVID-19 in solid organ transplant recipients: Dynamics of disease progression and inflammatory markers in ICU and non-ICU admitted patients

Abstract

Background: COVID-19 infection varies in severity from minimal symptoms to critical illness associated with a hyperinflammatory response. Data on disease progression in immunosuppressed solid organ transplant (SOT) recipients are limited.

Methods: We examined the electronic medical records of all SOT recipients with COVID-19 from 12 Massachusetts hospitals between February 1, and May 6, 2020. We analyzed the demographics, clinical parameters, course, and outcomes of illness in these patients.

Results: Of 52 COVID-19-positive SOT patients, 77% were hospitalized and 35% required ICU admission. Sixty-nine percent of hospitalized patients had immunosuppression reduced, 6% developed suspected rejection. Co-infections occurred in 45% in ICU vs 5% in non-ICU patients (P = .037). A biphasic pattern of evolution of laboratory tests was observed. In the first 5 days of illness, inflammatory markers were moderately increased. Subsequently, WBC, CRP, ferritin, and D Dimer increased with increasing stay in the ICU, and lymphocyte counts were similar. Five patients (16%) died.

Conclusions: Our data indicate that SOT is associated with high rate of hospitalization, ICU admission, and death from COVID-19 compared to data in the general population of patients with COVID-19. Despite reduction in immunosuppression, suspected rejection was rare. The clinical course and trend of laboratory biomarkers is biphasic with a later, pronounced peak in inflammatory markers seen in those admitted to an ICU. CRP is a useful marker to monitor disease progression in SOT.

Keywords: COVID-19; cytokines; hospitalization; immunosuppression; inflammation; solid organ transplantation.

FIGURE 1

Mean daily laboratory results for first 20 d of illness since symptom onset. Mean daily WBC (panel A), ALC (panel B), CRP (panel C), Ferritin (panel D), D Dimer (panel E) and albumin (panel E) in ICU (black line) vs non‐ICU (dashed line) group, with mean day of ICU admission demonstrated by black arrow (7 d). For each group, daily values of CRP, ferritin, D Dimer, and albumin are averaged over 3 d for each individual patient to account for alternate day testing. ICU, intensive care unit, WBC, white blood cell count, ALC, absolute lymphocyte count, CRP, C‐reactive protein. Mean daily WBC, CRP, ferritin and D Dimer are higher in the ICU group than Non‐ICU group (P < .0001). Mean daily albumin is lower in the ICu group vs the non‐ICU group (P < .001). There is no difference in mean daily ALC between the ICU and non‐ICU group (P = .991). ICU, intensive care unit; WBC, white blood cell count; ALC, absolute lymphocyte count; CRP, C‐reactive protein