Kidney allograft recipients, immunosuppression, and coronavirus disease-2019: a report of consecutive cases from a New York City transplant center

Abstract

Background: Kidney graft recipients receiving immunosuppressive therapy may be at heightened risk for coronavirus disease 2019 (Covid-19) and adverse outcomes. It is therefore important to characterize the clinical course and outcome of Covid-19 in this population and identify safe therapeutic strategies.

Methods: We performed a retrospective chart review of 73 adult kidney graft recipients evaluated for Covid-19 from 13 March to 20 April 2020. Primary outcomes included recovery from symptoms, acute kidney injury, graft failure and case fatality rate.

Results: Of the 73 patients screened, 54 tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-39 with moderate to severe symptoms requiring hospital admission and 15 with mild symptoms managed in the ambulatory setting. Hospitalized patients were more likely to be male, of Hispanic ethnicity and to have cardiovascular disease. In the hospitalized group, tacrolimus dosage was reduced in 46% of patients and mycophenolate mofetil (MMF) therapy was stopped in 61% of patients. None of the ambulatory patients had tacrolimus reduction or discontinuation of MMF. Azithromycin or doxycycline was prescribed at a similar rate among hospitalized and ambulatory patients (38% versus 40%). Hydroxychloroquine was prescribed in 79% of hospitalized patients. Graft failure requiring hemodialysis occurred in 3 of 39 hospitalized patients (8%) and 7 patients died, resulting in a case fatality rate of 13% among Covid-19-positive patients and 18% among hospitalized Covid-19-positive patients.

Conclusions: Data from our study suggest that a strategy of systematic triage to outpatient or inpatient care, early management of concurrent bacterial infections and judicious adjustment of immunosuppressive drugs rather than cessation is feasible in kidney transplant recipients with Covid-19.

Keywords: SARS-CoV-2; immunosuppression; kidney transplantation.

FIGURE 1

Flow chart of outpatientmanagement and referral of patients for ambulatory monitoring, WCM Fever Clinic and/or NYP-WCM ED. Mild symptoms were defined as temperature >37.8°C/100°F, shortness of breath, productive cough, chest pain and/or lightheadedness. Moderate symptoms were defined as persistent temperature ≥38.3°C/101°F, hemodynamic disturbance with systolic blood pressure lower than baseline or tachycardia, oxygen saturation <94% and/or shortness of breath interfering with normal activities. Patients referred to the WCM Fever Clinic who on presentation were found to have moderate symptoms were then sent to the NYP-WCM ED for hospital admission.

FIGURE 2

(A) Weekly cases of kidney transplant recipients with Covid-19. The graph displays the number of kidney transplant recipients from our transplant center who received a diagnosis of Covid-19 for each week during the study period. (B) Cumulative cases of kidney transplant recipients with Covid-19. The graph displays the cumulative number of cases for each week during the study period.

FIGURE 3

(A) The graph displays the percentage of patients who self-reported on a telephone interview that their symptoms associated with Covid-19 diagnosis were completely resolved, improved or not improved among those hospitalized (n = 39) and not hospitalized (n = 15) for Covid-19. Those who were still hospitalized or died were counted as ‘not improved’. (B) The clinical outcomes of patients hospitalized for Covid-19 are shown as a percentage of the total hospitalized cohort. AKI was defined by a 30% increase in serum creatinine from baseline or an absolute increase of ≥0.5 mg/dL. Recovery in AKI was defined by a return of serum creatinine to a value within 15% of the baseline serum creatinine value. The eGFR was calculated using the Modification of Diet in Renal Disease formula.