Incidence and Outcomes of COVID-19 in Kidney and Liver Transplant Recipients With HIV: Report From the National HOPE in Action Consortium

Abstract

Background: Transplant recipients with HIV may have worse outcomes with coronavirus disease 2019 (COVID-19) due to impaired T-cell function coupled with immunosuppressive drugs. Alternatively, immunosuppression might reduce inflammatory complications and/or antiretrovirals could be protective.

Methods: Prospective reporting of all cases of SARS-CoV-2 infection was required within the HOPE in Action Multicenter Consortium, a cohort of kidney and liver transplant recipients with HIV who have received organs from donors with and without HIV at 32 transplant centers in the United States.

Results: Between March 20, 2020 and September 25, 2020, there were 11 COVID-19 cases among 291 kidney and liver recipients with HIV (4%). In those with COVID-19, median age was 59 y, 10 were male, 8 were kidney recipients, and 5 had donors with HIV. A higher proportion of recipients with COVID-19 compared with the overall HOPE in the Action cohort were Hispanic (55% versus 12%) and received transplants in New York City (73% versus 34%, P < 0.05). Most (10/11, 91%) were hospitalized. High-level oxygen support was required in 7 and intensive care in 5; 1 participant opted for palliative care instead of transfer to the intensive care unit. HIV RNA was undetectable in all. Median absolute lymphocyte count was 0.3 × 103 cells/μL. Median CD4 pre-COVID-19 was 298 cells/μL, declining to <200 cells/μl in 6/7 with measurements on admission. Treatment included high-dose steroids (n = 6), tocilizumab (n = 3), remdesivir (n = 2), and convalescent plasma (n = 2). Four patients (36%) died.

Conclusions: Within a national prospective cohort of kidney and liver transplant recipients with HIV, we report high mortality from COVID-19.

Figure 1.

Clinical course of HIV-positive transplant recipients with COVID-19. Duration of hospitalization and time to death in recipients. Recipients above the solid line received an HIV-positive donor organ and those below received an HIV-negative donor organ. Time of diagnosis is marked by an arrow. Recipients who died are indicated with an asterisk. D-/R+, donor-negative recipient-positive; D+/R+, donor-positive recipient-positive; ICU, intensive care unit; KT, kidney transplant; LT, liver transplant.

Figure 2.

Lymphocyte and CD4 counts in HIV-positive transplant recipients pre– and post–COVID-19, stratified by recipient outcome. Lymphocyte counts before and after COVID-19 diagnosis are shown in recipients who A) survived and B) died. CD4 counts before and after COVID-19 diagnosis are shown in recipients who C) survived and D) died. Blue vs black line indicates lymphocyte depleting vs nonlymphocyte depleting induction. Recipient numbers are shown next to each line, and measurements taken at the time of transplant are indicated by a red arrow.