COVID-19 in solid organ transplant recipients: A systematic review and meta-analysis of current literature

Abstract

Severe acute respiratory virus syndrome 2 (SARS-CoV-2) has led to a worldwide pandemic. Early studies in solid organ transplant (SOT) recipients suggested a wide variety of presentations, however, there remains a paucity of robust data in this population. We conducted a systematic review and meta-analysis of SOT recipients with SARS-CoV-2 infection from January 1^st t October 9^th, 2020. Pooled incidence of symptoms, treatments and outcomes were assessed. Two hundred and fifteen studies were included for systematic review and 60 for meta-analysis. We identified 2,772 unique SOT recipients including 1,500 kidney, 505 liver, 141 heart and 97 lung. Most common presenting symptoms were fever and cough in 70.2% and 63.8% respectively. Majority (81%) required hospital admission. Immunosuppressive medications, especially antimetabolites, were decreased in 76.2%. Hydroxychloroquine and interleukin six antagonists were administered in59.5% and 14.9% respectively, while only few patients received remdesivir and convalescent plasma. Intensive care unit admission was 29% from amongst hospitalized patients. Only few studies reported secondary infections. Overall mortality was 18.6%. Our analysis shows a high incidence of hospital admission in SOT recipients with SARS-CoV-2 infection. As management of SARS-CoV-2 continues to evolve, long-term outcomes among SOT recipients should be assessed in future studies.

Keywords: COVID-19; Immunosuppression; Meta-analysis; SARS-CoV-2; Solid organ transplant; Systematic review.

Fig. 1

Study selection flow. Majority of the cases were excluded due to opinion commentaries for COVID-19 or related to other viruses. Abbreviations: COVID; Coronavirus disease 2019, SOT; Solid organ transplant, RT-PCR; Reverse transcriptase-polymerase chain reaction.

Fig. 2A

Pooled incidence of fever showing the absolute risk and 95% confidence intervals of each study (n=38) [18,20,22,31,56,59,60,65,70,79,81,85,88,96,102,108,117,133,136,[141], [142], [143],151,152,156,158,166,179,189,190,192,210,212,216,217,219,229,231]. Abbreviations. ES; Effect Size, CI; Confidence Interval, *=study period not defined.

Fig. 2B

Pooled incidence of shortness of breath showing the absolute risk and 95% confidence intervals of each study (n=36) [18,20,22,31,55,60,65,70,79,81,85,88,96,102,108,117,133,136,142,143,151,152,156,158,166,179,189,190,192,210,212,216,217,219,229,231] Abbreviations. ES; Effect Size, CI; Confidence Interval, *=study period not defined.

Fig. 2C

Pooled incidence of cough showing the absolute risk and 95% confidence intervals of each study (n=38) [18,20,22,31,55,59,60,65,70,79,81,85,88,96,102,108,114,117,133,136,141,143,151,152,156,158,166,179,189,190,192,210,212,216,217,219,229,231]. Abbreviations. ES; Effect Size, CI; Confidence Interval, *=study period not defined.

Fig. 2D

Pooled incidence of diarrhea showing the absolute risk and 95% confidence intervals of each study (n=36) [16,18,24,31,38,40,43,51,55,65,69,79,85,96,100,117,133,136,141,142,149,151,158,162,166,179,185,189,190,192,212,216,217,219,228,231]. Abbreviations. ES; Effect Size, CI; Confidence Interval, *=study period not defined.

Fig. 3

Pooled incidence of abnormal chest imaging (either radiography or computerized tomography) in solid organ transplant recipients and COVID-19, showing the absolute risk and 95% confidence intervals of each study (n=28)[22,31,59,65,79,81,85,96,102,114,117,133,143,152,156,158,166,179,189,190,192,210,212,216,217,219,229,231]. Abbreviations. ES; Effect Size, CI; Confidence Interval, *=study period not defined.

Fig. 4A

Pooled incidence of reduction in anti-metabolite showing the absolute risk and 95% confidence intervals of each study (n=27)[18,[20], [21], [22], [23],55,59,79,81,108,117,133,135,143,156,166,175,[189], [190], [191], [192],212,216,229,231]. Abbreviations. ES; Effect Size, CI; Confidence Interval, *=study period not defined.

Fig. 4B

Pooled incidence of reduction in calcineurin inhibitor showing the absolute risk and 95% confidence intervals of each study (n=31)[16,18,20,21,23,24,38,51,55,79,81,117,128,133,143,151,166,175,189,191,212,216,228,229,231]. Abbreviations. ES; Effect Size, CI; Confidence Interval, *=study period not defined.

Fig. 4C

Pooled incidence of reduction in steroid showing the absolute risk and 95% confidence intervals of each study (n=17)[18,21,23,51,81,100,128,151,166,191,192,212,216,229]. Abbreviations. ES; Effect Size, CI; Confidence Interval, *=study period not defined.