Coronavirus disease 2019 in heart transplant recipients: Risk factors, immunosuppression, and outcomes

Abstract

Background: COVID-19 continues to inflict significant morbidity and mortality, particularly on patients with preexisting health conditions. The clinical course, outcomes, and significance of immunosuppression regimen in heart transplant recipients with COVID-19 remains unclear.

Methods: We included the first 99 heart transplant recipients at participating centers with COVID-19 and followed patients until resolution. We collected baseline information, symptoms, laboratory studies, vital signs, and outcomes for included patients. The association of immunosuppression regimens at baseline with severe disease were compared using logistic regression, adjusting for age and time since transplant.

Results: The median age was 60 years, 25% were female, and 44% were white. The median time post-transplant to infection was 5.6 years. Overall, 15% died, 64% required hospital admission, and 7% remained asymptomatic. During the course of illness, only 57% of patients had a fever, and gastrointestinal symptoms were common. Tachypnea, oxygen requirement, elevated creatinine and inflammatory markers were predictive of severe course. Age ≥ 60 was associated with higher risk of death and the use of the combination of calcineurin inhibitor, antimetabolite, and prednisone was associated with more severe disease compared to the combination of calcineurin inhibitor and antimetabolite alone (adjusted OR = 7.3, 95% CI 1.8-36.2). Among hospitalized patients, 30% were treated for secondary infection, acute kidney injury was common and 17% required new renal replacement therapy.

Conclusions: We present the largest study to date of heart transplant patients with COVID-19 showing common atypical presentations and a high case fatality rate of 24% among hospitalized patients and 16% among symptomatic patients.

Keywords: coronavirus disease 2019; epidemiology; heart transplant; hospitalization; mortality; outcomes.

Figure 1

Course of COVID-19 in heart transplant recipients. Cumulative incidence of select symptoms, need for supplemental oxygen, and hospital admission relative to date of diagnosis or first medical attention for COVID-19, shown for (A) Patients with non-severe disease, (B) patients with severe disease, and (C) all patients.

Figure 2

Association of immunosuppressive regimen with odds of severe COVID-19.Odds ratios (OR) for severe disease (vs non-severe disease) among heart transplant recipients diagnosed with COVID-19. Figure shows the result of three different models, one for risk factors of age and time since transplant, a second for individual immunosuppression agents (adjusted for age and time since transplant), and a final for combination regimens (again adjusted for age and time since transplant). CNI = calcineurin inhibitor; AM = antimetabolite; PSI = proliferation signal inhibitor. Patients on the combination of CNI and PSI were grouped together whether or not they also took prednisone due to low numbers.