Clinical course of SARS-CoV-2 infection and recovery in lung transplant recipients

Abstract

Background: Reports on outcomes following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in lung transplant recipients remain limited.

Methods: We performed a single-center, observational study of outcomes in lung transplant recipients diagnosed with SARS-CoV-2 between 5/1/2020 and 3/15/2022 that were followed for a median of 123 days. We analyzed changes in spirometry, acute lung allograft dysfunction (ALAD) incidence, hospitalization, mechanical ventilation needs, secondary infection, and survival.

Results: In our cohort of 336 patients, 103 developed coronavirus disease (COVID) (27 pre-Delta, 20 Delta, and 56 Omicron-era). Twenty-five patients (24%) required hospitalization and 10 patients ultimately died (10%). Among 85 survivors who completed ambulatory spirometry, COVID-19 did not alter change in forced expiratory volume in 1 s (FEV₁ ) or forced vital capacity (FVC) over time compared to the preceding 6 months. The pre-COVID FEV₁ change was -0.05 ml/day (IQR -0.50 to 0.60) compared to -0.20 ml/day (IQR -1.40 to 0.70) post-COVID (p = .16). The pre-COVID change in FVC was 0.20 ml/day (IQR -0.60 to 0.70) compared to 0.05 ml/day (IQR -1.00 to 1.10) post-COVID (p = .76). Although the cohort overall had stable lung function, 33 patients (39%) developed ALAD or accelerated chronic lung allograft dysfunction (FEV₁ decline >10% from pre-COVID baseline). Nine patients (35%) with ALAD recovered lung function. Within 3 months of acute COVID infection, 18 patients (17%) developed secondary infections, the majority being bacterial pneumonia. Finally, vaccination with at least two doses of mRNA vaccine was not associated with improved outcomes.

Conclusions: This study describes the natural history of SARS-CoV-2 infection in a large cohort of lung transplant recipients. Although one third of patients develop ALAD requiring augmented immunosuppression, infection with SARS-CoV-2 is not associated with worsening lung function.

Keywords: COVID-19; SARS-CoV-2; acute lung allograft dysfunction; clinical outcomes; lung transplantation.

Figure 1.. The effect of SARS-CoV-2 infection on rate of change of FEV₁ in lung transplant recipients.

FEV₁ rate of change was calculated before and after SARS-CoV-2 infection for 85 lung transplant recipients with two spirometric measurements at least 30 days apart after completion of isolation after acute SARS-CoV-2 infection. The slope of FEV1 change over time was calculated over 3–6 months before SARS-CoV-2 infection and for a minimum of 3 months after SARS-CoV-2 infection. Change in the slope of FEV1 decline before and after SARS-CoV-2 were compared by Wilcoxon ranked sum testing. A) Pre-Delta era, n=23. B) Delta era, n=18. C) Omicron era, n=44.