Induction immunosuppression and outcome in kidney transplant recipients with early COVID-19 after transplantation

Abstract

Coronavirus disease 2019 (COVID-19) in kidney transplant recipients has a high risk of complications and mortality, especially in older recipients diagnosed during the early period after transplantation. Management of immunosuppression has been challenging during the pandemic. We investigated the impact of induction immunosuppression, either basiliximab or thymoglobulin, on the clinical evolution of kidney transplant recipients developing COVID-19 during the early period after transplantation. We included kidney transplant recipients with ˂6 months with a functioning graft diagnosed with COVID-19 from the initial pandemic outbreak (March 2020) until 31 July 2021 from different Spanish centres participating in a nationwide registry. A total of 127 patients from 17 Spanish centres developed COVID-19 during the first 6 months after transplantation; 73 (57.5%) received basiliximab and 54 (42.5%) thymoglobulin. Demographics were not different between groups but patients receiving thymoglobulin were more sensitized [calculated panel reactive antibodies (cPRAs) 32.7 ± 40.8% versus 5.6 ± 18.5%] and were more frequently retransplants (30% versus 4%). Recipients ˃65 years of age treated with thymoglobulin showed the highest rate of acute respiratory distress syndrome [64.7% versus 37.1% for older recipients receiving thymoglobulin and basiliximab (P < .05), respectively, and 23.7% and 18.9% for young recipients receiving basiliximab and thymoglobulin (P > .05)], respectively, and the poorest survival [mortality rate 64.7% and 42.9% for older recipients treated with thymoglobulin and basiliximab, respectively (P < .05) and 8.1% and 10.5% for young recipients treated with thymoglobulin and basiliximab (P > .05), respectively]. Older recipients treated with thymoglobulin showed the poorest survival in the Cox regression model adjusted for comorbidities. Thus thymoglobulin should be used with caution in older recipients during the present pandemic era.

Keywords: COVID-19 infection; basiliximab; lymphocyte-depleting agents; renal transplantation.

FIGURE 1:

Kaplan–Meier analysis of patient survival in renal transplant recipients younger or older than 65 years (P <.001 by logrank test).

FIGURE 2:

Kaplan–Meier analysis of patient survival in renal transplant recipients treated with basiliximab or thymoglobulin (P > .05 by logrank test).

FIGURE 3:

Kaplan–Meier analysis of patient survival in renal transplant recipients categorized according to patient’s age older or younger than 65 years and induction immunosuppression with basiliximab or thymoglobulin (P < .001 by logrank test).

FIGURE 4:

Linear mixed models for repeated measures for the evolution of circulating lymphocytes (y-axis, number of cells × 10⁹/L) in basiliximab- and thymoglobulin-treated patients during the first month after infection (x-axis, days) (P < .001 for time and P = .008 for intergroup differences).