Recipients of transplanted kidneys and other organs are at high risk for COVID-19 as a result of being on immunosuppressive medications, and those who contract the disease often experience a disease course that is more severe than in the general population. As a result, transplant centers have decreased the number of transplants they perform, according to the findings of a national survey of solid organ transplant (SOT) programs conducted by Dorry L. Segev, MD, PhD, of Johns Hopkins Medical Institutions in Baltimore, and colleagues.

Of 111 transplant centers surveyed, 79.3% responded, Dr Segev’s team reported in an article published online in the American Journal of Transplantation. Of the programs that perform live-donor kidney transplants, 71.8% reported complete suspension of these transplants. In addition, 80.2% of deceased-donor kidney transplant programs reported operating with at least some restrictions.

Respondents reported a total of 148 SOT recipients with COVID-19 who were less than 1 year to more than 10 years post-transplant. Of these, 69.6% were kidney recipients. Survey results showed that 78.1% of respondents used hydroxychloroquine, 46.9% used azithromycin, 31.3% used tocilizumab, and 25% used remdesivir to treat patients.

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“In conclusion,” the authors wrote, “this national survey of SOT programs suggests that COVID-19 is widely recognized in the United States as a major threat to the field of SOT. However, there were no consistent policies, testing practices, or treatment mechanisms.”

In an article published online in The Lancet on May 11, French researchers reported that deceased-donor organ transplantations during the pandemic declined by 51.1% and 90.6% in the United States and France, respectively. The reduction in both countries was driven mostly by a decrease in kidney transplantation, according to Alexandre Loupy, MD, PhD, of the Paris Translational Research Centre for Organ Transplantation, and colleagues.

“Transplant professionals will need to adapt to these rapidly changing circumstances, provide reassurance to their patients, and remain poised to reinvigorate the valuable transplant infrastructure when the COVID-19 crisis begins to abate,” they wrote.  

Zero risk does not exist

Richard N. Formica, MD, Director of Transplant Medicine the Yale School of Medicine in New Haven, Connecticut, and President-Elect of the American Society of Transplantation, said transplant programs should not allow the risk of infection with the SARS-CoV-2 coronavirus, the cause of COVID-19, to dissuade transplantation. Programs that do not want to perform transplants to protect patients “are not truly weighing the risks,” believing they are taking the safe option for patients, Dr Formica said. The notion of zero risk does not exist. The programs need to consider the risks that patients with organ failure face by not receiving a transplant. For example, dialysis patients who are candidates for a kidney transplant already are at risk of exposure to SARS-CoV-2 in dialysis units as well as traditional infections associated with dialysis, such as bacterial infections from vascular access. They also are at risk of other dialysis related complications. “This is the new environment we are in, and we need to figure out a way to do our jobs in these new conditions,” he said.

Dr Formica’s program, which has about 40 kidney transplant recipients who have tested positive for COVID-19, has instituted measures to protect patients. Staff members advise patients to follow recommendations from the Centers for Disease Control and Prevention and emphasize the need for social distancing, wearing face masks in public, and washing hands. They advise patients to monitor their temperature twice a day.

In the outpatient setting, he said, immunosuppressive regimens remain the same for patients who do not have COVID-19. Physicians maintain immunosuppression for patients who test positive for COVID-19, but discontinue antimetabolites and decrease tacrolimus dosages.

“For new transplant recipients, we’re still immunosuppressing based upon what we assume their risk profile was and how we would have done it before,” Dr Formica said. “We’re doing that because we don’t want to end up setting up a situation where we under immunosuppress somebody upfront, they have a rejection, and then you’ve got to dump immunosuppression on them.”

Transplant recipients hard hit

Recently published medical papers reveal how severe COVID-19 can be in transplant recipients. In a case series of 36 consecutive adult kidney transplant recipients who tested positive for COVID-19 at Montefiore Medical Center in Bronx, New York, 10 (28%) died during a median follow-up of 21 days, Enver Akalin, MD, and colleagues reported online in the New England Journal of Medicine on April 24. Of 11 patients who were intubated, 7 (64%) died. Of the 36 patients, 28 (78%) were hospitalized and 8 (22%) were in stable condition without major respiratory symptoms and were monitored at home.

“Our results show a very high early mortality among kidney-transplant recipients with Covid-19—28% at 3 weeks as compared with the reported 1% to 5% mortality among patients with Covid-19 in the general population who have undergone testing in the United States and the reported 8 to 15% mortality among patients with Covid-19 who are older than 70 years of age,” the authors wrote.

Writing in the American Journal of Transplantation, physicians at Columbia University Irving Medical Center and Weill Cornell Medicine in New York reported their initial experience with 90 solid organ transplant recipients—including 46 kidney recipients (51%)—with COVID-19. All had tested positive for SARS-CoV-2 in an inpatient or outpatient setting from March 13 to April 3, 2020. Of the 90 patients, 68 were hospitalized. Twenty-three patients (26% overall, 34% of inpatients) required ICU admission. Overall, 16 (18%) died from COVID-19 complications. The death rate was 24% of inpatients and 52% of ICU patients.

In the same journal, Vinay Nair, DO, and colleagues reported on a case series of 10 KTRs who tested positive for COVID-19 at Northwell Health acute care hospitals in the New York area, 9 of whom were hospitalized. Three patients (30%) died, and AKI developed in 5 (50%).