Kidney transplant recipients appear to be at high risk for moderate to severe COVID-19 due to immunosuppressive medications and pre-existing conditions, according to Enver Akalin, MD, and colleagues from Montefiore Medical Center in the Bronx, New York.

At their center, 36 kidney transplant recipients (75% transplanted with a deceased donor kidney; 72% male; median age 60 years; 42% Hispanic; 39% black) tested positive for COVID-19 from March 16 to April 1, 2020. Overall, 94% had hypertension, 69% had diabetes mellitus, and 17% had heart disease — conditions associated with more severe COVID-19 infection. A third of patients had smoking history.

Fewer transplant recipients than expected initially presented with fever (58%) and 22% had diarrhea. Immune cell counts were lower in the transplant recipients than in the general population with COVID-19, and their condition deteriorated more rapidly; inflammation was rampant. Of the 36 patients, 28 (78%) of the transplant recipients were admitted to Montefiore’s hospital, where chest radiographs revealed viral pneumonia in 27 (96%) and 11 (39%) required mechanical ventilation. Six patients (21%) received renal replacement therapy for acute kidney injury.

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For immunosuppression, 35 patients (97%) had been receiving tacrolimus, 34 (94%) prednisone, and 31 (86%) mycophenolate mofetil or mycophenolic acid. Montefiore clinicians withdrew an antimetabolite from 24 (86%) of the hospitalized patients and tacrolimus from 6 (21%).

For COVID-19 treatment, 24 patients (86%) received investigational hydroxychloroquine. Six patients (21%) received the CCR5 inhibitor leronlimab (PRO 140, CytoDyn) on a compassionate-use basis, and 2 (7%) received the interleukin-6 receptor antagonist tocilizumab. Nearly half of patients received the antibiotic azithromycin. Patients with d-dimer levels higher than 3.0 μg/mL received the anticoagulant apixaban.

Of the 36 patients, 10 (28%) died. Among 11 intubated patients, 7 (64%) died. Patients who died at home had recently received T-cell-depleting antithymocyte globulin. Ten hospitalized patients were eventually discharged.

“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,” Dr Akalin and his colleagues stated.

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Akalin E, Azzi Y, Bartash R, et al. Covid-19 and kidney transplantation [April 24, 2020]. N Engl J Med. doi: 10.1056/NEJMc2011117