COVID‐19 pneumonia in kidney transplant recipients: A promising treatment algorithm in the absence of a disease‐specific drug

Abstract

There is no consensus on the management of coronavirus disease 2019 (COVID‐19) and modification of immunosuppressive therapy in kidney transplant recipients (KTRs). In this study, we examined the clinical outcome of our KTRs with COVID‐19 disease, who were treated with a broad‐spectrum anti‐inflammatory protocol. This protocol is essentially composed of intravenous immunoglobulin +/‐ tocilizumab in KTRs with severe COVID‐19 pneumonia. Among 809 KTRs, 64 patients diagnosed with COVID‐19 disease between April 2020 and February 2021, were evaluated. Twenty‐nine patients with pneumonia confirmed by chest computed tomography (CCT) were hospitalized. The treatment protocol included high‐dose intravenous methylprednisolone, favipiravir, enoxaparin, and empirical antibiotics. Patients with pneumonic involvement of more than 25% on CCT with or without respiratory failure were given a total of 2 g/kg intravenous immunoglobulin (IVIg) therapy. Nonresponders received tocilizumab, an interleukin‐6 receptor antibody. Of the 29 patients with pneumonia, 6 were treated in other hospitals. These six patients did not receive IVIg and 5 of them deceased. In our center, IVIg treatment was applied to 15 of 23 patients. Seven of them required tocilizumab. Respiratory parameters improved significantly in all but one patient after IVIg ± tocilizumab treatment. The mortality rate was 6.6% in patients who received IVIg therapy and 35.7% in those who did not ( p = 0.08). The mortality rate was higher in patients who received treatment in external centers (2.2% vs. 26.3%; p = 0.0073). The treatment of KTRs with severe COVID‐19 pneumonia in organ transplant centers with significant experience yields better results. The administration of broad‐spectrum anti‐inflammatory treatment in this patient group was safe and provided excellent outcomes.

COVID‐19 reinfection or reactivation in a renal transplant patient

“…High-dose methylprednisolone with or without initial pulse treatment was administered according to the severity of the disease. 14 In the presented case, we discontinued mycophenolate, but cyclosporine and steroid were continued.…”

“…In the study by Karatas et al in renal transplant patients, mycophenolate mofetil, mycophenolic acid, or azathioprine was stopped and CNIs were interrupted. High‐dose methylprednisolone with or without initial pulse treatment was administered according to the severity of the disease 14 . In the presented case, we discontinued mycophenolate, but cyclosporine and steroid were continued.…”

Impact of COVID-19 on Global Kidney Transplantation Service Delivery: Interim Report

“…Similar findings were described by discussants from Spain and the US. COVID-19 mortality rates were lower for patients who were several years post-kidney transplant if they were hospitalized at centers that were also specialist transplantation centers ( 21 ).…”

“…Research is required to ascertain short- and long-term levels of COVID-19 immunity among transplant recipients ( 41 – 46 ), and how best to treat those with severe infections. Administering a monoclonal antibody has been suggested ( 21 ). Without robust clinical evidence, prevention remains key: kidney transplant recipients’ antibody responses are monitored frequently ( 44 ) and repeated mRNA vaccine boosters are administered ( 44 – 47 ), given that immunity often appears to be short lived in these patients ( 48 ).…”

Kidney replacement therapy patients with COVID-19 in the vaccine era: what do we need to know?

“…This observation is in the line with the decreased mortality observed in the Randomised Evaluation of COVID-19 Therapy clinical trial in patients in the general population with severe COVID-19 randomized to dexamethasone [ 16 ]. Immunosuppression-free regimens reported high rejection rates [ 17 ]. The British Transplantation Society guideline on KT patients with COVID-19 recommends total discontinuation of antiproliferative agents and minimization of calcineurin inhibitors.…”