key: cord-0684078-1v70vpvd
authors: Meena, Priti; Crew, R. John
title: Understanding the Risks of Immunosuppression Reduction For Active COVID-19 Infection
date: 2022-03-12
journal: Kidney Int Rep
DOI: 10.1016/j.ekir.2022.03.005
sha: 6318e3caa2ebadca5b660210072410c9d0f73230
doc_id: 684078
cord_uid: 1v70vpvd

nan

Kidney transplant recipients (KTRs) are at higher risk of mortality and morbidity of COVID-19 infection compared to the general population. 1 Some of this elevated risk comes from non-modifiable factors common to KTRs, such as diabetes, hypertension, and chronic kidney disease. On the other hand, transplant immunosuppression is a theoretically modifiable risk factor. Though better studied in the setting of COVID-19 vaccination rather than active COVID-19 infection, immunosuppressed patients are less likely to mount a T cell response measured via ELISPOT assay and less likely to mount a robust, durable antibody response. 2 This is particularly true for patients on mycophenolate or belatacept. There is some evidence to support the intuitive idea that reduction in immunosuppression helps transplant recipients develop a more robust anti-COVID immune response. In at least one study, transplant recipients who underwent immunosuppression reduction in the setting of active infection had the ability to generate Interferon-ɣ (IFN-ɣ ) secreting CD3+ T cells against SARS-COV2 peptides as well as generate anti-S protein and anti-N protein IgG, presumably markers of cellular and humoral immunity against COVID, respectively. 3 Alternatively, underimmunosuppression, whether through patient non-compliance or physician directed, is J o u r n a l P r e -p r o o f associated with rejection and the development of de novo donor specific anti-HLA antibodies (dnDSA). 4 Balancing the risk of immunosuppression reduction with the potential benefits is quite challenging and carried out on a case-by-case basis depending on the severity of COVID-19 infection. A common approach among clinicians is to stop antiproliferative agents in moderate COVID 19 infection and discontinue or reduce the dose of calcineurin inhibitors (CNIs) in more severe cases. 5 In a systematic review involving 420 adult KTRs, reduction or discontinuation of immunosuppression was observed in 58% of patients, antimetabolites and CNIs were discontinued in 91% and 58% of KTRs respectively. 6 

IMPact of the COVID-19 epidemic on the moRTAlity of kidney transplant recipients and candidates in a French Nationwide registry sTudy (IMPORTANT)

Poor Anti-SARS-CoV-2 Humoral and T-cell Responses After 2 Injections of mRNA Vaccine in Kidney Transplant Recipients Treated With Belatacept

T cell and antibody responses to SARS-CoV-2: Experience from a French transplantation and hemodialysis center during the COVID-19 pandemic

Understanding the causes of kidney transplant failure: the dominant role of antibody-mediated rejection and nonadherence

How should I manage immunosuppression in a kidney transplant patient with COVID-19? An ERA-EDTA DESCARTES expert opinion

A Systematic Review of COVID-19 Infection in Kidney Transplant Recipients: A Universal Effort to Preserve Patients' Lives and Allografts

Risk of acute rejection in kidney transplant recipients after COVID-19

Immunosuppression minimization in kidney transplant recipients hospitalized for COVID-19

Occurence of de novo Donor Specific Antibodies after COVID-19 in kidney transplant recipients is low despite immunosuppression modulation

COVID-19 and kidney transplantation: Results from the TANGO International Transplant Consortium