key: cord-0753053-iry8w01h authors: Craig‐Schapiro, Rebecca; Salinas, Thalia; Lubetzky, Michelle; Abel, Brittany T.; Sultan, Samuel; Lee, John R.; Kapur, Sandip; Aull, Meredith J.; Dadhania, Darshana M. title: COVID‐19 outcomes in patients waitlisted for kidney transplantation and kidney transplant recipients date: 2020-11-08 journal: Am J Transplant DOI: 10.1111/ajt.16351 sha: 08e9cf653ba9917cc95571ebeb526fd1be53a394 doc_id: 753053 cord_uid: iry8w01h The COVID‐19 pandemic has brought unprecedented challenges to the transplant community. The reduction in transplantation volume during this time is partly due to concerns over potentially increased susceptibility and worsened outcomes of COVID‐19 in immunosuppressed recipients. The consequences of COVID‐19 on patients waitlisted for kidney transplantation, however, have not previously been characterized. We studied 56 waitlisted patients and 80 kidney transplant recipients diagnosed with COVID‐19 between March 13 and May 20, 2020. Despite similar demographics and burden of comorbidities between waitlisted and transplant patients, waitlisted patients were more likely to require hospitalization (82% vs. 65%, P = .03) and were at a higher risk of mortality (34% vs. 16%, P = .02). Intubation was required in one third of hospitalized patients in each group, and portended a very poor prognosis. The vast majority of patients who died were male (84% waitlist, 100% transplant). Multivariate analysis demonstrated waitlist status, age, and male sex were independently associated with mortality. COVID‐19 has had a dramatic impact on waitlisted patients, decreasing their opportunities for transplantation and posing significant mortality risk. Understanding the impact of COVID‐19 on waitlist patients in comparison to transplant recipients may aid centers in weighing the risks and benefits of transplantation in the setting of ongoing COVID‐19. caring for posttransplant recipients. Additional challenges that contributed to reduced transplantation volumes included ensuring safe organ procurement in the setting of unknown risks of transmission, and difficulties in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing of donors and recipients. This was particularly challenging in the early stages of the pandemic due to limited testing capacity, unclear testing reliability, prolonged waiting for test results, exceeds that of waitlisted patients. 3 Here, we describe our center's experience with COVID-19 in waitlisted patients, and compare their presentation and outcomes to kidney transplant recipients. We studied all adult (>18 years) patients waitlisted for kidney trans- Illness on Kidney Transplant Candidates and Recipients. Baseline patient demographics and co-morbidities, transplantation characteristics, immunosuppressive regimens, concomitant infections, COVID-19 treatment approaches, and clinical course were extracted from the electronic medical record. For patients who were not admitted to our institution, information was obtained from electronic medical records, their dialysis center, and by Transplant provider and coordinator phone calls to patients and their family. As clinical practices and knowledge evolved during the pandemic, testing of inflammatory markers possibly associated with COVID-19 was more frequently performed; however, early in the course, laboratory testing was not uniformly employed, and laboratory data were not available for all patients admitted to other centers. The percentage of transplant and waitlisted patients who had data available for analysis is indicated in Table S1 . Early findings of 54 of the 80 transplant patients with COVID-19 were included in a prior publication by Lubetzky et al. 4 Hospitalized transplant patients were evaluated by a Transplant physician and a Transplant Infectious Disease specialist who guided anti-viral, anti-inflammatory, and anti-bacterial therapies. Likewise, hospitalized waitlisted patients were managed by Nephrology and Infectious Disease specialists. Patients were evaluated on a case-bycase basis by Infectious Disease physicians for inclusion in ongoing clinical trials at our institution, including for remdesivir, tocilizumab, selinexor, and convalescent plasma. The general approach to immunosuppressive therapy for hospitalized transplant patients involved decreasing mycophenolate mofetil dosage by 50% or more, and reducing tacrolimus dosage to trough levels of 4-6 ng/mL. Immunosuppressive dosing adjustments were generally not made for patients managed at home. Active (status 1) patients on the waitlist who were diagnosed with COVID-19 were made inactive (status 7) and monitored for symptom resolution prior to re-activation. Baseline characteristics were compared between all COVID-19positive waitlist and transplant patients ( Table 1 ). The subset of patients who required hospitalization were further analyzed in a more detailed study of their baseline characteristics, presenting symptoms and labs, COVID-19 treatments, and outcomes (Tables 2, 3 Nearly all patients were on a tacrolimus and mycophenolate mofetil regimen, and 41% were on steroid maintenance. For the waitlist patients, the median waitlist qualifying time was 4.9 years (IQR 3.4-7.3 years). In-center hemodialysis was the regimen for 86% (n = 48), while five were on peritoneal dialysis (PD), one was switched from HD to PD during COVID-19 illness, and two were not yet on dialysis. The most common presenting symptom reported in both groups was fever (76% waitlist, 71% transplant) and cough (77% waitlist, 59% transplant). More waitlisted patients reported fatigue and myalgias (77% vs. 47%), and the remaining symptoms were similar between the groups (Table 1) . Hospitalization was required for 82% of the COVID-19-positive waitlist patients and for 65% of the kidney transplant patients (P = .03). Laboratory values at the time of hospital admission are displayed in Table 2 . While the median white blood cell count at presentation was normal and similar between waitlist and transplant groups, patients were generally lymphopenic (waitlist 0.8 × 10 3 /uL vs. transplant 0.6 × 10 3 /uL, P = .02). A number of inflammatory markers associated with COVID-19 severity, including procalcitonin, C-reactive protein, erythrocyte sedimentation rate, ferritin, D-dimer, and interleukin-6, were elevated in both groups of admitted patients. These laboratory markers trended higher in the waitlist group, with procalcitonin and ferritin significantly elevated compared to transplant patients (P = .002 and P = .005, respectively) ( Table 2 ). Nearly all of the admitted waitlist and transplant patients with imaging available for review had pulmonary findings consistent with COVID-19 infection (89% and 87%, respectively). To evaluate the risk factors associated with hospitalization, we calculated the odds ratios (OR) and 95% confidence intervals (CI) from univariate logistic regression ( The data that support the findings of this study are available from the corresponding author, R.C.S., upon reasonable request. Samuel Sultan Organ procurement and transplantation during the COVID-19 pandemic COVID-19-related collapse of transplantation systems: A heterogeneous recovery? 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