key: cord-0778000-avh3xgxv
authors: Abolghasemi, Sara; Mardani, Masoud; Sali, Shahnaz; Honarvar, Negin; Baziboroun, Mana
title: COVID‐19 and kidney transplant recipients
date: 2020-07-31
journal: Transpl Infect Dis
DOI: 10.1111/tid.13413
sha: f4ed2eaf08488434368dc407630be257afe3e110
doc_id: 778000
cord_uid: avh3xgxv

BACKGROUND: The novel coronavirus has become a global threat and healthcare concern. The manifestations of COVID‐19 pneumonia in transplant patients are not well understood and may have more severe symptoms, longer duration, and a worse prognosis than in immunocompetent populations. AIMS: This study proposed to evaluate the clinical characteristics of COVID‐19 pneumonia in kidney transplant recipients. PATIENTS/METHODS: Clinical records, laboratory results, radiological characteristics, and clinical outcome of 24 kidney transplant patients with COVID‐19 pneumonia were evaluated from March 20, 2020, to May 20, 2020. RESULTS: The most common symptom was shortness of breath (70.8%), followed by fever (62.5%) and cough (45.8%). Five patients had leukopenia, and only one patient had leukocytosis, while 75% of the patients had a white blood cell (WBC) count in the normal range, and 79% of recipients developed lymphopenia. All of the patients had an elevated concentration of C‐reactive protein and an increase in blood urea levels. Chest CT images of 23 patients (95.8%) showed typical findings of patchy ground‐glass shadows in the lungs. Of the 24 patients, 12 were admitted to ICU (invasive care unit), and ten of 24 patients (41.6%) died, and 14 patients were discharged after complete recovery. CONCLUSION: It seems that COVID‐19 is more severe in transplant patients and has poorer outcomes. Multiple underlying diseases, low O(2) saturation, and multilobar view in chest CT scan may be of prognostic value. However, many SARS‐CoV‐2 demonstrations are similar to those of the general population.

We developed a questionnaire about the epidemiological, clinical, laboratory, and radiological characteristics of the patients, as well as treatment and clinical outcome data. After obtaining consent, we filled the questionnaire for each patient. The data were reviewed by two study investigators independently to verify data accuracy.

Statistical analysis was done with SPSS, version 20.0. Continuous variables were expressed as a range, and categorical variables were as the number.

Among the 24 patients with COVID-19 pneumonia, 62.5% were male, and the mean age was 49 years (range, 29 to 64). The time range after transplantation was 1-20 years, with the meantime of 10.3 years. Eighteen recipients (83.3%) had received a deceaseddonor kidney. Only one patient had a history of smoking tobacco, and all 24 patients had a BMI (body mass index) less than 40. Table 1 shows the detailed clinical characteristics of 24 patients. 62.5% of patients had hypertension, and 20% had diabetes mellitus. Among immunosuppressive regimens, all patients were receiving prednisolone, 83.3% were receiving mycophenolate mofetil (MMF), 41.6% tacrolimus, and 50% cyclosporine.

The most common symptom was shortness of breath (in 17 patients [70.8%]), followed by fever (62.5%), cough (45.8%), and chilling (33.3%). The highest body temperature was 38.9 •C. Data from laboratory tests showed that 5 patients with COVID-19 pneumonia (20.8%) had leukopenia (<4000 per mm 3 ) and only one patient had leukocytosis (>11 000 per mm 3 ) while 75% of the patients had a white cell count in the normal range. A total of 19 patients (79%) developed lymphopenia (<1100 per mm 3 ), and the lowest lymphocyte count was 165 per mm 3 , with the mean of 893.5 lymphocytes per mm 3 . All of the patients had an elevated concentration of C-reactive protein (CRP) (>10 mg/L) with a range of (11-88 mg/L). Additionally, an increase in blood urea levels was also observed in all recipients (32-227 mg/dL), and 18 patients (75%) had elevated serum creatinine (cr) level with a mean of 3.026 mg/dL. On admission, 16 patients (66.6%) had an O 2 saturation of less than 93%. All patients had a non-contrast chest CT scan. Chest CT images of 23 patients (95.8%) had typical findings of patchy groundglass shadows in the lungs in addition to other views, and 41.6% of patients showed multilobar pattern on chest CT scans. In 20 patients (83.3%), bilateral pulmonary involvement was seen, predominantly on the right side ( Figure 1 ).

On admission, the dose of immunosuppressive agents was reduced under consultation with a nephrologist and an infectious disease specialist. All of the patients received hydroxychloroquine (HCQ), and Kaletra (lopinavir/ritonavir) was administered to 18 patients (75%). Intravenous immunoglobulin (IVIG) was administered to 8 patients (33%) with severe pneumonia and hypoxemia. And finally, 3 patients received hemoperfusion in acute respiratory distress syndrome (ARDS) phase. Of the 24 patients, 12 were admitted to ICU, and despite all the measures taken, ten of 24 patients (41.6%) died, and 14 patients were discharged after complete recovery. The median hospital stay between the discharged patients was 6.6 days (range 5-9 days), and the median time to stay in the hospital for those who died was 18 days, with the most prolonged hospital stay of 22 days. In patients with more than one underlying disease, the rate of mortality was higher than patients with one or without the underlying disease (50% versus 14%, OR: 6.48, 95% CI: 1.30 to 32.29, P: .02). Also, patients with multilobar involvement on chest CT scans had significantly higher mortality than patients with other pulmonary involvement patterns (90% versus 7%, OR: 24, 95% CI: 2.78 to 206.96, P: .003) ( Figure 2 ). The mortality rate among patients who had O 2 saturation less than 93% on admission also was higher than those with O 2 saturation more than 93% (80% versus 35.7%, OR: 7.2, 95% CI: 1.08 to 47.96, P: .04) (Figure 3 ). 

F I G U R E 1 A, 50-y-old woman presented with a dry cough, dyspnea and myalgia, and a history of kidney transplantation 17 y ago that had multiple bilateral ground-glass opacity and consolidation with air bronchogram in chest CT scan. She was discharged after a lengthy hospital stay. B, Her latest CT scan showed some resolution of the pulmonary infiltrates. C, Chest CT scan of a 53-year-old man with fever and cough and history of kidney transplantation that shows typical ground-glass opacities. He had made a full recovery and was discharged after 1 wk of hospitalization. D, A 43-year-old woman with a history of kidney transplantation from 15 y ago presented with chilling and dyspnea. Her chest CT scan showed bilateral consolidation and patchy ground-glass opacities. She deteriorated rapidly and died. E, Chest CT scan from a 62-year-old man with a history of kidney transplantation that shows bilateral ground-glass opacities. included shortness of breath, fever, and cough, but the percentage of shortness of breath higher than in other studies (70.8%). 6 In Envar

Akalin's report, 9 diarrhea was the most common presenting symptom.

Laboratory tests indicated leukopenia in 20.8% and lymphopenia in 79% of patients, and normal white blood cell count was more frequent in our study, as Alireza Abrishami 10 reported in their case series, while in Fishman and Grossi's study, 11 leukopenia was the characteristic finding. Besides, the most common pattern in chest CT scan was bilateral peripheral ground-glass opacity was similar to the general population, but the multilobar pattern was more frequent among patients who needed ICU and had a poor prognosis. Two patients developed pneumothorax, and both of them were expired (Figure 4) .

Management of the patient`s immunosuppressive medication regimens remains a challenge due to the lack of data about COVID-19. Decisions in this regard must be taken on a case-by-case considering factors such as time since transplantation, baseline graft function, and age. 11 Despite the apparent concern about the risk of rejection with the reduction in immunosuppression, due to the high mortality rate in hospitalized patients with COVID-19 pneumonia, we stopped or reduced the dose of immunosuppressive agents as previously reported, as other clinicians in other studies did. 6, 12 Currently, it is unclear whether transplant recipients are more likely to develop severe forms of the disease. 5 In our study, in patients with more than one underlying disease and patients who had O 2 saturation less than 93% on admission, the mortality rate was higher. Also,

The relationship between the multilobar pattern on CT scan and mortality 

We conclude that COVID-19 is more severe in transplant patients and has poorer outcomes. Multiple underlying diseases, low O 2 saturation, and multilobar view in chest CT scan may be of prognostic value.

However, many SARS-CoV-2 demonstrations are similar to those of the general population. Although the small sample size limits our study, we believe that the findings we reported are going to help to understand the clinical characteristics of COVID-19 in transplant patients. 

No conflict of interest was reported regarding this study.

Mana Baziboroun had full access to data in the study and responsibility of the integrity of the data and drafting of the manuscript.

Honarvar involved in acquisition of data. Shahnaz Sali involved in analysis and interpretation of data. Sara Abolghasemi invoved in critical revision of the manuscript.

Mana Baziboroun https://orcid.org/0000-0001-6251-9682

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