key: cord-0831457-z4k9d8ry
authors: Kute, Vivek B.; Bhalla, Anil K.; Guleria, Sandeep; Ray, Deepak S.; Bahadur, Madan M.; Shingare, Ashay; Hegde, Umapati; Gang, Sishir; Raju, Sreebhushan; Patel, Himanshu V.; Jain, Siddharth; Godara, Suraj; Modi, Pranjal; Gumber, Manoj; Engineer, Divyesh P.; Dalal, Sonal; Darji, Prakash; Balwani, Manish; Patel, Ansy H.; Mishra, Vineet V.
title: Clinical Profile and Outcome of COVID-19 in 250 Kidney Transplant Recipients: A Multicenter Cohort Study From India
date: 2020-12-21
journal: Transplantation
DOI: 10.1097/tp.0000000000003593
sha: a0e198db3e5cf6092353085dcf44bdd764a53554
doc_id: 831457
cord_uid: z4k9d8ry

BACKGROUND. There is a scarcity of data on the consequences of coronavirus disease-19 (COVID-19) infections in kidney transplant recipients (KTRs) from emerging countries. METHODS. Here, we present a cohort study of 13 transplant centers in India including 250 KTR (226 living and 24 deceased donors) with polymerase chain reaction-confirmed COVID-19 positivity from March 23, 2020, until September 15, 2020. We detailed demographics, immunosuppression regimen, clinical profile, treatment, and outcomes. RESULTS. Median age of transplant recipients was 43 years, and recipients presented at a median of 3.5 years after transplant. Most common comorbidities (94%) included arterial hypertension (84%) and diabetes (32%); presenting symptoms at the time of COVID-19 included fever (88%), cough (72%), and sputum production (52%). Clinical severity ranged from asymptomatic (6%), mild (60%), and moderate (20%) to severe (14%). Strategies to modify immunosuppressants included discontinuation of antimetabolites without changes in calcineurin inhibitors and steroids (60%). Risk factors for mortality included older age; dyspnea; severe disease; obesity; allograft dysfunction before COVID-19 infection; acute kidney injury; higher levels of inflammatory markers including C-reactive protein, interleukin-6 level, and procalcitonin; chest X-ray abnormality, and intensive care unit/ventilator requirements. Overall patient mortality was 11.6% (29 of 250), 14.5% (29 of 200) in hospitalized patients, 47% (25 of 53) in intensive care unit patients, and 96.7% (29 of 30) in patients requiring ventilation. KTRs with mild COVID-19 symptoms (n = 50) were managed as outpatients to optimize the utilization of scarce resources during the COVID-19 pandemic. CONCLUSIONS. Mortality rates in COVID-19-positive KTR appear to be higher than those in nonimmunosuppressed patients, and high mortality was noted among those requiring intensive care and those on ventilator.

volume, India currently ranks second worldwide based on transplant volume. 1 As of September 26, 2020, India reported a total of 5 810 553 confirmed COVID-19-positive individuals including 960 969 (16.28%) requiring medical care, 4 849 584 (82.14%) recovered patients, and 93 379 deaths (1.6%). 2 Tragically, India has at this time the second-highest COVID-19 caseload worldwide (Table 1) . To combat the spread of the disease, the Indian Government ordered a national lockdown in a phased manner from March 24 to July 31, 2020. 2 Kidney transplant recipients (KTRs) are at a higher risk of developing severe COVID-19 based on their immunosuppressed state and associated comorbidities. Recent studies have reported on outcomes of COVID-19 positivity in KTRs in the developed world ; however, there is a lack of data from emerging countries. 30 To address this knowledge gap, we analyzed demographics, clinical manifestations, immunosuppression regimen, treatment, and outcomes (patient survival, graft survival, graft function) in 250 COVID-19-positive KTRs across 13 transplant centers (2 public and 11 private sectors) in India.

The clinical study was approved by the ethics committee based on international standards of Good Clinical Practice per local laws and regulations (Transplant Human Organ Act, India). Our study also abided by the Declaration of Helsinki and Declaration of Istanbul principles. Written informed consent was obtained from all recipients.

The diagnosis of COVID-19 was confirmed by real-time reverse transcription polymerase chain reaction (RT-PCR) from nasopharyngeal (nasal) and oropharyngeal (throat) swab. 2, 29 Study Population

Adult KTRs with COVID-19 (age >18 y) were included from (1) Clinical severity and assessment parameters were divided into 31 Detailed clinical histories including comorbidities were recorded. KTRs were followed daily for body temperature changes, vitals, complete blood counts, and additional evaluations as indicated; chest X-rays (CXR) were obtained daily; target SpO 2 was 92%-96%.

Prophylactic doses of unfractionated heparin and lowmolecular-weight heparin (eg, enoxaparin 40 mg/d SC) were applied, and comorbidities were treated. 2, 22 Antibiotics were prescribed for clinical suspicion of bacterial infections as per the hospital antibiotic policy. Awake early self-proning was suggested for improving oxygen saturation.

Hydroxychloroquine (HCQ) (400 mg) BID was applied on day 1 of admission followed by 200 mg BID for 4 days under ECG guidance; HCQ dosage was adjusted based on renal function. Intravenous methylprednisolone 0.5-1 mg/kg or dexamethasone 0.2-0.4 mg/kg for 3 days (preferably within 48 h of admission or if oxygen requirement was increasing or when inflammatory markers were increasing) was administered in all moderate and severe cases.

This was considered in patients with moderate disease in the absence of clinical improvement (progressively increasing Volume of convalescent ranged from 4 to 13 mL/kg (usually, a single dose of 200 mL was given slowly over at least 2 h).

The interleukin-6 (IL-6) receptor antibody tocilizumab may be considered in patients with moderate disease, with progressively increasing oxygen requirements or in mechanically ventilated patients who do not show improvements despite the use of steroids. As the data on long-term safety of tocilizumab in COVID-19 remain largely unknown, special considerations before its use in our study included: a. Presence of increased inflammatory markers (eg, C-reactive protein [CRP], ferritin, IL-6). b. Patients should be carefully monitored posttocilizumab for secondary infections and neutropenia. c. Active infections and tuberculosis should be ruled out before use.

Tocilizumab was applied at 8 mg/kg (maximum 800 mg at 1 time) diluted in 100 mL normal saline and infused over 1 hour.

The drug controlling service of the Indian Government approved favipiravir for the treatment of mild to moderate COVID-19 on June 19, 2020. A dosage of 200 mg × 9 tablets BID on day 1 and 200 mg × 4 tablets BID for 14 days is suggested.

A revised discharge policy for COVID-19 has been issued by the Indian Ministry of Health and Family Welfare on May 8, 2020. 32 Earlier criteria for discharging patients with COVID-19 were based on (a) a normal CXR and (b) 2 consecutive negative test results on RT-PCR. Specific additional recommendations included: a. Patient with mild/very mild/presymptomatic signs can be discharged after 10 days of symptom onset and absent fever for 3 days. b. Patients with moderate symptoms can be discharged (1) if asymptomatic for 3 days and (2) after 10 days of symptom onset. c. Patients with severe symptoms, clinical recovery in addition to negative RT-PCR COVID tests (after the resolution of symptoms) are required.

This was offered carefully for selected patients with symptoms and controlled comorbidities; this cohort received teleconsultation surveillance until disease resolution; home visits were carried out as required.

If recipient or donor become COVID-19 positive, then National Organ and Tissue Transplant Organization suggests treatment as per local authority guidelines; at this time, there are no country-wide standard accepted treatment guidelines. As in other countries, there is also currently no consensus on the modification of immunosuppressants in India. Transplant teams base their decision therefore on a case-by-case evaluation balancing infection control and rejection. 33 

Statistical analysis was performed using the Statistical Package for Social Science (SPSS) version 17.0 (SPSS Inc., Chicago, IL). Continuous data are presented as median and interquartile ranges (IQRs) and mean ± SD; Student's t tests were used to compare 2 groups. Categorical data were compared using χ 2 tests or Fisher exact tests. A P value <0.05 indicated statistical significance. A Cox regression model was performed for multivariate analysis.

We included 226 living donor and 24 deceased donor KTRs in our analysis. The overall median age of the cohort was 43 years (IQR, 35-51); the majority (86%, n = 215) of patients were male individuals. We divided patients by age subgroups, including 21-30 years (n = 35), 31-40 years (n = 83), 41-50 years (n = 70), 51-60 years (n = 53), and 61-70 years (n = 9). Patients had a median time interval from transplant to COVID-19 diagnosis of 3.5 years (IQR, 1.8-6.2). In detail, time after transplant surgery was <3 months in 11 patients (4.4%), 3-6 months in 19 (7.6%), 6-12 months in 20 (8%), 1-5 years in 113 (45.2%), 5-10 years in 54 (21.6%), 11-20 years in 28 (11.2%), and >20 years in 5 (2%). Baseline demographics, comorbidities, and medications of KTRs with COVID-19 at the time of diagnosis are summarized in Table 2 .

Comorbidities were present in 235 patients (94%) and included arterial hypertension (84%, n = 210), diabetes (32%, n = 80), allograft dysfunction (30.8%, n = 77), obesity (body mass index >30 kg/m 2 ; 23.9%, n = 53), ischemic heart disease (12%, n = 30), hepatitis B or C virus (10%, n = 25), chronic lung disease including asthma and chronic obstructive pulmonary disease (4%, n = 10), and sickle cell disease (n = 1); 15 patients (6%) had no comorbidities. Multiple comorbidities were present in 115 patients (46%) with hypertension and diabetes (30%, n = 75) being the most common. One hundred fifteen patients (46%) demonstrated anxiety (n = 115); 30 patients (12%) had a history of smoking at time of COVID-19 infection diagnosis; and 75 patients (30%) were on an angiotensinconverting enzyme inhibitor or an angiotensin receptor blocker at the time of COVID diagnosis.

One hundred eighty-two recipients (72.8%) had an induction treatment with thymoglobulin, 20 received basiliximab (8%), and 48 patients (19.2%) had not received an induction treatment. Thymoglobulin induction was applied as a single 1.5 mg/kg dose in Mumbai and Ahmedabad and a single dose of 3 mg/kg in the other participating centers. The most common maintenance immunosuppression regimen included a triple regimen consisting of prednisolone, tacrolimus, and mycophenolate. The total daily dose of prednisolone, tacrolimus, and mycophenolate mofetil at COVID-19 presentation was 5-10 mg/d, 0.06 mg/kg/d, and 1-1.5 g/d, respectively. Recipients have not been on either belatacept or steroid-free regimen. Twenty patients received high immunological risk transplants including 12 ABO-incompatible and 8 sensitized recipients. Forty patients had a history of rejection treatments (16%), including steroid pulse treatments (16%, n = 40), thymoglobulin (8%, n = 20), rituximab/bortezomib (10%, n = 25), and plasma exchange (12%, n = 30). Table 3 summarizes symptoms and laboratory findings. 

Presenting symptoms included fever (88%, n = 220), cough (72%, n = 180), sputum production (52%, n = 130), myalgia (25%, n = 62), diarrhea (24%, n = 60), dyspnea (22%, n = 55), rhinorrhea (22%, n = 55), sore throat (22%, n = 55), headache (20%, n = 50), loss of appetite (20%, n = 50), fatigue (17%, n = 43), loss of taste/smell (15%, n = 37), nausea/vomiting (14%, n = 35), abdominal pain (10%, n = 25), and altered mental state (5%, n = 12); 6% (n = 15) were asymptomatic.

The cause of COVID-19 exposure was frequently related to community transmission (n = 81), with an exposure to a family cluster (n = 30) or a social cluster (n = 51), and a nosocomial/healthcare cluster (n = 30). COVID exposure was unknown in 139 recipients, and there was no donor transmission. The average time between exposure and clinical symptoms was 6-7 days; the time between the onset of symptoms and the first medical visit was 2-3 days, and the average time between the first medical visit and hospital admission was 1-2 days. The time between the onset of symptoms and confirmation of COVID-19 was on average 10 days. Nearly 50% of patients had access to their transplant physician between the onset of symptoms and hospital admission for confirmation and management of COVID-19 by telehealth consultation. The time between the first positive severe acute respiratory syndrome coronavirus 2 sample and the first negative severe acute respiratory syndrome coronavirus 2 sample was 21 days (n = 15).

At presentation, the median hemoglobin was 11.2 g/dL (IQR, 9.9-12.5), total white blood cell count was 6737/ [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] , and platelet count was 215 × 10 3 /mm 3 (IQR, 174-254). Forty-nine percent of patients had normal CXR findings; abnormalities were seen in 51% (n = 112) and included consolidation (n = 112), pulmonary nodules (n = 20), lung cavitation (n = 5), pleural effusion (n = 5), and white lung (n = 10). The most common computed tomography (CT) findings (n = 120) were ground-glass opacities (n = 70), consolidation (n = 40), pulmonary nodules (n = 10), pleural effusion (n = 10), and lung cavitation (n = 10). Fifty patients (20%) showed CXR/ CT scan abnormalities before a positive COVID test. Treatment modalities and clinical outcomes of KTRs with COVID-19 are summarized in Table 4 .

Immunosuppressive treatments were modified in the majority of patients. Antimetabolites (mycophenolate/azathioprine) were discontinued in the majority of patients (75%, n = 188); in other patients (23%, n = 57), the dosage was reduced. Calcineurin inhibitors (CNIs) were not changed in most patients (66%, n = 165); 20% (n = 50) underwent a dose reduction of CNIs. The dose of prednisolone was increased in 40% (n = 100) cases, whereas no changes were made in the remaining 60% (n = 150).

Specific treatments included the application of azithromycin (n = 200, 80%), HCQ (n = 160, 64%), favipiravir (n = 54, 21.6%), remdesivir (n = 35, 14%), tocilizumab (n = 26, 10.4%), convalescent plasma (n = 15, 6%), and cytosorb filter (n = 4, 1.6%). No adverse effects such as prolonged QTc interval requiring early treatment discontinuation were documented with the combination of HCQ and azithromycin. Twenty of 26 recipients who received tocilizumab died, whereas 6 survived. Possible reasons for the poor outcome may have been delayed tocilizumab administration due to resource limitations with the initial dose being administered after the recipients were intubated (n = 2). Fifteen recipients received convalescent plasma, of whom 10 died and 5 were discharged. Thirty-five received remdesivir, of whom 7 died and 28 were discharged. The mortality was attributed to clinical severity at the time of treatment, associated comorbid conditions, multiorgan dysfunction, and secondary bacterial infections. Ten recipients received intravenous immunoglobulin (100 mg/kg for 5-10 d) in COVID treatment in high immunological risk for rejection, and all were discharged with normal kidney allograft function. Fifty-four recipients with mild-moderate disease severity received oral favipiravir, and 49 were discharged with normal kidney allograft function (Table 4 ). No mortality was reported in any COVID-19 KTR treated as an outpatient. Patients did not receive oseltamivir, chloroquine, colchicine, Chinese traditional medications, lopinavir/ritonavir + interferon, ribavirin, and plasma exchange.

Bacterial pneumonia and urinary tract infection were the most common coinfections (n = 39, 19.5%). A total of 53 (21%) required admission to the intensive care unit (ICU). Thirty-four percent (n = 85) required oxygen supplementation, 10% (n = 25) required noninvasive ventilation, and 12% (n = 30) required mechanical ventilation (29 died with 1 patient still in the hospital). Acute kidney injury (creatinine increase by 0.3% or >50% of baseline) (48.4%, n = 121) was more frequent in moderate to severe cases and uncommon in mild/asymptomatic cases. Twelve (4.8%) recipients reported graft loss during COVID-19 infection, all of whom had baseline chronic kidney graft dysfunction before COVID-19. Of 20 high immunological risk recipients screened for donor-specific antibodies, 10 had de novo donor-specific antibodies, potentially linked to a reduction in maintenance immunosuppression. Fifteen patients (7.5%) remained hospitalized; 156 patients (78%) were discharged from the hospital with a median followup of 28 days.

Overall patient mortality was 11.6% (29 of 250) and 14.5% (29 of 200) for hospitalized patients. Mortality rates increased to 47% (25 of 53) for patients in the ICU and 96.7% (29 of 30) for patients on mechanical ventilation. Statistically significant risk factors for increasing mortality were older age (P < 0.0001), dyspnea (P < 0.0001), disease severity (P < 0.0001), allograft dysfunction (P < 0.05), obesity (P < 0.0001), higher levels of inflammatory markers, such as CRP (P < 0.0001), IL-6 level (P < 0.05), and procalcitonin (P < 0.0001), CXR abnormality (P < 0.0001), and ICU/ventilator requirement (P < 0.0001) (Tables 2-4 ). An additional multivariate analysis (Table 5 ) has been performed, suggesting an elevated baseline creatinine before COVID-19 as a risk factor for mortality (P = 0.043). Recipients with mild COVID-19 (n = 50) were managed as outpatients; no mortalities were observed in this group.

We have detailed a retrospective multi-institutional study on COVID-19-positive KTRs in 13 public and private sector transplant centers in India. To our knowledge, this is the largest transplant cohort with COVID-19 positivity reported from emerging countries. Although all 13 transplant centers in this study are actively involved in pediatric transplants, we did not observe symptomatic COVID-19 infections or COVID-19-positive pediatric recipients. On March 26, 2020, the Indian Government advisory suspended elective living donor and nonurgent deceased donor kidney transplants because of COVID-19 pandemic as a health priority leading to restricted transplant activities during national lockdown from March 24, 2020, to July 31, 2020, potentially explaining that they have seen less frequent cases recently. 2, 25 It is also relevant to point out that many patients with COVID-like symptoms have undergone uneventful home treatment for acute febrile illness during the nationwide lockdown when local testing could not be performed because of resource and testing limitations. Those patients were not included in this analysis. Our multicenter study may thus overestimate mortality rates in Indian KTRs as it is possible that many KTRs remained undiagnosed and were never hospitalized or tested.

Mortality rates of 4.8%-33% have been reported in solid organ transplant (SOT) recipients with COVID-19 in recent studies from the developed world 3-28 ( Table 6) .

Rates of COVID-19 in Spain have been high with a more aggressive course in recipients of SOTs. 25 Moreover, hospitalized SOT recipients with COVID-19 had a trend toward higher mortality compared with controls (37% versus 22.9%; P = 0.51) in a recent study. 26 Recipients in our study had high rates of acute kidney injury similar to reports from the developed world. However, our transplant population seemed to have a lower mortality (11.8%), potentially linked to the relatively younger age of KTRs in India.

Risk factors for mortality in studies of the developed world have been older age (>60 y), lower lymphocyte counts, CRP (cutoff: 100 mg/L), high IL-6 levels (cutoff: 65 ng/L), high procalcitonin, high D-dimer (>960 ng/mL), oxygen requirement ≥6 L/min, mechanical ventilation, elevated serum creatinine before COVID-19, higher serum lactate dehydrogenase (>300 µ/L), thymoglobulin induction therapy, HCQ, 27 past treatment for acute rejections, disease severity at the time of presentation, >1 comorbidity, or concomitant infections. Those risk factors are also present in our study (Tables 2-5 ). Most KTRs 

Cravedi et al 3 Pereira et al 4 Bossini et al 5 Akalin et al 6 Caillard et al 7 developed asymptomatic (6%), mild (60%) to moderate (20%) COVID-19, and we observed a low incidence of severe disease (12%) in our KTR population comparable with the recent report of asymptomatic (25%), mild (28%), moderate (34%), and severe (12%) COVID-19 in SOT recipients. 28 The mortality was higher in transplant and waitlisted patients (32% versus 15%; P = 0.72), and CRP at 48 hours and peak CRP were associated with mortality in 2 groups, whereas quick sequential organ failure assessment score at 48 hours was associated with mortality for transplant patients in the study from London, United Kingdom. 20 Our study also shows that carefully selected KTRs with mild COVID-19 can be managed at home with favorable outcomes as described in an Italian and United Kingdom cohort. 5, 19, 22 This finding supports that home treatment is feasible for mild COVID-19 KTRs with relevance for countries of the developing world with limited healthcare resources. 22 Although our mortality rate appears overall lower compared with that of reports coming from the developed world, mortalities are significantly higher as compared with the general populations (2%-3%) that have undergone COVID-19 testing in India (Table 1) . Possible contributing factors for higher mortality of COVID-19 in KTRs may be linked to both immunosuppression and higher rates of comorbidities (94% versus 70%). 2 For a meaningful conclusion on the risks of morbidity and mortality of COVID-19-positive transplant patients, it appears relevant to assess the risks of the overall population in India.

The All India Institute of Medical Sciences, New Delhi, a tertiary care center in North India, reported a mortality of 1.4% in a single-center study of 144 hospitalized patients with confirmed COVID-19 from March 23 to April 15, 2020. 34 The Indian Government reported on a COVID-19-related mortality of 1.8% due to timely and effective clinical management of patients in critical care. 35 The mortality was 5.1% in a retrospective cohort analysis of 445 COVID-19-positive hospitalized patients in Karnataka from March 9 to April 23, 2020, exceeding the overall national mortality rate of 3.4% as on May 8, 2020. 36 In a retrospective study of 20 patients in a tertiary care hospital at Ahmedabad in Western India receiving tocilizumab for moderate and severe COVID-19, a mortality rate of 11% has been reported. 37 The mortality rate increased furthermore in severely ill patients, and a designated COVID-19 ICU at Pune in Western India reported a mortality rate of 16.7% in 24 critically ill COVID-19 patients from April to May 15, 2020. 38 An analysis of 3000 deaths till August 31, 2020, by the Gujarat state health department revealed that 26% succumbed to viral infections within 3 days of hospital admission. Sixty-five percent of patients had comorbidities, and 58% of deaths were in patients aged ≥60 years. 39 Thus, the mortality rate of hospitalized COVID-19 nontransplant patients appears to be significantly lower than that of transplant patients in India. [34] [35] [36] [37] [38] [39] [40] Differences seem less pronounced with increasing severity of the disease.

Comparing outcomes of COVID-19 in transplant patients with that of COVID-19 in the dialysis population may be of additional relevance. Published data from dialysis centers in India have reported mortality rates between 12% and 37.8%. 41, 42 Although those numbers are sobering, they may encourage transplant centers to remain active during the COVID-19 pandemic.

As the epidemiological situation is constantly evolving, it is recommended that each transplant team assess the current scenario that best describes their local situation. Transplant programs are advised that there will be a case-by-case evaluation when carrying out a transplant based on the availability of healthcare resources including ICU; risk/benefit of exposing an immunosuppressed patient to the potential risk of COVID-19 (according to the number of cases and the possibility of admission under ideal isolation conditions) versus the urgent medical need for transplantation (clinical situation of the patient). 33 We understand that our study has limitations as there was no uniform treatment protocol for COVID-19positive patients and that treatment changes continued to evolve based on new evidence and new data from the growing number of COVID-19 published reports. It is possible that our data shows an underreporting of COVID-19 in transplant recipients as patients are treated at home with teleconsultation for mild febrile illness. Our report also focused on hospitalized patients, and thus conclusions may not be broadly applicable to all patients diagnosed and managed in the outpatient setting, particularly as testing practices evolve. In summary, our data provides relevant insides into outcomes of kidney transplant patients in India and may thus serve to assess risks and improve outcomes of patients with COVID worldwide.

Deceased-donor organ transplantation in India: current status, challenges, and solutions

Ministry of Health and Family Welfare

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

COVID-19 in solid organ transplant recipients: initial report from the US epicenter

Kidney transplant patients with SARS-CoV-2 infection: the Brescia Renal COVID task force experience

Covid-19 and kidney transplantation

An initial report from the French SOT COVID Registry suggests high mortality due to COVID-19 in recipients of kidney transplants

COVID-19 in solid organ transplant: a multi-center cohort study

Early experience with COVID-19 and solid organ transplantation at a US high-volume transplant center

A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia

Early description of coronavirus 2019 disease in kidney transplant recipients in New York

Management of patients on dialysis and with kidney transplant during SARS-COV-2 (COVID-19) pandemic in Brescia, Italy

COVID-19 in solid organ transplant recipients: a single-center case series from Spain

COVID-19 in kidney transplant recipients

COVID-19 infection in kidney transplant recipients

Earliest cases of coronavirus disease 2019 (COVID-19) identified in solid organ transplant recipients in the United States

Clinical characteristics and immunosuppressant management of coronavirus disease 2019 in solid organ transplant recipients

Identification of kidney transplant recipients with coronavirus disease 2019

Early outcomes of outpatient management of kidney transplant recipients with coronavirus disease 2019

Outcomes of renal transplant recipients with SARS-CoV-2 infection in the eye of the storm: a comparative study with waitlisted patients

Biomarkers of cytokine release syndrome predict disease severity and mortality from COVID-19 in kidney transplant recipients

Initial report from a Swedish high-volume transplant center after the first wave of the COVID-19 pandemic

Covid-19 and solid organ transplantation: a review article

COVID-19 therapeutics for solid organ transplant recipients; 6 months into the pandemic: where are we now?

Organ donation and transplantation during the Covid-19 pandemic: a summary of the Spanish experience

COVID-19 in solid organ transplantation: a matched retrospective cohort study and evaluation of immunosuppression management

COVID-19 outcomes among solid organ transplant recipients: a case-control study

Coronavirus disease-19: disease severity and outcomes of solid organ transplant recipients: different spectrums of disease in different populations?

Summary of international recommendations for donation and transplantation programs during the coronavirus disease pandemic

COVID-19 in recent kidney transplant recipients

Clinical Management Protocol: COVID-19

Revised Discharge Policy for COVID-19

NOTTO transplant specific guidelines with reference to COVID-19

Clinico-demographic profile & hospital outcomes of COVID-19 patients admitted at a tertiary care centre in north India

Is India missing COVID-19 deaths?

COVID-19-hospitalized patients in Karnataka: survival and stay characteristics

Safety and efficacy of tocilizumab in the treatment of severe acute respiratory syndrome coronavirus-2 pneumonia: a retrospective cohort study

Initial experience of critically ill patients with COVID-19 in western India: a case series

26% Covid patients in Gujarat died within 72 hours of hospitalization

Differential mortality in COVID-19 patients from India and western countries

Study of COVID-19 pandemic in representative dialysis population across Mumbai, India: an observational multicentric analysis

Impact of COVID-19 on maintenance haemodialysis patients: the Indian scenario

The authors are grateful for the editing support that they have received from Stefan G. Tullius, MD, PhD, Harvard Medical School, Boston, MA.