key: cord-0913848-v17l6t5u authors: Aziz, Fahad; Mandelbrot, Didier; Singh, Tripti; Parajuli, Sandesh; Garg, Neetika; Mohamed, Maha; Astor, Brad C.; Djamali, Arjang title: Early report on published outcomes in kidney transplant recipients compared to non-transplant patients infected with COVID-19 date: 2020-07-13 journal: Transplant Proc DOI: 10.1016/j.transproceed.2020.07.002 sha: ba5e24c495ac824892e352f8e7c9743502080fd3 doc_id: 913848 cord_uid: v17l6t5u Abstract Background Kidney transplant recipients (KTR) present unique characteristics including disease vintage, immunosuppression, and single functioning kidneys. We conducted preliminary analyses to assess the impact of COVID-19 on outcomes in KTR compared to non-transplant patients. Methods We evaluated published information in peer-reviewed journals between 01/01/20 and 04/24/2020 with available data on AKI, renal replacement therapy (RRT), intensive care unit (ICU) stay, and death, and compared clinical outcomes in KTR versus non-transplant recipients with COVID-19. Results A total of 19 published articles were identified, including a total of 88 KTR and 5,342 non-transplant patients. The sample size varied between 2 and 2,634. Mean age was 58.6 years vs. 58.9 years in KTR vs. non-transplant. Patient-level incidence of AKI (27.5% vs. 13.3%, p<0.001), RRT (15.4% vs. 3.3%, p<0.001), ICU stay (34.1% vs. 15.1%, p<0.001), and death (22.7% vs 16.2%, p=0.10), was higher in KTR, representing relative risks of 2.06 (1.44, 2.96), 4.72 (2.62, 8.51), 2.25 (1.67, 3.03), and 1.41 (0.95, 2.08), respectively. Conclusion Early results suggest that the KTR are at significantly greater risk of AKI, RRT, and ICU stay from COVID-19 infection compared to the general population. The risk of death may not be significantly different. Severe acute respiratory syndrome (SARS) from coronavirus-2 (COVID-19) emerged as a lifethreatening infection that has affected more than 2.7 million people and caused the death of close to 200,000 patients worldwide over the last few months. Original studies from Wuhan, China, where the novel virus emerged, showed that 5-29% of the patients with SARS-COVID-19 infection experienced acute kidney injury (AKI) 1, 2 . With the evolving pandemic, kidney transplant recipients (KTR) with chronically suppressed immune systems and baseline chronic kidney disease (CKD-T), might be theoretically at significant risk of this potentially fatal infection. The clinical manifestations, treatment, and prognosis of SARS-COVID-19 infection in KTR are limited to only a few case reports and case series. We reviewed the literature to compare the outcome of COVID-19 infection in KTR to those in non-transplant patients. We reviewed the incidence of AKI, intensive care unit (ICU) stay, renal replacement therapy (RRT) requirement, and death in published articles of SARS-COVID-19 infection published in journals with impact factor > 2.5 between 01/01/2020 and 04/24/2020. Single case reports were not included. We compared these clinical outcomes in patients with and without kidney transplantation using patient-level analyses. Studies of autopsies were excluded from mortality analyses. We identified 19 case series 1-19 , 6 of which included only KTR [12] [13] [14] [15] 17, 19 (Table 1) Table 2 ). Mean age was not statistically associated with the prevalence of death, ICU admission, or need for renal replacement therapy (p-value = 0.1) in analyses weighted by the relative size of each study. With the sudden and unexpected spread of COVID-19 throughout the world, there is significant uncertainty about the management of patients with the virus. This uncertainty becomes further complicated when KTR, a particularly vulnerable group, are infected with SARS-COVID-19. We analyzed the recent literature and compared outcomes between KTR and the general population. Our analysis indicated that AKI, RRT, ICU stay, and death were more common in KTR with COVID-19. Although the difference in mortality did not reach statistical difference, the other outcomes were significantly worse in KTR. Not all published data reported poor outcomes in KTR. In a recent case series from Columbia University, New York, KTR with COVID-19 infection were found to have a similar presentation and favorable outcomes compared to the general population 17 . On the other hand, Akalin et al. 19 observed high rates of AKI, need for RRT, and death in KTR, which is intriguing, because both studies reported data from NYC. However, similar to the Akalin study, others have found rapid disease progression and poor outcomes in KTR [12] [13] [14] [15] . While environmental and social-economic factors might, in part, explain the differences in these observations, one might consider that KTRs have unique characteristics including immunosuppression, single functioning kidneys, and potentially long disease vintage that place them at a higher risk of progression and death with COVID-19. however, the specifics remain unknown. While it seems logical to avoid T-cell depletion for induction therapy in pandemic areas, it is unclear how immunosuppression management can prevent or mitigate the cytokine storm, known to be associated with poor outcomes in patients with COVID-19. Furthermore, despite the favorable outcomes of high dose dexamethasone treatment for the Acute Respiratory Distress Syndrome 20 , the role of intravenous steroids in KTR with COVID-19 remains unknown. We recognize several limitations to our study, including the lack of detailed characteristics of patients from each study, missing data from some studies, potential selection bias, and relatively few transplant recipients. Due to a lack of patient-level information, metaanalysis cannot be performed. Despite its limitations, our study highlights the importance of close follow-up in transplant recipients with COVID-19 infection. In conclusion, based on current evidence, KTRs may be at higher risk of poor outcomes than non-transplant patients with COVID-19 infection. Preventive strategies, close monitoring, and a low threshold for hospitalization may be indicated. 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