key: cord-0971621-esjmr1is
authors: Bossini, Nicola; Alberici, Federico; Delbarba, Elisa; Valerio, Francesca; Manenti, Chiara; Possenti, Stefano; Econimo, Laura; Maffei, Camilla; Pola, Alessandra; Terlizzi, Vincenzo; Salviani, Chiara; Moscato, Marianna; Pasquali, Stefano; Zambetti, Nicole; Tonoli, Michela; Affatato, Stefania; Pecchini, Paola; Battista Viola, Fabio; Malberti, Fabio; Depetri, Giorgio; Gaggiotti, Mario; Scolari, Francesco
title: Kidney transplant patients with SARS‐CoV‐2 infection: the brescia renal COVID task force experience
date: 2020-07-06
journal: Am J Transplant
DOI: 10.1111/ajt.16176
sha: 184f9368de12a065b3d8bb327ebda8eb224fb9b6
doc_id: 971621
cord_uid: esjmr1is

The outcome of kidney transplant patients with SARS‐CoV‐2 infection is still unclear. Here we describe the clinical characteristics, disease outcome and risk factors for ARDS and death of a cohort of 53 kidney transplant patients with COVID‐19. 8/53 have been handled as outpatients due to mild disease, on average with immunosuppression reduction and the addiction of hydroxychloroquine and azithromycin; no patients required admission, developed ARDS or died. 45/53 required admission due to severe symptoms: this cohort has been managed with immunosuppression withdrawal, methylprednisolone 16 mg/day, hydroxychloroquine and antiviral drugs. Dexamethasone and tocilizumab were considered in case of ARDS. 33% of the patients developed AKI, 60% ARDS and 33% died. In this group, thrombocytopenia was associated to ARDS while lymphopenia at the baseline, higher D‐dimer and lack of CRP reduction with risk of death. In the overall population, dyspnoea was associated with the risk of ARDS while age older than 60 years and dyspnoea with the risk of death with only a trend towards an increased risk of death for patients on tacrolimus. In conclusion, SARS‐CoV‐2 infection may have a variable outcome in renal transplant patients, with higher risk of ARDS and death in the ones requiring admission.

This article is protected by copyright. All rights reserved 28%. In both of these cohorts the antimetabolite was withdrawn, while the calcineurin inhibitors (CNIs) cessation was restricted to severe cases. The vast majority of the Columbia cohort patients received hydroxychloroquine and azithromycin, while these drugs were employed, respectively, in 86% and 46% of the Montefiore Medical Center cohort.

Tocilizumab was administered only in few cases (3, 4) .

Here we describe the clinical characteristics and outcomes of a cohort of 53 kidney transplant patients (KTx) with COVID-19 followed within 3 centers of the Brescia Renal COVID task force, and try to identify prognostic factors for poor outcome. The manuscript includes 20 patients already described in another report (1) with extended follow-up and 33 patients that have not been, up to today, subject of publication. The indication on patients' management (inpatients vs outpatients) was based only on symptoms severity as well as the presence of signs or symptoms of on-going pneumonia.

The therapeutic strategy followed our protocol (2) . Antiviral therapy with Lopinavir/Ritonavir associated to hydroxychloroquine (with dose adjusted according to kidney function) was considered for all patients requiring admission, if not contraindicated, for a treatment length of a minimum of 7 days up to a maximum of 15 according to clinical evolution or treatment with glucocorticoids and/or tocilizumab. In case of shortage of Lopinavir/Ritonavir, Darunavir and Ritonavir were employed.

Patients experiencing clinical deterioration after at least 7 days following symptom onset, or no fever for >72h, with escalating oxygen requirements, progression of the chest x-ray and no signs of bacterial infection, were considered for dexamethasone (20 mg/daily for 5 days,

This article is protected by copyright. All rights reserved then 10 mg/daily for 5 days) and up to two tocilizumab infusions at an interval of [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] hours (8 mg/kg of body weight, maximum dose per infusion 800 mg).

Considering the well-known potential of lopinavir/ritonavir and hydroxychloroquine for increasing QTc, a baseline EKG was performed before therapy commencement and, afterwards, every 2-3 days; in case of QTc prolongation a reduction or discontinuation of treatment was considered in a case by case manner.

The outpatients were monitored daily, using a telemedicine approach; in this subgroup baseline blood tests were not performed in order to promote social distancing.

Low dose of glucocorticoids was defined as methylprednisolone 4 mg or equivalent, medium dose of glucocorticoids was defined as 16 mg of methylprednisolone or equivalent. ARDS was defined as per previous publications (5) .

Ethical approval for this study was obtained according to Italian regulations.

Statistical analysis was performed using R software (https://www.r-project.org) and GraphPad Prism 7. Results are expressed as the number and percentage for categorical variables and the median (interquartile range [IQR]) for continuous variables.

Changes in variables were compared by a related sample Wilcoxon test, proportions of patients were compared using a chi-squared or Fisher test, as appropriate.

Univariate and multiple logistic regression models were used to assess the ability of some predefined clinical characteristics to predict the risk of ARDS or death. All the statistically significant predictors at univariate analysis were entered in a multivariate model; age at disease diagnosis was added to the multivariate models as a factor likely to play a priori role (6) . Finally, the best multivariate model was identified by adopting a stepwise selection approach. Odds ratios (ORs) and their 95% CIs were estimated from logistic regression analysis. P values less than 0.05 (2-tailed) were considered significant.

53 patients were included in this study; all the patients had symptoms suggestive for COVID-19 and have been assessed in the emergency room or in our clinics. In both settings, patients received the swab and were than admitted in case of severe symptoms and/or low blood

This article is protected by copyright. All rights reserved oxygen levels or managed as outpatients in case of mild symptoms and normal blood oxygen levels. For all the patients, diagnosis has been established on RT-PCR of nasopharyngeal swabs. Of the 53 patients, 42 have been managed as inpatients while 11 as outpatients; of the latter group, 3 were admitted within 3 days from the diagnosis due to aggravation of symptoms and were considered in the admitted cohort. Of the 45 patients admitted, 28 were followed at the Spedali Civili of Brescia, 13 at the Cremona hospital and 4 at the Crema hospital. Patients' characteristics are shown in table 1.

This group included 8 patients; the median time from symptoms onset to the diagnosis was For ARDS management and in the context of progressive respiratory failure, 18/45 (40%) received dexamethasone: 10/18 (56%) died, while 6/18 (33%) were subsequently discharged. 9/18 (50%) showed amelioration in terms of chest x-ray or respiratory failure improvement. 8/18 patients (44%) also received tocilizumab on top of dexamethasone: 3/8 (38%) died and 3/8 (38%) have been discharged. 5/8 (63%) showed improvement in terms of chest x-ray or respiratory failure (reduction of infiltrates, improvement of the pO2/FIO2 ratio; data not shown). Patients who received dexamethasone and tocilizumab were more likely to experience an amelioration compared to the ones receiving only dexamethasone (5/8, 63% vs 4/10, 40%).

This article is protected by copyright. All rights reserved At the end of the follow-up, 27/45 patients (60%) were discharged. At discharge, all the patients continued the immunosuppressive scheme adopted during the hospitalization (table 1) 

This article is protected by copyright. All rights reserved Clinical characteristics associated to the risk of ARDS and death

In the overall population of 53 patients, at univariate analysis, the only clinical characteristic associated to the risk of developing ARDS was shortness of breath at disease onset (OR 5.9, (95%CI 1.6-29.1), p=0.015). A trend for increased risk of ARDS was recorded in patients on tacrolimus (OR 2.77 (95%CI 0.91-8.9, p=0.077) and in patients with pharyngitis at disease onset (OR 6.9 (95%CI 0.76-61.7), p=0.09), while a protective trend towards the risk of ARDS 

The first version of this paper has been drafted at the end of April 2020 when, apart from our preliminary cohort of 20 patients (1), only two further cohorts of kidney transplant patients had been published (3, 4) ; at that stage the outcome of this population was still relatively unclear with mortality ranging from 7% to 28%. Since then, further data became available and the mortality of kidney transplant patients with SARS-CoV-2 infection appears now to have been consistently described as around 25-28% across different cohorts with a sufficient sample size and follow-up(1, 3, 4, 7-9). Our findings suggest a clear difference in terms of outcome according to disease severity: patients with mild symptoms and manageable at home experienced a benign disease course, while patients requiring hospitalization experienced a mortality rate of 33%; the overall fatality rate of our population was 28%. Of interest, this wide spectrum of disease severity is in keeping with

This article is protected by copyright. All rights reserved what described in the general population as well as in other KTx transplant cohorts (10) although the mortality rate of the latter group, when presenting with severe disease, appears to be higher (11) ; of note this variability has been observed also in the haemodialysis population (12) .

In our admitted kidney transplant population we adopted from day one a policy based on immunosuppression cessation, introduction/increase of the glucocorticoid dose to methylprednisolone 16 mg or equivalent dose of prednisone, antivirals and hydroxychloroquine (2) . In our outpatient population we opted, on average, to withdraw the antiproliferative, reduce the CNI dose and to start hydroxychloroquine and azithromycin. Of note, in both our subgroups adverse events due to the therapeutic approach were rare and no cardiac toxicity has been documented. The interaction between antivirals and CNIs metabolism has been well documented and this may explain the slow reduction rates of cyclosporine and tacrolimus in our population; the impact of this on kidney function evolution as well as the overall outcome is unclear. The combined approach of protease inhibitors start and CNIs withdrawn seems reasonable due to the interactions in the metabolism of the two drugs; however caution in terms of CNIs withdrawn in different clinical contexts where protease inhibitors are not employed should be advised. Of note, heterogeneous approaches in terms of CNIs management for renal transplant patients during COVID-19 outbreaks have been described ranging from our approach to their maintenance(3).

In the general population, the role of antivirals is debated. Remdesivir seems a promising option(13) while the benefits of lopinavir/ritonavir are contradictory (14, 15) ; of note for the latter a trend towards a reduced risk of death was observed in a RCT in the general population although the difference was not statistically significant compared to placebo. It should be stressed that the viral load may represent a risk factor for severe disease(16) and impacting on this might reduce the risk of ARDS (15) . The mortality rate of our cohort was similar to the one of other kidney transplant case series(9) and of interest higher compared to carriers of liver transplant (17) . Of interest, case fatality rate was similar to the one of the Montefiore Medical Center, where no antivirals were employed(4): this might be interpreted as in support for a lack of role for the antivirals commercially available at the moment.

However, in our opinion, data are still scarce and more information is needed including long-

This article is protected by copyright. All rights reserved term outcomes in terms of patients' survival, renal outcome and residual lung damages as consequence of the infection.

An inflammatory syndrome is likely to be central in the development of ARDS and progressive respiratory failure in a subgroup of patients. Longitudinal blood tests showed persistently high CRP levels in the subgroup that would die compared to the one with a more favourable outcome. In this context, a role for anti-inflammatory approaches have been proposed(2): in our cohort patients with ARDS were treated with high-dose steroids, with or without tocilizumab. Although this subgroup experienced, on average, an unfavourable outcome, the combination of these two drugs was associated to higher rates of chest x-ray and respiratory failure improvements compared to the use of dexamethasone alone (63% vs 40%); these results are too preliminary to draw conclusions on the potential role of tocilizumab in this clinical setting and further studies will be needed to clarify this aspect.

Moreover, in the light of recent reports, the role of glucocorticoids in COVID-19 patients is debated and on average discouraged during the viremic phase (18) ; however our approach has been to employ moderate dose of glucocorticoids only in the patients with ARDS and progressive respiratory failure at distance from the likely viremic phase. Of note, the benefits of such approach has been confirmed in the preliminary results of the RECOVERY trial which showed a role for dexamethasone in reducing mortality in mechanical ventilated patients and in the ones receiving oxygen(19). It should be however stressed that, although in our therapeutic protocol moderate doses were reserved only to the subgroup with ARDS, lower doses have been employed from the day of the admission due to the concerns of increased risk of rejection secondary to the reduction of the immunosuppression; the impact of this change at early stages of hospitalisation will need to be clarified.

Our study provides some information on the role of baseline and longitudinal blood tests on the outcome. Low platelets and lymphocytes were found, respectively, associated to an increased risk of ARDS and to a trend towards an increased risk of death. In a subgroup of 28 patients, the ones that eventually died had lower baseline lymphocytes count compared to the rest of the population; of interest the trend towards the reduction of the lymphocytes count during follow-up was similar. In the same population, D-dimer at admission was higher. These findings are in keeping with what already described in the general

This article is protected by copyright. All rights reserved population (20) . The mechanisms causing lymphopenia are still to be clarified, and ranges from potential direct viral infection of the lymphocytes to a possible role for the inflammatory milieu associated with the disease (21) .

With the first wave of SARS-CoV-2 infections weaning off in Italy, the focus is now moving on how to routinely manage renal transplant patients in the COVID-19 era with a special focus on how and if modifications of the baseline immunosuppression would be required in the entire transplant population. In our cohort the use of tacrolimus as baseline CNI showed a trend as risk factor for ARDS and a significant association as risk factor for death at univariate analysis; the latter maintained a trend as risk factor also after multivariate analysis. In a model of multivariate not shown in the results and including baseline therapy with tacrolimus, age, transplant vintage and dyspnoea at disease onset, the trend of treatment with tacrolimus as a risk factor for death has been maintained (OR 6.9 (95%CI 0.99-67), p=0.07). The reasons for this association are unclear. For both cyclosporine and tacrolimus an antiviral effect in general, and towards the coronaviruses more specifically, was described in vitro (22, 23) . However data in vivo or regarding their effects on SARS-CoV-2 are not available and importantly this should be balanced against the higher potency of tacrolimus compared to cyclosporine (24) . Of note, this finding may be consequence of our population characteristics; however, of interest, a benign outcome of COVID-19 during a cyclosporine-based therapy in kidney transplant patients has been proposed also in other cohorts (25) . Despite that, this result will need to be interpreted with caution and further investigations will be required in order to provide confirmation.

Our study has some strengths: it includes a big cohort of kidney transplant patients, the therapeutic approach has been homogenous allowing robust data interpretation and comparisons with other published cohort with similar consistent approaches.

Limitations need to be acknowledged: despite the cohort size, this is still a relatively small study; moreover our population has on average a severe disease profile and therefore our findings may not necessarily be extended to subgroups with mild symptoms or even asymptomatic at the moment of the diagnosis. Importantly, our findings are restricted to a short follow-up time and long-term observations will need to be performed in order to

This article is protected by copyright. All rights reserved better clarify the outcome of kidney transplant patients with COVID-19. Of note, the mortality rates of the patients with ARDS managed in ICU and in the ward (respectively, 80% and 41%) may be a consequence of the different disease severity in the two subgroups; however an impact for delayed ICU referral as well as reduced ICU availability at some stages of the emergency may have played a role in the overall fatality rates of our population with ARDS. It is necessary to underline, however, that among the seven patients with ARDS and managed in the ward that would later die, 6 had not been considered eligible for ICU due to comorbidities and therefore an unfavourable risk benefit balance; however it should be acknowledged that this happened in the context, at least at some point of the emergency, of reduced resources. One of these seven patients refused however ICU care.

Of note, Italy in general and the province of Brescia in particular has been among the first western areas hit by this epidemic, urging physicians in employing treatment protocols based on partial evidence. At the moment of the writing, data do not further support a role for hydroxychloroquine in preventing the development of severe disease or in preventing the development of symptoms as post-exposure prophylaxis (26, 27) ; however protocols designed before this publication have extensively employed this approach in kidney transplant population (3, 4) . It should also be underlined that data on the general population may not necessarily be applicable to the kidney transplant one.

In conclusion, renal transplant patients may experience a heterogeneous range of disease severity; the ones requiring admission may experience a poor outcome with high ARDS and mortality rates. The ideal therapeutic approach other than supportive care is still unclear and the impact of the single interventions to be determined.

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

The data that support the findings of this study are available from the corresponding author upon reasonable request. 

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