key: cord-1001074-f3p1kzvp authors: Bansal, Neha; Ovchinsky, Nadia; Foca, Marc; Lamour, Jacqueline M.; Kogan‐Liberman, Debora; Hsu, Daphne T.; Beddows, Kimberly; Abraham, Lincy; Coburn, Maura; Cunningham, Ryan; Nguyen, Trang; Hayde, Nicole title: COVID‐19 infection in pediatric solid organ transplant patients date: 2021-10-11 journal: Pediatr Transplant DOI: 10.1111/petr.14156 sha: bc235cf0e1742c99c839413bea9ecaa729e1a59c doc_id: 1001074 cord_uid: f3p1kzvp BACKGROUND: Adult SOT recipients with COVID‐19 have higher mortality rates when compared to general population. There is paucity of data on outcomes in pediatric SOT recipients. METHODS: This is a cross‐sectional study investigating the prevalence of COVID‐19 infection and outcomes in pediatric SOT (heart, liver, and kidney) recipients. We extracted demographic and clinical characteristics and COVID‐19 testing (PCR or [Ab] test) results from medical records. Clinical characteristics were compared between patients who were positive for COVID‐19 (PCR or Ab) and those who did not, using Mann‐Whitney, Student's t test, or chi‐square test. p value <.05 was statistically significant. RESULTS: A total of 108 SOT recipients with a median age of 13.1 (8.4, 17.8) years and median 4.2 (2.7, 7.9) years from transplant were checked for COVID‐19 via a PCR or Ab test. A positive PCR was confirmed in 10 patients (9.3%), while 12 patients (11.1%) were positive for COVID‐19 Ab. The patients who tested positive in our cohort were 9/50 (18%) heart, 6/68 (8.8%) kidney, and 7/50 (14%) liver transplant recipients. There were no differences in the clinical characteristics between patients with and without COVID‐19 infection. All patients were either asymptomatic (50%) or had self‐limiting symptoms. No changes were made to the immunosuppressive regimen. Only one patient was hospitalized and none had an oxygen requirement. CONCLUSIONS: In our cohort of pediatric SOT recipients, COVID‐19 infection was asymptomatic or mild. This data may aid clinicians in counseling patients and families in this increased‐risk population. NYC was a major initial epicenter for COVID-19 infection in the United States and, in the borough of Bronx, where our hospital is located, there was a higher prevalence of infection compared to other NYC boroughs. 1 The clinical manifestations of COVID-19 are typically mild in children. [2] [3] [4] A review by the Chinese CDC indicated that only 1% of the cases (416/72 134) were in children younger than 10 years of age with no mortality in this population. 5 In general, immunocompromised patients are more susceptible to viral infections than immunocompetent individuals. 6 This knowledge led to the concern that SOT recipients on immunosuppressive medications may be at a higher risk for infection, morbidity and mortality from COVID-19. The reports in adult SOT, particularly kidney transplant recipients, indicate a significantly increased morbidity and mortality when compared to the general population. 7, 8 Initial reports in pediatric kidney transplant recipients indicate a decreased risk for infection and less severe disease when compared to their adult counterparts. 9 The main objective of this study was to determine the prevalence of COVID-19 infection and the clinical outcomes in pediatric SOT (heart, liver, and kidney) recipients at our center. After approval from the institutional review board with a waiver of consent, we conducted a cross-sectional study at our institution from April 2020 to December 2020 as testing became readily available in April 2020. While COVID-19 PCR testing was done on symptomatic or for pre-procedural testing, all other patients were tested once for the presence COVID-19 Ab during their routine clinical follow-up starting April 2020. All patients were screened for COVID-19 exposure and symptoms during their clinical care using a standardized series of questions based on US CDC symptom checklist. 10 We extracted the demographic and clinical data of the study population from the electronic medical record. Variables of interest included organ transplanted, date of transplant, age at transplant, immunosuppression regimen, current height in centimeters, current weight in kilograms, and the presence of comorbidities (hypertension, diabetes, chronic lung disease, and history of malignancy). Trough tacrolimus levels for the 6 months prior to COVID-19 Ab testing were also extracted from the EMR, and the mean trough levels were calculated. There was no standard protocol decided whether or not children should go to daycare or school, but was based on the comfort and resource availability of the individual families. It should be noted that for most of the study period, most schools in the NYC metro area did not have in person classes. SOT recipients were tested for SARS CoV-2 using a real-time reverse transcriptase PCR assay obtained from a nasopharyngeal swab, if they exhibited symptoms concerning for infection or prior to any scheduled surgical procedures. All Descriptive data for patients were expressed as median (interquartile range), mean/median (standard deviation) and frequency (%) as appropriate. Mann-Whitney or Student's t test (continuous variables) and chi-square tests (categorical variables) were used to compare clinical characteristics between pediatric SOT recipients who were COVID-19 positive (PCR or Ab positive) and those who were negative. We compared clinical characteristics between the 2 groups using SPSS software. A p value <.05 was considered statistically significant. At our center, a total of 50 heart transplant, 50 liver, and 68 kidney transplant patients are followed. Of the 168 SOT patients, 108 (64.3%) were seen at our clinic site during the study period and were tested for COVID-19 via a PCR or Ab test. The other SOT recipients were being followed via telemedicine and off-site laboratory testing due to personal concerns of becoming infected with COVID-19. Twenty-two of the 108 patients (20.4%) tested positive for COVID-19 either via PCR or Ab test. The demographics of the patients, stratified by organ, are shown in Table 1 . The patients who tested positive in our cohort were 9/50 (18%) heart, 6/68 (8.8%) kidney, and 7/50 (14%) liver transplant recipients. A positive COVID-19 PCR from a respiratory specimen was confirmed in 10 patients. Of 9 In the cohort, the median time after transplant was 2.9 years. 9 Similar to their study, this study also showed that 50% of the patients were asymptomatic and tested positive on Ab testing during a routine clinic visit. Due to the higher mortality rates in adult transplant recipients when compared to the general population, providers may adapt aggressive approaches in SOT recipients with COVID-19, including discontinuation of immunosuppressive agents. This may result in the formation of donor specific antibodies and rejection, ultimately decreasing graft survival. Unlike adult recipients, we did not modify or discontinue immunosuppression in COVID-19 patients 19 Despite the uncertainty and lack of evidence regarding the optimal management of COVID-19 in transplant recipients, especially in the pediatric age group, these data add to the literature showing that pediatric SOT recipients with COVID-19 are mostly asymptomatic and the few recipients who develop symptoms recover well with no significant complications. Thus, the majority of pediatric SOT recipients can be adequately monitored in the home environment. Immunosuppression alteration may not be always necessary for a complete and rapid recovery. The results of this study may help the provider to triage these patients while reassuring the patient and family about the risks with COVID-19 in these patients. None. The data that support the findings of this study are available from the corresponding author upon reasonable request. https://orcid.org/0000-0001-7026-3058 Kimberly Beddows https://orcid.org/0000-0002-2563-0477 Department of Health. 2020. Last accessed SARS-CoV-2 infection in children Epidemiology, clinical features, and disease severity in patients with coronavirus disease 2019 (COVID-19) in a children's hospital in Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese center for disease control and prevention Infections in pediatric solid organ transplant recipients Covid-19 and kidney transplantation Early experience with COVID-19 and solid organ transplantation at a US high-volume transplant center COVID-19 in pediatric kidney transplantation: the improving renal outcomes collaborative Prevention CDC. Symptoms of COVID-19. Last Accessed COVID-19 in heart transplant recipients: a multicenter analysis of the Northern Italian outbreak Early description of coronavirus 2019 disease in kidney transplant recipients in New York SARS-CoV-2 infection and early mortality of waitlisted and solid organ transplant recipients in England: a national cohort study COVID-19 infection in kidney transplant recipients at the epicenter of pandemics Mild COVID-19 in a pediatric renal transplant recipient A case of an infant with SARS-CoV-2 hepatitis early after liver transplantation The pediatric solid organ transplant experience with COVID-19: an initial multi-center, multi-organ case series Coronavirus disease (COVID-19) in kidney and liver transplant patients: a single-center experience Does comorbidity increase the risk of patients with COVID-19: evidence from meta-analysis Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area Risk factors associated with in-hospital mortality in a US national sample of patients with COVID-19 Infections in solid-organ transplant recipients. Mandell, Douglas, and Bennett's Princ Pract Infect Dis Effects of COVID-19 pandemic on pediatric kidney transplant in the United States Immunogenicity of a single dose of SARS-CoV-2 messenger RNA vaccine in solid organ transplant recipients COVID-19 infection in pediatric solid organ transplant patients