Much has been learned about COVID-19 since the White House declared it to be a national emergency on March 13, 2020. Researchers have conducted thousands of studies that have characterized myriad aspects of the disease, including populations at high risk for infection and predictors of disease severity and outcomes. Particular interest has centered on solid organ transplant (SOT) recipients, who are prone to infection because of the immunosuppressive medications they must take to prevent organ rejection.
Some of the latest research findings, including those presented at the 2021 American Transplant Congress (ATC) in June, document an evolution in the understanding and management of COVID-19 in this patient population.
Shift in Therapies
In a study presented at the ATC, for example, Madeleine R. Heldman, MD, and colleagues at the University of Washington in Seattle, demonstrated a shift in therapies as the pandemic progressed. In their analysis of 946 SOT recipients hospitalized with COVID-19, they compared medications prescribed during an early period in the pandemic (patients diagnosed up to June 19, 2020) and a late period (patients diagnosed during June 20 to December 31, 2020).1 Between the early and late period, the proportion of patients treated with hydroxychloroquine plummeted from 60% to 1%, Dr Heldman reported. Remdesivir use jumped from 9% to 52% of patients and corticosteroid use increased from 11% to 62% of patients. Patients diagnosed in the late period had significant 32% decreased odds of 28-day mortality compared with those diagnosed in the early period after adjusting for comorbidities, according to Dr Heldman. “This provides indirect evidence that novel therapies for COVID-19 may [positively] impact SOT recipients,” she said.
In a separate study of 157 SOT recipients presented at the congress2, investigators from the Miami Transplant Institute of the University of Miami-Jackson Health System in Miami, Florida, concluded that remdesivir and convalescent plasma are safe to use in SOT recipients. Of the 157 patients, 64 (40.8%) and 41 (26.1%) received remdesivir and convalescent plasma, respectively. Liver function test abnormalities developed in 5 (7.8%) of the remdesivir recipients, but none of the patients required cessation of treatment, according to Anmary Fernandez, MD, a transplant infectious disease fellow who reported study findings. She and her colleagues observed no infusion reactions among patients who received convalescent plasma. Acute rejection occurred in 2 patients (4.9%) within 9 days after infusion, but this rate was similar to that of patients who did not receive the plasma, Dr Fernandez said.
Transplant infectious disease specialist Robin K. Avery, MD, professor of medicine at Johns Hopkins University School of Medicine in Baltimore, Maryland, who was not involved with these studies, said the research findings are encouraging.
“There had been questions early on in the pandemic as to whether these newer therapies were going to be okay for transplant recipients, like whether remdesivir was going to be okay for patients with renal dysfunction or [on] dialysis [and] whether convalescent plasma was going to cause alloimmune responses and rejection later on,” Dr Avery told Renal & Urology News. “This [study by Dr Fernandez and colleagues] and some other studies have underscored the fact that these therapies seem to be safe in our organ transplant recipients.”
SOT Recipients At Risk for Severe Disease
Zeroing in on which therapies are effective for SOT recipients with COVID-19 is critical because the disease course in these individuals can be particularly severe. For example, an analysis of retrospective data from the TANGO International Transplant Consortium by Leonardo V. Riella, MD, of Massachusetts General Hospital in Boston, and colleagues found that 44 (30%) of 145 kidney transplant recipients (KTRs) hospitalized with COVID-19 in March and April 2020 died after a median follow-up of 10 days following hospital admission for COVID-19.3 Acute kidney injury (AKI) developed in 46% of cases, and respiratory failure requiring intubation occurred in 29% of cases. The study, which was described during the American Society of Nephrology’s 2020 Kidney Week conference, included 9697 KTRs followed at 11 transplant centers, of whom 145 (1.5%) were hospitalized with COVID-19. Of the 145 patients, 55% were older than 60 years and 65% were male. The median time since receiving a transplant was 5 years. Only 16% had received a transplant less than 1 year from presentation.
Novel epidemiologic findings also emerged in recent studies. A study by Gaurav Agarwal, MD, of the University of Alabama at Birmingham, and colleagues revealed that kidney transplant recipients are at higher risk for COVID-19 than other SOT recipients.4
In a study of 19,031 SOT recipients, of whom 2183 tested positive and 16,848 tested negative for SARS-CoV-2, 71.8% of patients who tested positive had a kidney transplant compared with 57.4% of those who tested negative.
SOT recipients who tested positive were significantly more likely to have hypertension (86.7% vs 81.1%), diabetes (64.5% vs 59.0%), coronary artery disease (71.2% vs 67.6%), chronic kidney disease (76.3% vs 70.2%), and peripheral vascular disease (28.5% vs 23.2%), Dr Agarwal’s team reported. Hispanic or Latino patients were significantly more likely to test positive vs negative (17.3% vs 10.4%).
The study also characterized complications in SOT recipients following a COVID-19 diagnosis: 13.7% experienced major adverse cardiac events, 3.8% had graft rejection, and 3.4% had graft loss during the study period, according to the investigators.
This article originally appeared on Renal and Urology News