key: cord-0870516-mqv7106v authors: Kolonko, Aureliusz; Dudzicz, Sylwia; Wiecek, Andrzej; Król, Robert title: COVID‐19 infection in solid organ transplant recipients: A single‐center experience with patients immediately after transplantation date: 2020-07-06 journal: Transpl Infect Dis DOI: 10.1111/tid.13381 sha: b0dc5ea1329dd992486a60cae0047cf10a132955 doc_id: 870516 cord_uid: mqv7106v In our transplant center, infection with SARS‐CoV‐2 virus was confirmed in 4 organ transplant recipients (3 kidney and 1 liver transplant recipients) during their early post‐transplant hospital stay. In this paper, we report the basic characteristics, management, clinical course, and outcomes of these patients. The ongoing pandemic of novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affected the global population heavily. Special concerns arose concerning chronic kidney disease (CKD) patients, as the meta-analysis of early data suggested that CKD was associated with severe clinical course of coronavirus disease 2019 (COVID-19). 1 Still more close attention should be paid to kidney transplant recipients (KTRs), as their immunity is further compromised by the immunosuppression regimen. To date, several papers reported diverse symptomatology and clinical course in KTR subjects. [2] [3] [4] [5] [6] Acute kidney graft impairment and overall mortality were high. The modification of immunosuppressive treatment varied and was related to clinical course, including discontinued administration of antimetabolite drugs and reduction of calcineurin inhibitor dose, or even immunosuppression withdrawal. [2] [3] [4] [5] [6] Until now, there has been only limited experience concerning clinical characteristics and treatment of stable KTRs with co-occurring COVID-19 and virtually no publication concerning transplant recipients infected during the early period after transplantation. In March and April 2020, the COVID-19 infection during the first post-transplant hospital stay was confirmed in our transplant center in 3 KTRs and in one liver transplant recipient (LTR). Following the first diagnosed case, epidemiological investigation revealed an in-hospital cluster of infection, which comprised the transplant surgical ward and operating room personnel. Patients were immediately referred to the regional hospital dedicated specifically for COVID-19 infected patients. Hereby, we report the characteristics, management, clinical course, and outcomes of these patients. The clinical characteristics of 4 patients with COVID-19 are provided in Table 1 . All patients signed their informed consent for performing the transplantation in the time of increased epidemiological risk and have had nasopharyngeal swabs performed, whose results were negative immediately before the transplant procedure. Both of the deceased donors were negatively screened for COVID-19, using nasopharyngeal swab specimens and high-resolution computed tomography (HRCT), prior to taking the final decision concerning the organ procurement in other hospitals. All patients received basiliximab as induction therapy and standard maintenance immunosuppressive regimen, including tacrolimus (TAC), mycophenolate mofetil (MMF), and steroids. The first and third referred KTRs had the organs transplanted from the same donor (from whom the liver for patient 4 was also procured). The second referred patient had undergone the transplantation 3 days earlier. All patients were operated on at the same operating block and shared the same nursing personnel thereafter. Informed consent for publication of their clinical data was obtained from the patients or their relatives. A 61-year old man with the history of type 2 diabetes treated with insulin, arterial hypertension, and atrial fibrillation, underwent transplant after 18 months of hemodialysis. Before transplantation, he received TAC 5.5 mg BID, MMF 750 mg BID, and steroids in standard protocol (iv methylprednisolone during operation procedure and post-transplant day (POD) 1, then 20 mg of oral prednisone). The early graft function was excellent, and serum creatinine concentration (S Cr ) reached 1.1 mg/dL on POD 7. The TAC through blood level (C0) on POD 2 was 24.7 ng/mL, then on POD 5 and 7 C0 values were 9.4 and 7.1 ng/mL, respectively. On POD 6, high fever was noted up to 40°C and C-reactive protein (CRP) levels increased to 107 mg/L (normal range, 0-5 mg/L), whereas procalcitonin level was normal. No other clinical abnormalities were observed. Meropenem administration was started. The following day, he was positively tested for COVID-19. Oxygen saturation was normal. HRCT revealed mild patchy ground-glass shadows located in the upper pulmonary lobes. Thus, MMF was ceased. During the following week, his general condition was still good, despite high CRP levels (160 mg/L on POD 12), so levofloxacin was started. He did not receive antiviral medications. Blood and urine cultures were negative, and the body temperature was normal. S Cr was stable (0.8 mg/dL). On POD 15, the body temperature increased to 38.2°C. On the following day, his clinical condition deteriorated rapidly, S Cr rose to 1.8 mg/dL and systolic blood pressure lowered to 100 mm Hg with tachycardia. CRP level increased to 280 mg/L and procalcitonin level to 0.26 ng/mL. In the abdominal CT scan, the signs of perigraft fluid collection and ileus were revealed. During the preparation for surgery, the patient died suddenly after cardiac arrest. A 24-year old man with a history of vesico-ureteral reflux, right-side nephrectomy, and arterial hypertension, diagnosed 5 years before hemodialysis treatment, received TAC 6 mg BID, MMF 750 mg BID with steroids at transplantation. Immediately, S Cr started to decrease and reached 2.7 mg/dL on POD 11. TAC C0 on POD 2 was 5.8 ng/ mL, then on POD 4 and 7 was 8.5 and 9.9 ng/mL, respectively. The maximum CRP level was noted on POD 4 (62.5 mg/L) and then decreased to 8.9 mg/L on POD 11, and patient was to be discharged. However, as COVID-19 infection was diagnosed in patient 1, the referred patient has also been tested and the result was positive. As the clinical condition was excellent, the decision concerning HRCT has been delayed. Because of non-optimal kidney graft function at that moment and the lack of information about MMF blood level, due to the temporary reference laboratory shutdown caused by COVID-19 epidemic, MMF was maintained at a reduced dose (250 mg BID). During the 35-day stay at reference infectious hospital, no clinical or biochemical signs of infection were observed. The consecutive TAC C0 results were between 8 and 10 ng/mL. Prednisone dose was reduced to 7.5 mg/d. The patient did not receive antiviral medications. His swab test was positive on POD 24, 31, and 38 and negative on POD 45 and 47, and then, he was discharged home, with S Cr of 1.5 mg/dL. A 42-year old man had been diagnosed with arterial hypertension and CKD at advanced stage, its detailed cause was not clarified. A In this report, we present our experience with COVID-19 infection, diagnosed in 4 solid organ recipients during early post-transplant period. Importantly, SARS-CoV-2 pandemic rapidly changed the everyday medical care of CKD patients, including transplant programs. The limited accuracy of PCR tests was raised as a potential hazard, as COVID-19 could be not detected both in donors and waitlisted recipients who are asymptomatic. 7 Another diagnostic procedure, HRCT, appeared to be not applicable to potential organ transplant recipients during the final pre-transplant decision making period. Additionally, the time required to swab test the patient would increase the cold ischemia time and can therefore negatively affect the outcomes. 7 Moreover, the issue of virus transmission by asymptomatic or pre-symptomatic hospital staff members has recently become evident. 8 immunized and all received basiliximab induction, and thus, we were able to realize such a scenario. Steroids were not escalated, as was suggested by some authors, 10 mainly due to good clinical condition of our patients. Interestingly, the prolonged viral shedding time observed in patient 2 may be attributed to immunosuppressive regimen. 11 As recent studies describing the inpatient care of COVID-19 in KTRs differ widely in disease severity, time from transplantation, and the immunosuppression modifications, it is important to collect more data about the treatment and outcome of this specific population of patients. 12 We would like to conclude that, in spite of the fact that patients immediately after solid organ transplantation are among the group of high risk of complications and mortality related to the COVID-19 infection, our results may suggest a relatively low symptomatic clinical course and positive outcome of this disease. All authors have no conflict of interest to disclose. AK participated in study concept, data curation, and writing of the original manuscript. RK participated in study concept and writing the paper. SD participated in data curation. AW critically revised the manuscript. https://orcid.org/0000-0002-9647-1872 Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID-19) infection Case report: a kidney transplant patient with mild COVID-19 A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-Cov2 pneumonia COVID-19 pneumonia in kidney transplant recipients -Where we are? Coronavirus disease 2019 pneumonia in immunosuppressed renal transplant recipients: a summary of 10 confirmed cases in Wuhan, China COVID-19 in solid organ transplant recipients: initial report from the US epicenter Kidney transplant programmes during the COVID-19 pandemic Kidney Transplantation with pre-symptomatic COVID-19 positive surgeon Position statement regarding the use of organs for transplantation in the era of SARS-Cov-2 epidemia On the use of corticosteroids for 2019-nCoV pneumonia Viral shedding prolongation in a kidney transplant patient with COVID-19 pneumonia Managing COVID-19 in renal transplant recipients: a review of recent literaturę and case supporting corticosteroid-sparing immunosuppression COVID-19 infection in solid organ transplant recipients: A single-center experience with patients immediately after transplantation