key: cord-1033988-15g5iti9
authors: Wang, Tianyu; Qiu, Tao; Wang, Ming; Yuan, Yan; Chen, Zhongbao; Ma, Xiaoxiong; Zhang, Long; Zou, Jilin; Jin, Zeya; Xu, Yu; Zhang, Yalong; Zhou, Jiangqiao
title: A patient with end-stage renal disease who recovered from coronavirus disease 2019 then received a kidney transplant
date: 2021-04-22
journal: Transpl Immunol
DOI: 10.1016/j.trim.2021.101395
sha: 9ae3d978c4a1bb623b6a94986481ee0e363c475e
doc_id: 1033988
cord_uid: 15g5iti9

Since its emergence in December 2019 many end-stage renal disease (ESRD) patients have been infected with coronavirus disease 2019 (COVID-19). Herein, we describe the case of an ESRD patient who received a kidney transplant after recovering from COVID-19. We described the clinical course of COVID-19 and kidney transplant management, including the patient's symptoms, laboratory results, computed tomography, and antibody profiles. He recovered well, without complications. Chest computed tomography, PCR, and IgG results indicated no recurrence of COVID-19 during the subsequent two weeks. Therefore, kidney transplantation is feasible in an ESRD patient who has recovered from COVID-19, under a normal immunosuppressive regimen.

As of May 14, more than four million people have confirmed coronavirus disease 2019 and more than 290,000 patients have died 1 . Patients with end-stage renal disease (ESRD) are susceptible to infection with the virus that causes COVID-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to frequent hospital visitation for hemodialysis, and their reduced immunity status 2 . absorbed, and multiple SARS-CoV-2 PCR tests were negative. On 21 February 2020 SARS-CoV-2 antibody testing indicated an IgM titer of 392 AU/mL and an IgG titer of 76 AU/mL. After a long period of treatment the patient recovered, and he was discharged from the hospital on 28 February 2020 and recommenced regular hemodialysis. Multiple subsequent CT examinations indicated that the lesions were slowly absorbed. Multiple subsequent SARS-CoV-2 PCR tests conducted at multiple sites were all negative, and serum SARS-CoV-2 IgG remained positive and serum IgM gradually disappeared ( Figure 1 ).

The patient had recently moved to Wuhan and routinely traveled to the dialysis room and hospital. These risk factors led to susceptibility to SARS-CoV-2 infection, and there were no confirmed cases of SARS-CoV-2 infection in any of his family members. The patient-who had come to Wuhan from far away hoping to receive a kidney transplant-experienced a huge shock, but fortunately he did recover from COVID-19. The next questions were whether to proceed with a kidney transplant, what the best timing for a transplant was, and whether any altered immune suppression regimen would be required.

To the best of our knowledge 6 lung transplants have been performed to save the lives of critical COVID-19 patients in China, and there were no recurrences of COVID-19 in these patients despite the administration of immunosuppressant drugs 7,10 . After immunosuppressant drug withdrawal and treatment with antiviral drugs many organ transplant patients have also recovered from COVID-19, and there was no recurrence of COVID-19 associated with restarting immunosuppressants to J o u r n a l P r e -p r o o f Journal Pre-proof prevent rejection 8, 9 . The traditional immunological view is that IgG antibody is the main protective isotype, and it may have been helpful in preventing late COVID-19 in the current patient. After detailed discussion and literature review we surmised that a kidney transplant was feasible. Clinical symptoms, CT imaging, PCR testing, and antibody levels all indicated a complete recovery. The patient was effectively no different from a normal person. CT imaging is shown in Figure 2 . The complete timeline of the patient's clinical test results and treatment is shown in Figure 1 .

Fortunately, a matched kidney was allocated to the patient in early May 2020. A 45-year-old man donated an organ after brain death caused by cerebral hemorrhage.

Creatine was 51 µmol/L and the estimated glomerular filtration rate was 123 mL/min. Ultrasound of the kidney was normal, and a urine sediment test was negative.

Procalcitonin and other infection markers were also negative. A rigorous evaluation of the donor was conducted to exclude COVID-19, including routine blood tests, CT, nasal, throat, and anal swab PCR tests, and SARS-CoV-2 antibody testing.

Basiliximab (20 mg on day 0 and 20 mg on day 4) and methylprednisolone (500 mg per day on days 0-3) were used as induction drugs, and mycophenolic acid + Tacrolimus + prednisone triple maintenance immunosuppressive therapy was administered. A routine operation was performed under strict protective measures. A series of PCR tests and antibody titer determinations were conducted after the transplant. As shown in in Table 1 , renal function was restored quickly, other indicators were similar to those of normal transplant patients (Table 1) . After transplantation, we continuously took the blood, urine, nasopharyngeal swab, J o u r n a l P r e -p r o o f Journal Pre-proof oropharyngeal swab and anal swab every day for SARS-CoV-2 detection. There were no post-transplant SARS-CoV-2-positive PCR results ( Table 2 ).The SARS-CoV-2

IgM titer was very low and considered as negative level. Although the IgM titer value was positive, the titer gradually decreased comparable to post-COVID-19 recovery pre-transplant levels ( Figure 3 ). Tests for liver function and other inflammatory markers were also normal 2 weeks post-transplant (Table 1 ).

Kidney transplantation is an important therapy for end-stage renal disease. It is used to improve quality of life in ESRD patients, in which cases it is not regarded as an urgently needed salvage therapy. To our knowledge to date there have been no reports of ESRD patients recovering from COVID-19 then receiving a kidney transplant. 6 cases lung transplants have been performed to save patients with pulmonary fibrosis and respiratory failure caused by COVID-19 infection 7,10 . No recurrence of COVID-19 was detected in those pulmonary transplant patients, and there were no subsequent cases of COVID-19 in associated medical staff.

In the present patient it was concluded that a kidney transplant was appropriate, thus only the correct timing of it remained to be decided. There is currently no guideline for kidney transplants in ESRD patients who have recovered from COVID-19 pneumonia. In lung transplant waiting-list patients infected with SARS-CoV-2 it is recommended that the results of two viral RNA tests performed at least 24 hours apart should be negative prior to proceeding with a transplant. Test After nearly one year's follow-up, the patient's renal function is stable, blood creatinine is maintained between 110-130mmol/L, WBC is maintained between 6.1-6.5mmol/L, Hb is maintained between 130-145g/L, erythropoietin is not used, and 24-hour urine volume is maintained between 2000-3000ml. Furosemide was not administered orally. The current immunosuppressive regimen for the patient was 

Information on the donor: The donor is a brain-dead painent with no kinship with the recipient. And the donor was deceased.

The transplant operation and publication of this case report were proved by the Ethics Committee of Wuhan University Renmin Hospital, Wuhan, China.

The patient whose case is described in the report has provided written informed consent for its publication

All authors agreement with the publication of this report.

All authors declare that there are no conflicts of interest.

The reporting of this case was supported by the National Natural Science Foundation 

Covid-19 Update

We thank Kang Jing from Renmin Hospital of Wuhan University for providing the CT J o u r n a l P r e -p r o o f Journal Pre-proof imaging information, and we thank the patient whose case is described in this report.