key: cord-1050579-zrsq834x
authors: Giorgakis, Emmanouil; Zehtaban, Shannon P.; Stevens, Amanda E.; Bhusal, Sushma; Burdine, Lyle
title: COVID‐19 in solid organ transplant recipients
date: 2020-07-27
journal: Transpl Infect Dis
DOI: 10.1111/tid.13419
sha: e84ffe8f9e15f8a8d7e6270685a6c8e543d543d3
doc_id: 1050579
cord_uid: zrsq834x

First identified in December 2019, the novel severe acute respiratory syndrome coronavirus-2 has spread widely. Coronavirus disease 2019 (COVID-19) was declared a pandemic in March 2020. Post-transplant patients appear to be particularly vulnerable. University of Arkansas for Medical Sciences (UAMS) is the only abdominal transplant institution in the state of Arkansas. Between March 25 to April 20, four transplant recipients with functioning grafts tested positive for COVID-19. Three were African American; one was Hispanic. Median age was 62.5 years (range 49-65). Three patients had received kidney transplant (KT). One had received a simultaneous liver-kidney (SLK).

To the Editor, half were morbidly obese. The SLK recipient was also diabetic with chronic kidney disease. None was a smoker. The median time since transplant was 292 days (range 70-523) ( Table 1) . All patients had been on tacrolimus and an antimetabolite. All but the SLK patient had been on prednisone.

The most common symptoms were fever, sore throat, and shortness of breath (75% of patients) ( Table 2) . Half patients reported fatigue, rhinorrhea, headache, cough, and nausea. Altered taste/ smell or diarrhea was reported by one. 75% had contracted COVID-19 by a family member. ¾ patients were hospitalized. At a median follow-up of 41 days (range 26-52), three patients have recovered. One developed acute respiratory distress syndrome (ARDS), was placed on mechanical ventilation, and eventually succumbed.

Three patients were lymphopenic on initial presentation.

Inflammatory markers were measured on inpatients. All patients had ferritin levels higher than 1300 ng/mL, c-reactive protein (CRP) above 5 mg/dL, and lactate dehydrogenase (LDH) higher than 200 IU/L. Troponin was above 0.5 ng/mL on the ARDS case (Table 2) .

All patients had received immunosuppression induction (Table 3) .

Half had received antithymocyte globulin. The ARDS patient had received basiliximab; that patient had had a history of monoclonal gammopathy of unknown significance and had received plasma exchange for antibody-mediated rejection.

There is currently no proven COVID-19 treatment. 3, 8 With the assumption that T-cell depression poses patients to higher viral infection risk, antimetabolites were discontinued. 9 Tacrolimus was withheld on hospitalized patients. 3,4,10,11 Azithromycin and hydroxychloroquine were administered to all hospitalized patients. [12] [13] [14] [15] On the ARDS patient, D-dimer and IL-6 were very high, corroborating reports of high D-dimer and IL-6 association to dismal outcome. 16 The patient received tocilizumab which reversed IL-6 up-trending yet did not alter the outcome.

Despite the small sample, our data resonate reports from the epidemic epicenter 3,4,11 : Disease tends to be more severe among the Abbreviations: ATG, antithymocyte globulin; azithro, azithromycin; d/c, discontinue; FK, tacrolimus; HCAP, healthcare-associated pneumonia; HCQ, hydroxychloroquine; MMF, mycophenolate mofetil; MPA, mycophenolic Acid; mTOR, mammalian target of rapamycin inhibitor; PNA, pneumonia; SRL, sirolimus; UTI, urinary tract infection; vanc, vancomycin; zosyn, piperacillin-tazobactam. a Patient had received plasma exchange × 6 in 11/2018 for the treatment of antibody-mediated rejection. confers a shield against severe COVID-19 elicited cytokine storm. 19 To be determined.

The authors of this manuscript have no conflicts of interest to disclose as described by Transplant Infectious Disease.

EG was responsible for conception, design, analysis and writing of the study; SZ, AS, SB, and LB were involved with the collection and interpretation of data, review and editing of the manuscript. 

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