Unusually high rates of acute rejection during the COVID-19 pandemic: cause for concern?
Authors: Fahad Aziz, Brenda Muth, Sandesh Parajuli, Neetika Garg, Maha Mohamed, Didier Mandelbrot, Arjang Djamali
Journal: Kidney International (2020)

The coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented health care, economic, and psychosocial crises. We report a case series of 6 kidney and pancreas transplant recipients who presented in an unusually short time frame during the COVID-19 pandemic with transplant organ dysfunction and rejection (Table 1). Mean time from the time of transplant to the current presentation was 7.3 ± 4 years. Of these 6 patients, 3 had severe allograft dysfunction requiring initiation of dialysis or insulin therapy. Two had a previous history of missing clinic visits. All patients presented with nonadherence during the "stay-at-home" social distancing orders. As the general socioeconomic status of our population is slightly above the general transplant population in the United States, these findings are concerning.Table 1Kidney and SPK transplant recipients admitted with acute rejection within 1 week of stay-at-home state orders during COVID-19 pandemicPtSexAge (yr)RaceTime since transplant (yr)Transplant typeInductionCause of ESRDMaintenance ISScr baseline (mg/dl)NonadherencePresentationScr at presentation (mg/dl)BiopsyTreatmentOutcomes1M43W5LUKTrATGPCKDT/M/P1.6YesNausea, vomiting30NDNoneDialysis2M37AA7LUKTIL-2 (−)HTNT/M/P1.3YesNausea, vomiting16TCMRPulse steroidsDialysis3M38W11SPKrATGDMT/M/P1YesNausea, vomiting1.5NDNoneFailed pancreas4F22W5DDrATGMCKDT/M/P0.9YesElevated UPC1ABMRPulse steroids i.v. Ig5F37W3LUKTrATGHTNT/M/P1.5YesElevated creatinine2.5MixedPulse steroids i.v. Ig6F59AA5DDrATGHTNT/L/P2YesElevated creatinine3ABMRIncrease baseline ISAA, African American; ABMR, antibody-mediated rejection; COVID-19, coronavirus disease 2019; DD, deceased donor; DM, diabetes mellitus; ESRD, end-stage renal disease; F, female; HTN, hypertension; IL-2 (−), interleukin-2 blockade; IS, immunosuppression; LUKT, living unrelated kidney transplant; M, male; MCKD, medullary cystic kidney disease; ND, not done; PCKD, polycystic kidney disease; Pt, patient; rATG, rabbit antithymocyte globulin; Scr, serum creatinine; SPK, simultaneous pancreas-kidney transplantation; TCMR, T cell–mediated rejection; T/L/P, tacrolimus, leflunomide, prednisone; T/M/P, tacrolimus, mycophenolate, prednisone; UPC, urine protein-creatinine ratio; W, white. Open table in a new tab AA, African American; ABMR, antibody-mediated rejection; COVID-19, coronavirus disease 2019; DD, deceased donor; DM, diabetes mellitus; ESRD, end-stage renal disease; F, female; HTN, hypertension; IL-2 (−), interleukin-2 blockade; IS, immunosuppression; LUKT, living unrelated kidney transplant; M, male; MCKD, medullary cystic kidney disease; ND, not done; PCKD, polycystic kidney disease; Pt, patient; rATG, rabbit antithymocyte globulin; Scr, serum creatinine; SPK, simultaneous pancreas-kidney transplantation; TCMR, T cell–mediated rejection; T/L/P, tacrolimus, leflunomide, prednisone; T/M/P, tacrolimus, mycophenolate, prednisone; UPC, urine protein-creatinine ratio; W, white. Kidney transplant recipients infected with coronavirus have a significant risk of graft loss and death.1Akalin E. Azzi Y. Bartash R. et al.Covid-19 and kidney transplantation.N Engl J Med. 2020; 382: 2475-2477Crossref PubMed Scopus (632) Google Scholar, 2Banerjee D. Popoola J. Shah S. et al.COVID-19 infection in kidney transplant recipients.Kidney Int. 2020; 97: 1076-1082Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar, 3Columbia University Kidney Transplant ProgramEarly description of coronavirus 2019 disease in kidney transplant recipients in New York.J Am Soc Nephrol. 2020; 31: 1150-1156Crossref PubMed Scopus (191) Google Scholar However, the psychosocial impact of the COVID-19 pandemic on graft and patient outcomes in non-COVID kidney transplant recipients is unclear. The federal and local governments have enforced confinement orders to mitigate the spread of infection, but these restrictions have also limited health care access to "essential visits" only. Posttransplant management of solid organ transplant recipients is further compromised by loss of health insurance for many patients and cost reduction strategies at transplant centers. Our case series suggests that rigorous, medical, and psychosocial risk stratification strategies are needed to avoid untoward outcomes in stable solid organ transplant recipients. Despite, or because of, the current financial crisis, the government and transplant centers need to consider further investment in life-long immunosuppression coverage,4Kadatz M. Gill J.S. Gill J. et al.Economic evaluation of extending Medicare immunosuppressive drug coverage for kidney transplant recipients in the current era.J Am Soc Nephrol. 2020; 31: 218-228Crossref PubMed Scopus (13) Google Scholar telehealth, mobile phlebotomy, noninvasive diagnostic tools, and person-power to keep their patients safe. COVID-19 infection in kidney transplant recipientsKidney InternationalVol. 97Issue 6PreviewBy 21 March 2020 infections related to the novel coronavirus SARS-CoV-2 had affected people from 177 countries and caused 11,252 reported deaths worldwide. Little is known about risk, presentation and outcomes of SARS-CoV-2 (COVID-19) infection in kidney transplantation recipients, who may be at high-risk due to long-term immunosuppression, comorbidity and residual chronic kidney disease. Whilst COVID-19 is predominantly a respiratory disease, in severe cases it can cause kidney and multi-organ failure. Full-Text PDF Open AccessThe forgotten fallen: painful reality of a pandemicKidney InternationalVol. 98Issue 2PreviewWhen coronavirus disease 2019 (COVID-19) became a global pandemic, health professionals were particularly concerned about the potential risk it might impose on the most vulnerable groups, including our kidney and kidney pancreas transplant recipients. Emerging data from the United States and Europe indicated the risk of early deaths for hospitalized transplant recipients is at least 20%,1 and these patients experienced more rapid disease progression and lower lymphocyte counts than immunocompetent patients with COVID-19. 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