Fatal SARS-CoV-2 infection in a renal transplant recipient

SARS-CoV-2 mechanisms of cell tropism in various organs considering host factors

A critical step in the drug design for SARS-CoV-2 is to discover its molecular targets. This study comprehensively reviewed the molecular mechanisms of SARS-CoV-2, exploring host cell tropism and interaction targets crucial for cell entry. The findings revealed that beyond ACE2 as the primary entry receptor, alternative receptors, co-receptors, and several proteases such as TMPRSS2, Furin, Cathepsin L, and ADAM play critical roles in virus entry and subsequent pathogenesis. Additionally, SARS-CoV-2 displays tropism in various human organs due to its diverse receptors. This review delves into the intricate details of receptors, host proteases, and the involvement of each organ. Polymorphisms in the ACE2 receptor and mutations in the spike or its RBD region contribute to the emergence of variants like Alpha, Beta, Gamma, Delta, and Omicron, impacting the pathogenicity of SARS-CoV-2. The challenge posed by mutations raises questions about the effectiveness of existing vaccines and drugs, necessitating consideration for updates in their formulations. In the urgency of these critical situations, repurposed drugs such as Camostat Mesylate and Nafamostat Mesylate emerge as viable pharmaceutical options. Numerous drugs are involved in inhibiting receptors and host factors crucial for SARS-CoV-2 entry, with most discussed in this review. In conclusion, this study may provide valuable insights to inform decisions in therapeutic approaches.

The Outcome of COVID-19 Infection on Kidney Transplantation Recipients in Southern Saudi Arabia: Single-Center Experience

BACKGROUND

To report the incidence, risk factors, and outcome of severe COVID-19 disease in kidney transplant recipients attending a Saudi hospital at a single center in the Kingdom of Saudi Arabia.

METHODS

A retrospective chart-based cohort study involving all kidney transplant recipients tested for COVID-19 in the Armed Forces Hospital Southern Region, KSA.

RESULTS

Of 532 kidney transplant recipients who reported to the center, from March 2020 to June 2022, 180 were tested for COVID-19. Of these recipients, 31 (17%) tested positive. Among the 31 positive recipients, 11 were treated at home, 15 were admitted to the noncritical isolation ward, and 5 were admitted to the intensive care unit (ICU). Older age (P = .0001), higher body mass index (P = .0001), and history of hypertension (P = .0023) were more frequent in the COVID-19-positive recipients. Admission to the ICU was more frequent in older recipients (P = .0322) with a history of ischemic heart disease (P = .06) and higher creatinine baseline (P = .08) presenting with dyspnea (P = .0174), and acute allograft dysfunction (P = .002). In the ICU group, 4 (80%) patients required hemodialysis, and 4 (80%) died.

CONCLUSIONS

Kidney transplant recipients with COVID-19 could have a higher risk for developing acute kidney injury, dialysis, and mortality than the general population. ICU admission and renal replacement therapy were more evident in older recipients with a history of ischemic heart disease, presenting with shortness of breath (P = .017) and a higher serum creatinine baseline. Acute allograft dysfunction was the independent predictor of mortality among patients admitted to the ICU.

Favipiravir in Kidney Transplant Recipients With COVID-19: A Romanian Case Series

Background

Favipiravir (FPV) is an orally administrable antiviral drug that selectively inhibits RNA-dependent RNA polymerase and has been repurposed for COVID-19 treatment. There is limited information on the use of FPV in kidney transplant recipients (KTx), who often have multiple comorbidities and run a higher risk for death from COVID-19.

Methods

We retrospectively reviewed all KTx at our institution who got sick with COVID-19 between March 1, 2020, and May 31, 2021, and who received FPV (loading dose of 1800 mg × 2 on day 1, maintenance dose 2  ×  800 mg/d for 5-14 days) as part of their COVID treatment. We analyzed demographics, clinical course, laboratory data, management, and outcome.

Results

Nine KTx with COVID-19 received FPV; all were hospitalized. The median age was 52 years (range, 32-60 years), and women were predominant (77.7%). Eight KTx had pulmonary involvement on chest radiograph. On admission 1 patient had mild, 5 had moderate, 2 had severe, and 1 had critical disease. Leukopenia and increased creatinine were universally noted. Three patients had disease progression under treatment. Seven patients (77.7%) required additional oxygen, and 4 (57.1%) needed intensive care unit admission. Three KTx died, resulting in an overall mortality of 33.3%. Survivors did not show increased transaminases or creatinine during or after FPV treatment; leukocytes, neutrophils, and platelets improved on discharge compared with admission values.

Conclusions

FPV appears well tolerated by KTx with COVID-19, but its clinical benefit remains unclear. Larger analyses are needed.

Covid-19 in kidney transplant recipients with immunosuppressive therapy

BACKGROUND

Since the outbreak of COVID-19, various treatments have been frequently reported for patients infected with this virus, especially in transplant patients/recipients. Objective: Investigating of kidney transplant patients under immunosuppressive therapy infected with COVID-19 can pave the way to understanding, handling, and treatment of COVID-19.

METHODS

We had a brief review of the literature on immunosuppressive therapy in kidney transplants infected with COVID-19. This was based on the PubMed Database with keywords "kidney, transplant, COVID-19, and immunosuppress" after hospitalization of kidney transplantation infected with COVID-19. He had already been recorded in the Organ Transplant Registry (ID≠ 64510) of Tabriz University of Medical Sciences /Iran.

RESULTS

We reported the clinical course of a 45-year-old man with a history of kidney transplantation and immunotherapy who was infected with COVID-19 with respiratory infections and positive RT-PCR (Real-time polymerase chain reaction). He was treated with hydroxychloroquine, Kaletra, CellCept, and prednisolone for 5 days, and finally discharged from the hospital. In addition, reviewing of 47 papers with 851 samples showed that immunosuppressant medications alone could be a therapeutic choice in kidney transplants infected with COVID-19 with careful management.

CONCLUSION

Patients with organ transplantation infected with COVID-19 may show different clinical signs, clinical course, and prognosis due to underlying diseases and the use of immunosuppressant medications. It might be best to continue taking the immunosuppressant medications but modify them based on the patients' conditions such as clinical symptoms, laboratory results, paraclinical examinations.

SARS-CoV-2 in Solid Organ Transplant Recipients: A Structured Review of 2020

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is challenging health systems all over the world. Particularly high-risk groups show considerable mortality rates after infection. In 2020, a huge number of case reports, case series, and consecutively various systematic reviews have been published reporting on morbidity and mortality risk connected with SARS-CoV-2 in solid organ transplant (SOT) recipients. However, this vast array of publications resulted in an increasing complexity of the field, overwhelming even for the expert reader.

METHODS

We performed a structured literature review comprising electronic databases, transplant journals, and literature from previous systematic reviews covering the entire year 2020. From 164 included articles, we identified 3451 cases of SARS-CoV-2-infected SOT recipients.

RESULTS

Infections resulted in a hospitalization rate of 84% and 24% intensive care unit admissions in the included patients. Whereas 53.6% of patients were reported to have recovered, cross-sectional overall mortality reported after coronavirus disease 2019 (COVID-19) was at 21.1%. Synoptic data concerning immunosuppressive medication attested to the reduction or withdrawal of antimetabolites (81.9%) and calcineurin inhibitors (48.9%) as a frequent adjustment. In contrast, steroids were reported to be increased in 46.8% of SOT recipients.

CONCLUSIONS

COVID-19 in SOT recipients is associated with high morbidity and mortality worldwide. Conforming with current guidelines, modifications of immunosuppressive therapies mostly comprised a reduction or withdrawal of antimetabolites and calcineurin inhibitors, while frequently maintaining or even increasing steroids. Here, we provide an accessible overview to the topic and synoptic estimates of expectable outcomes regarding in-hospital mortality of SOT recipients with COVID-19.

The Management of Immunosuppression in Kidney Transplant Recipients with COVID-19 Disease: An Update and Systematic Review of the Literature

Background and Objectives: In the era of the coronavirus disease 2019 (COVID-19) pandemic, the management of immunosuppressive (IS) therapy in kidney transplant (KT) recipients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requires attention. It is not yet understood whether IS therapy may protect from the cytokine storm induced by SARS-CoV-2 infection or a temporary adjustment/withdrawal of IS therapy to restore the immune system may be necessary. We performed a systematic literature review to investigate the current management of IS therapy in KT recipients with COVID-1. Materials and Methods: Out of 71 articles published from 1 February 2020 until 30 October 2020, 554 KT recipients with SARS-CoV-2 infection were identified. Results: Modifications of IS therapy were based on the clinical conditions. For asymptomatic patients or those with mild COVID-19 symptoms, a "wait and see approach" was mostly used; a suspension of antimetabolites drugs (347/461, 75.27%) or mTOR inhibitors (38/48, 79.2%) was adopted in the majority of patients with symptomatic COVID-19 infections. For CNIs, the most frequent attitude was their maintenance (243/502, 48.4%) or dose-reduction (99/502, 19.72%) in patients asymptomatic or with mild COVID-19 symptoms, while drug withdrawal was the preferred choice in severely symptomatic patients (160/450, 31.87%). A discontinuation of all IS drugs was used only in severely symptomatic COVID-19 patients on invasive mechanical ventilation. Renal function remained stable in 422(76.17%) recipients, while 49(8.84%) patients experienced graft loss. Eight (1.44%) patients experienced a worsening of renal function. The overall mortality was 21.84%, and 53(9.56%) patients died with functioning grafts. Conclusion: A tailored approach to the patient has been the preferred strategy for the management of IS therapy in KT recipients, taking into account the clinical conditions of patients and the potential interactions between IS and antiviral drugs, in the attempt to balance the risks of COVID-19-related complications and those due to rejection or graft loss.

COVID-19 progression in kidney transplant recipients: a single-center case series

The novel coronavirus disease 2019 (COVID-19) is a respiratory infection that has received much attention due to its rapid expansion. Currently, it has been revealed that patients with underlying disease, especially those with kidney disease are more prone to develop complications. Some studies associate kidney transplantation as a risk factor for COVID-19 progression; however, epidemiologic data that demonstrate this are amazingly rare. Considering the importance of the topic, we report on six kidney transplant recipients (median age 47 [41–55]) with confirmed or clinically suspected COVID-19. The most common admission presentations were fever (83.3%), dyspnea, and myalgia. At baseline, immunosuppressive therapy was ceased, prednisolone dose was increased, and all patients received antiviral treatment including hydroxychloroquine and umifenovir. After a median follow-up of 11.5 days from admission, six patients (100%) developed acute kidney injury (AKI), 50% required intensive care unit (ICU) admission, and two patients (33.3%) deceased as a result of deterioration in respiratory status. Overall, these findings demonstrate that respiratory involvement may be a risk indicator of in-hospital mortality in kidney recipients with COVID-19. In addition, AKI development in kidney recipients with COVID-19 is of utmost importance given the higher AKI occurrence in these patients compared with others. Therefore, more intensive attention should be paid to kidney transplant recipients with COVID-19.

Successful pulsed methylprednisolone and convalescent plasma treatment in a case of a renal transplant recipient with COVID-19 positive pneumonia: a case report

Coronavirus 2019 disease (COVID-19) is a deadly disease that was first seen in Wuhan, China, and primarily affects the respiratory system, but also has different systemic involvements. It has caused 89 million cases and 1.9 million deaths worldwide. COVID-19 positive renal transplant recipients have a higher mortality rate than COVID-19 patients in the normal population. There is no specific treatment and follow-up protocol for COVID-19 infection in transplant recipients. COVID-19 treatment and immunosuppressive therapy choices are controversial. Recently, pulse steroid therapies have been used in cases with severe COVID-19 pneumonia. Convalescent plasma therapy is used limitedly in COVID-19 patients. Our 49-year-old male patient has been a recipient of a renal transplant from a cadaver for 6 years. We aimed to make an additional contribution by presenting our patient to the literature whose COVID-19 PCR-RT test performed in the emergency department due to the complaints of fever, shortness of breath, and cough for five days was positive and had moderate COVID-19 pneumonia in thorax tomography and had serious clinical and radiological improvement after pulsed methylprednisolone and convalescent plasma therapy in the early period.

Predictors of disease severity and outcome of hospitalized renal transplant recipients with COVID-19 infection: a systematic review of a globally representative sample

Introduction. COVID-19 presents a special challenge to the kidney transplant population.Methods. A systematic review of articles that examined COVID-19 in kidney transplant recipients was performed. Patients' demographics, clinical, laboratory and radiological presentations, immunosuppression modification, and COVID-19 specific management were abstracted and analyzed. COVID-19 severity was classified into mild, moderate, and severe. Disease outcome was classified by whether the patient was discharged, still hospitalized, or died.Results. 44 articles reporting individual data and 13 articles reporting aggregated data on 149 and 561 kidney transplant recipients respectively with COVID-19 from Asia, Europe and America fulfilled all inclusion and exclusion criteria. Among studies reporting case specific data, 76% of cases had severe disease. Compared to patients with mild/moderate disease, patients with severe disease had higher CRP, LDH, Ferritin, D-dimer and were more likely to have bilateral lung involvement at presentation and longer time since transplantation (P < 0.05 for all). Recipients' age, gender and comorbidities did not impact disease severity. Patients with severe disease had a more aggressive CNI reduction and more antiviral medications utilization. Outcome was reported on 145 cases, of those 34 (23%) died all with severe disease. Longer duration from transplant to disease diagnosis, hypoxia and higher LDH were associated with mortality (P < 0.05). Different immunosuppression reduction strategies, high dose parenteral corticosteroids use and various antiviral combinations did not demonstrate survival advantage. Similar finding was observed for studies reporting aggregated data.Conclusion. COVID-19 in kidney transplant patients is associated with high rate of disease severity and fatality. Higher LDH and longer time since transplantation predicted both disease severity and mortality. None of the COVID-19 specific treatment correlated with, or improved disease outcome in kidney transplant recipients.

Effect of immunosuppression maintenance in solid organ transplant recipients with COVID-19: Systematic review and meta-analysis

Background

The aim of this study was to assess the effect of continuing immune suppressive therapy in solid organ transplant recipients (SOTR) with coronavirus disease 2019 (COVID‐19).

Methods

Systematic review and meta‐analysis of data on 202 SOTR with COVID‐19, published as case reports or case series. We extracted clinical, hemato‐chemical, imaging, treatment, and outcome data.

Results

Most patients were kidney recipients (61.9%), males (68.8%), with median age of 57 years. The majority was on tacrolimus (73.5%) and mycophenolate (65.8%). Mortality was 18.8%, but an equal proportion was still hospitalized at last follow up. Immune suppressive therapy was withheld in 77.2% of patients, either partially or completely. Tacrolimus was continued in 50%. One third of survivors that continued immunosuppressants were on dual therapy plus steroids. None of those who continued immunosuppressants developed critical COVID‐19 disease. Age (OR 1.07, 95% CI 1‐1.11, P = .001) and lopinavir/ritonavir use (OR 3.3, 95%CI 1.2‐8.5, P = .013) were independent predictors of mortality while immunosuppression maintenance (OR 0.067, 95% CI 0.008‐0.558, P = .012) and tacrolimus continuation (OR 0.3, 95% CI 0.1‐0.7, P = .013) were independent predictors of survival.

Conclusions

Our data suggest that maintaining immune suppression might be safe in SOTR with moderate and severe COVID‐19. Specifically, receiving tacrolimus could be beneficial for COVID‐19 SOTR. Because of the quality of the available evidence, no definitive guidance on how to manage SOTR with COVID‐19 can be derived from our data.

COVID-19 in solid organ transplant recipients: A systematic review and meta-analysis of current literature

Severe acute respiratory virus syndrome 2 (SARS-CoV-2) has led to a worldwide pandemic. Early studies in solid organ transplant (SOT) recipients suggested a wide variety of presentations, however, there remains a paucity of robust data in this population. We conducted a systematic review and meta-analysis of SOT recipients with SARS-CoV-2 infection from January 1st t October 9th, 2020. Pooled incidence of symptoms, treatments and outcomes were assessed. Two hundred and fifteen studies were included for systematic review and 60 for meta-analysis. We identified 2,772 unique SOT recipients including 1,500 kidney, 505 liver, 141 heart and 97 lung. Most common presenting symptoms were fever and cough in 70.2% and 63.8% respectively. Majority (81%) required hospital admission. Immunosuppressive medications, especially antimetabolites, were decreased in 76.2%. Hydroxychloroquine and interleukin six antagonists were administered in59.5% and 14.9% respectively, while only few patients received remdesivir and convalescent plasma. Intensive care unit admission was 29% from amongst hospitalized patients. Only few studies reported secondary infections. Overall mortality was 18.6%. Our analysis shows a high incidence of hospital admission in SOT recipients with SARS-CoV-2 infection. As management of SARS-CoV-2 continues to evolve, long-term outcomes among SOT recipients should be assessed in future studies.

A Systematic Review of COVID-19 Infection in Kidney Transplant Recipients: A Universal Effort to Preserve Patients' Lives and Allografts

The coronavirus disease 2019 (COVID-19) pandemic has posed a significant challenge to physicians and healthcare systems worldwide. Evidence about kidney transplant (KTx) recipients is still limited. A systematic literature review was performed. We included 63 articles published from 1 January until 7 July 2020, reporting on 420 adult KTx recipients with confirmed COVID-19. The mean age of patients was 55 ± 15 years. There was a male predominance (67%). The majority (74%) were deceased donor recipients, and 23% were recently transplanted (<1 year). Most patients (88%) had at least one comorbidity, 29% had two, and 18% three. Ninety-three percent of cases were hospitalized. Among them, 30% were admitted to the intensive care unit, 45% developed acute respiratory distress syndrome, and 44% had acute kidney injury with 23% needing renal replacement therapy. From the hospitalized patients a total of 22% died, 59% were discharged, and 19% were still in hospital at the time of publication. Immunosuppression was reduced in 27%, discontinued in 31%, and remained unchanged in 5%. Hydroxychloroquine was administered to 78% of patients, antibiotics to 73%, and antivirals to 30% while 25% received corticosteroid boluses, 28% received anti-interleukin agents, and 8% were given immunoglobulin. The main finding of our analysis was that the incidence of COVID-19 among kidney transplant patients is not particularly high, but when they do get infected, this is related to significant morbidity and mortality.