COVID-19 in Solid Organ Transplant Recipients

Initial Report From the US Epicenter

Marcus R. Pereira; Sumit Mohan; David J. Cohen; Syed A. Husain; Geoffrey K. Dube; Lloyd E. Ratner; Selim Arcasoy; Meghan M. Aversa; Luke J. Benvenuto; Darshana M. Dadhania; Sandip Kapur; Lorna M. Dove; Robert S. Brown Jr.; Russell E. Rosenblatt; Benjamin Samstein; Nir Uriel; Maryjane A. Farr; Michael Satlin; Catherine B. Small; Thomas J. Walsh; Rosy P. Kodiyanplakkal; Benjamin A. Miko; Justin G. Aaron; Demetra S. Tsapepas; Jean C. Emond; Elizabeth C. Verna

Disclosures

American Journal of Transplantation. 2020;20(7):1800-1808. 

In This Article

Abstract and Introduction

Abstract

Solid organ transplant recipients may be at a high risk for SARS-CoV-2 infection and poor associated outcomes. We herein report our initial experience with solid organ transplant recipients with SARS-CoV-2 infection at two centers during the first 3 weeks of the outbreak in New York City. Baseline characteristics, clinical presentation, antiviral and immunosuppressive management were compared between patients with mild/moderate and severe disease (defined as ICU admission, intubation or death). Ninety patients were analyzed with a median age of 57 years. Forty-six were kidney recipients, 17 lung, 13 liver, 9 heart, and 5 dual-organ transplants. The most common presenting symptoms were fever (70%), cough (59%), and dyspnea (43%). Twenty-two (24%) had mild, 41 (46%) moderate, and 27 (30%) severe disease. Among the 68 hospitalized patients, 12% required non-rebreather and 35% required intubation. 91% received hydroxychloroquine, 66% azithromycin, 3% remdesivir, 21% tocilizumab, and 24% bolus steroids. Sixteen patients died (18% overall, 24% of hospitalized, 52% of ICU) and 37 (54%) were discharged. In this initial cohort, transplant recipients with COVID-19 appear to have more severe outcomes, although testing limitations likely led to undercounting of mild/asymptomatic cases. As this outbreak unfolds, COVID-19 has the potential to severely impact solid organ transplant recipients.

Introduction

With at least 75 795 cases of COVID-19 and 1550 deaths by March 31, 2020, New York State has become the current epicenter of COVID-19 in the United States.[1] As this pandemic continues to unfold, data on the clinical characteristics and outcomes of COVID-19 are emerging across continents.[2–5] It has been reported that approximately 20% of those with COVID-19 suffer moderate or severe symptoms and 5% progress to critical disease.[6] The case fatality rate so far has ranged widely from 1% to 7.2% overall reaching up to 49% among the critically ill.[6,7] Risk factors identified for severe disease described to date include older age and the presence of comorbidities such as diabetes, hypertension, chronic kidney disease, morbid obesity, coronary heart disease, and chronic lung disease.[3]

The impact of chronic immunosuppression on outcomes of COVID-19 is not known but is potentially highly relevant since host inflammatory responses appear to constitute an important cause of associated organ injury. Most cohorts reported thus far do not include immunosuppressed patients or details about immunosuppression-related risk factors, including a history of solid organ transplantation. While transplant recipients have a high prevalence of the comorbidities that have been established as risk factors for severe disease, as the role of the immune system and inflammatory response to infection is now being elucidated, there is also significant debate regarding the role of immunosuppression in the pathogenesis and outcome of COVID-19. Despite widespread concern about the potential for high prevalence and severity of COVID-19 among transplant recipients, data on this population is lacking so far aside from a few single patient case reports.[8–10] As transplant centers around the United States and the world prepare for a rising incidence of disease, important questions around differences in disease susceptibility, clinical presentation, severity and transplant specific management of both antiviral therapy and immunosuppression remain unanswered. Here we present the clinical characteristics of solid organ transplant recipients with COVID-19 at two large academic centers during the initial 3 weeks of the epidemic in New York City.

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