In kidney transplant patients with COVID-19, withdrawal of immunosuppressants safe

Immunosuppressed patients, in particular solid-organ transplant recipients (SOTs), have an increased risk of viral and bacterial infections as a consequence of diminished T cell immunity. Despite the overwhelming number of current publications on COVID-19 and kidney transplantation, there is scarce information on the evolution of alloimmune humoral response after reduction of immunosuppression in KTs hospitalized due to SARS-CoV-2 infection. So far, no data on the evolution of kidney graft function in COVID-19 survivors have been reported. Therefore, researchers of Spain conducted a study, to evaluate the impact of immunosuppression reduction/withdrawal during the course of COVID-19 on kidney graft function and to assess the influence of immunosuppression reduction/withdrawal on the possible appearance of de novo donor-specific antibodies (DSA) or changes in calculated panel reactive antibodies (cPRA).

Researchers reported the follow-up data of a cohort of 47 KTs admitted at two Spanish Kidney Transplant Units who survived COVID-19. They evaluated the impact of the management of immunosuppression during COVID-19on graft function and immunologic events. They assessed the outcomes of 47transplant recipients for 3months after hospital discharge for COVID-19 (median time from kidney transplantation to COVID-19 diagnosis was 109months). They further noted 8.5%of the study population had known donor-specific antibodies before admission and12.7% had a history of rejection episodes.

Key findings of the study were:

• The authors mentioned that at least one immunosuppressive agent was withdrawn, in 83% of patients with antimetabolites being the most frequent. They also noted that the steroids were not stopped and the dose was even increased in 15%of patients, as part of the treatment of COVID-19.

• After immunosuppressive drugs were suspended during a median time of 17 days, they observed no rejection episodes or de novo donor-specific antibodies for up to 3 months after discharge.

• They also found no significant changes occurred in calculated panel reactive antibodies.

• They reported that acute graft dysfunction was common (55%)and the severity was related to tacrolimus trough levels, which were higher in patients receiving antivirals.

• All patients recovered baseline kidney function by the end of follow-up.

The authors concluded, "our study has found that temporary withdrawal of immunosuppressive treatments in KTs with COVID-19 appears to be safe, since no patients experienced rejection episodes or developed de novo DSA. Additionally, most of AKI events in our cohort were probably due to CNI nephrotoxicity rather than directly associated to COVID-19."

For further information:

https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfab025/6123741