Kidney transplant recipients recovering from COVID-19: Management strategies, outcomes

The outcomes of Kidney transplant (KT) after COVID-19 recovery are excellent with the absence of COVID-19 sequelae during follow-up and there does not seem to be a need for changes in the induction/immunosuppression regimen based on the severity of COVID-19, a study has found. The study has been published in eClinicalMedicine.

There is an enormous knowledge gap in management strategies, clinical outcomes, and follow-up after kidney transplantation (KT) in recipients that have recovered from coronavirus disease (COVID-19). The study was a multicentre, retrospective, cohort study that was conducted at transplant centers across India between June 26, 2020 (the index transplant date of the study) to December 1, 2021 (the last follow-up date). Through a nationwide collaboration of 23 participating centers, data of a total of 372 KT in COVID-19 recovered patients were collected.

Among 372 KT which included 38(10·21%) ABO-incompatible, 12(3·22%) sensitized 64(17·20%) coexisting donors with COVID-19 history, and 20 (5·37%) recipients with residual radiographic abnormalities, the incidence of AR was 34 (9·1%) with 1(0·26%) death censored graft loss, and 4(1·07%) all-cause mortality over a median (interquartile range) follow-up of 241 (106–350) days. In our cox hazard proportional analysis, the absence of oxygen requirement during COVID-19 compared to oxygen need [HR = 0·14(0·03–0·59); p-value = 0·0071], and use of thyroglobulin use compared to other induction strategies [HR = 0·17(0·03–0.95); p-value = 0·044] had a lower risk for AR. Degree of Human leukocyte antigen (HLA) DR mismatch had the highest risk of AR [HR = 10.2(1·74–65·83); p-value = 0·011]. With competing risk analysis, with death as a competing event, HLA DR mismatch, and oxygen requirement continued to be associated with AR. Age, gender, obesity, inflammatory markers, dialysis vintage, steroid use, sensitization, and ABO-incompatibility have not been associated with a higher risk of AR. The median duration between COVID-19 real-time polymerase test negativity to transplant was 88(40–145) days (overall), and ranged from 88(40–137), 65(42–120), 110(49–190), and 127(64–161) days in World Health Organization ordinal scale ≤ 3, 4, 5, and 6–7, respectively. There was no difference in the quality of life, tacrolimus levels, blood counts, and mean serum creatinine assessed in patients with a past COVID-19 infection independent of the severity.

Patients with severe clinical COVID-19 symptoms requiring oxygen or those with a less potent induction treatment had more frequent acute rejection (AR) in the report. This observation can be explained by the fact that the patients with increasing COVID-19 severity, who are well known to have greater co-morbidities, had a trend for a lower induction strategy. Based on the findings, we hypothesize that COVID-19 disease severity or recovery time may not serve as a criterion for reducing immunosuppression.

The strength of this study is based on an extensive and detailed follow-up, a large number of 100(27%) moderate-severe cases, feasibility and safety of transplants in 20(5·37%) recipients with residual radiological abnormality in the chest without active infection before transplant surgery, 38(10·21%) ABO-incompatible KT, 12(3·22%) sensitized patients, and 64(17·20%) donor/recipient pairs who recovered from COVID-19. We tested and demonstrated that the outcomes in the above-mentioned high-risk transplantation are also safe while yielding favorable graft outcomes.