Clinical course and approaches to therapy in kidney transplant recipients with the novel COVID-19 disease

Abstract

The COVID-19 pandemic has had global consequences due to the wide spread of the infection in the world, lack of currently proven effective therapy, resistance to treatment in a significant proportion of those affected and, as a result, high mortality, especially among high-risk groups. Kidney transplant recipients with coronavirus-induced pneumonia are among the most problematic categories of patients. This patient cohort experiences a severe form of the disease, taking into account a combination of risk factors, such as long-term immunosuppression, comorbid background of patients, and consequences of chronic kidney disease. Difficulties in the management of recipients with COVID-19 are also down to the limitation of the use of drugs due to adverse drug-drug interactions. Objective: to analyze the course of COVID-19 disease in organ recipients, to assess the factors influencing the prognosis of the disease, and to optimize approaches to treatment of these patients. Materials and methods. During the period from April 15, 2020 to June 15, 2020, 68 people (38 men and 30 women) were hospitalized at our clinic. Their average age was 49.7 ± 9.2 years (22 to 70 years). COVID-19 diagnosis was verified by PCR. Multispiral computed tomography (MSCT) scans showed that in all cases, there were characteristic lung lesions of varying degrees of severity. Results. Out of the 68 people treated, 61 (89.8%) were discharged with recovery, 7 patients died. So, the mortality rate was 10.2%. This indicator did not depend on age and gender. First of all, mortality depended on the severity of lung lesions: at CT4 it was 43% (3/7), at CT3 – 11.1% (4/36), there were no deaths in patients with CT2. There was a 100% mortality among patients who received mechanical ventilation. Severity of graft dysfunction was also an important prognostic factor: with moderate dysfunction, this indicator was 8% (5/63), while with severe dysfunction it was 40% (2 out of 5). Besides, a more severe prognosis was observed in patients in the early post-transplant period: 5 patients out of the 7 who died of COVID-19 (71%) lived for less than a year after kidney allotransplantation (ATP). Mortality in this category of patients was 24%, while in the period from 1 to 5 years, this indicator was 13.6%; no deaths were recorded among patients with a period of over 5 years after ATP. All patients received antibacterial (levofloxacin or azithromycin) and antiviral (hydroxychloroquine) therapy. In all cases, the baseline immunosuppressive therapy (IST) was changed, including withdrawal of mycophenolic acid preparations, minimization of the calcineurin inhibitor dose (target concentration 1.5–3 ng/mL for tacrolimus and 30–50 ng/mL for cyclosporine), and increase in prednisolone dose by 5 mg relative to the current one. About 78% of cases received pathogenetic therapy with anti-interleukin monoclonal antibodies (mainly tocilizumab). These patients also received intravenous immunoglobulin at 10 g average dose. In severe COVID-19 accompanied in by clinical and laboratory signs of thrombotic microangiopathy 22% of cases, plasma exchange sessions and/or infusion of fresh frozen plasma and dose adjustment of low molecular weight heparins were performed. Conclusions. COVID-19-induced pneumonia in kidney transplant recipients is characterized by a high risk of progressive lung damage and respiratory failure. Mortality in COVID-19 is independent of gender and age, but correlates with post-transplantation period, severity of pneumonia, and severity of graft dysfunction. The need for mechanical ventilation is associated with an extremely unfavorable prognosis of the disease.

Keywords

• covid-19
• pneumonia
• kidney allotransplantation
• kidney graft.