COVID-19 Hit NYC Kidney Transplant Recipients Hard

Kidney transplant recipients in New York City with COVID-19 had a higher mortality rate, more rapid clinical progression, and lower lymphocyte count than others with COVID-19, researchers found.
At one medical center, early mortality rates were 28% at 3 weeks among this group of 36 patients with COVID-19, outpacing the 8% to 15% mortality rates observed in patients older than age 70 with COVID-19, reported Enver Akalin, MD, of Montefiore Medical Center in New York City, and colleagues.

Of these 36 patients who tested positive for COVID-19 from March 16 to April 1, 28 were admitted to the hospital, while eight were in stable condition and were monitored at home, according to the researchers’ letter in the New England Journal of Medicine.
At median follow up of 21 days, 10 of 36 patients had died, including seven of the 11 who were intubated.
National Kidney Foundation (NKF) President-elect Paul Palevsky, MD, of the University of Pittsburgh School of Medicine, who was not involved in the study, characterized the mortality rate as “troublingly high…. It raises very serious concerns about the safety of transplant patients in this outbreak.”
Patients with serious underlying conditions are said to be at higher risk of COVID-19 infection, but Akalin and colleagues said kidney transplant recipients are at particularly high risk because of “chronic immunosuppression and coexisting conditions.”
“Everything is really risky right now. It’s risky bringing our patients into the clinic to evaluate,” Holly Kramer, MD, the NKF’s current president, who also had no role in the research, told MedPage Today. “It’s a very, very difficult time to take care of chronic illness; that’s the collateral damage from COVID-19.”

Overall, patients’ median age was 60, over 70% were men, and over 80% were either black or Hispanic. Three-quarters had a deceased-donor kidney. Nearly all had hypertension, about 70% had diabetes mellitus, and 36% either had a history of smoking or were current smokers.
Fever was the most common symptom in kidney transplant patients (58%), though the authors noted these patients had “less fever as the initial symptom” than the general COVID-19 population, and eight patients had diarrhea.
Almost all patients were receiving immunosuppressive agents, such as tacrolimus, prednisone, mycophenolate mofetil, or mycophenolic acid. Immunosuppressive management among hospitalized patients included withdrawing 86% from an antimetabolite, and withholding tacrolimus in 21%.
Of the hospitalized patients, nearly all had viral pneumonia and 11 were intubated. In terms of treatment, 86% of these patients received hydroxychloroquine. Six severely ill patients received the CCR5 inhibitor leronlimab (PRO 140, CytoDyn), while two received interleukin-6 receptor antagonist tocilizumab, the authors said. They noted the patient with the lowest interleukin-6 level “remained in stable condition without intubation.”

Two of eight patients who died outside the hospital were recent kidney transplant recipients who had received antithymocyte globulin, which Akalin and colleagues said reduces “all T-cell subsets for many weeks.”
Palevsky noted that the report lacked data on the time since patients’ transplants, which would be helpful to know.
“It’s troubling that two of the patients died at home rather than being hospitalized and we don’t know the details,” he said.
Akalin and colleagues found lower CD3, CD4, and CD8 counts among this population, noting these counts “indirectly supports the need to decrease doses of immunosuppressive agents in patients with COVID-19.”
Sumit Mohan, MD, of Columbia University Irving Medical Center in New York City, who was also not involved with the research, said immunosuppression protocol changes mostly “include a reduction of at least one of the immunosuppression agents as a safety measure especially for those with moderate and severe disease.”
However, he told MedPage Today that “complete cessation of immunosuppression is not recommended.”

Disclosures

Akalin disclosed no conflicts of interest.
Other co-authors disclosed support from Merck & Co., Inc. and Abbott Laboratories.
One co-author disclosed being a co-investigator and assisting with recruitment and consent of patients for a trial of a medication leronlimab in patients with COVID, though never being paid for that work.

Primary Source

New England Journal of Medicine

Source Reference: Akalin E, et al “Covid-19 and Kidney Transplantation” N Engl J Med 2020; DOI: 10.1056/NEJMc2011117.

https://www.medpagetoday.com/infectiousdisease/covid19/86156