COVID-19 in Recent Lung Transplant Recipients: Clinical Outcomes and Management Strategies

BackgroundCOVID-19 causes a wide range of symptoms, with particularly high risk of severe respiratory failure and death in patients with predisposing risk factors such as advanced age or obesity. Recipients of solid organ transplants, and in particular lung transplantation, are more susceptible to viral infection owing to immune suppressive medication. As little is known about the SARS-CoV-2 infection in these patients, this study was undertaken to describe outcomes and potential management strategies in early COVID-19 infection early after lung transplantation.MethodsWe describe the incidence and outcome of COVID-19 in a cohort of recent lung transplant recipients in Munich. Six of 186 patients who underwent lung transplantation in the period between March 2019 and March 2021 developed COVID-19 within the first year after transplantation. We documented the clinical course and laboratory changes for all patients showing differences in the severity of the infection with COVID-19 and their outcomes.ResultsThree of 6 SARS-CoV-2 infections were hospital-acquired and the patients were still in inpatient treatment after lung transplantation. All patients suffered from symptoms. One patient did not receive antiviral therapy. Remdesivir was prescribed in 4 patients and the remaining patient received remdesivir, bamlanivimab and convalescent plasma.ConclusionsCOVID-19 does not appear to cause milder disease in lung transplant recipients compared with the general population. Immunosuppression is potentially responsible for the delayed formation of antibodies and their premature loss. Several comorbidities and a general poor preoperative condition showed an extended hospital stay.     

Navigating Kidney Transplantation in the Early Phase of Coronavirus Disease 2019: Screening Patients With Reverse Transcriptase Polymerase Chain Reaction and Low-Radiation-Dose Chest Computed Tomography

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic of 2020 changed organ transplantation. All elective cases at our institution were postponed for approximately 3 months. Centers for Medicare and Medicaid Services considers organ transplant surgery a Tier 3b case, along with other high acuity procedures, recommending no postponement. Our transplant program collaborated with our transplant infectious disease colleagues to create a protocol that would ensure both patient and staff safety during these unprecedented times.MethodsThe living donor program was electively placed on hold until we had the proper protocols in place. Preoperative COVID-19 testing was required for all recipients and living donors. All patients underwent a rapid nasopharyngeal swab test. After testing negative by nasopharyngeal swab, recipients also underwent a low-radiation-dose computed tomography scan to rule out any radiographic changes suggestive of a COVID-19 infection.ResultsWe performed 8 living donor and 9 deceased donor kidney transplants. In comparison, we performed 10 living donor and 4 deceased donor transplants during the same time period in the previous year. Our testing protocol enabled efficient use of all suitable organs offered during the viral pandemic. No recipients or living donors tested positive or developed COVID-19.ConclusionsCreation of a viral testing protocol, developed in conjunction with our infectious disease team, permitted kidney transplantation to be performed safely, and the number of deceased donor transplants increased considerably without adversely affecting our outcomes.     

Allogeneic Kidney Transplantation After COVID-19: A Case Report

BackgroundPatients undergoing organ transplantation are immunosuppressed and already at risk of various diseases. We report about a patient who underwent ABO-incompatible kidney transplantation after coronavirus disease 2019 (COVID-19) without a recurrence of infection.Case ReportA 68-year-old woman presented with end-stage renal failure owing to primary autosomal dominant polycystic kidney disease; accordingly, hemodialysis was initiated in September 2020. Her medical history included bilateral osteoarthritis, lumbar spinal stenosis, hypertension, and hyperuricemia. In mid-January 2021, she contracted severe acute respiratory syndrome coronavirus 2 infection from her husband. Both of them were hospitalized and received conservative treatment. Because their symptoms were mild, they were discharged after 10 days. The patient subsequently underwent ABO-incompatible kidney transplantation from her husband who recovered from COVID-19 in March 2021. Before kidney transplantation, her COVID-19 polymerase chain reaction test was negative, confirming the absence of pre-existing COVID-19 immediately before the procedure. Computed tomography revealed no pneumonia. Initial immunosuppression was induced by administering tacrolimus, mycophenolate mofetil, methylprednisolone, basiliximab, rituximab, and 30 g of intravenous immunoglobulin. Double-filtration plasmapheresis and plasma exchange were performed once before ABO-incompatible kidney transplantation. The renal allograft functioned immediately, and the postoperative course was normal without rejection. COVID-19 did not recur. In addition, her serum creatinine levels and renal function had otherwise remained stable.ConclusionLiving kidney transplantation was safely performed in a patient with COVID-19 without postoperative complications or rejection. During the COVID-19 pandemic, the possibility of severe acute respiratory syndrome coronavirus 2 infection during transplantation surgery must be considered.     

Retrospective Evaluation of COVID-19 Infection and COVID-19 Vaccines in Heart Transplant Patients

BackgroundPatients who have performed solid organ transplantation in terms of COVID-19 infection are included in the high-risk group. In this study, it was aimed to evaluate the relationship between vaccination and retrospective evaluation of 32 patients who underwent a heart transplant in the clinic and tested positive for SARS-CoV-2 polymerase chain reaction.MethodsIn this study, demographic characteristics of the cases, comorbidities, timing of heart transplantation, immunosuppressive treatments, symptoms of COVID-19 infection, lung imaging findings, follow-up (outpatient/inpatient), treatments, 1-month mortality, and vaccination histories against COVID-19 infection were evaluated. The data obtained from the study were analyzed with SPSS version 25.0.ResultsThe 3 most common symptoms are cough (37.5%), myalgia (28.1%), and fever (21.8%). COVID-19 infection was severe in 6.2% of the patients, moderate in 37.5%, and mild in 56.2%. Hospitalization was required in 5 patients (15.6%, 1 in the intensive care unit), and the other patients were followed up as an outpatient. Severe COVID-19 infection was seen more in 33% of unvaccinated patients; 93.5% were vaccinated. Nineteen patients (68%) were vaccinated before COVID-19 infection. Our patients received the CoronoVac (Sinovac, China) vaccine.ConclusionCOVID-19 infection is more likely to be severe and mortal in patients with heart transplant recipients. It is also crucial to comply with preventive measures other than immunization in this group of patients. This study is the largest series investigating COVID-19 infection in heart transplant recipient patients in our country.     

Global Impact of the COVID-19 Pandemic on Solid Organ Transplant

BackgroundCOVID-19 has drastically affected transplant services, but there is limited understanding of the discrepancy of COVID-19 effects on various regions of the world.MethodsWe have explored the Global Observatory for Organ Donation and Transplantation data for assessing the transplant number changes between the calendar year 2019 (n = 157,301) and 2020 (129,681).ResultsThere was a disproportionate impact of COVID-19 on different areas of the world. Globally, there was a decline of 17.5%, in which deceased donation, kidney (20.9%), pancreas (16.2%), lung (12.7%), liver (11.3%), and heart (8%) transplant declined disproportionally in different regions of the world. The pandemic affected almost all geographic regions and nations, but China and the United States were mostly able to recover from the initial halt of the transplant practices by the pandemic so that there was a cumulative increase in transplant numbers.ConclusionsOur data show that developing nations lagged behind, whereas developed nations have been able to recover their transplantation programs during the pandemic. Further policy making and preparedness is required to safeguard the most vulnerable areas of the world to minimize the impact of any future pandemic on transplantation practices.     

The impact of COVID-19 on kidney transplantation and the kidney transplant recipient – One year into the pandemic

The COVID-19 pandemic has significantly changed the landscape of kidney transplantation in the United States and worldwide. In addition to adversely impacting allograft and patient survival in postkidney transplant recipients, the current pandemic has affected all aspects of transplant care, including transplant referrals and listing, organ donation rates, organ procurement and shipping, and waitlist mortality. Critical decisions were made during this period by transplant centers and individual transplant physicians taking into consideration patient safety and resource utilization. As countries have begun administering the COVID vaccines, new and important considerations pertinent to our transplant population have arisen. This comprehensive review focuses on the impact of COVID-19 on kidney transplantation rates, mortality, policy decisions, and the clinical management of transplanted patients infected with COVID-19.     

Perioperative use of intra-articular steroids during the COVID-19 pandemic

Purpose

There are growing concerns with the widely used glucocorticoids during the Coronavirus disease-19 (COVID-19) pandemic due to the associated immunosuppressive effects, which may increase the risk of COVID-19 infection and worsen COVID-19 patient outcome. Heavily affecting orthopaedics, the pandemic led to delay and cancellation of almost all surgical cases, and procedures including perioperative intra-articular corticosteroid injections (ICIs) saw similar decreases. However, the benefits of ICI treatments during the pandemic may outweigh these potential risks, and their continued use may be warranted.

Methods

A literature search was conducted, and all relevant articles including original articles and reviews were identified and considered in full for inclusion, and analysed with expert opinion. Epidemiological statistics and medical guidelines were consulted from relevant authorities.

Results

ICIs allow a targeted approach on the affected joint and are effective in reducing pain while improving functional outcome and patient quality-of-life. ICIs delay the requirement for surgery, accommodating for the increased healthcare burden during the pandemic, while reducing postoperative hospital stay, bringing significant financial benefits. However, ICIs can exert systemic effects and suppress the immune system. ICIs may increase the risk of COVID-19 infection and reduce the efficacy of COVID-19 vaccinations, leading to important public health implications.

Conclusion

Perioperative ICI treatments may bring significant, multifaceted benefits during the pandemic. However, ICIs increase the risk of infection, and perioperative COVID-19 is associated with mortality. The use of ICIs during the COVID-19 pandemic should therefore be considered carefully on an individual patient basis, weighing the associated risks and benefits.

     

SARS-CoV-2 Infection After Vaccination: Kidney Transplant Recipient Profile and Disease Evolution in a Single Center

BackgroundSARS-CoV-2 infection has had a major impact on kidney transplant patients. Recent evidence suggests that solid organ transplant recipients who received mRNA vaccines reach low immunization rates. There are only few reports about the risk factors and severity of COVID-19 in these patients. Our single center experience describes the patient profile and disease evolution observed in this vulnerable group after inoculation.Material and MethodsRetrospective cohort study with kidney transplant patients who received a COVID-19 vaccine before testing positive for SARS-CoV-19 using polymerase chain reaction. Demographic characteristics and clinical information are described and compared with our previous series of patients who were infected before the initiation of the vaccination rollout.ResultsSixteen kidney transplant recipients diagnosed with COVID-19 after being vaccinated were included and compared with our previous series of 76 unvaccinated patients who were positive for COVID-19. No differences were found among risk factors such as age, time after transplant, hypertension, and obesity between groups (P value > .05). After COVID-19 diagnosis among inoculated patients, 10 patients were hospitalized, and 4 of who met the criteria for admission to the intensive care unit. Three patients died of COVID-19 complications. Despite this, the incidence of infections has decreased after vaccination rollout (P value < .05).ConclusionsPatients’ risk profiles remain constant among recipients who were positive for COVID-19 between waves. We did not find significant differences in hospitalization and severity rates in this reduced group of patients. However, the overall incidence in our kidney transplant population has decreased.     

Serologic Status According Severe Acute Respiratory Syndrome Coronavirus 2 in Patients After Orthotopic Heart Transplantation

BackgroundThe SARS-CoV-2 pandemic is ongoing. In this context, patients after organ transplantation are especially endangered because of their increased susceptibility to infections. Real effectiveness of vaccinations against SARS-CoV-2 and exposition to the virus in populations after organ transplantation is still being assessed.MethodsWe investigated 371 adult patients (82.7% men, 17.3% women), aged 54 ± 14 years, with a median time from transplantation of 1296 days (interquartile range, 473-400 days) after orthotopic heart transplantation consecutively admitted to the transplant center between February and September 2021. SARS-CoV-2 spike protein antibodies were assessed quantitatively by Elecsys Anti-SARS-CoV-2 S. Data according to past COVID-19 infection and vaccination were compared with the test results.Among the whole group, 59 patients were unvaccinated and had no past COVID-19 infection, 200 patients had a full course of vaccination (2 doses) with an mRNA vaccine, 1 patient had received a viral vector vaccine, 11 patients had had a single dose of an mRNA vaccine, and 99 patients had previously had a COVID-19 infection. Median time from vaccination to antibody assessment was 54 days (interquartile range, 30-76 days).AimThe aim of this study was to determine exposure to the virus among patients after heart transplantation before vaccination and humoral response to the vaccination and assess the role of antispike antibodies in the prevention of infection.ResultsAfter vaccination, 22.3% had no antibodies (45 patients), 47.3% had titers between 0.8 U/mL [0.82 binding antibody units (BAU)/mL] and 250 U/mL (257.25 BAU/mL; 95 patients), and 30.2% had titers above 250 U/mL (257.25 BAU/mL; 61 patients). After a single dose of vaccine, 63% patients had no antibodies. In the group of unvaccinated patients, 3 patients had titers above 250 U/mL (257.25 BAU/mL; 5.1%) and 12 patients had titers up to 250 U/mL (257.25 BAU/mL; 20.3%).In patients after COVID-19 infection, only 2% did not show antispike antibodies, and in 61.4% the titers were above 250 U/mL (257.25 BAU/mL).In the group of patients infected after the full course of vaccination (4 patients after a single dose and 2 after 2 doses), none of the patients developed antibodies after vaccination. Up to the end of September 2021, none of the patients with antibodies against SARS-CoV-2 developed COVID-19.ConclusionsThe presence of spike protein antibodies may be a relevant marker of effective vaccination. In patients after heart transplantation, exposure to SARS-CoV-2 is high.     

Heart Transplantation from COVID-19–Positive Donors: A Word of Caution

BackgroundDuring the COVID-19 pandemic, efforts to maintain solid-organ transplantation have continued, including the use of SARS-CoV-2–positive heart donors.MethodsWe present our institution's initial experience with SARS-CoV-2–positive heart donors. All donors met our institution's Transplant Center criteria, including a negative bronchoalveolar lavage polymerase chain reaction result. All but 1 patient received postexposure prophylaxis with anti-spike monoclonal antibody therapy, remdesivir, or both.ResultsA total of 6 patients received a heart transplant from a SARS-CoV-2–positive donor. One heart transplant was complicated by catastrophic secondary graft dysfunction requiring venoarterial extracorporeal membrane oxygenation and retransplant. The remaining 5 patients did well postoperatively and were discharged from the hospital. None of the patients had evidence of COVID-19 infection after surgery.ConclusionHeart transplants from SARS-CoV-2 polymerase chain reaction–positive donors are feasible and safe with adequate screening and postexposure prophylaxis.     

The Course of SARS-CoV-2 in a Patient After a Recent Kidney Transplant: A Literature Review on COVID-19 Therapy

BackgroundKidney transplant recipients are at high risk of severe complications and death due to coronavirus disease 2019 (COVID-19).MethodsThe first part of the article describes a case of COVID-19 in our patient after a recent kidney transplant. The second part of the article presents the outcome of literature search from multiple resources from April 2020 until March 2021. Abstracts were screened, followed by full-text review with data extraction. Part 2 discusses current treatment options of COVID-19, and part 3 refers to this treatment application in patients after solid organ transplant.ResultsWe have summarized 45 studies from China, France, Italy, Spain, the United Kingdom, and the United States. Mortality rates from published studies were variable. Based on early data from Spain, 42% of patients who developed COVID-19 within 60 days of transplant died. According to results of the European Renal Association COVID-19 Database collaboration group, the 28-day COVID-19–related mortality is 21.3% for kidney transplant recipients, which is still markedly higher than what is observed in other populations. Acute kidney injury was common, and mycophenolate mofetil and mammalian target of rapamycin were discontinued in most patients.ConclusionsEffective therapy has been sought since the outbreak of the pandemic, and at the same time intensive work has been done to produce a vaccine that could effectively protect against the disease. Summing up the efforts of numerous groups of researchers from around the world that have been continued since the beginning of 2020, we may assume the following:(1) we still do not have causal drugs that would reduce severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replication and allow its complete elimination, but antispike monoclonal antibodies against SARS-CoV-2 seem to be very promising, and (2) the withdrawal of antiproliferative and antimetabolic drugs and the continuation of steroids and calcineurin inhibitors is now a commonly accepted approach in patients after organ transplant.     

Focal Segmental Glomerulosclerosis (FSGS) Progressing to Collapsing Glomerulopathy in Renal Transplant Recipients With and Without COVID-19 Infection.

BackgroundCollapsing glomerulopathy (CGN) secondary to HIV or COVID-19 infection mainly occurs in patients of African American descent due to APOL-1 gene mutations, but CGN is occasionally reported in white patients. CGNs are rarely reported in renal transplant biopsies and their association with idiopathic focal segmental glomerulosclerosis (FSGS) is unclear.Methods and ResultsPatient #1 was a 48-year-old Caucasian white man who had a renal transplant 8 years ago and was recently diagnosed with COVID-19 infection. Two weeks post infection, his serum creatinine (SCr) increased to 2.01 mg/dL from a baseline of 1.40 mg/dL, and he developed concomitant nephrotic range proteinuria. The first renal transplant biopsy showed FSGS. Four weeks later, his sCr level increased to 2.65 mg/dL with worsening proteinuria, and a second renal transplant biopsy revealed CGN. Patient #2 was a 32-year-old African American man whose native renal biopsy revealed primary FSGS. He received a renal transplant with initial post-transplant sCr level at 1.17 mg/dL. Four months later, his sCr and protein-to-creatinine ratio began to rise. Sequential biopsies revealed that the patient had developed recurrent FSGS, which progressed to show features of CGN. The CGN was further confirmed in his transplant kidney graft at autopsy later.ConclusionsThis is the first case report of CGN in a white renal recipient with COVID-19 infection. The pathologic presentations of FSGS progressing to collapsing FSGS in our 2 renal transplant recipients suggest that FSGS and GGN may share a common pathophysiologic mechanism of podocytopathy.     

Influenza and pneumococcal vaccination and COVID-19 in kidney transplant patients

BackgroundThis study aims to investigate the effect of recent influenza and pneumococcal vaccines' administration on the development of COVID-19 infection in kidney transplant recipients during the pandemic.MethodsThe effect of influenza and pneumococcal vaccines on the clinical course of the disease in COVID-positive (COVID group, n: 105) and COVID-negative (control group, n: 127) recipients has been examined. The control group included patients with negative rRT-PCR test results. At the time of the study, no patient was vaccinated with COVID-19 vaccine. The patients' influenza and/or pneumococcal vaccination rates in 2019 and 2020 were determined. In 2019 and 2020, 32 and 33 people in the COVID-positive group and 61 and 54 people in the COVID-negative group had received influenza and/or pneumococcal vaccines, respectively. The median study follow-up times of the COVID-negative and COVID-positive groups were 13.04 and 8.31 months, respectively.ResultsCompared with the COVID-negative group, the patients in the COVID-positive group were younger and had a longer post-transplant time. In addition, the rate of transplantation from a living donor and the rate of COVID positivity in family members were also higher. The influenza vaccination rates in the COVID negative group were significantly higher than the COVID-positive group in 2020 (23.8% vs 37%, p = 0.031). Multivariate logistic regression analysis revealed that the presence of COVID-19 in family members and lack of pneumococcal vaccination in 2020 increased the risk of being positive for COVID-19. There was no significant difference in the hospitalization rates, the need for dialysis and intensive care, the hospital stay, and the graft dysfunction in the COVID-positive patients with and without influenza and pneumococcal vaccines.ConclusionThe observations made throughout this study suggest that influenza and pneumococcal vaccination in transplant patients may reduce the risk of COVID-19 disease and provide additional benefits during the pandemic period.     

Immediate impact of COVID-19 on transplant activity in the Netherlands

The rapid emergence of the COVID-19 pandemic is unprecedented and poses an unparalleled obstacle in the sixty-five year history of organ transplantation. Worldwide, the delivery of transplant care is severely challenged by matters concerning - but not limited to - organ procurement, risk of SARS-CoV-2 transmission, screening strategies of donors and recipients, decisions to postpone or proceed with transplantation, the attributable risk of immunosuppression for COVID-19 and entrenched health care resources and capacity. The transplant community is faced with choosing a lesser of two evils: initiating immunosuppression and potentially accepting detrimental outcome when transplant recipients develop COVID-19 versus postponing transplantation and accepting associated waitlist mortality. Notably, prioritization of health care services for COVID-19 care raises concerns about allocation of resources to deliver care for transplant patients who might otherwise have excellent 1-year and 10-year survival rates. Children and young adults with end-stage organ disease in particular seem more disadvantaged by withholding transplantation because of capacity issues than from medical consequences of SARS-CoV-2. This report details the nationwide response of the Dutch transplant community to these issues and the immediate consequences for transplant activity. Worrisome, there was a significant decrease in organ donation numbers affecting all organ transplant services. In addition, there was a detrimental effect on transplantation numbers in children with end-organ failure. Ongoing efforts focus on mitigation of not only primary but also secondary harm of the pandemic and to find right definitions and momentum to restore the transplant programs.     

Kidney Transplant Recipient with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) Secondary to COVID-19 Pneumonia: A Case Report

BackgroundCurrently, COVID-19 is becoming one of the most common causes of viral pneumonia worldwide. In the medical literature, very few case reports describe the association between COVID-19 and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) in kidney transplant patients.MethodsA 74-year-old immunocompromised man post–kidney transplant presented with nonspecific symptoms consisting of fatigue, malaise, and anorexia. He was also found to have hyponatremia in the context of pulmonary insults. SIADH in the setting of COVID-19 pneumonia was diagnosed after exclusion of other causes of hyponatremia. He was treated for COVID-19 pneumonia with antiviral therapy, secondary bacterial infection prophylaxis, dexamethasone and ventilatory support in addition to modification of antirejection medications.ResultsThe patient has improved and his serum sodium normalized with management of primary insult.Conclusions. SIADH should be suspected in transplant patients with COVID-19 pneumonia once they develops hyponatremia. The decision of intravenous fluid administration should be taken carefully in these settings.     

A comparison of patient same-day discharge selection after shoulder arthroplasty before and after the COVID-19 pandemic

BackgroundEarly discharge has been a target of cost control efforts, given the growing demand for joint replacement surgery. Select patients are given the choice for same-day discharge (SDD) or overnight stay after shoulder arthroplasty. The COVID-19 pandemic changed patient perspectives regarding hospital visitation and admission. The purpose of this study was to determine if the COVID-19 pandemic impacted the utilization of SDD after shoulder arthroplasty. We hypothesize that patients undergoing shoulder arthroplasty after the start of the COVID-19 pandemic will have higher rates of SDD.MethodsA retrospective continuous review was performed on 370 patients who underwent a primary anatomic (total shoulder arthroplasty) or reverse shoulder arthroplasty between August 2019 and December 2020 by a single surgeon. This group of patients represent the 185 arthroplasty cases completed before the COVID-19 pandemic and the first 185 patients after the start of the pandemic. April 1, 2020, was chosen as the cutoff for pre-COVID patients, as this represents the date a statewide ban on elective surgery was declared. All patients were counseled preoperatively regarding SDD and given the choice to stay overnight, unless medically contraindicated. Demographics, medical history, length of stay, 30- and 90-day readmissions, and 90-day emergency room (ER) and urgent care visits were obtained from medical records and compared. Two-tailed student t-tests, chi-square tests, and Fischer’s exact were performed where appropriate.ResultsThe 2 groups were similar in age, body mass index, gender distribution, and Outpatient Arthroplasty Risk Assessment score. During the collection period, there were more anatomic shoulder arthroplasties performed after (54%) than before (44%) the COVID-19 pandemic (P = .029). Patients treated after the start of the COVID-19 pandemic were almost 3 times more likely to have an SDD (P < .001), with 85.4% (158/185) of patients being discharged the same day after COVID-19, compared with 34.6% (64/185) before COVID-19. Discharge disposition (location of discharge) was significantly different, as 99% (183/185) of patients undergoing surgery after the start of the COVID-19 pandemic were discharged home, compared with 94% (174/185) of patients before COVID-19. There was no difference in 30-day readmissions, 90-day readmissions, and 90-day (ER) and urgent care visits between the 2 groups.ConclusionOur study suggests that the COVID-19 pandemic has dramatically impacted patient choices for SDD within a single surgeon’s practice, with nearly 3 times as many patients electing for SDD. Readmissions and ER visits were similar, indicating that SDD remains a safe alternative for patients after total shoulder arthroplasty and reverse shoulder arthroplasty.Level of evidenceLevel III; Retrospective Comparative Study