Risk factors for mortality in kidney transplant recipients with COVID-19

Background: There is limited information on the presentation and risk factors for poor outcome in kidney transplant recipients with COVID-19. Methods: We reviewed data of admitted kidney transplant recipients at 12 system hospitals with COVID-19 between March 1, 2020, and April 30th, 2020. We analyzed risk factors for mortality. Results: 31 patients were identified, 30 were admitted. Median age was 58 (IQR 53- 68), 61% male, 32% Caucasian, 29% African American, 29% multiracial and 6% Asian. Median time from transplant to COVID-19 testing was 1178 days (IQR 252-2897). The most common symptom was cough, followed by fever, shortness of breath and fatigue. Chest X-ray/CT revealed multifocal patchy opacities. Ten patients required mechanical ventilation. Laboratory markers can be seen in the table. Acute kidney injury occurred in 39% of patients. The majority of patients were on triple immunosuppression (94% on tacrolimus, 90% on mycophenolate, and 74% on prednisone). During the hospital course 87% had the antimetabolite stopped while 35% had CNI stopped. Treatments utilized included hydroxychloroquine (93%), azithromycin (50%), convalescent plasma (14%), IL-6 inhibitor (10%) and 1 received remdesivir. At a median follow up of 19 days (IQR 8 - 26) 10 patients died. Risk of death was greater if the patient was admitted to a nontransplant hospital (80% vs 23%, p=0.027), lymphopenic at presentation (47% vs 8%, p=0.013 or had O2 saturation less than 94% upon admission (100% vs 57%, p=0.03). During hospitalization mortality was also higher in patients with higher peak serum creatinine (3.2 mg/dl vs 1.5 mg/dl, p=0.013), or if requiring intubated (70% vs 14%, p<0.001). Increase in inflammatory markers including peak D-dimer, peak CRP, ferritin and procalcitonin were also predictive of mortality. Conclusions: Kidney transplant recipients with COVID-19 should be monitored closely in a transplant center. Mortality is high, particularly in patients presenting with lymphopenia and hypoxemia.

COVID-19 and kidney transplant outcomes

Background: Recent publications report great variations in the clinical course and mortality of COVID-19 in solid organ transplant (SOT) recipients. It is unclear whether these differences are related to study methods, treatment choices, or variables associated with patient populations. Methods: We reviewed and summarized 9 published articles of COVID-19 in solid organ transplant recipients. We contrasted difference between study design and compared outcomes. Results: All studies included kidney transplant recipients while study 6 and 8 included non-renal SOT. Four come from the United States. Results can be seen in the attached table. Most studies had a median age in the 50's, with hypertension and diabetes being common comorbidities. Tacrolimus, mycophenolate analogs and prednisone was the most common immunosuppression regimen. Presenting symptoms were usually fever, cough, dyspnea, and diarrhea. Immunosuppression was either reduced or discontinued in all studies. The majority of patients received hydroxychloroquine. Azithromycin, remdesevir, leronlimab, lopinavir/ritonavir, darunavir, oseltamivir, and tocilizumab were also used. Mortality ranged from 0% to 30%. All studies described hospitalized patients. A third of reports also included outpatients. The median follow up was approximately 3 weeks for most studies (range of 7 to 29 days). All but one series with reported patient deaths under 20% either did not include or had follow-up periods of less than 10 days. Conclusions: Presentation of COVID-19 and immunosuppression strategies are similar among transplant centers. Differing outcomes may be related to small number of cases, potentially varying acuities of illness and follow up periods. Given that cytokine storm occurs late in the course of COVID-19, it is plausible that mortality may increase in studies with short follow up. When excluding short or missing follow up, mortality appears to be between 20-30%, which suggests that transplant recipients have a higher mortality than their non-immunocompromised peers.

Impact of COVID-19 on hand surgery in Italy: A comparison between the Northern and the Southern regions.

The aims of this study were to evaluate the impact of the COVID-19 pandemic on emergency and elective hand surgery in four Italian regions that had either a high (Lombardy and Piemonte) or a low (Sicilia and Puglia) COVID-19 case load to discuss problems and to elaborate strategies to improve treatment pathways. A panel of hand surgeons from these different regions compared and discussed data from the centers they work in. The COVID-19 pandemic had an enormous impact on both elective and emergency surgery in Italy, not only in highly affected regions but also - and paradoxically even at a higher extent - in regions with a low COVID-19 case load. A durable and flexible redesign of hand surgery activities should be promoted, while changing and hopefully increasing human resources and enhancing administrative support. Telematics must also be implemented, especially for delivering rehabilitation therapy.