A Propensity-Matched Analysis of COVID-19 in Kidney Transplant Recipients Compared With Non-Kidney Transplant Patients: A Single-Center Report From India.

OBJECTIVES: Comparisons of COVID-19 incidence between kidney transplant recipients and patients who did not receive kidney transplant are underexplored in various geographic regions. MATERIALS AND METHODS: This Indian, single-center, retrospective study analyzed COVID-19 data of patients hospitalized between May 12, 2020, and January 11, 2021. A propensity matching score was used to compare outcomes between the 2 groups. We also used multivariable Cox proportional hazard analyses to assess association of kidney transplantation with mortality. RESULTS: Of the 1627 COVID-19 cases, 179 were kidney transplant recipients and 1448 were not kidney transplant patients (control group). Ofthe 436 reported in-hospital deaths, 20 (11.1%) were in the kidney transplant group and 416 (28.7%) were in the control group. Propensity matching identified 98 kidney transplantrecipients and167 controlpatients. InKaplanMeier survival plots for these patients, there was no statistical difference in mortality (log-rank, Mantel Cox test; P = .07) or severity (log-rank, Mantel Cox test; P = .07) with regard to COVID-19. In Cox analysis, age groups from 61 to 70 years (hazard ratio = 1.5; 95% CI, 1.0-2.2; P = .04), 71 to 80 years (hazard ratio = 1.64; 95% CI, 1.0-2.5; P = .02), and >80 years (hazard ratio = 1.91; 95% CI, 1.1-3.1; P = .01)were associatedwith statistically significant greater mortality.Having a kidney transplant (hazard ratio = 0.43; 95% CI, 0.3-0.7; P = 0.001) was not associated with mortality. CONCLUSIONS: In our analysis, age was the most important predictor of mortality. Kidney transplant status was not found to have an independent association with mortality and severity.

Mucormycosis as SARS-CoV2 sequelae in kidney transplant recipients: a single-center experience from India.

PURPOSE: Coronavirus disease (COVID-19) sequelae in the transplant population are scarcely reported. Post-COVID-19 mucormycosis is one of such sequelae, which is a dreadful and rare entity. The purpose of this report was to study the full spectrum of this dual infection in kidney transplant recipients (KTR). METHODS: We did a comprehensive analysis of 11 mucormycosis cases in KTR who recovered from COVID-19 in IKDRC, Ahmedabad, Gujarat, India during the study period from Nov 2020 to May 2021. We also looked for the risk factors for mucormycosis with a historical cohort of 157 KTR who did not develop mucormycosis. RESULTS: The median age (interquartile range, range) of the cohort was 42 (33.5-50, 26-60) years with 54.5% diabetes. COVID-19 severity ranged from mild (n = 10) to severe cases (n = 1). The duration from COVID-19 recovery to presentation was 7 (7-7, 4-14) days. Ten cases were Rhino-orbital-cerebral-mucormycosis (ROCM) and one had pulmonary mucormycosis. Functional endoscopic sinus surgery (FESS) was performed in all cases of ROCM. The duration of antifungal therapy was 28 (24-30, 21-62) days. The mortality rate reported was 27%. The risk factors for post-transplant mucormycosis were diabetes (18% vs 54.5%; p-value = 0.01), lymphopenia [12 (10-18) vs 20 (12-26) %; p-value = 0.15] and a higher neutrophil-lymphocyte ratio [7 (4.6-8.3) vs 3.85 (3.3-5.8); p-value = 0.5]. CONCLUSION: The morbidity and mortality with post-COVID-19 mucormycosis are high. Post-transplant patients with diabetes are more prone to this dual infection. Preparedness and early identification is the key to improve the outcomes.

Clinical Profiles and Outcomes of COVID-19 in Kidney Transplant Recipients: Experience From a High-Volume Public Sector Transplant Center in India.

OBJECTIVES: Data are so far limited on outcomes of kidney transplant recipients with COVID-19 seen at public sector hospitals in developing countries with limited resources. MATERIALS AND METHODS: We retrospectively investigated a cohort of 157 kidney transplant recipients (75% living and 25% deceased donors) seen at a public sector transplant hospital in India from March to December 2020 who had reverse-transcriptase polymerase chain reaction tests that confirmed COVID-19. Demographic data, immunosuppression regimens, clinical profiles, treatments, and outcomes were analyzed. In our center, maintenance immunosuppression was reduced according to disease severity and case-by-case evaluations. There were also 53 patients with asymptomatic or mild COVID-19 symptoms who received home care to optimize the utilization of scarce resources during travel restrictions. RESULTS: In our kidney transplant recipient group, median age was 43 years (133 male; 24 female patients); recipients presented at a median of 4 years after transplant. The most common comorbidities included arterial hypertension (73%) and diabetes (24%); presenting symptoms at the time of COVID-19 positivity included cough (49%), fever (58%), and sputum production (32%). Clinical severity ranged from asymptomatic (4%), mild (45%), moderate (31%), and severe (20%) disease. Statistically significant risk factors for mortality included older age, dyspnea, severe disease, obesity, allograft dysfunction prior to COVID-19, acute kidney injury, higher levels of inflammatory markers (C-reactive protein, interleukin 6, procalcitonin), abnormality in chest radiography, and intensive care/ventilator requirements (P < .05). Overall patient mortality was 9.5% (15/157) in hospitalized patients, 21% (15/71) in patients in the intensive care unit, 100% (15/15) in patients who required ventilation, and 0% among those in home treatment. CONCLUSIONS: The mortality rate in kidney transplant recipients with COVID-19 was higher than in the nonimmunosuppressed general population (1.2%) in India. To our knowledge, this is a largest single-center study of kidney transplant recipients with COVID-19 so far.

Consequences of the first and second COVID-19 wave on kidney transplant recipients at a large Indian transplant centre.

BACKGROUND: There is a scarcity of data comparing the consequences of first and second COVID-19 waves on kidney transplant recipients (KTRs) in India. METHODS: We conducted a single-centre retrospective study of 259 KTRs with COVID-19 to compare first wave (March 15-December 31 2020, n = 157) and second wave (April 1-May 31 2021, n = 102). RESULTS: KTRs during second wave were younger (43 vs. 40 years; p-value .04) and also included paediatric patients (0 vs. 5.9%; p-value .003). Symptoms were milder during the second wave (45 vs. 62.7%; p-value .007); COVID-19 positive patients had less frequent cough (32 vs. 13.8%; p-value .001), fever was less frequent (58 vs. 37%; p-value .001), and we observed fewer co-morbidities (11 vs. 20.6%; p-value .04). The percentages of neutrophils (77 vs. 83%; p-value .001) and serum ferritin (439 vs. 688; p-value .0006) were higher during second wave, while lymphocyte counts were reduced (20 vs. 14%; p-value .0001). Hydroxychloroquine (11 vs. 0%; p-value .0001) and tocilizumab (7 vs. 0%; p-value .004) were more frequently prescribed during first wave, while utilization of dexamethasone (6 vs. 27%; p-value .0001) and remdesivir (47 vs. 65%; p-value .03) increased during the second wave. Mucormycosis (1.3 vs. 10%; p-value .01) and ICU admissions (20 vs. 37.2%; p-value .002) were more frequent during second wave. The 28-day mortality rate (9.6 vs. 10%; p-value 1) was not different. CONCLUSIONS: There has been a different clinical spectrum of COVID-19 amongst KTR with similar mortality between the two waves at a large Indian transplant centre.

The Impact of COVID-19 Pandemic on Nephrology and Transplant Services and Clinical Training in India.

OBJECTIVES: COVID-19 has emerged as a global pandemic with significant impacts on health care systems. The present study was conducted to analyze the effects of the COVID-19 pandemic on nephrology and transplant services and clinical training at our center. MATERIALS AND METHODS: This observational study was conducted at the Institute of Kidney Disease and Research Centre (Ahmedabad, India). Our institute is one of the largest tertiary care centers of its kind in India with around 400 total inpatient beds for nephrology, urology, and transplant patients. In 2019, our center had annual outpatient and inpatient numbers of 132 181 and 7471, respectively, and conducted 412 renal transplant procedures. For this study, monthly data on number of outpatients, inpatients, and patients undergoing renal transplant, as well as various nonelective procedures, conducted in 2019 and 2020 were collected and analyzed. We investigated the impact of the COVID-19 pandemic on various non-COVID-19-related health care facilities and on clinical training and research activities at our institute. RESULTS: During the 2020 COVID-19 period, the number of outpatients and inpatients was greatly reduced compared with data from 2019. A similar decrease was seen in patients undergoing hemodialysis, renal transplant, and nonelective procedures at our center. The COVID-19 period also greatly affected clinical training of residents enrolled at our institute and research activities, as a result of focus on COVID-19 as a priority. CONCLUSIONS: The effects of reduced numbers of outpatients and inpatients on workflow, as well as reduced numbers of renal transplants and nonelective procedures on the health of our patients, are unknown. Hence, a strategic scheme is needed to develop new health care models that can help manage the COVID-19 pandemic at present and any further waves arising in the future.

Feasibility and safety of remdesivir in SARS-CoV2 infected renal transplant recipients: A retrospective cohort from a developing nation.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection has drastically impacted the transplant communities. Remdesivir (RDV) has shown some promising results in coronavirus disease (COVID-19) albeit with low certainty. Data in kidney transplant recipients (KTR) are still lacking. METHODS: This was a retrospective cohort of 57 moderate to severe COVID-19 positive KTR in a single center who received RDV as a part of COVID-19 management. No dose adjustments were done. The outcomes were measured as acute kidney injury (AKI) recovery; liver function tests abnormalities; other side effects; graft loss and death. RESULTS: The median (inter-quartile range) age of presentation was 44 (31-51) years. The duration from onset of symptoms to RDV initiation was 6 (5-7) days. Thirty-two (56%) cases received RDV on the day of admission. Forty-six (81%) cases were on oxygen support upon initiation of RDV. Thirty-eight (66.6%) cases had acute kidney injury on admission. The median baseline, admission, and 28-day follow-up serum creatinine of the cohort were 1.59 (1.1-2.1), 2.13 (1.3-3.1), and 1.58 (1.05-2.1) mg/dl, respectively. A total of 8(14%) cases died in the study with 1 (1.7%) graft loss. All those cases that died were on oxygen therapy at the time of initiation of RDV. No liver function derangements or any other major adverse events with the drug were reported. CONCLUSION: RDV therapy is safe and clinically feasible in renal transplant recipients as seen in our cohort. Larger clinical registries and randomized clinical trials should be conducted to further explore the efficacy in transplant recipients.

Feasibility of Convalescent Plasma Therapy in Kidney Transplant Recipients With Severe COVID-19: A Single-Center Prospective Cohort Study.

OBJECTIVES: There are limited clinical data on feasibility and safety of convalescent plasma therapy in kidney transplant recipients with severe COVID-19. The present study was conducted to explore the feasibility of convalescent plasma treatment in 10 kidney transplant recipients with severe COVID-19. MATERIALS AND METHODS: The prospective observational cohort study was conducted at the Institute of Kidney Disease and Research Centre, Ahmedabad, India. All patients were admitted to the intensive care unit and received antiviral therapy, glucocorticoids, and other supportive care. Two doses of 200 mL each of convalescent plasma with neutralization activity of >1:640 were transfused into patients 24 hours apart following the World Health Organization blood transfusion protocol. The endpoints were the improvement of clinical symptoms and laboratory parameters within 1 day and 7 days after convalescent plasma transfusion. RESULTS: The patients showed resolution of clinical symptoms, and there was a significant decrease in inflammatory markers (P < .05) within 7 days of convalescent plasma transfusion. Of the 10 patients, 9 patients had full recovery and 1 patient died. CONCLUSIONS: Convalescent plasma therapy is highly safe and clinically feasible and reduces mortality in kidney transplant recipients with severe COVID-19. Larger clinical registries and randomized clinical trials should be conducted to further explore the clinical outcomes associated with convalescent plasma use in kidney transplant recipients with severe COVID-19.