Decreased Mortality from Sars-CoV-2 Infection in Kidney Transplant Recipients Over the Course of the Pandemic

Purpose: We aimed to investigate the mortality from SARS-CoV-2 in kidney transplant recipients in the Bronx, New York since the beginning of the pandemic Methods: Between March 16, 2020 and November 5, 2021, 453 patients were diagnosed with SARS-CoV-2 infection. 316 were diagnosed by RT-PCR while the remaining 137 tested positive for anti-SARS-CoV-2 nucleocapsid IgG and did not have significant symptoms and had not been previously tested by RT-PCR Results: Of the 316 patients diagnosed by RT-PCR, 214 patients were hospitalized while 102 patients were managed at home as outpatient. 194 (61.3%) were male, median age 61 years old (IQR: 48-69), predominantly Hispanic (56.2%) and African American (29.5%). 75% received a deceased-donor renal transplant, 58% received anti-thymocyte induction. Most patients were on triple immunosuppression (95% on calcineurin inhibitors, 87% on anti-metabolite, and 97% on prednisone). Hypertension was the most common comorbidity followed by diabetes mellitus, heart disease and lung disease. A total of 65 patients (20.5%) died. The mortality rate was 37 % (47/128) in patients diagnosed between March 16 and April 30, 2020. From May 1, 2020 to end of December 2020 mortality rate has significantly decreased to 11% (7/61). Since the beginning of 2021 till November 5, 2021 the mortality rate is 7.7% (10/129). Twenty-seven patients were diagnosed with COVID-19 despite being partially of fully vaccinated (25 fully vaccinated, 2 after one dose of vaccine). 13/27 (48%) were managed at home while 14/27 (52%) were hospitalized and 2 (7%) of them died. Twenty-eight patients received treatment with casirivimab and imdevimab post diagnosis of SARS-CoV-2 starting 2021 and none of those patients have died. Conclusion(s): In summary, mortality from SARS-CoV-2 infection in kidney transplant recipients was higher earlier at the pandemic and has significantly decreased over time. This could be explained by initial exposure of the patients with higher viral load due to lack of personal protection and social distancing. However, since the judicious use of monoclonal antibodies and vaccination, in addition to social distancing protocols and use of facemask, the mortality in kidney transplant recipients has decreased over time.

Inefficiencies of the COVID-19 Vaccine Distribution in California

As we enter the new year, two companies’ COVID-19 vaccines have been authorized for emergency use in the United States. While they are only in the beginning stages of distribution, we have already seen many complications in the United States as each state has a unique policy on its distribution process. Within the state of California, the different counties are dealing with COVID-19 differently depending on the size of the population and geographical location. Depending on these factors, the counties throughout the state have their own ways of distributing the vaccine that is advised by the state. Even though each county has its own distribution method, California as a whole ranked 35th out of the 50 states for efficiency in vaccine distribution as of February 28, 2021. With the efficiency so low, and cases at an all-time high, states need to more effectively distribute the vaccine to those who need it most: at-risk individuals, frontline healthcare workers, and older adults. With the discovery of a new strain, counties within the state must properly contain the spread while administering vaccines in order for the country to rebound from extended lockdowns. Our paper addresses the distribution of the vaccine within California and provides insight on how the state can effectively and adequately do so. © IEOM Society International.

Covid 19 re-infection versus re-activation in two renal transplant patients

Purpose: Rare cases of potential COVID 19 re-infection have been reported throughout the world. Methods: We describe two renal transplant recipients with possible SARS-COV-2 re-infection. Results: Patient #1 is a 63-year-old man with a history of renal transplant in February 2010, who initially experienced symptoms consistent with COVID-19 in April 2020 along with several family members. Due to limitations in outpatient testing, no SARS-CoV2 testing was able to be performed but he was treated as presumed COVID-19 infection due to high community prevalence and three weeks following his symptoms, SARS-CoV2 IgG was positive. The patient subsequently had four negative PCR tests from July-September 2020. In October, he was admitted for hypoxic respiratory failure and was found to be SARS-COV-2 positive by PCR and SARS-COV-IgG was negative (Figure 1). The patient was treated with Remdesivir and recovered. Patient #2 is a 64-year-old man with history of renal transplant in 2003, who was found to be SARS-COV-2 positive by RT-PCR in April 2020 after presenting with hypoxia. The patient had an uneventful hospital course and was discharged off supplemental oxygen. He had two negative SARS-COV-2 PCR tests in August and September and his SAR-COV-2 IgG was positive. In September, he was readmitted with hypoxic respiratory failure requiring intubation and ICU admission and was again found to be SARS-COV-2 positive by PCR. The patient had a complicated hospital course and expired on September 30th (Figure 1). Conclusions: Potential cases of SARS-COV-2 re-infection have been previously reported, but it is unclear whether these are true re-infections versus reactivation of a prior infection, prolonged viral shedding, or dynamic RT-PCR results. In our cases, we believe prolonged viral shedding from the initial infection or inaccurate testing is less likely given the prolonged time interval between the two events, the multiple negative tests in between, and the severity of the second episodes. While both of these patients were suspected of having re-infections, this could not be confirmed as genomic analysis was not performed. Future studies of similar cases are needed to determine factors contributing to re-infection.

Variation of mortality from sars-cov-2 infection in kidney transplant recipients over the course of the pandemic

Purpose: We aimed to investigate the mortality from SARS-CoV-2 in kidney transplant recipients in the Bronx, New York, one of the epicenters of the pandemic over the period of the pandemic. Methods: Between March 16 and November 30, 2020, 158 patients were tested positive by SARS-CoV-2 RT-PCR. Results: 94 (59.5%) were male, at a median age of 62 years old (IQR: 51-71), predominantly Hispanic (54.4%) and African American (29.7%). 127 patients were admitted to the hospital and 29 were observed at home. 75.3% received a deceased-donor renal transplant, 57% received anti-thymocyte globulin induction. Most patients were on triple immunosuppression (94.3% on calcineurin inhibitors, 86.7% on anti-metabolite, 96.7% on prednisone). Hypertension was present in 96.2%, diabetes mellitus in 62.7%, heart disease in 19.6% and lung disease in 8.9% of the patients. The figure shows the number of RT-PCR positivity and mortality over the course of the pandemic starting on March 16, 2020. A total of 50 (31.6%) died as of November 30, 2020. The mortality rate was 40% (17/43) in patients diagnosed between March 16 and 31,2020, 39% (23/59) in patients diagnosed between April 1 and 15,2020 and 29% (7/24) in patients diagnosed between April 16 and 30, 2020. Since May 1st 2020, the mortality rate has significantly decreased to 9% (3/32). Conclusions: In summary, mortality from SARS-CoV-2 infection in kidney transplant recipients was higher during the first 6 weeks of the pandemic and has significantly decreased over time. This could be explained by initial exposure of the patients with higher viral load due to lack of personal protection and social distancing due to the fact that there is no current proven treatment for SARS-CoV-2 infection and clinical approach to patients has not been changed since the beginning of the pandemic.

Prevalence and dynamics of SARS-CoV-2 IGG in kidney transplant recipients

Purpose: We aimed to investigate the prevalence and dynamics of SARS-CoV-2 IgG in kidney transplant recipients in the Bronx, New York, one of the epicenters of the pandemic Methods: Between March 16 and November 30, 2020, 158 patients tested positive by SARS-CoV-2 RT-PCR. From May 3 to November 30, 2020, 1042 patients were screened for SARS-CoV-2 IgG antibodies and 164 (15.7%) were tested positive (Figure). Results: Sixty of the 164 patients were previously diagnosed COVID-19 by RTPCR, while the remaining 104 did not have significant symptoms and had not been previously tested by RT-PCR. Overall prevalence of COVID-19 diagnosis by RT-PCR and/or SARS-CoV-2 IgG in 1130 patients were 23.2%. Seventy RT-PCR positive patients were screened for SARS-CoV-2 IgG antibody at a median of 43 days postdiagnosis (IQR: 29-57) and 60 (85.7%) were positive. A total of 39 patients out 164 who previously tested positive for SARS-CoV-2 IgG (25 diagnosed with IgG and 14 with RT-PCR) were retested at a median time of 105 days (IQR: 83-116). Twenty patients (51.3%) became seronegative at a median time of 107 days (IQR: 87-134) from their first positive SARS-CoV-2 IgG. Six patients out of 14 (43%) who were diagnosed by positive RT-PCR became seronegative at a median time of 105 days (IQR: 83-166) from their first positive SARS-CoV-2 IgG while 14 patients out of 25 (56%) who were initially diagnosed by a positive SARS-CoV-2 IgG, became seronegative at a median time of 112 days (IQR: 91-138) from date of diagnosis Conclusions: . In summary, 40% of kidney transplant recipients were asymptomatic or mildly symptomatic and developed SARS-CoV-2 IgG without requiring testing by SARS-CoV-2 RT-PCR. However, half of the patients who initially developed antibodies lost them over time raising the questions of lasting immunity against SARS-CoV-2 and how effective are those antibodies.

Remdesivir plus convalescent plasma for the treatment of COVID-19 in a patient with a recent liver transplant

Background: SARS-CoV2 is a novel betacoronavirus that was first noted Wuhan, Hubei Province, China in late December 2019 This virus is the causative agent of COVID-19 and has rapidly spread across the globe The impact of this novel virus on the transplant community is under rapid investigation Previous studies involving the 2003 SARS-CoV and MERSCoV infections have demonstrated to apparent increase in mortality for solid organ transplant recipient Outcome data in solid organ transplant is currently limited although data from the United States and Europe suggesting that overall survival may be affected There is additional ambiguity in the impact of COVID-19 infection in the immediate post-transplant period In this communication, we describe a case of a patient who was infected with SARS-CoV2 within 3 months of orthotopic liver transplantation The clinical and therapeutic course will be described in detail Methods: This is a retrospective case report All data was obtained from the electronic medical record Results: The patient is a 47-year-old female with a history of multi-focal HCC treated with surgical and loco-regional therapy who underwent liver transplantation February 11th, 2020 Her post-operative course was complicated by early bile leak requiring re-do biliary anastomosis and surgical biliary stent placement She underwent the institutional standard steroid and basiliximab induction therapy She underwent a semi-elective ERCP with biliary stent removal April 3rd, 2020 The patient developed upper respiratory symptoms and diarrhea 3 days prior to admission and was diagnosed with COVID-19 on April 20th, 2020 in the hospital Oxygen saturation was 93% on admission although her oxygen requirement peaked at 5L nasal cannula Hydroxychloroquine was started per institutional guidelines along with ceftriaxone/ doxycycline for superimposed bacterial pneumonia Full dose mycophenolate mofetil was held The mean tacrolimus level during the hospitalization 10 4 Starting hospital day 3, the patient was started on compassionate use remdesivir daily given worsening pulmonary status followed by one dose of convalescent plasma on hospital day 4 The patient's symptoms gradually improved and she was discharged on hospital day 9 without home oxygen Conclusion: This case demonstrates the feasibility and efficacy of remdesivir and convalescent plasma in the immediate post liver transplant period These experimental drugs that have shown modest benefit based on recently unpublished data in the general population but has not been described in a liver transplant recipient It was also noted that tacrolimus pharmacokinetics were affected causing elevated tacrolimus levels during periods of worsening inflammatory symptoms. The mechanism of this change has never been described in the recent literature and will need to be addressed in future studies.