COVID-19 in small bowel transplant recipients: A single center experience

ABSTRACT

Introduction: Coronavirus disease 2019 (COVID-19) outbreak posed unique challenges for immunosuppressed patients. Little is known about the clinical course and immunosuppression management of this novel infection in intestinal transplant recipients. Methods: We experienced 6 adult intestinal transplant recipients who had a positive swab test of COVID-19 and symptoms. Baseline characteristics, clinical presentation, management of immunosuppressive therapy and outcomes were collected. Results: Median age was 53 years (range 30-71). They had 3 liver-free composite allografts, 2 isolated intestine, and 1 intestine-kidney with median time from transplant of 8 years (range 4-12). Maintenance immunosuppressive therapy was tacrolimus/steroid in 4, and tacrolimus monotherapy in 2 patients. The most common symptom was cough (n=5) followed by fever (n=3) and dyspnea (n=3). All had ground glass opacities on computed tomography. Four patients were admitted to our institution but two were managed at local hospital due to difficulty of transportation. Immunosuppression therapy was never suspended and was reduced for one patient. Pharmacological therapy consisted in remdesivir and steroids for 4 recipients (67%) associated with convalescent plasma in 2 cases (33%) plus tocilizumab in 1 case (17%), and steroids for 2 patients (33%) associated with convalescent plasma in 1 case (17%). Two patients required intubation for acute respiratory distress syndrome. One patient received antibiotics for superimposed bacterial pneumonia. Mean white blood cells and lymphocyte count were 4.72±0.6 k/uL and 0.96±0.65 k/uL at presentation, respectively. Mean D-Dimer, C-reactive protein and ferritin were 740±160 ng/ml, 4.1±5 mg/dl and 249±149 ng/ml, respectively at presentation, with a peak of 1255±785 mg/ml, 10.9±8 mg/dl and 630±318 ng/ml, respectively. No significant changes were noted in liver and renal function. Before discharge, all patients underwent ileoscopy and allograft biopsies with no evidence of inflammation/rejection. Mean hospital stay was 36±21 days. Death occurred in 2 patients (33%) who were managed at local hospital. No recurrence was noted with mean follow up of 90 days. Conclusions: We treated intestinal transplant recipients symptomatic for COVID-19 without immunosuppression interruption. No increased inflammation or rejection was noted in the intestinal grafts. Aggressive treatment of COVID-19 infection should be granted under expertise of intestinal transplant and transplant infectious disease team.