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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 6  |  Page : 1439-1440
Successful experience of coronavirus disease-2019 pneumonia in a renal-transplant recipient

1 Department of Nephrology Dialysis Renal Transplantation, Civic Hospital, Palermo, Italy
2 Department of Infectious Diseases, Civic Hospital, Palermo, Italy
3 Department of Radiology, Civic Hospital, Palermo, Italy

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Date of Web Publication29-Jan-2021

How to cite this article:
Li Cavoli G, Amato A, Iaria C, Onorato F, Finazzo F, Mongiovi R, Oliva B, Azzolina V, Li Cavoli TV, Carollo C. Successful experience of coronavirus disease-2019 pneumonia in a renal-transplant recipient. Saudi J Kidney Dis Transpl 2020;31:1439-40

How to cite this URL:
Li Cavoli G, Amato A, Iaria C, Onorato F, Finazzo F, Mongiovi R, Oliva B, Azzolina V, Li Cavoli TV, Carollo C. Successful experience of coronavirus disease-2019 pneumonia in a renal-transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Jul 31];31:1439-40. Available from: https://www.sjkdt.org/text.asp?2020/31/6/1439/308366

To the Editor,

Among the reported experiences in the developing coronavirus disease-2019 (COVID-19) pandemic, we observe different strategies on the treatment of the renal-transplant recipients with COVID-19 about home management or hospital admission, complete withdrawal or minimization of baseline immunosuppression, hydroxychloroquine, antiviral, or antibiotic therapy.[1],[2],[3]

Our experience: a 53-year-old Caucasian male suffering from autosomal dominant polycystic kidney diseasewho was on hemodialysis during the period between 2016 and 2018 till he received a living donor renal transplant. He was treated with tacrolimus 10 mg/day, mycophe-nolate mofetil 500 mg/day, prednisolone 4 mg/day. On January 15, 2020, creatinine was 1.42 mg/dL, estimated glomerular filtration rate 56 mL/min/1.73 m2, tacrolimus trough level 8.1 ng/mL, and proteinuria <0.1 g/day. On March 24, 2020, the patient was admitted to isolation ward after a positive swab for COVID-19. Five days before hospitalization, he began to suffer from fever, cough, and mild shortness of breath. In the emergency department, the body temperature was 38.3°C, blood pressure 140/80 mm Hg, heart rate 66 beats/min, respiratory rate 20 breaths/min and oxygen saturation 96% with 2 L of O2 administration. Chest computed tomography (CT) scan showed bilateral, peripheral, ground glass opacities [Figure 1]. Laboratory parameters showed high levels of: fibrinogen 547 mg/dL, D Dimer 580 mg/dL, ferritin 635 μg/L, and C-reactive protein (CRP) 4.41 mg/dL. In normal range were: white blood cells 5.360 × 109/L, lymphocyte 1.130 × 109/L, Hb 12.7 g/dL, ESR 72 mm/h, creatinine 1.19. HIV, hepatitis B virus, hepatitis C virus, urine culture, polymerase chain reaction for cyto-megalovirus-DNA and microbiological respiretory screening were negative. The mycophe-nolate administration was discontinued and tacrolimus was reduced to 5 mg/day. The patient was treated with lopinavir/ritonavir 800/ 200 mg/day and hydroxychloroquine 400 mg/ day. His respiratory status rapidly ameliorated was comfortable breathing ambient air. During the hospitalization, the patient complained of mild diarrhea and slight headache. On March 27, the tacrolimus trough level was >30 ng/mL. Therefore, we immediately stopped the tacrolimus administration. On March 28 and 29, the tacrolimus levels were still >30 ng/mL. Therefore, we stopped lopinavir/ritonavir and hydroxy-chloroquine. On admission, liver function tests were in normal range but during the hospitallization alanine transaminase went up to 79 UI/L, total bilirubin to 2.03 mg/dL and direct bilirubin to 1 mg/dL. On April 1, creatinine went up to 1.96 mg/dL. On April 6 and 7, the swabs for COVID-19 were reported negative. On April 3, tacrolimus trough level was reduced to 14.5 ng/mL and we restarted tacrolimus at 5 mg/day. The patient was discharged on day 16 with a full recovery. Creatinine was 1.25 mg/dL, tacrolimus trough level 7.5 ng/mL, CRP 1.25 mg/dL, total bilirubin 0.47 mg/dL. During this period, the function of the graft has been maintained but we had to withdraw both lopinavir/ritonavir and hydroxychloroquine to decrease the concentration of Tacrolimus. We highlight the known interaction between Tacrolimus and lopinavir/ritonavir due to the common CYP 3A-dependent pharmacokinetics.[4] In addition, the interaction between tacrolimus and hydroxychloroquine was also a possible cause, similar to a recently reported study.[5] We stress the need for careful monitoring of drug interactions to avoid exposure of kidney-transplant recipients to toxic concentrations of calcineurin inhibitors.
Figure 1: (a) Coronal and (b) axial chest computed tomography scan on admission: Bilateral, mainly peripheral (white arrow), ground glass opacities.

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Conflict of interest: None declared.

   References Top

Alberici F, Delbarba E, Manenti C, et al. A single center observational study ofthe clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia. Kidney Int 2020;97:1083-8.  Back to cited text no. 1
Banerjee D, Popoola J, Shah S, Ster IC, Quan V, Phanish M. COVID-19 infection in kidney transplant recipients. Kidney Int 2020;97:1076-82.  Back to cited text no. 2
Akalin E, Azzi Y, Bartash R, et al. Covid-19 and kidney transplantation. N Engl J Med 2020; 382:2475-7.  Back to cited text no. 3
Xia T, Wang Y. Coronavirus disease 2019 and transplantation: The combination of lopinavir/ ritonavir and hydroxychloroquine is responsible for excessive tacrolimus trough level and unfavorable outcome Am J Transplant 2020; 20:2630-1.  Back to cited text no. 4
Bartiromo M, Borchi B, Botta A, et al. Threatening drug-drug interaction in a kidney transplant patient with Coronavirus Disease 2019 (COVID-19). Transpl Infect Dis 2020;22:e13286.  Back to cited text no. 5

Correspondence Address:
Gioacchino Li Cavoli
Department of Nephrology Dialysis Renal Transplantation, Civic Hospital, Palermo
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DOI: 10.4103/1319-2442.308366

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