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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2021  |  Volume : 32  |  Issue : 3  |  Page : 875-879
Better Outcome of Coronavirus Disease 2019 Infection in Kidney Transplant Recipients: A Case Series from Eastern India


1 Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Nephrology, Patna Medical College; Department of Nephrology, All India Institute of Medical Sciences, Patna, Bihar, India

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Date of Web Publication29-Jan-2022
 

   Abstract 


The coronavirus disease 2019 (COVID-19) led to a global pandemic which is still unfolding. Little is known about the presentation, course of disease, treatment, and outcome in kidney transplant recipients. In this series, we describe nine such patients who presented with COVID-19. The mean age of the patients was 41.22 years. The mean duration of kidney transplantation was 63.22 months. The most common symptom was fever (9/9), followed by malaise (7/9), cough (5/9), dyspnea (4/9), diarrhea (2/9), and hemoptysis (2/9). Five patients developed acute kidney injury. Antiproliferative was stopped in all cases. Three patients needed hospitalization due to hypoxia while others were managed at home. We observed that majority of patients could be managed at home with isolation and self-monitoring. Even patents with moderate-to-severe disease were managed with oxygen supplement, low molecular weight heparin, and remdesivir. All patients recovered without any short-term sequelae in two months follow-up.

How to cite this article:
Krishna A, Singh PP, Vardhan H, Kumar O. Better Outcome of Coronavirus Disease 2019 Infection in Kidney Transplant Recipients: A Case Series from Eastern India. Saudi J Kidney Dis Transpl 2021;32:875-9

How to cite this URL:
Krishna A, Singh PP, Vardhan H, Kumar O. Better Outcome of Coronavirus Disease 2019 Infection in Kidney Transplant Recipients: A Case Series from Eastern India. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Sep 28];32:875-9. Available from: https://www.sjkdt.org/text.asp?2021/32/3/875/336787



   Introduction Top


The novel coronavirus disease 2019 (COVID-19) that started from Wuhan, China in December 2019, led to a global pandemic which is still unfolding. This is caused by an RNA virus, severe acute respiratory syndrome coronavirus-2 of Coronaviridae family.

The virus usually involves the respiratory tract; in severe cases, renal failure and multi-organ dysfunction are also seen. Kidney transplant recipient is a subgroup which is believed to be at greater risk of morbidity and mortality from this virus.[1],[2] Little is known about the presentation, course of disease, treatment and outcome of COVID-19 in kidney transplant recipients except data emerging from small case series.[1],[2] Alberici et al have shown that the incidence of acute kidney injury (AKI) was 30% and mortality was 25%in renal transplant patients with COVID 19.[1] We share our experience of nine kidney transplant recipients with COVID-19.


   Case Report Top


Among 157 kidney transplant recipients under active follow-up in our outpatient department, we describe nine patients who presented with COVID-19 between June 20, 2020, and July 31, 2020. The diagnosis was based on the presence of symptoms and positive real-time reverse-transcriptase-polymerase chain reaction (RT-PCR) report of the sample taken from nasopharynx. The characteristics of these patients are described in [Table 1].
Table 1: Clinical and laboratory characteristics of patients.

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The mean age of the patients was 41.22 years (range: 28–60 years). Only one patient (Case 1) was female. None of the patients had any addiction. Average body mass index was 23.3 kg/m2 (range: 19.1–26.8 kg/m2). The mean duration of kidney transplantation was 63.22 months (Range: 6–218 months). The mean serum creatinine prior to COVID-19 was 1.22 mg/dL (Range: 0.88–1.66 mg/dL). Relevant laboratory investigations done at the first visit are shown in [Table 1], [Figure 1] and [Figure 2]. Investigations were repeated as required on individual basis and one day prior to discharge of the patients in all cases.
Figure 1: Chest X-ray postero-anterior view of Case 7 showing increased heterogeneous radio-opacity peripheral part of lungs bilaterally. Permanent pacemaker is also seen in left upper zone.

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Figure 2: High resolution computed tomography-scan (case 8) showing faint patchy ground-glass opacity in peripherally with increased vascular thickening suggestive of atypical pneumonia.

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The most common symptom was fever (9/9), followed by malaise (7/9), cough (5/9), dyspnea (4/9), diarrhea (2/9), and hemoptysis (2/9). Case 3, 5, and 9 also had anosmia, ageusia, and abdominal pain, respectively. Five patients developed AKI as per KDIGO definitions.[3] None of them required dialysis and renal function recovered with supportive measures alone.

Three patients had moderate-to-severe COVID-19 (Case 1, 2, and 6).[4] They received in-patient treatment. The remaining six patients were advised home isolation and were actively monitored by audio/video calls twice daily and on need basis. They self-monitored their oxygen saturation by pulse-oximeter at room air (SpO2), body temperature, respiratory rate measurement four times a day, and blood pressure measurement by automatic digital sphygmomanometer twice a day. All of them were given orally Vitamin C 500 mg, Zinc 50 mg, Vitamin D 60,000 U, and tablet paracetamol.[5]

Immunosuppressants were modified in all patients. Anti-proliferative was stopped in all patients after diagnosis and was reintroduced two weeks after recovery. Tacrolimus dose was reduced by 50% in Case 1 and 2 while in Case 6; cyclosporine was continued without dose modification. Prednisolone was replaced by dexamethasone 6 mg by intravenous injection for first five days of admission in Case 1, 2, and 6.

SpO2 of Case 1, 2, and 6 were 86, 82, and 84 respectively at admission. They were able to maintain SpO2 of more than 95% with oxygen supplement and did not require noninvasive or mechanical ventilation during hospitalization. They were also given remdesivir[6] and low molecular weight heparin for five days followed by antiplatelet agent.[4],[6] The mean duration of hospitalization was 11 days (range: 8–15 days).[4] The patients were discharged after clinical recovery and repeat RT-PCR reports were negative, as per protocol issued by the National Center for Disease Control, Government of India.[7] All the nine cases recovered without any sequelae.


   Discussion Top


As novel coronavirus disease is peaking in India, kidney transplant recipients are also getting infected and numbers are progressively increasing in this subgroup. Kidney transplant patients are expected to have poorer outcome due to chronic immunosuppression and multiple comorbidities such as diabetes mellitus, hypertension, and chronic kidney disease.

In this case series, we have described the clinical parameters, management, and outcome of nine kidney transplant recipients who developed COVID-19. Nine out of 157 patients (5.7%) developed COVID-19 during the month of June–July 2020.

Fever was the most common symptom in our series which was reported in all the cases. This is much higher than that reported by Alberici et al[1] or Akalin et al[2] where the symptoms of fever were present only in around half of the cases. This may be explained by the ethnicity of our patients being different from that seen in Europe and the USA.

AKI was observed in five out of nine patients. All of them were AKI network Class 1 and 2 and only one patient (Case 1) was hospitalized. The kidney function improved with conservative management in all cases.

We hospitalized patients with moderate-to-severe COVID syndrome while those with mild form of disease were treated at home.[4] This is similar to strategy followed by Banerjee et al[8] but in our study, the majority of patients had less severe disease, most of them were managed at home and had an excellent outcome.

The treatment strategy in kidney transplant recipients with COVID-19 is still evolving. The management of immunosuppression in these patients is under debate and confusing. Some authors withdrew both MMF and tacrolimus in their patients after diagnosis of COVID-19 while others withdrew only anti-proliferative.[1],[2] In our study, immunosuppressants were modified on an individual basis.

Till date, no drug has shown substantial benefit in the treatment of COVID-19. Multinational trials like SOLIDARITY and RECOVERY may, in near future, provide the answer. Along with supportive treatment, dexamethasone and remdesivir were used in the treatment of these patients and may be of some value in moderate-to-severe cases.[8],[9],[10]

In contrast to 28 % mortality as shown by Akalin et al[2] and 20% mortality by Alberici et al,[1] no mortality or sequelae occurred in our study at least in short-term basis within two months of follow-up and all of the patients including those hospitalized had improved.


   Conclusions Top


Clinical presentation and outcome of COVID-19 in kidney transplant recipient in our population are different from that observed in patients from Europe and the USA. The majority of patients with mild disease were managed at home with self-monitoring under supervision with the transplant team.

Conflict of interest: None declared.



 
   References Top

1.
Alberici F, Delbarba E, Manenti C, et al. A single center observational study of the 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
    
2.
Akalin E, Azzi Y, Bartash R, Seethamraju H, Parides M, Hemmige V. COVID-19 and kidney transplantation. N Engl J Med 2020; 382:2475-7.  Back to cited text no. 2
    
3.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012;2:1–138.  Back to cited text no. 3
    
4.
Government of India. Ministry of Health and Family Welfare, Directorate General of Health Services (EMR Division). Clinical Management Protocol: COVID-19. Version 5; July 03, 2020. Available from: https://www.mohfw.gov.in/pdf/UpdatedClinicalManagementProtocol forCOVID19dated03072020.pdf. [Last accessed on 2020 Jul 15].  Back to cited text no. 4
    
5.
Zhang L, Liu Y. Potential interventions for novel coronavirus in China: A systematic review. J Med Virol 2020;92:479-90.  Back to cited text no. 5
    
6.
Grein J, Ohmagari N, Shin D, et al. Compassionate use of remdesivir for patients with severe COVID-19. N Engl J Med 2020; 382:2327-36.  Back to cited text no. 6
    
7.
National Center for Disease Control, DGHS, MOHFW, GOI. Revised Discharge Policy for COVID-19. Available from: https://ncdc.gov. in/showfile.php?lid=505. [Last accessed on 2020 Jun 29].  Back to cited text no. 7
    
8.
Banerjee D, Popoola J, Shah S, Ster IC, Quan V, Phanish M. Early experience with COVID-19 in kidney transplantation. Kidney Int 2020; 97:1074-5.  Back to cited text no. 8
    
9.
Science. WHO Launches Global Mega Trial of the Four Most Promising Coronavirus Treatments. Available from: https://www. sciencemag.org/news/2020/03/who-launches-global-megatrial-four-most-promising-coronavirus-treatments. [Last accessed on 2020 Jul 31].  Back to cited text no. 9
    
10.
RECOVERY Collaborative Group; Horby P, Lim WS, Emberson JR, et al. Dexamethasone in hospitalized patients with COVID-19 –Preliminary report. N Engl J Med 2021;384: 693-704.  Back to cited text no. 10
    

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Correspondence Address:
Prit Pal Singh
Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Fatna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.336787

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