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Letters to the Editor

COVID-19 Early After a Deceased Donor Kidney Transplant Surgery

Abuzeineh, Mohammad MD1; Desai, Niraj MD2; Brennan, Daniel C. MD1; Alasfar, Sami MD1

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doi: 10.1097/TP.0000000000003439
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Many transplant centers reduced their solid organ transplant procedures in response to the coronavirus disease 2019 pandemic.1,2 We describe the course of a kidney transplant recipient who presented with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection 10 days after transplant surgery.

The patient is a 41-year-old Hispanic woman with end-stage kidney disease secondary to lupus nephritis on maintenance hydroxychloroquine 200 mg daily who presented for a zero HLA A, B, DR mismatched deceased donor kidney transplant. The donor was involved in a motor vehicle accident and sustained multiple injuries resulting in his death. He had a negative SARS-CoV-2 nasopharyngeal swab. The patient denied symptoms of SARS-CoV-2 infection or exposure to SARS-CoV-2-positive individuals and stayed at home before transplant except for going to her dialysis unit. Her preoperative nasopharyngeal swab for SARS-CoV-2 was negative and her chest X-ray was normal. She received induction immunosuppression with intravenous high-dose steroids and reduced-dose rabbit anti-thymocyte globulin, 3 mg/kg per our center’s protocol for zero antigen-mismatched transplants, and maintenance tacrolimus, mycophenolate 500 mg twice daily and prednisone taper in addition to hydroxychloroquine. She had immediate allograft function and was discharged 5 days following her transplant with serum creatinine of 1.7 mg/dL. Her absolute lymphocyte count at the time of discharge was 550 cells/mm3.

Ten days posttransplant, she developed a fever of 100°F, dry cough, sore throat, and 2 episodes of diarrhea. A nasopharyngeal swab was obtained and was positive for SARS-CoV-2. It is thought that she acquired SARS-CoV-2 infection from contact with a family member who worked in a grocery store. Her oxygen saturation was 97% on room air and she had normal vital signs. Chest X-ray showed a new discoid opacity within the right lower lung (Figure 1). Mycophenolate was held, prednisone dose was immediately reduced from 20 mg to 10 mg and then to 5 mg maintenance, tacrolimus was dosed to maintain trough levels of 7–10 ng/mL, and hydroxychloroquine was increased to 200 mg twice daily, based on earlier reports in the pandemic about its presumed effectiveness. C-reactive protein was 0.4 mg/dL, absolute lymphocyte count was 1200 cells/mm3, and serum creatinine was 1.1 mg/dL. She received 1 unit of convalescent plasma transfusion through Food and Drug Administration expanded access pathway under a protocol that was approved by our Institutional Review Board; however, after completion, she developed urticaria, which was treated with antihistamines. She had a positive direct antiglobulin test confirming the transfusion reaction. She remained clinically stable and was discharged after 1 day of hospitalization with a pulse oximeter to monitor her oxygen saturation at home. More than 60 days have passed since discharge, and she continues to do well.

FIGURE 1.
FIGURE 1.:
Left, Preoperative chest X-ray. Right, Chest X-ray at the day of presentation with COVID-19 symptoms.

This report demonstrates that despite acquiring SARS-CoV-2 at the “peak” of immunosuppression, which included lymphocyte depletion, our patient had only mild symptoms and did not develop serious complications. The utility of convalescent plasma in renal transplant recipients with SARS-CoV-2 is not well defined. A recent report described successful recovery in a kidney transplant recipient who had severe infection with SARS-CoV-2 and was treated with 2 units of convalescent plasma.3 In view of the very recent and “heavy” immunosuppression in our patient, we decided to utilize convalescent plasma, despite her mild illness. More data are needed to better describe SARS-CoV-2 infection and treatment in peritransplant period. Finally, it is crucial to highlight the importance of taking meticulous measures and precautions in this patient population, especially in the presence of household contacts working at potentially “high risk” jobs for acquiring and transmitting SARS-CoV-2. Self-quarantine, physical distancing, and frequent hand hygiene should be undertaken at the highest potential levels.

REFERENCES

1. Boyarsky BJ, Po-Yu Chiang T, Werbel WA, et al. Early impact of COVID-19 on transplant center practices and policies in the United States. Am J Transplant. 2020; 20:1809–1818
2. Loupy A, Aubert O, Reese PP, et al. Organ procurement and transplantation during the COVID-19 pandemic. Lancet. 2020; 39510237e95–e96
3. Jiang J, Miao Y, Zhao Y, et al. Convalescent Plasma Therapy: Helpful Treatment of COVID-19 in a Kidney Transplant Recipient presenting with serve clinical manifestation and complex complications. Clin Transplant. [Epub ahead of print. June 30, 2020]. doi: 10.1111/ctr.14025.
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