Kidney transplant recipients may develop severe COVID-19 because long-term immunosuppression and comorbidities can worsen respiratory disease and increase the risk of acute kidney injury. This article is published for educational purposes and is based on a conference poster (1).

Setting

The Emergency Hospital in Constanța followed 54 kidney transplant recipients. Between August 2020 and March 2021, five patients had RT-PCR–confirmed SARS-CoV-2 infection; three required hospitalization and are described below.

Case descriptions

Case 1

A 43-year-old woman (living-donor transplant in 2011; autosomal recessive polycystic kidney disease) was admitted with cough, dyspnea, and low-grade fever. Imaging supported COVID-19 pneumonia. Kidney function was unchanged from baseline. Mycophenolic acid was temporarily withheld, while cyclosporine was continued with monitoring. She received remdesivir, systemic corticosteroids, anticoagulation, oxygen, and supportive care. She was discharged after 9 days with stale allograft function.

Case 2

A 61-year-old woman (deceased-donor transplant; acquired cystic kidney disease) had chronic graft dysfunction with ureterohydronephrosis and cutaneous nephrostomy. She presented with fever and diarrhea; computed tomography showed COVID-19 pneumonia. Admission findings included acute kidney injury on chronic dysfunction (creatinine 4.59 mg/dL), metabolic acidosis (bicarbonate 12 mEq/L), hyperkalemia (6.3 mmol/L), hyponatremia (130 mmol/L), elevated inflammatory markers, and lymphopenia. Mycophenolate mofetil was discontinued, tacrolimus was reduced, and prednisolone was continued. She received remdesivir, anticoagulation, nephrostomy tube replacement, and careful fluid and electrolyte correction. Renal function improved (creatinine 1.35 mg/dL), oxygenation normalized, and she was discharged after 9 days.

Case 3

A 51-year-old woman with hypertension (deceased-donor transplant in 2008; chronic glomerular nephropathy) developed severe COVID-19 pneumonia with marked hypoxemia and a high computed tomography severity score (19/25), requiring intensive care and high-flow oxygen with prone positioning. Mycophenolate was withheld; tacrolimus and oral prednisone were temporarily discontinued during the severe phase, while intravenous corticosteroids were administered. She received remdesivir and tocilizumab because of insufficient early response, alongside anticoagulation and supportive care. Acute kidney injury occurred but resolved with metabolic correction and supportive management. She was discharged after 10 days with improved oxygen saturation and radiologic regression, and renal function returned to baseline.

Clinical message

In these three hospitalized kidney transplant recipients, chronic allograft dysfunction coincided with more severe disease and acute kidney injury. Temporary reduction of immunosuppression, prompt correction of metabolic derangements, and timely respiratory support were followed by short-term recovery without graft loss in all cases.

Reference

1. Pașatu-Cornea A-M, Ciciu E, Tuța L. COVID-19 in kidney transplant recipients: three case reports. Poster presented at: Scientific Conference of Doctoral Schools (SCDS-UDJG 2021): Perspectives and Challenges in Doctoral Research; 2021 Jun 10–11; Galați, Romania. “Dunărea de Jos” University of Galați. https://www.researchgate.net/publication/352284620_COVID_19_in_Kidney_transplant_recipients_-_three_cases_report