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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 16  |  Issue : 4  |  Page : 458-460

Coronavirus infection in immediate postrenal transplant period - A case report


1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi, Karnataka, India
2 Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Nehru Nagar, Belagavi, Karnataka, India

Date of Submission10-Aug-2020
Date of Acceptance27-Jun-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. R B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_97_20

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  Abstract 


The novel coronavirus (severe acute respiratory syndrome coronavirus [SARS-CoV-2]) has spread out to most of the world with the World Health Organization (WHO) classifying it as a global pandemic. There exists very little information on the infectious course of COVID-19 in immunocompromised individuals, including transplant recipients. We report a case of a young adult who tested positive for SARS-CoV-2 in the immediate postoperative period following renal transplantation.

Keywords: Coronavirus, corticosteroid, COVID-19, immunosuppression, kidney transplantation, SARS-CoV-2 infection


How to cite this article:
Nerli R B, Gupta P, Adhikari P, Dixit NS, Ghagane SC, Pathan P. Coronavirus infection in immediate postrenal transplant period - A case report. Indian J Transplant 2022;16:458-60

How to cite this URL:
Nerli R B, Gupta P, Adhikari P, Dixit NS, Ghagane SC, Pathan P. Coronavirus infection in immediate postrenal transplant period - A case report. Indian J Transplant [serial online] 2022 [cited 2023 Feb 3];16:458-60. Available from: https://www.ijtonline.in/text.asp?2022/16/4/458/364631




  Introduction Top


Novel coronavirus disease-2019 (COVID-19), has spread globally at an alarming rate, with the World Health Organization in March 2020 declaring the outbreak a pandemic and a major threat to international public health.[1] Most people (about 80%) recover from the disease without needing hospital treatment. One out of every five people who get COVID-19 becomes seriously ill and develops difficulty in breathing. Older people, and those with underlying medical problems such as high blood pressure, heart and lung problems, diabetes, or cancer, are at higher risk of developing a serious illnesses.[2],[3]

The Centers for Disease Control and Prevention (CDC) also included immunocompromised patients, including those requiring immunosuppressive therapy following organ transplantation, as high risk for severe disease from severe acute respiratory syndrome virus (SARS-CoV-2).[4] As of now, there are no prophylactic agents, treatments, or vaccines available that are approved for SARS-CoV-2.[5] Currently, supportive care seems to be the only strategy of paramount importance in combating this virus in renal transplant recipients. As of today, very little data are available regarding the optimal medical management of renal transplant patients testing positive for SARS-CoV-2 including strategies for reducing or modifying immunosuppression.[6],[7],[8] In this article, we report a case of a young adult who tested positive for SARS-CoV-2 in the immediate postoperative period following renal transplantation and review the literature related to this.


  Case Report Top


A 25-year-old male underwent live-related renal transplantation with his mother being the live donor. Preoperative tests were carried out as per the standard protocol. A real-time polymerase chain reaction test (RT-PCR) for SARS-CoV-2 was done both in the donor and recipient 72 h before the transplantation procedure. The tests were negative. Immunosuppressive induction included methylprednisolone 1 gm, tacrolimus 10 mg, and mycophenolate (MMF) 1 gm. The immediate posttransplantation period was uneventful. Serum creatinine was 0.99 mg% on the 7th postoperative day. The patient had a dry cough for 3 days, hence a repeat RT-PCR for SARS-CoV-2 was performed on the 7th postoperative day, which was positive. In view of this, the patient was given all supportive treatment and the cough subsided 2 days later.

In view of this positive report, his other family members were also tested for SARS-CoV-2, and in this, his elder brother, father, sister-in-law, and niece turned out positive. His brother was responsible for bringing in food to the recipient and could be primarily responsible. The recipient has remained asymptomatic since then. His urinary drain was removed on the 6th postoperative day and the catheter on the 8th day. He tested positive for SARS-CoV-2 again on the 12th postoperative day and was in quarantine for two more weeks. RT-PCR done on the 35th postoperative day turned negative for SARS-CoV-2. Chest computed tomography (CT) showed CO-RADS score-I changes [Figure 1]. The patient was not put on any antiviral drugs as he was asymptomatic at the time of turning positive for SARS-CoV-2 and the treating physician felt it was not necessary. At present, the patient is on tacrolimus (5 mg bd), mycophenolate (360 mg tid), and low-dose prednisolone (30 mg).
Figure 1: Both the arrows indicate the presence of infection in the chest, designated shortly as: CO-RADS (a) Chest X Ray (b) CT scan chest. CT: Computed tomography

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  Discussion Top


There is no established optimal management of SARS-CoV-2 as of now, outside of supportive care. This is all the more very true in renal transplant recipients where adjustments to immunosuppressive medications must be considered while balancing the potential for acute rejection and coinfection with bacterial or opportunistic pathogens.[9] Several recently published reports have described different immunosuppressant management strategies for renal transplant recipients with SARS-CoV-2. Most patients received corticosteroid monotherapy for maintaining immunosuppression, and all but two of the remaining cases also received a corticosteroid in combination with other agents, although the details presented in these cases have many differences.[9]

Banerjee et al.[10] reported on seven cases of COVID-19 in kidney transplant recipients (median age 54 years (range 45–69), three females, from a cohort of 2082 managed transplant follow-up patients) over 6 weeks in three south London hospitals. Two of seven patients presented within 3 months of transplantation. Overall, two were managed on an outpatient basis, but the remaining five required hospital admission, four in intensive care units. All patients displayed respiratory symptoms and fever. Other common clinical features included hypoxia, chest crepitation, lymphopenia, and high C-reactive protein. Very high D-dimer, ferritin, and troponin levels occurred in severe cases and are likely prognostic. Immunosuppression was modified in six of seven patients. Three patients with severe disease were diabetic. During a 3-week follow-up, one patient recovered, and one patient died. The authors concluded that COVID-19 infection in kidney transplant patients could become severe, requiring intensive care admission. Most patients need to have their immunosuppression reduced and need to be treated with supportive therapy.

Devresse et al.[11] reported 22 COVID-19 disease cases among their cohort of 1200 kidney transplant recipients followed up in their academic institution in Belgium. The most common initial symptoms included fever, cough, or dyspnea. About 18 (82%) patients required hospitalization. Of those patients, three had everolimus-based immunosuppression. CT of the chest at admission (performed in 15 patients) showed mild (n = 3), moderate (n = 8), extensive (n = 1), severe (n = 2), and critical (n = 1) involvement. Immunosuppression reduction was initiated in all patients. Hydroxychloroquine (HCQ) was administered to 15 patients. 11 patients required supplemental oxygen; 2 of them were admitted to an intensive care unit (ICU) with mechanical ventilation. After a median of 10 days, 13 kidney transplant recipients were discharged, 2 were hospitalized in non-ICU units, 1 was in the ICU, and 2 patients had died. The authors opined that the clinical presentation of COVID-19 infection was similar to that reported in the general population. A standard strategy of immunosuppression minimization and treatment was applied, with 11% mortality among kidney transplant recipients hospitalized with COVID-19 infection.

Nair et al.[12] studied 10 kidney transplant recipients who tested positive at 12 adult care hospitals. The SARS-CoV-2 infection was confirmed by PCR. The median age was 57 years, 60% were male, 40% Caucasian, and 30% African American. The median time from transplant to COVID-19 testing was 2822 days (IQR 1272–4592). The most common symptom was fever, followed by cough, myalgia, chills, and fatigue. The most common chest X-ray and CT abnormality were multifocal patchy opacities. Three patients had no abnormal findings. Leukopenia was seen in 20% of patients, and allograft function was stable in 50% of patients. Nine patients were on tacrolimus and a mycophenolic antimetabolite, and 70% were on prednisone. Hospitalized patients had their antimetabolite agent stopped. All hospitalized patients received HCQ and azithromycin. Three patients died (30%), and 5 (50%) developed acute kidney injury. The authors concluded that renal transplant recipients infected with COVID-19 should be monitored closely in the setting of lowered immunosuppression. Most individuals do require hospitalization and the presenting symptoms are similar to those of nontransplant individuals.

There is no proven treatment yet for COVID-19. Chloroquine and HCQ have been reported to have antiviral activity, inhibit cytokine production, and be associated with improved CT pulmonary images, a rapid decline in fever, and a quicker recovery period.[12] Similarly, azithromycin was used in some centers, but it has been discontinued. Corticosteroids are not routinely recommended but have also been utilized.[13],[14] Current treatments include supportive care as well as chloroquine, HCQ, and various agents currently under investigation such as interleukin-6 inhibitors and remdesivir.[15],[16]

Banerjee et al.[10] stated that managing immunosuppression in these patients was challenging and one should consider the age of the patient, severity of COVID-19 infection, associated comorbidities, and time after transplant. They suggested that in patients with mild-to-moderate infections, it is better to continue or make reductions in the dose of immunosuppressive drugs. They also suggested that antiproliferative agents (MMF and azathioprine) should be stopped at the time of admission to the hospital, dose of prednisolone should be either unchanged or increased, and tacrolimus dose should be reduced. In patients with severe infections (requiring intubation and ventilation), it is better to stop calcineurin inhibitors completely while maintaining corticosteroid therapy. Firm recommendations cannot be made based on the small sample size of patients as of now. Recommendations can be improved based on the analysis of multi-institutional data.

In conclusion, renal transplant recipients infected with COVID-19 should be monitored closely in the setting of a lowered immunosuppression. Individuals having moderate-to-severe symptoms need to be hospitalized. Presenting symptoms are similar to those of nontransplant individuals. Mortality is high in hospitalized patients needing intensive care services. However, asymptomatic patients with mild symptoms and being monitored at home need to be closely followed through telehealth.

Declaration of patient consent

The authors certify that the patient consent has been taken for participation in the study and for publication of clinical details and images. The patient understands that his name and initials would not be published, and all standard protocols will be followed to conceal his identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. 11 March 2020. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19. [Last accessed on 2020 Aug 06].  Back to cited text no. 1
    
2.
Sharma M, Ghagane SC, Muralidhar S, Patil S, Naina R, Nerli NR, et al. Urological surgery in the time of coronavirus pandemic. J Emer Pract Trauma 2020;6:98-101.  Back to cited text no. 2
    
3.
Nerli RB, Sharma M, Ghagane SC, Dixit NS, Pratil SD, Gupta P, et al. Renal transplants in COVID-19 pandemic. J Nephrol Ren Ther 2020;6:035.  Back to cited text no. 3
    
4.
Nerli RB, Ghagane SC. Safety of health-care workers during COVID-19 times. Indian J Health Sci Biomed Res (KLEU) 2020;13:61.  Back to cited text no. 4
    
5.
Manuel O, Estabrook M, American Society of Transplantation Infectious Diseases Community of Practice. RNA respiratory viral infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019;33:e13511.  Back to cited text no. 5
    
6.
Guillen E, Pineiro GJ, Revuelta I, Rodriguez D, Bodro M, Moreno A, et al. Case report of COVID-19 in a kidney transplant recipient: Does immunosuppression alter the clinical presentation? Am J Transplant 2020;20:1875-8.  Back to cited text no. 6
    
7.
Zhang H, Chen Y, Yuan Q, Xia QX, Zeng XP, Peng JT, et al. Identification of kidney transplant recipients with coronavirus disease 2019. Eur Urol 2020;77:742-7.  Back to cited text no. 7
    
8.
Gandolfini I, Delsante M, Fiaccadori E, Zaza G, Manenti L, Degli Antoni A, et al. COVID-19 in kidney transplant recipients. Am J Transplant 2020;20:1941-3.  Back to cited text no. 8
    
9.
Johnson KM, Belfer JJ, Peterson GR, Boelkins MR, Dumkow LE. Managing COVID-19 in renal transplant recipients: A review of recent literature and case supporting corticosteroid-sparing immunosuppression. Pharmacotherapy 2020;40:517-24.  Back to cited text no. 9
    
10.
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. 10
    
11.
Devresse A, Belkhir L, Vo B, Ghaye B, Scohy A, Kabamba B, et al. COVID-19 infection in kidney transplant recipients: A single-center case series of 22 cases from Belgium. Kidney Med 2020;2:459-66.  Back to cited text no. 11
    
12.
Nair V, Jandovitz N, Hirsch JS, Nair G, Abate M, Bhaskaran M, et al. COVID-19 in kidney transplant recipients. Am J Transplant 2020;20:1819-25.  Back to cited text no. 12
    
13.
Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet 2020;395:473-5.  Back to cited text no. 13
    
14.
Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ, et al. COVID-19: Consider cytokine storm syndromes and immunosuppression. Lancet 2020;395:1033-4.  Back to cited text no. 14
    
15.
Fauci AS, Lane HC, Redfield RR. COVID-19 – Navigating the uncharted. N Engl J Med 2020;382:1268-9.  Back to cited text no. 15
    
16.
Conti P, Ronconi G, Caraffa A, Gallenga CE, Ross R, Frydas I, et al. Induction of pro-inflammatory cytokines (IL-1 and IL-6) and lung inflammation by coronavirus-19 (COVI-19 or SARS-CoV-2): Anti-inflammatory strategies. J Biol Regul Homeost Agents 2020;34:327-31.  Back to cited text no. 16
    


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