RAPID COMMUNICATION www.jasn.org Early Description of Coronavirus 2019 Disease in Kidney Transplant Recipients in New York The Columbia University Kidney Transplant Program* Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York ABSTRACT Background The novel SARS-CoV-2 virus has caused a global pandemic of coronavirus kidney recipients (80%), with a me- disease 2019 (COVID-19). Although immunosuppressed individuals are thought to be dian time since transplant of 49 at an increased risk of severe disease, little is known about their clinical presentation, (interquartile range, 38–118; range, disease course, or outcomes. 0–232) months (Table 1). All but one Methods We report 15 kidney transplant recipients from the Columbia University patientweretakingtacrolimusatthe kidney transplant program who required hospitalization for confirmed COVID-19, time of COVID-19 diagnosis, and and describe their management, clinical course, and outcomes. most (80%) were also taking either my- cophenolate mofetil or mycophenolic Results Patients presented most often with a fever (87%) and/or cough (67%). Initial acid. Despite our status as an early ste- chest x-ray most commonly showed bilateral infiltrates, but 33% had no acute ra- roid withdrawal center for most trans- diographic findings. Patients were managed with immunosuppression reduction plants, ten patients (67%) were taking and the addition of hydroxychloroquine and azithromycin. Although 27% of our prednisone at the time of COVID-19 patients needed mechanical ventilation, over half were discharged home by the diagnosis. The underlying cause of end of follow-up. ESKD varied. Conclusions Kidney transplant recipients with COVID-19 have presentations that Patients reported symptom onset are similar to that of the general population. Our current treatment protocol ap- ranging from 1 day to nearly 3 weeks be- pears to be associated with favorable outcomes, but longer follow-up of a larger fore admission. The most common pre- cohort of patients is needed. senting symptom was fever, which was JASN 31: ccc–ccc, 2020. doi: https://doi.org/10.1681/ASN.2020030375 reported in 13 (87%) cases, followed by cough, which was present in nine (60%) cases (Table 1). Only one patient had neither fever nor cough as a presenting Coronavirus disease 2019 (COVID-19), of organ transplant recipients who de- symptom, and instead reported exer- caused by the novel severe acute respira- velop COVID-19. International data re- tional dyspnea and malaise. Three pa- tory syndrome coronavirus 2 (SARS- garding the management and prognosis tients (20%) reported diarrhea, and fi CoV-2) virus, rst spread to the United for kidney transplant recipients with only two patients (13%) reported myal- fi States in January 2020, with the rst COVID-19 has been limited to case re- gias. Two patients were in the hospital 3,4 case in New York City diagnosed at ports. Here, we describe 15 consecutive for 6 and 7 days, respectively, before de- 1,2 the end of the following month. cases of COVID-19 among kidney trans- veloping a fever and being tested for Sincethattime,theNewYorkmetro- plant recipients at our center, Columbia COVID-19. politan area has become the epicenter University Medical Center, who required of COVID-19 in the United States, with hospitalization through March 27, 2020. approximately 40% of confirmed Received March 29, 2020. Accepted April 6, 2020. COVID-19 cases and 25% of all report- *For a full list of Columbia University Kidney ed COVID-19 deaths as of March 28, CASE SERIES Transplant Program members see the Supplemen- 2020. Given that the metropolitan area tal Material. is home to nine major academic trans- The15patientsincludedinthisseries Published online ahead of print. Publication date plant centers, there is significant had a median age of 51 (interquartile available at www.jasn.org. – concern regarding the susceptibility, range, 28 72) years and were predom- Copyright © 2020 by the American Society of presentation, and ideal management inantly men (65%) and deceased donor Nephrology JASN 31: ccc–ccc, 2020 ISSN : 1046-6673/3106-ccc 1 RAPID COMMUNICATION www.jasn.org Table 1. Characteristics of kidney transplant recipients with COVID-19 Significance Statement Characteristics All Patients, n515 Currently, the clinical presentation, optimal Baseline characteristics management strategy, and outcomes for Age, yr 51 (IQR, 28–72; range, 21–78) patients with kidney transplants who develop Female, n (%) 5 (33) COVID-19 infection remain unknown. The – – Time since transplant, mo 49 (IQR, 38 118; range, 0 232) description of our cohort represents the first Deceased donor, n (%) 12 (80) cohort of patients with kidney transplants Multiorgan recipient, n (%) 2 (13) and COVID-19 infection and includes clinical Maintenance immunosuppression, n (%) features, markers of inflammation, and a Tacrolimus 14 (93) strategy for management that includes both Mycophenolate mofetil or 12 (80) immunosuppression reduction and the mycophenolic acid use of adjuvant therapy, including hy- droxychloroquine, azithromycin, and to- Belatacept 2 (13) cilizumab. This approach appears to have Leflunomide 1 (7) resulted in favorable outcomes in our Azathioprine 1 (7) cohort of hospitalized kidney transplant Prednisone 10 (67) patients and provides an effective treat- Clinical presentation, n (%) ment strategy for the management of Fever 13 (87) these patients Cough 9 (60) Fatigue/malaise 4 (27) Dyspnea (exertional or rest) 4 (27) The primary change in immunosup- Diarrhea 3 (20) pression in the majority of patients was Myalgia 2 (13) complete cessation of antimetabolites or Hemoptysis 1 (7) leflunomide (ten out of 14, 71%) while Emesis 1 (7) continuing the tacrolimus (with a goal a Laboratory tests on diagnosis trough of 4–7 ng/ml) and the baseline 3 m – White blood cell count, 1000/ l 4.8 (range, 2.1 12.7) prednisone in those individuals who were (n513) on maintenance prednisone (Table 2). One Absolute lymphocyte count, /ml(n511) 800 (range, 110–1410) Ferritin, ng/ml (n512) 471 (range, 93–1963) patientwhowasonaregimenoftacro- Lactate dehydrogenase, U/L (n512) 275 (range, 113–450) limus and high-dose prednisone was Procalcitonin, ng/ml (n513) 0.46 (range, 0.08–18.7) switched to a regimen of prednisone Erythrocyte sedimentation rate, mm/h 40.5 (range, 0–75) 20 mg only, as was a patient who had (n512) just completed a course of thymoglobu- C-reactive protein, mg/L (n513) 104 (range, 0.3–232) lin induction therapy (6 mg/kg) after a IL-6, pg/ml (n512) 24 (range, ,5–120) deceased donor transplantation. Two Initial chest x-ray, n (%) patients were also on maintenance be- Multifocal/bilateral patchy opacities 7 (47) latacept, including one patient who was No acute findings 5 (33) on a four-drug regimen and a second Left lower lobe opacities 1 (7) Right lower lobe opacity 1 (7) patient whose dose was deferred be- Report not available 1 (7) cause of their severe ongoing hypox- Data are displayed as n (%), median (IQR), or median (range). COVID-19, coronavirus disease 2019; IQR, emia. (Tables 3 and 4). interquartile range. As per the Columbia University a n,15 because of some patients being diagnosed at outside hospitals or as outpatients, or inconsistent COVID-19 protocol, in addition to holding laboratory test ordering upon admission. the antimetabolite, 13 (87%) patients re- ceived hydroxychloroquine, including About half of our patients had bilat- 110–1410). We observed wide variation nine that received it with adjunctive azi- eral/multifocal opacities noted on initial in admission values for ferritin (median, thromycin. Hydroxychloroquine therapy chest x-ray, whereas two patients (13%) 471 ng/ml; range, 93–1963), lactate de- was not used for the recent transplant re- had lobar opacities and five patients hydrogenase (median, 275 U/L; range, cipient and for the patient first admitted (33%) had unremarkable radiographs 113–450), procalcitonin (median, to another institution. A single dose of to- initially (Table 1). Among patients for 0.46 ng/ml; range, 0.08–18.70), erythro- cilizumab was given to the patient whose whom laboratory data obtained at the cyte sedimentation rate (median, immunosuppression was reduced to pred- time of diagnosis were available, median 40.5mm/h;range,0–75), C-reactive nisone alone shortly after intubation for white blood cell count was 4.83103/ml protein (median, 104 mg/L; range, acute respiratory distress syndrome. This (range, 2.1–12.7) and median absolute 0.3–232), and IL-6 (median, 24 pg/ml; patient has since been successfully been ex- lymphocyte count was 800/ml (range, range, ,5–120). tubated on day 5 of mechanical ventilation. 2 JASN JASN 31: ccc–ccc,2020 www.jasn.org RAPID COMMUNICATION Table 2. Clinical management and outcomes of kidney transplant recipients with early uncertainty in the identification COVID-19 and management of this disease. Al- Clinical Management and Outcomes All Patients, n515 (%) though the general understanding of Change in immunosuppression the clinical presentation of COVID-19 Discontinued only MMF/MPA/AZA/ 10/14 (71) is improving, information about select leflunomide patient groups who may warrant special Prednisone decreased 1/10 (10) consideration, such as transplant recipi- Belatacept infusion postponed 1/2 (50) ents, remains limited. Here, we present a Discontinued all immunosuppression 2 (14) series of 15 cases of COVID-19 in kidney Replaced tacrolimus and MMF with 1(7) transplant recipients at our center who prednisone required