Reducing immunosuppression appears safe for kidney transplant recipients with COVID-19
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For kidney transplant recipients hospitalized with COVID-19, neither reducing nor withdrawing immunosuppression therapy led to allograft rejection or the development of donor-specific antibodies.
As such, Paula Anton Pampols, of the department of nephrology at Bellvitge University Hospital in Barcelona, and colleagues concluded the practice is safe for this patient population, which may be at increased risk for “severe manifestations of coronavirus disease 2019 (COVID-19) due, at least in part, to chronic immunosuppressive therapy.”
The researchers elaborated, writing: “It has been proposed that management of viral infections after solid-organ transplantation should include antiviral drug therapies and immunosuppression reduction, since progression to severe disease has been correlated with overimmunosuppression. Consequently, a reduction of immunosuppressive agents appears as a rational strategy to allow the development of specific immunity.”
As few “evidence-based strategies concerning therapeutic management” of these patients exist, the researchers described practice patterns and considered outcomes for 47 transplant recipients 3 months after hospital discharge for COVID-19 (median time from kidney transplantation to COVID-19 diagnosis was 109 months). They noted 8.5% of the study population had known donor-specific antibodies before admission and 12.7% had a history of rejection episodes.
Regarding therapeutic management, Anton Pampols and colleagues discovered 83% of patients had at least one immunosuppressive agent withdrawn (which were most frequently antimetabolites) and 17% had all immunosuppressants withdrawn.
However, researchers found steroids were frequently not stopped, with the dose increased for 15% of patients as part of COVID-19 treatment.
As for the impact of immunosuppressive medications being suspended (which was for a median of 17 days), researchers observed no rejection episodes or de novo donor-specific antibodies at 3 months after discharge.
Further, there were “no significant changes” in calculated panel reactive antibodies and all patients recovered baseline kidney function by the end of follow-up.
When examining episodes of AKI, the researchers found a relationship between the severity of AKI and tacrolimus trough levels; they therefore proposed that the development of AKI was likely due to calcineurin inhibitor nephrotoxicity rather than being directly related to COVID-19.
“Our data suggests that withdrawal of immunosuppressants in the course of illness and their later reintroduction is safe in [kidney transplant recipients] KTs,” Anton Pampols and colleagues wrote. “Furthermore, since dexamethasone at high doses is currently recommended for the treatment of moderate-severe COVID-19, withdrawal of antimetabolites or other immunosuppressive agents is probably advisable in order to prevent complications associated to overimmunosuppression.”
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