By 21 March 2020 infections related to the novel coronavirus SARS-CoV-2 had affected people from 177 countries and caused 11,252 reported deaths worldwide. Little is known about risk, presentation and outcomes of SARS-CoV-2 (COVID-19) infection in kidney transplantation recipients, who may be at high-risk due to long-term immunosuppression, comorbidity and residual chronic kidney disease. Whilst COVID-19 is predominantly a respiratory disease, in severe cases it can cause kidney and multi-organ failure. It is unknown if immunocompromised hosts are at higher risk of more severe systemic disease. Therefore, we report on seven cases of COVID-19 in kidney transplant recipients (median age 54 (range 45-69), three females, from a cohort of 2082 managed transplant follow-up patients) over a six-week period in three south London hospitals. Two of seven patients presented within three months of transplantation. Overall, two were managed on an out-patient 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 likely prognostic. Immunosuppression was modified in six of seven patients. Three patients with severe disease were diabetic. During a three week follow up one patient recovered, and one patient died. Thus, our findings suggest COVID-19 infection in kidney transplant patients may be severe, requiring intensive care admission. The symptoms are predominantly respiratory and associated with fever. Most patients had their immunosuppression reduced and were treated with supportive therapy. By 21 March 2020 infections related to the novel coronavirus SARS-CoV-2 had affected people from 177 countries and caused 11,252 reported deaths worldwide. Little is known about risk, presentation and outcomes of SARS-CoV-2 (COVID-19) infection in kidney transplantation recipients, who may be at high-risk due to long-term immunosuppression, comorbidity and residual chronic kidney disease. Whilst COVID-19 is predominantly a respiratory disease, in severe cases it can cause kidney and multi-organ failure. It is unknown if immunocompromised hosts are at higher risk of more severe systemic disease. Therefore, we report on seven cases of COVID-19 in kidney transplant recipients (median age 54 (range 45-69), three females, from a cohort of 2082 managed transplant follow-up patients) over a six-week period in three south London hospitals. Two of seven patients presented within three months of transplantation. Overall, two were managed on an out-patient 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 likely prognostic. Immunosuppression was modified in six of seven patients. Three patients with severe disease were diabetic. During a three week follow up one patient recovered, and one patient died. Thus, our findings suggest COVID-19 infection in kidney transplant patients may be severe, requiring intensive care admission. The symptoms are predominantly respiratory and associated with fever. Most patients had their immunosuppression reduced and were treated with supportive therapy. The novel coronavirus 2019 (or coronavirus disease 2019 [COVID-19]) infection, which originated in the city of Wuhan, in Hubei province, China, in December 2019 shares close similarities in its genomic structure with the severe acute respiratory syndrome coronavirus (SARS-CoV) that caused the SARS global pandemic in 2003 and the Middle East respiratory syndrome (MERS) epidemic in 2012 (MERS-CoV), and even closer similarities to bat SARS-like betacoronavirus (bat-SL-CoVZC45 betacoronavirus and bat-SL-CoVZXC21).1Wu F. Zhao S. Yu B. et al.A new coronavirus associated with human respiratory disease in China.Nature. 2020; 579: 265-269Crossref PubMed Scopus (7720) Google Scholar,2Lu R. Zhao X. Li J. et al.Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding.Lancet. 2020; 395: 565-574Abstract Full Text Full Text PDF PubMed Scopus (8314) Google Scholar Between December 31, 2019, and March 27, 2020, 532,692 COVID-19 cases and 24,077 deaths worldwide have been identified as being caused by a newly identified enveloped RNA virus named SARS-CoV-2.3Johns Hopkins University of Medicine—Coronavirus Resource CenterCoronavirus COVID-19 global cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. March 27, 2020.https://coronavirus.jhu.edu/map.htmlDate accessed: March 27, 2020Google Scholar In the United Kingdom, between January 31, 2020, and March 20, 2020, 3983 cases were identified with 177 (4% of tested patients) deaths.4UK Government. Number of coronavirus (COVID-19) cases and risk in the UK 2020. Available at: https://www.gov.uk/government/publications/covid-19-track-coronavirus-cases. Accessed April 14, 2020.Google Scholar Due to widespread nature, COVID-19 was declared as a pandemic by World Health Organization on March 11, 2020, and 176 countries are affected as of March 27, 2020.3Johns Hopkins University of Medicine—Coronavirus Resource CenterCoronavirus COVID-19 global cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. March 27, 2020.https://coronavirus.jhu.edu/map.htmlDate accessed: March 27, 2020Google Scholar The SARS pandemic was reported to affect both pediatric and adult kidney transplant recipients in Hong Kong, with less severe disease in the pediatric population.5Chiu M.C. Suggested management of immunocompromised kidney patients suffering from SARS.Pediatr Nephrol. 2003; 18: 1204-1205Crossref PubMed Scopus (16) Google Scholar One liver transplant patient died with the SARS-CoV infection in 2003.6Kumar D. Tellier R. Draker R. et al.Severe Acute Respiratory Syndrome (SARS) in a liver transplant recipient and guidelines for donor SARS screening.Am J Transplant. 2003; 3: 977-981Crossref PubMed Scopus (122) Google Scholar The MERS coronavirus infection had a variable impact on kidney transplant recipients. In 1 report of 2 kidney transplant patients, one died of progressive respiratory disease and acute kidney injury while the other survived.7AlGhamdi M. Mushtaq F. Awn N. Shalhoub S. MERS CoV infection in two renal transplant recipients: case report.Am J Transplant. 2015; 15: 1101-1104Crossref PubMed Scopus (84) Google Scholar To the best of our knowledge, only 1 patient with kidney transplantation has been reported in the literature who suffered from COVID-19 infection in Wuhan, China, and improved 13 days after hospital admission.8Zhu L, Xu X, Ma K, et al. Successful recovery of COVID-19 pneumonia in a renal transplant recipient with long-term immunosuppression [e-pub ahead of print]. Am J Transplant. https://doi.org/10.1111/ajt.15869. Accessed March 27, 2020.Google Scholar The 63-year-old kidney transplant recipient presented with fever, chest pain, cough, low lymphocyte, high serum C-reactive protein (CRP), and abnormal chest computed tomography scan on February 2, 2020. Tacrolimus and mycophenolate administration was discontinued. He was treated with oxygen, methyl prednisolone, umifenovir, moxifloxacin, biapenem, i.v. Ig, inhaled interferon-α, and pantoprazole. He made a successful recovery and was discharged on day 13. We report here the first 7 cases of COVID-19 in kidney transplant recipients in south London hospitals. We have seen 7 cases of kidney transplant recipients with proven COVID-19 infection in south London in March 2020. These patients are described herein, and their main characteristics are summarized in Tables 1 and 2.Table 1Clinical characteristics and outcome of 7 kidney transplant patients with COVID-19 infectionPatientAge/sexTx dateComorbiditiesRespiratory and renal involvementBaseline creatinine (eGFR ml/min per 1.73 m2)Baseline immunosuppression and treatmentACEI or ARBOutcome148/M1989HTNo350 (15–18)Aza/PredNo changeNoStayed at home, full recovery267/F03/2019T2D/HTYes, ARDS + AKI (CVVH)150 (45)Tac/MMF/PredMMF stoppedYes ACEIDied354/F12/2019PTDM/CMVYes, ARDS + AKI (CVVH)132 (48)Tac/MMF/PredTac and MMF stoppedNoAlive, ventilated465/M08/2018Wheelchair/HTNNo ARDS180 (23)Tac/MMF/PredMMF stoppedNoAlive, in medical ward569/F02/2020DM/HTNo ARDSAKI165 (31)Tac/MMF/PredMMF stoppedNoBrief ITU stay, not intubated; stepped down to ward654/M05/2013Hemolytic anemia/HTNo ARDS187 (47)Tac/MMFMMF stoppedNoStayed at home, still has cough and some flu-like symptoms745/M09/2017 (2nd Tx)HTNo ARDSAKI (HD)450 (12–16)Tac/Aza/AzaAza stoppedTac dose reducedNoAdmitted, managed in the ward; severe AKIACEI, angiotensin-converting enzyme inhibitor; AKI, acute kidney injury; ARB, angiotensin receptor blocker; ARDS, acute respiratory distress syndrome; Aza, azathioprine; CMV, cytomegalovirus; COVID-19, coronavirus disease 2019; CVVH, continuous venovenous hemofiltration; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate; F, female; ITU, intensive therapy unit; M, male; MMF, mycophenolate mofetil; Pred, prednisolone; PTDM, post-transplant diabetes mellitus; T2D, type 2 diabetes; Tac, tacrolimus; Tx, treatment(s). Open table in a new tab Table 2Blood parameters during COVID-19 infectionPatientWhite cell count (× 109/l) (3.5–10)Lymphocyte count (× 109/l) (1–3.5)Serum CRP (mg/l) (<5)Serum ferritin (μg/l) (25–200)Serum D dimer (μg/l) (0–500)Serum LDH (U/l) (100–240)Serum troponin I (ng/l) (<34)1———————26 (D1)0.8 (D1)83 (D1)2032 (D3), >6000 (D10)1226 (D10)78 (D1), 395 (D10)311.25 (D1)0.5 (D1)329 (D1)————4———————59.4 (D1)0.3 (D1)————30 (D4)aSerum troponin T (0–14 ng/l).610 (D1)4.0 (D1)—————75.5 (D1)0.3 (D1)198 (D1)6919 (D3)1907 (D3)502 (D3)35 (D7)COVID-19, coronavirus disease 2019; CRP, C-reactive protein; D, day after admission; D1, day of admission; LDH, lactate dehydrogenase.a Serum troponin T (0–14 ng/l). Open table in a new tab ACEI, angiotensin-converting enzyme inhibitor; AKI, acute kidney injury; ARB, angiotensin receptor blocker; ARDS, acute respiratory distress syndrome; Aza, azathioprine; CMV, cytomegalovirus; COVID-19, coronavirus disease 2019; CVVH, continuous venovenous hemofiltration; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate; F, female; ITU, intensive therapy unit; M, male; MMF, mycophenolate mofetil; Pred, prednisolone; PTDM, post-transplant diabetes mellitus; T2D, type 2 diabetes; Tac, tacrolimus; Tx, treatment(s). COVID-19, coronavirus disease 2019; CRP, C-reactive protein; D, day after admission; D1, day of admission; LDH, lactate dehydrogenase. A 48-year-old man with deceased donor kidney transplant in 1989 with failing transplant kidney (estimated glomerular filtration rate [eGFR]: 15–18 ml/min per 1.73 m2) called the National Health Service (111) helpline in the first week of March 2020 with cough, fever, and mild shortness of breath. He tested positive for COVID-19 by nose and throat swabs taken on March 2. As he was clinically well, he was asked to stay at home and self-isolate. His immunosuppression was azathioprine 75 mg once daily (OD) and prednisolone 5 mg OD, which was not changed. He was not on angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker at the time of presentation. He has made a full recovery. The transplant kidney function remained stable. A 67-year-old woman with insulin-dependent type 2 diabetes and end-stage kidney disease on hemodialysis therapy for 4 years received a deceased donor kidney transplant in March 2019. Her eGFR was 45 to 55 ml/min per 1.73 m2. She was maintained on tacrolimus with levels between 5 and 8 ng/ml, mycophenolate mofetil (MMF) 250 mg twice a day (BD), and prednisolone 5 mg OD. Her other medications included ramipril, aspirin, alfacalcidol, and amiloride. She presented on March 5 with cough, fever, and shortness of breath. Chest X-ray revealed bilateral patchy consolidation (Figure 1a). SARS-CoV-2 RNA polymerase chain reaction tests from nose and throat viral swabs were positive. Bronchial washing for pneumocystis polymerase chain reaction was negative, as was blood polymerase chain reaction for cytomegalovirus DNA. There was no other positive microbiological diagnosis. She was hypoxic with peripheral oxygen saturation of 86% and a respiratory rate of 26 breaths/min, so she was transferred to intensive therapy unit (ITU) and commenced noninvasive ventilation (continuous positive airway pressure for type 1 respiratory failure) and subsequent intubation and ventilation as her clinical condition deteriorated. Serum CRP on admission was 83 mg/l, hemoglobin 110 g/l, with normal total white cell count, and mild lymphopenia (lymphocyte count 0.8 × 109/l). She was treated with broad spectrum antibiotics. No specific were MMF was tacrolimus was but 1 day day admission, she acute kidney injury with a serum creatinine to She remained on the with oxygen and in on chest X-ray (Figure but on March with high serum lactate and lactate levels and an acute of CRP to She severe to on continuous venovenous to an and/or She and died on March A woman with a of adult kidney disease, end-stage kidney disease in was on hemodialysis for 7 and received a deceased donor kidney transplant in December 2019. she an of cytomegalovirus infection and post-transplant diabetes Her medications included of tacrolimus mg and MMF mg and of prednisolone 5 5 75 2 and mg and mg and Three months after deceased donor kidney on March she presented with shortness of to the her oxygen were with rate of and blood pressure of She was on continuous positive airway pressure and her oxygen improved to of the chest revealed widespread and her chest X-ray bilateral She was to be positive for SARS-CoV-2 Her and other respiratory viral with pneumonia were There was no other positive microbiological diagnosis. She features of acute respiratory distress syndrome and AKI Her respiratory in the and she required intubation 8 and to be MMF was on March and tacrolimus on March spectrum and were She was treated for pneumocystis with high dose Serum CRP from on day of admission to 7 days She and continuous venovenous which Her chest X-ray some of the A with a of and end-stage renal disease in and received a deceased donor kidney transplant in months after kidney he presented to hospital with shortness of and chest and was to He was with COVID-19 infection on March MMF was and he with tacrolimus and He was discharged from the ITU and is to a medical still requiring 4 to oxygen to function remained stable. A woman with and end-stage kidney disease was on therapy 2012 and hemodialysis therapy she received a deceased donor kidney transplantation on February and was discharged on March Her included MMF, and Other medications included as as 4 mg and 1 mg as She presented with shortness of and on March 13. Her chest X-ray of on March 13 that on March and She tested positive for SARS-CoV-2 RNA on March 14, 2020. She was with oxygen saturation of and blood pressure saturation improved to with 4 oxygen by was g/l, serum of and serum Her count on day of admission to × and has remained Tacrolimus was and MMF was from March She was treated with and blood She was to ITU on March for respiratory but not more 5 oxygen and transferred to on March March 20, her serum creatinine was She an and is being managed in a A man with and of received a kidney transplant 7 years He presented on March with cough and and tested positive for SARS-CoV-2 RNA on March 13. He was and were stable. He received and medications the mg OD, MMF mg mg OD, mg at mg OD, mg OD, 8 mg 1 OD, and 250 mg OD. He AKI with a in creatinine from to was cell are in Table 2. He remained on March 21 with cough and mild fever. As the symptoms were not MMF was and he has managed to stay at A man with a kidney transplant from presented with fever, flu-like cough for 7 and shortness of for 1 He had with no other He was a recipient with at and was maintained on long-term azathioprine in from MMF due to and prednisolone mg OD. admission on March he was and hypoxic with oxygen saturation of on which was to on 4 oxygen and throat swabs were positive for SARS-CoV-2 He AKI with serum creatinine and eGFR 5 ml/min per 1.73 He was with count of × × 109/l) with normal hemoglobin and white cell function tests were normal on admission, but up to on day Chest X-ray revealed bilateral was on admission, tacrolimus and prednisolone to mg OD. he 1 hemodialysis He is from respiratory of and as of March 2020, the oxygen are on 2 He stable. In report we our first 7 cases of COVID-19 infection in kidney transplant recipients from south United age of transplant recipients was 54 years 4 7 patients, 2 were managed on an and at home, with the remaining 5 requiring hospital admission. the required ITU admission, and 1 is being managed in the renal 4 patients to ITU, 2 intubation and the other 2 were managed with oxygen and noninvasive ventilation There was 1 in of 7 patients rate of All patients with severe disease were and had Two patients presented within months of kidney transplantation within 2 while kidney transplant was months or more in the remaining 5 The patients were managed in and the total of transplant patients in was with patients from December 2019, to March 2020, during the patients are at higher risk due to immunosuppression, chronic kidney disease, and other in diabetes and which are as that outcomes in patients with COVID-19 F. Yu R. et and risk for of adult with COVID-19 in Wuhan, a cohort 2020; 395: Full Text Full Text PDF PubMed Scopus Google Scholar Three of our patients had chronic kidney disease 4 to with 1 at home and 1 requiring hospital admission but ITU admission. The remaining 4 patients had chronic kidney disease of which 2 had severe disease requiring intubation and ventilation and 1 of died. patients who had severe COVID-19 the one who died had diabetes immunosuppression in patients is and of COVID-19 infection, associated and time In transplant patients with mild to the is to or in the dose of but high in patients to hospital with COVID-19 we that are not on the of we suggest that and be at the time of admission to dose of prednisolone be or and tacrolimus dose be In severe infections intubation and an can be made for while therapy. The of and due to as a of severe respiratory disease and acute respiratory distress syndrome has been the of disease in December 2019, of and case for in patients. 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