Iranian kidney transplant recipients with COVID-19 infection: Clinical outcomes and cytomegalovirus coinfection

COVID-19 Infection May Lead to Increased CMV Infection in Renal Transplant Recipients

BACKGROUND

The COVID-19 pandemic has caused significant mortality and morbidity, especially in renal transplant recipients. The mortality and hospitalization rate of COVID-19 infected transplant recipients is much higher than in the healthy population. Although progress has been made in the management of COVID-19 in renal transplant recipients, there are still unexplained clinical differences among patients. We think that cytomegalovirus (CMV) infection may also play a role in this clinical difference in COVID-19 infected transplant recipients. For this purpose, we aimed to screen for the presence of CMV viremia or infection in kidney transplant patient groups who were and were not diagnosed with COVID-19 in the last year.

METHOD

We included 191 consecutive kidney transplant recipients followed in our transplant clinic. The patients were divided into two groups according to whether they had COVID-19 infection or not in the last 1 year. CMV DNA levels were tested in the whole patients' groups. We compared CMV positivity rates in patients with and without COVID-19.

RESULTS

There were 83 patients who had COVID-19 and 108 patients who did not. Whereas CMV viremia was detected in 15 transplant recipients with COVID-19 infection, CMV viremia was detected in 4 patients who did not have COVID-19 (P = .001, logistic regression = 4.8, 95% confidence interval [CI] = 1328-17,103; Figure 1).There was no difference in terms of immunosuppressive therapy, steroid use, duration, and type of transplantation. The COVID-19 negative and positive groups were similar in lymphocyte and leukocyte counts (Table 1). In the multivariate analysis, CMV positivity was found to be positively associated with COVID-19 infection but lymphocyte count and estimated glomerular filtration rate (eGFR) were found to be independently and negatively correlated.

CONCLUSIONS

CMV infection may accompany COVID-19 or may occur in the post-COVID-19 period. It can cause increased morbidity and mortality. Routine screening and early treatment for CMV may reduce mortality in high-risk group.

Narrative review of factors associated with SARS-CoV-2 coinfection in Middle Eastern countries and the need to vaccinate against preventable diseases

This review evaluated the frequency of, and outcomes associated with, bacterial, fungal, and viral coinfection with SARS-CoV-2 in Middle Eastern countries via a PubMed search through February 2023. Ninety articles reported bacterial (n = 57), fungal (n = 32), and viral (n = 32) coinfections. High frequencies of coinfection with COVID-19 were identified, with rates and outcomes varying by setting, pathogen, surveillance/detection method, population characteristics, and drug-resistance status. Mortality rates were higher in patients with community-acquired (10.0 -42.9 %) and hospital-acquired (51.5 -66 %) bacterial coinfection versus those without (10.5 -21.7 %). Outcomes were worse with than without fungal coinfection, and fatality rates with mucormycosis coinfection reached 66.7 %. Outcomes with viral coinfection were highly variable; however, some data suggested a positive corelation between COVID-19 severity and influenza A and adenovirus coinfection. The negative outcomes associated with bacterial, fungal and some viral coinfections in individuals with COVID-19 support regular vaccination against vaccine-preventable diseases caused by these pathogens, especially among at-risk populations.

What's New: Updates on Cytomegalovirus in Solid Organ Transplantation

Cytomegalovirus (CMV) is one of the most common infections occurring after solid organ transplantation. This high burden of disease, which incurs sizeable morbidity, may be worsening with the proportion of high-risk D+/R- solid organ transplantation recipients increasing in some regions globally. Cohort studies continue to support either universal prophylaxis or preemptive therapy as effective prevention strategies. Letermovir prophylaxis was noninferior to valganciclovir in adult high-risk D+/R- kidney transplant recipients with fewer drug-related adverse events in a recent clinical trial and has now been approved for such use in some regions. Maribavir preemptive therapy failed to demonstrate noninferiority when compared with valganciclovir in hematopoietic stem cell transplant recipients but looked promising for safety. Donor matching could be useful in prevention CMV disease with a survival advantage demonstrated in seronegative recipients waiting up to 30 mo for a seronegative kidney. Immune-guided prophylaxis resulted in fewer CMV infection episodes in lung transplant recipients when compared with fixed-duration prophylaxis in a recent clinical trial. For treatment of refractory or resistant CMV infection, maribavir was more efficacious and better tolerated when compared with investigator-initiated therapy in its registration trial for this condition. Further research regarding best treatment and prophylaxis of resistant or refractory CMV infection is needed to reflect best clinical practice choices. Optimal use of immune globulin or CMV-specific T cells for prevention or treatment of CMV disease remains undefined. Standardized definitions for the design of CMV clinical trials have been developed. In this review, we highlight recent updates in the field from data published since 2018.

Coronavirus disease 2019 in kidney transplant recipients: a systematic review and meta-analysis

Introduction

The clinical presentation and outcomes of coronavirus disease 2019 (COVID-19) in kidney transplant recipients (KTRs) have not been well studied.

Methods

We performed a meta-analysis to examine the presenting features, outcomes and the effect of treatment on outcomes of KTRs with COVID-19. Database search was performed up to 5 September 2020 through PubMed, Embase, Web of Science, Scopus and CENTRAL.

Results

Overall, 23 studies (1,373 patients) were included in the review and meta-analysis. The most common presenting symptoms included fever (74.0%, 95% confidence interval [CI] 65.3-81.1), cough (63.3%, 95% CI 56.5-69.6) and dyspnoea (47.5%, 95% CI 39.6-55.6). Pooled rates of mortality and critical illness were 21.1% (95% CI 15.3-28.4) and 27.7% (95% CI 21.5-34.8), respectively. Acute kidney injury occurred in 38.9% (95% CI 30.6-48.1) and dialysis was required in 12.4% (95% CI 8.3-18.0) of the cases.

Conclusion

Kidney transplant recipients with COVID-19 have a similar clinical presentation as the general population, but they have higher morbidity and mortality. It is uncertain whether high-dose corticosteroid or hydroxychloroquine reduces the risks of mortality in KTRs with COVID-19.

Diagnostic stewardship to limit repeat plasma cytomegalovirus viral load testing

BACKGROUND

Frequent serial monitoring of plasma cytomegalovirus (CMV) viral load caused unnecessary budgets for laboratory testing without changes in treatment. We aimed to implement diagnostic stewardship to limit CMV viral load testing at appropriate intervals.

METHODS

A quasi-experimental study was performed. To avoid unnecessary plasma CMV viral load testing, the inpatient electronic pop-up reminder was launched in 2021. In cases with plasma CMV viral load testing was ordered in intervals of less than five days, telephone interview and feedback were performed. Pre-post intervention data was compared in terms of clinical and monetary outcomes. The rate of plasma CMV viral load testing performed in intervals of less than five days was compared between 2021 and 2019 using the Poisson regression model.

RESULTS

After the protocol implementation, there was a significant decrease in the rate of plasma CMV viral load test orders in intervals of less than five days from 17.5% to 8.0% [incidence rate ratio 0.40, p < 0.001]. There was no statistically significant difference in the incidence of CMV DNAemia and CMV disease (p = 0.407 and 0.602, respectively). As a result, the hospital could save the costs of plasma CMV viral load testing per 1,000 patients performed with intervals of less than five days from 2,646,048.11 to 1,360,062.89 Thai Baht.

CONCLUSIONS

The diagnostic stewardship program is safe and helpful in reducing unnecessary plasma CMV viral load testing and costs.

Co-infection of coronavirus disease 19 and cytomegalovirus in a kidney transplant recipient

It has been suggested that severe SARS-CoV-2 infection could be a risk factor for Herpesviridae reactivation due to the state of sepsis-associated immunosuppression. We presented the case of co-infection of CMV and COVID-19 infection in a 43-year-old woman with end-stage renal disease.

Severe acute respiratory syndrome coronavirus-2 Alpha variant (B.1.1.7), original wild-type severe acute respiratory syndrome coronavirus 2, and cytomegalovirus co-infection in a young adult with acute lymphoblastic leukemia, case report, and review of the possible cytomegalovirus reactivation mechanisms

BACKGROUND

Like other viral infections, severe acute respiratory syndrome coronavirus-2 infection could affect different human body systems, including host immune responses. Three years after its pandemic, we learn more about this novel coronavirus. As we expected, different co-infections with various organisms, such as viruses, bacteria, and even fungi, have been reported. However, concurrent infection with two severe acute respiratory syndrome coronavirus-2 strains and cytomegalovirus is extremely unusual. We have only a rudimentary understanding of such co-infections and their long-term consequences for patients with cancer.

CASE PRESENTATION

An 18-year-old young Iranian adult with acute lymphoblastic leukemia presented with abdominal pain, diarrhea, nausea, and vomiting following a recent history of severe acute respiratory syndrome coronavirus-2 infection. The patient never experienced respiratory symptoms, and the chest imaging study was normal on admission. His primary laboratory investigation revealed prerenal azotemia and severe abnormal liver function tests (blood urea nitrogen 32 mg/dL, creatinine 1.75 mg/dL, prothrombin time 66 s, partial thromboplastin time 44.5 s, international normalized ratio 5.14, total bilirubin 2.9 mg/dL, and direct bilirubin 2.59 mg/dL). Cytomegalovirus disease was diagnosed by polymerase chain reaction in his blood and stool samples. The patient's gastrointestinal signs and symptoms improved shortly after receiving intravenous ganciclovir treatment. His gastrointestinal symptoms continued intermittently for weeks despite maintenance valganciclovir prescription, necessitating frequent hospitalizations. The patient was complicated by the recurrence of gastrointestinal symptoms during the sixth hospitalization, even though he had no respiratory symptoms, and the nasopharyngeal test revealed severe acute respiratory syndrome coronavirus-2 Wuhan strain for the first time. Remdesivir and valganciclovir were administrated due to persistent enteritis and evidence of intestinal tissue invasion by severe acute respiratory syndrome coronavirus 2 and cytomegalovirus on multiple intestinal biopsies, which led to partial clinical responses. Cytomegalovirus and severe acute respiratory syndrome coronavirus-2 fecal shedding continued for more than 6 months despite repeated antiviral therapy, and the Wuhan and Alpha strains were also detected in his nasopharyngeal samples through repeated sampling (confirmed by four nasopharyngeal sampling and multiple stool specimens and several intestinal biopsies). Finally, during the Delta-variant (B.1.617.2) outbreak in Iran, the patient was admitted again with febrile neutropenia and decreased level of consciousness, necessitating respiratory support and mechanical ventilation. During the Delta-variant peak, the patient's nasopharyngeal sample once more tested positive for severe acute respiratory syndrome coronavirus 2. The patient died a few days later from cardiopulmonary arrest.

CONCLUSION

The coronavirus disease 2019 pandemic has encountered patients with cancer with critical diagnostic and treatment challenges. Patients who are immunocompromised may co-infect with multiple severe acute respiratory syndrome coronavirus-2 strains and cytomegalovirus, and even with timely diagnosis and treatment, the prognosis may be poor.

Prognosis of COVID-19 in the middle eastern population, knowns and unknowns

Since its emergence in China in 2019, the SARS-CoV-2 virus has affected all countries worldwide. The virus is easily transmitted from one person to another via infected aerosols or contaminated surfaces. Unlike its counterparts, the prognosis of COVID-19 ranges from asymptomatic to critical disease or death. Several factors play a role in determining the severity of the disease in infected patients. Among others, is the pre-existence of an underlying medical condition such as diabetes, cancer, and others. Furthermore, although children are less prone to the severe form of the COVID-19 disease, they require attention due to the report of many atypical presentations of the infection, post-asymptomatic exposure. In the Middle East, little is known about the prognosis of the SARS-CoV-2 infection in high-risk categories, notably patients with diabetes, cancer, and pregnant women. The aim of this review is to summarize the current knowledge about this group of population in the middle eastern region as well as to highlight the gap in the literature. We have found that the majority of the papers were from the Gulf countries. Although, few studies were conducted; high-risk patients appear to have an increased risk of morbidity and mortality from COVID-19 compared to their counterparts. Higher levels of inflammatory markers, C-reactive protein, erythrocyte sedimentation rate, D-dimer, and ferritin levels were also observed. Children are often asymptomatic or present with atypical presentations. More studies should be conducted to determine the clinical biomarkers of COVID-19 in high-risk categories to help in patient risk stratification and management in the middle eastern population.

Pregnant women and infants against the infection risk of COVID-19: a review of prenatal and postnatal symptoms, clinical diagnosis, adverse maternal and neonatal outcomes, and available treatments

BACKGROUND

The establishment of a risk-appropriate care approach for pregnant women and newborn infants under the COVID-19 pneumonia is vital to prevent the main pregnancy complications.

OBJECTIVES AND DESIGN

This study reviewed the vertical transmission (VT) potential of COVID-19 pneumonia in pregnant women. Key-related symptoms and adverse clinical outcomes for mothers and infants before and after childbirth were summarized. Some practical therapies and preventive health solutions were also proposed.

RESULTS

There was a high susceptibility in pregnant women to COVID-19 infection, especially in the third trimester of pregnancy. The most common symptoms in 22-40-year-old patients infected with COVID-19 were fever (87.6%), cough (52.3%), dyspnea (27.6%), fatigue (22.4%), sore throat (13.5%), malaise (9.4%), and diarrhea (3.4%), respectively. The viral infection led to an increase in preterm labor and cesarean delivery without any intrauterine infection and severe neonatal asphyxia. No infection in the newborn infants was reported despite a high risk of the VT phenomenon. The most important therapies were the reception of antiviral and antibiotic drugs, oxygenation therapy, psychological interventions, and food supplements with health-promoting effects. The best proposed medical strategies to control the COVID-19 infection were bi-monthly screening and following-up the mothers' and fetuses' health, not using the potent broad-spectrum antibiotics and corticosteroids, providing the delivery room with negative pressure for emergency cesarean section, and the immediate isolation of newborns after childbirth without direct breastfeeding.

CONCLUSION

Babies with respiratory problems may be born to some mothers with COVID-19, who have weak immune systems. Thus, the virus transmission cycle should be disrupted to prevent adverse maternal and fetal outcomes by integrating individual health guidelines, efficient medical care therapies, and hospital preventive practices.

Effect of Cytomegalovirus on the Immune System: Implications for Aging and Mental Health

Human cytomegalovirus (HCMV) is a major modulator of the immune system leading to long-term changes in T-lymphocytes, macrophages, and natural killer (NK) cells among others. Perhaps because of this immunomodulatory capacity, HCMV infection has been linked with a host of deleterious effects including accelerated immune aging (premature mortality, increased expression of immunosenescence-linked markers, telomere shortening, speeding-up of epigenetic "clocks"), decreased vaccine immunogenicity, and greater vulnerability to infectious diseases (e.g., tuberculosis) or infectious disease-associated pathology (e.g., HIV). Perhaps not surprisingly given the long co-evolution between HCMV and humans, the virus has also been associated with beneficial effects, such as increased vaccine responsiveness, heterologous protection against infections, and protection against relapse in the context of leukemia. Here, we provide an overview of this literature. Ultimately, we focus on one other deleterious effect of HCMV, namely the emerging literature suggesting that HCMV plays a pathophysiological role in psychiatric illness, particularly depression and schizophrenia. We discuss this literature through the lens of psychological stress and inflammation, two well-established risk factors for psychiatric illness that are also known to predispose to reactivation of HCMV.

Risk factors for mortality in kidney transplant recipients with COVID-19: a single centre experience and case-control study

BACKGROUND

COVID-19 infection is considered to cause high mortality in kidney transplant recipients (KTR). Old age, comorbidities and acute kidney injury are known risk factors for increased mortality in KTR. Nevertheless, mortality rates have varied across different regions. Differences in age, comorbidities and varying standards of care across geographies may explain some variations. However, it is still unclear whether post-transplant duration, induction therapy, antirejection therapy and co-infections contribute to increased mortality in KTR with COVID-19. The present study assessed risk factors in a large cohort from India.

METHODS

A matched case-control study was performed to analyze risk factors for death in KTR (N = 218) diagnosed with COVID-19 between April 2020 to July 2021 at the study centre. Cases were KTR who died (non-survivors, N = 30), whereas those who survived were taken as controls (survivors, N = 188).

RESULTS

A high death-to-case ratio of 13.8% was observed amongst study group KTR infected with COVID-19. There was a high incidence (12.4%) of co-infections, with cytomegalovirus being the most common co-infection among non-survivors. Diarrhea, co-infection, high oxygen requirement, and need for mechanical ventilation were significantly associated with mortality on regression analyses. Antirejection therapy, lymphopenia and requirement for renal replacement therapy were associated with worse outcomes.

CONCLUSIONS

The mortality was much higher in KTR who required mechanical ventilation and had co-infections. Mortality did not vary with the type of transplant, post-transplant duration and usage of depletion induction therapy. An aggressive approach has to be taken for an early diagnosis and therapeutic intervention of associated infections.

Cytomegalovirus coinfection in patients with severe acute respiratory syndrome coronavirus 2 infection: a systematic review of reported cases

BACKGROUND

Dysfunction of both the innate and the adaptive immune systems is observed in severe coronavirus disease 2019 which, together with administration of immunosuppressive drugs, could lead to cytomegalovirus coinfection or reactivation associated with a poorer outcome. The current study aimed to systematically review the pattern, presentations, clinical course and outcome of patients with severe acute respiratory syndrome coronavirus 2 and cytomegalovirus coinfection.

METHODS

Three online databases, PubMed, Scopus and Web of Science, were searched, and after excluding duplicates and irrelevant reports, eligible articles were identified. Information about patients' age and gender, comorbidities, presentations of coronavirus disease 2019 and cytomegalovirus, treatment courses and outcomes were extracted.

RESULTS

A total of 34 reports with 59 patients with coinfection were considered to be eligible for data extraction. A majority of patients were middle-aged or elderly (84.5%). More than three-fourths (79.2%) had at least one comorbidity. Cytomegalovirus viremia was documented in 43 patients. The most common end organ involved was the gastrointestinal tract in 13 patients (48.1% of 27 patients with end organ involvement), mostly as cytomegalovirus colitis, followed by the respiratory tract in 12 patients. There was a significant association between intubation and fatal outcome (p = .011).

CONCLUSION

We comprehensively reviewed published cases with coronavirus disease 2019 and cytomegalovirus reactivation. The findings may assist in appraising signs and symptoms for early suspicion, detection and treatment in patients with unusual clinical courses or with severe, prolonged or unexplained deterioration of end organ function.

Impact of COVID-19 on Global Kidney Transplantation Service Delivery: Interim Report

This article gives a personal, historical, account of the impact of the COVID-19 pandemic on transplantation services. The content is based on discussions held at two webinars in November 2020, at which kidney transplantation experts from prestigious institutions in Europe and the United States reflected on how the pandemic affected working practices. The group discussed adaptations to clinical care (i.e., ceasing, maintaining and re-starting kidney transplantations, and cytomegalovirus infection management) across the early course of the pandemic. Discussants were re-contacted in October 2021 and asked to comment on how transplantation services had evolved, given the widespread access to COVID-19 testing and the roll-out of vaccination and booster programs. By October 2021, near-normal life and service delivery was resuming, despite substantial ongoing cases of COVID-19 infection. However, transplant recipients remained at heightened risk of COVID-19 infection despite vaccination, given their limited response to mRNA vaccines and booster dosing: further risk-reduction strategies required exploration. This article provides a contemporaneous account of these different phases of the pandemic from the transplant clinician's perspective, and provides constructive suggestions for clinical practice and research.

Are CMV and SARS-CoV-2 Infections Mutual Risk Factors in Kidney Transplant Recipients?

Throughout the years, much progress has been made in the field of renal transplantation; however, along with new developments, new problems have arisen. While transplantation is the optimal choice in patients suffering from end-stage renal disease, it is always connected to certain commonly associated risks, in particular those caused by opportunistic infections. One such risk includes the reactivation of cytomegalovirus (CMV), an issue commonly affecting all kinds of transplant recipients. Similarly, with the rise of the ever-evolving global SARS-CoV-2 pandemic, patients must be constantly monitored for any respiratory symptoms, and observed closely under the care of their attending physician. Treating these patients has become extremely difficult due to limitations caused by COVID-19 protocols (for instance, the reduction of immunosuppression dosages and the avoidance of lymphocyte-depleting induction therapy) and the lack of knowledge surrounding this relatively new and worsening risk factor. In order to give patients optimal care, these arising problems need to be studied and addressed.

COVID-19-associated opportunistic infections: a snapshot on the current reports

Treatment of the novel Coronavirus Disease 2019 (COVID-19) remains a complicated challenge, especially among patients with severe disease. In recent studies, immunosuppressive therapy has shown promising results for control of the cytokine storm syndrome (CSS) in severe cases of COVID-19. However, it is well documented that immunosuppressive agents (e.g., corticosteroids and cytokine blockers) increase the risk of opportunistic infections. On the other hand, several opportunistic infections were reported in COVID-19 patients, including Aspergillus spp., Candida spp., Cryptococcus neoformans, Pneumocystis jiroveci (carinii), mucormycosis, Cytomegalovirus (CMV), Herpes simplex virus (HSV), Strongyloides stercoralis, Mycobacterium tuberculosis, and Toxoplasma gondii. This review is a snapshot about the main opportunistic infections that reported among COVID-19 patients. As such, we summarized information about the main immunosuppressive agents that were used in recent clinical trials for COVID-19 patients and the risk of opportunistic infections following these treatments. We also discussed about the main challenges regarding diagnosis and treatment of COVID-19-associated opportunistic infections (CAOIs).

Cytomegalovirus pneumonia of infants in Africa: a narrative literature review

Cytomegalovirus pneumonia has repeatedly been described in the context of HIV-exposed uninfected and HIV-infected infants. Despite its significant role in the etiology of childhood pneumonia, there is still a paucity of literature generally, and specifically in Africa, suggesting that it might be a neglected disease. Emerging evidence highlights the importance of postnatal transmission through breastmilk. The pathogenetic significance of the multiplicity of strains acquired through repeated re-infections in early infancy is unknown. The development of cheap, accurate diagnostic tools and safe, effective antivirals and the maintenance of effective prevention and treatment of pediatric HIV are needed to manage cytomegalovirus pneumonia in low-resource settings.

Incidence of Mortality, Acute Kidney Injury and Graft Loss in Adult Kidney Transplant Recipients with Coronavirus Disease 2019: Systematic Review and Meta-Analysis

The adverse impact of Coronavirus disease 2019 (COVID-19) on kidney function has been reported since the global pandemic. The burden of COVID-19 on kidney transplant recipients, however, has not been systematically analyzed. A systematic review and meta-analysis with a random-effect model was conducted to explore the rate of mortality, intensive care unit admission, invasive mechanical ventilation, acute kidney injury, kidney replacement therapy and graft loss in the adult kidney transplant population with COVID-19. Sensitivity analysis, subgroup analysis and meta-regression were also performed. Results: we demonstrated a pooled mortality rate of 21% (95% CI: 19−23%), an intensive care unit admission rate of 26% (95% CI: 22–31%), an invasive ventilation rate among those who required intensive care unit care of 72% (95% CI: 62–81%), an acute kidney injury rate of 44% (95% CI: 39–49%), a kidney replacement therapy rate of 12% (95% CI: 9–15%), and a graft loss rate of 8% (95% CI: 5–15%) in kidney transplant recipients with COVID-19. The meta-regression indicated that advancing age is associated with higher mortality; every increase in age by 10 years was associated with an increased mortality rate of 3.7%. Regional differences in outcome were also detected. Further studies focused on treatments and risk factor identification are needed.

High mortality among kidney transplant recipients diagnosed with coronavirus disease 2019: Results from the Brazilian multicenter cohort study

BACKGROUND

Kidney transplant (KT) recipients are considered a high-risk group for unfavorable outcomes in the course of coronavirus disease 2019 (COVID-19).

AIM

To describe the clinical aspects and outcomes of COVID-19 among KT recipients.

METHODS

This multicenter cohort study enrolled 1,680 KT recipients diagnosed with COVID-19 between March and November 2020, from 35 Brazilian centers. The main outcome was the 90-day cumulative incidence of death, for the entire cohort and according to acute kidney injury (AKI) and renal replacement therapy (RRT) requirement. Fatality rates were analyzed according to hospitalization, intensive care unit (ICU) admission, and mechanical ventilation (MV) requirement. Multivariable analysis was performed by logistic regression for the probability of hospitalization and death.

RESULTS

The median age of the recipients was 51.3 years, 60.4% were men and 11.4% were Afro-Brazilian. Comorbidities were reported in 1,489 (88.6%), and the interval between transplantation and infection was 5.9 years. The most frequent symptoms were cough (54%), myalgia (40%), dyspnea (37%), and diarrhea (31%), whereas the clinical signs were fever (61%) and hypoxemia (13%). Hospitalization was required in 65.1%, and immunosuppressive drugs adjustments were made in 74.4% of in-hospital patients. ICU admission was required in 34.6% and MV in 24.9%. In the multivariable modeling, the variables related with the probability of hospitalization were age, hypertension, previous cardiovascular disease, recent use of high dose of steroid, and fever, dyspnea, diarrhea, and nausea or vomiting as COVID-19 symptoms. On the other hand, the variables that reduced the probability of hospitalization were time of COVID-19 symptoms, and nasal congestion, headache, arthralgia and anosmia as COVID-19 symptoms. The overall 90-day cumulative incidence of death was 21.0%. The fatality rates were 31.6%, 58.2%, and 75.5% in those who were hospitalized, admitted to the ICU, and required MV, respectively. At the time of infection, 23.2% had AKI and 23.4% required RRT in the follow-up. The cumulative incidence of death was significantly higher among recipients with AKI (36.0% vs. 19.1%, P < 0.0001) and in those who required RRT (70.8% vs. 10.1%, P < 0.0001). The variables related with the probability of death within 90 days after COVID-19 were age, time after transplantation, presence of hypertension, previous cardiovascular disease, use of tacrolimus and mycophenolate, recent use of high dose of steroids, and dyspnea as COVID-19 symptom. On the other hand, the variables that reduced the risk of death were time of symptoms, and headache and anosmia as COVID-19 symptoms.

CONCLUSION

The patients diagnosed with COVID-19 were long-term KT recipients and most of them had some comorbidities. One in every five patients died, and the rate of death was significantly higher in those with AKI, mainly when RRT was required.

SARS-CoV-2 and Cytomegalovirus Co-Infections-A Case Series of Critically Ill Patients

The SARS-CoV-2 pandemic has placed great strain on the most developed of health care systems, especially in the context of critical care. Although co-infections with cytomegalovirus (CMV) are frequent in the critically ill due to underlying immune suppression of multiple causes, the impact on COVID-19 patients remains unclear. Furthermore, severe COVID-19 has recently been associated with significant immune suppression, and this may in turn impact CMV reactivation, possibly contributing to clinical course. Nevertheless, multiple confounding factors in these patients will certainly challenge upcoming research. The authors present a case series of five patients admitted to the intensive care unit (ICU) in the context of respiratory failure due to severe COVID-19. All patients evolved with CMV reactivation during ICU stay.

The Management of Immunosuppression in Kidney Transplant Recipients with COVID-19 Disease: An Update and Systematic Review of the Literature

Background and Objectives: In the era of the coronavirus disease 2019 (COVID-19) pandemic, the management of immunosuppressive (IS) therapy in kidney transplant (KT) recipients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requires attention. It is not yet understood whether IS therapy may protect from the cytokine storm induced by SARS-CoV-2 infection or a temporary adjustment/withdrawal of IS therapy to restore the immune system may be necessary. We performed a systematic literature review to investigate the current management of IS therapy in KT recipients with COVID-1. Materials and Methods: Out of 71 articles published from 1 February 2020 until 30 October 2020, 554 KT recipients with SARS-CoV-2 infection were identified. Results: Modifications of IS therapy were based on the clinical conditions. For asymptomatic patients or those with mild COVID-19 symptoms, a "wait and see approach" was mostly used; a suspension of antimetabolites drugs (347/461, 75.27%) or mTOR inhibitors (38/48, 79.2%) was adopted in the majority of patients with symptomatic COVID-19 infections. For CNIs, the most frequent attitude was their maintenance (243/502, 48.4%) or dose-reduction (99/502, 19.72%) in patients asymptomatic or with mild COVID-19 symptoms, while drug withdrawal was the preferred choice in severely symptomatic patients (160/450, 31.87%). A discontinuation of all IS drugs was used only in severely symptomatic COVID-19 patients on invasive mechanical ventilation. Renal function remained stable in 422(76.17%) recipients, while 49(8.84%) patients experienced graft loss. Eight (1.44%) patients experienced a worsening of renal function. The overall mortality was 21.84%, and 53(9.56%) patients died with functioning grafts. Conclusion: A tailored approach to the patient has been the preferred strategy for the management of IS therapy in KT recipients, taking into account the clinical conditions of patients and the potential interactions between IS and antiviral drugs, in the attempt to balance the risks of COVID-19-related complications and those due to rejection or graft loss.

Clinical Manifestations and Characterization of COVID-19 in Liver Transplant Recipients: A Systematic Review of Case Reports and Case Series

BACKGROUND

This systematic review is conducted to explore available information on clinical presentations, laboratory finding and outcomes of SARS-COV-2 in liver transplant patients.

METHODS

We searched four databases for relevant terms related to COVID-19 and liver transplantation and collected both case reports and case series on liver transplantation published up to the end of September 2020.

RESULTS

After initial screening of irrelevant articles, 25 studies were included and analyzed in this review. Among the 59 patients included, 78.3% were over 50 years old, and 71.6% were males. The majority of patients (93.3%) were hospitalized. The most common presenting symptoms were fever (72.9%) followed by dyspnea and cough (54.2%). The majority of patients revealed a high level of CRP (64.3%). Moreover, high level ALT, AST and ALP were reported in 64.3, 37.5, 30.5 and 22.2% of patients. A total, 9(15.3%), of cases died as a result of complications of COVID-19. Chest radiographs were reported in 72.9%(43/59) of cases that 94% demonstrated radiologic evidence of abnormality.

CONCLUSION

The results demonstrated that the most prevalent symptoms and signs were fever, dyspnea and cough. Moreover, most patients were males and hospitalized. The rate of mortality and high level of CRP, ALT/AST and ALP is similar within the non-immune suppressed and general population. However, early detection of high level of serum CRP, ALT/AST and ALP combined with a clinical COVID-19 symptom and finding of CT scan may be used as an index for the presence and severity of the disease.

COVID-19 in solid organ transplant recipients: A systematic review and meta-analysis of current literature

Severe acute respiratory virus syndrome 2 (SARS-CoV-2) has led to a worldwide pandemic. Early studies in solid organ transplant (SOT) recipients suggested a wide variety of presentations, however, there remains a paucity of robust data in this population. We conducted a systematic review and meta-analysis of SOT recipients with SARS-CoV-2 infection from January 1st t October 9th, 2020. Pooled incidence of symptoms, treatments and outcomes were assessed. Two hundred and fifteen studies were included for systematic review and 60 for meta-analysis. We identified 2,772 unique SOT recipients including 1,500 kidney, 505 liver, 141 heart and 97 lung. Most common presenting symptoms were fever and cough in 70.2% and 63.8% respectively. Majority (81%) required hospital admission. Immunosuppressive medications, especially antimetabolites, were decreased in 76.2%. Hydroxychloroquine and interleukin six antagonists were administered in59.5% and 14.9% respectively, while only few patients received remdesivir and convalescent plasma. Intensive care unit admission was 29% from amongst hospitalized patients. Only few studies reported secondary infections. Overall mortality was 18.6%. Our analysis shows a high incidence of hospital admission in SOT recipients with SARS-CoV-2 infection. As management of SARS-CoV-2 continues to evolve, long-term outcomes among SOT recipients should be assessed in future studies.