Liver specialists in New York report a high frequency of
severe COVID-19 cases in organ transplant recipients who became infected with
SARS-CoV-2, while Italian specialists report that 15 of 17 patients who
underwent liver transplants in northern Italy since early February remain free
of SARS-CoV-2, in early reports on the impact of COVID-19 on organ transplants
published in the American Journal of Transplantation.
People undergoing organ transplants are at higher risk of
SARS-CoV-2 infection owing to hospitalisation. They may also be at risk of more
severe COVID-19 outcomes after infection due to immunosuppression, although data are lacking to answer this question.
transplants cannot be postponed so more information is needed about what
happens if people who have recently undergone transplants become infected with
SARS-CoV-2 and what proportion of patients are becoming infected.
Information is also lacking on what happens to long-term
transplant recipients who acquire SARS-CoV-2.
Transplant doctors at Columbia University and Weill Cornell
Medical College in New York reported on their experience in the first three
weeks of the outbreak in the city. They identified 90 cases of COVID-19,
confirmed by PCR testing, in people who had received a solid organ transplant
at their clinics. They do not state the overall number of transplant recipients
receiving care through their clinics.
Thirteen out of 90 were liver transplant recipients. The
remainder were kidney (46), lung (17) and heart (9) recipients, and five
multiple organ recipients.
People diagnosed with COVID-19 had undergone transplantation
a median of six years ago; only three were in the immediate post-transplant
period (< 1 month) and 13 had undergone transplantation less than a year
before diagnosis with COVID-19.
The average age of the patients was 57 years, 22% were black
and 68 out of 90 were admitted to hospital. Twenty-seven out of 90 were classed
as severe cases requiring mechanical ventilation and intensive care, the
remainder were mild (outpatient) or moderate (inpatient, non-ventilation care)
Severe cases were significantly more likely to have
hypertension (78% vs 60%, p = 0.001) and to be aged 60 or over (70% vs 30%).
Compared to Chinese cohorts of hospitalised patients, the
investigators say that the proportion of transplant patients with severe disease
appeared higher. One in four transplant patients admitted to hospital with
COVID-19 died and 18% of all transplant patients presenting with COVID-19 died.
Immunosuppression was not associated with disease severity
in this population and there was no difference in outcome between lung
transplant recipients and other organ recipients.
The investigators say that because of the high death rate in
transplant patients, there is an urgent need to identify the most effective
treatment strategies for this patient group.
The use of immunosuppressive drugs might prolong viraemia in
COVID-19 patients and lead to more severe illness, but reducing
immunosuppressive treatment might lead to graft rejection, the investigators
say. Doses of antimetabolite immunosuppressive drugs were reduced or held in 88%
of patients (42 of 48) but steroid doses were reduced in only 3 of 43 patients
and calcineurin inhibitors in 10 of 56 patients. No cases of rejection were
detected during the 20-day observation period.