Sandbox: GDS

COVID-19 Infection in Transplant Patients

Transplant patients are at higher risk due to immunosuppression, underlying chronic kidney disease, and other comorbidities, in particular diabetes and hypertension, which are now recognized as significant factors that influence outcomes in patients with COVID-19 infection.Based on experiences with previous coronaviruses, it is known that any transplant recipient exposed to the virus would become infected in a high percentage of cases; however, less is known about the risk of donor-recipient transmission. The possibility of a donor-derived infection may be influenced by exposure of the donor, the infectivity of individuals during the incubation period and by asymptomatic people. The extent and duration of viremia and the viability of the virus within specific blood or organ compartments would also affect the risk of donor transmission. Therefore, despite the possible negative consequences, temporary interruption of kidney transplantation may be necessary in areas where the virus is being exposed intensively.

General Considerations for Renal transplant Patients

• Maintain adequate hygiene. Wash your hands frequently with soap and water for at least 20s, or with an alcohol-based hand sanitizer (at least 60% alcohol), especially: after using the bathroom, before eating, after blowing, coughing or sneezing and after direct contact with sick people or their surroundings. Avoid touching your eyes, nose and mouth before washing your hands.
• Cleaning of house surfaces should be done regularly. Clean and disinfect frequently touched objects and surfaces.
• Avoid contact or maintain a distance of at least two meters with people with respiratory infection symptoms (fever, cough, generalized sore muscle, sore throat or respiratory difficulty) and do not share personal belongings.
• During the lockdown situation you must remain at home except for the stipulated exceptions, according to the rules established by the political and health authorities. Phone the kidney transplant clinic at your referral center or the phone numbers authorized by the health authorities.
• Try to follow a correct diet. Avoid smoking and alcohol. In addition to being harmful to health, these substances weaken the immune system, making the body more vulnerable to infectious diseases.
• Avoid sharing food and utensils (cutlery, glasses, napkins, handkerchiefs, etc.) and other objects without cleaning them properly.
• The Centers for Disease Control and Prevention and (CDC): does not recommend to the general population that people who are well to wear a face mask to protect himself from respiratory diseases, including COVID-19. Today, the kidney transplant population must comply with the recommended measures of protection in the general population, especially if they are asymptomatic at home. However, the responsible physicians will recommend the use of a mask on an individual basis, mainly in cases where the patient goes to a health center or other place with agglomeration. People who show symptoms of being infected with SARS-CoV-2 should wear masks to prevent the spread of the disease to others.
• It would be advisable to authorize a sick leave in patients whose profession entails a high risk for infection.
• It is recomended to monitor kidney transplant patients through teleconsultation in order to reduce the time spent in health centers and minimize the risk of infection

Treatment

Managing immunosuppression in these patients is challenging and should take into account age, severity of COVID-19 infection, associated comorbidities, and time post-transplant. In transplant patients with mild to moderate infections, the usual practice is to continue or make reductions in the dose of immunosuppressive drugs, but this approach might favor high mortality in patients admitted to hospital with COVID-19 infection.It is suggested that antiproliferative agents (MMF and azathioprine) should be stopped at the time of admission to hospital, dose of prednisolone should be either unchanged or increased, and tacrolimus dose should be reduced. In severe infections (requiring intubation and ventilation),calcineurin inhibitors should be stopped completely while maintaining corticosteroid therapy. The role of cytokine storm and inflammation due to antiviral immune response as a driver of severe respiratory disease and acute respiratory distress syndrome has been discussed since the outbreak of this disease in December 2019, prompting trials of anti-interleukin 6 monoclonal antibody tocilizumab and case for continuing steroids in infected patients. Low dose of Tacrolimus can be continued but more evidence is needed before drawing firm conclusions. There is a risk of rejection with reduction in immunosuppression but given the high mortality rate of COVID-19 infection in hospitalized patients, clinicians should focus on keeping their patients alive with a careful case-by-case assessment of risks versus benefits of continuing immunosuppression.