Unusually high rates of acute rejection during the COVID-19 pandemic: cause for concern?

To the editor:

The coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented health care, economic, and psychosocial crises. We report a case series of 6 kidney and pancreas transplant recipients who presented in an unusually short time frame during the COVID-19 pandemic with transplant organ dysfunction and rejection (Table 1 ). Mean time from the time of transplant to the current presentation was 7.3 ± 4 years. Of these 6 patients, 3 had severe allograft dysfunction requiring initiation of dialysis or insulin therapy. Two had a previous history of missing clinic visits. All patients presented with nonadherence during the “stay-at-home” social distancing orders. As the general socioeconomic status of our population is slightly above the general transplant population in the United States, these findings are concerning.

Table 1.

Kidney and SPK transplant recipients admitted with acute rejection within 1 week of stay-at-home state orders during COVID-19 pandemic

Pt	Sex	Age (yr)	Race	Time since transplant (yr)	Transplant type	Induction	Cause of ESRD	Maintenance IS	Scr baseline (mg/dl)	Nonadherence	Presentation	Scr at presentation (mg/dl)	Biopsy	Treatment	Outcomes
1	M	43	W	5	LUKT	rATG	PCKD	T/M/P	1.6	Yes	Nausea, vomiting	30	ND	None	Dialysis
2	M	37	AA	7	LUKT	IL-2 (−)	HTN	T/M/P	1.3	Yes	Nausea, vomiting	16	TCMR	Pulse steroids	Dialysis
3	M	38	W	11	SPK	rATG	DM	T/M/P	1	Yes	Nausea, vomiting	1.5	ND	None	Failed pancreas
4	F	22	W	5	DD	rATG	MCKD	T/M/P	0.9	Yes	Elevated UPC	1	ABMR	Pulse steroids i.v. Ig
5	F	37	W	3	LUKT	rATG	HTN	T/M/P	1.5	Yes	Elevated creatinine	2.5	Mixed	Pulse steroids i.v. Ig
6	F	59	AA	5	DD	rATG	HTN	T/L/P	2	Yes	Elevated creatinine	3	ABMR	Increase baseline IS

AA, African American; ABMR, antibody-mediated rejection; COVID-19, coronavirus disease 2019; DD, deceased donor; DM, diabetes mellitus; ESRD, end-stage renal disease; F, female; HTN, hypertension; IL-2 (−), interleukin-2 blockade; IS, immunosuppression; LUKT, living unrelated kidney transplant; M, male; MCKD, medullary cystic kidney disease; ND, not done; PCKD, polycystic kidney disease; Pt, patient; rATG, rabbit antithymocyte globulin; Scr, serum creatinine; SPK, simultaneous pancreas-kidney transplantation; TCMR, T cell–mediated rejection; T/L/P, tacrolimus, leflunomide, prednisone; T/M/P, tacrolimus, mycophenolate, prednisone; UPC, urine protein-creatinine ratio; W, white.

Kidney transplant recipients infected with coronavirus have a significant risk of graft loss and death.1, 2, 3 However, the psychosocial impact of the COVID-19 pandemic on graft and patient outcomes in non-COVID kidney transplant recipients is unclear. The federal and local governments have enforced confinement orders to mitigate the spread of infection, but these restrictions have also limited health care access to “essential visits” only. Posttransplant management of solid organ transplant recipients is further compromised by loss of health insurance for many patients and cost reduction strategies at transplant centers.

Our case series suggests that rigorous, medical, and psychosocial risk stratification strategies are needed to avoid untoward outcomes in stable solid organ transplant recipients. Despite, or because of, the current financial crisis, the government and transplant centers need to consider further investment in life-long immunosuppression coverage,⁴ telehealth, mobile phlebotomy, noninvasive diagnostic tools, and person-power to keep their patients safe.