Reply to Amit Bansal and Anant Kumar’s Letter to the Editor re: Lan Zhu, Nianqiao Gong, Bin Liu, et al. Coronavirus Disease 2019 Pneumonia in Immunosuppressed Renal Transplant Recipients: A Summary of 10 Confirmed Cases in Wuhan, China. Eur Urol 2020;77:748–54

We thank Drs. Bansal and Kumar for their questions and interest in our paper [1]. Owing to the word limit, some information was not provided in detail in our paper. Here we answer their questions and provide supplementary explanations.

We agree that a combination of bacterial or fungal infections during COVID-19 could aggravate a patient’s condition and lead to a poor prognosis. Because some of our patients had almost no sputum during the whole course of the disease, a sputum culture was not carried out for all ten of our patients. However, the clinical course and the sputum culture results obtained for some of the patients indicated that there was no evidence of bacterial or fungal co-infection.

The absence of co-infection was probably related to our prophylactic strategy: all patients were routinely given broad-spectrum antibiotics (eg, carbapenem or sulbactam/cefoperazone) after admission, and patients with a longer course of illness were given echinocandins to prevent fungal infections [2]. Although Yang et al [3] reported 13.5% incidence of hospital-acquired bacterial or fungal co-infection, all of the patients they observed were critically ill patients requiring treatment in the intensive care unit (ICU), and nearly half received invasive ventilation. By contrast, only one of the ten patients in our study required short-term treatment in the ICU, and none received invasive ventilation. This difference in incidence of critical illness may also be an important reason for the difference in the incidence of co-infection between the two studies. Regarding the use of intravenous immunoglobulin (IVIG), we recommend that transplant recipients with COVID-19 should receive a small daily dose of IVIG during the early period of their hospitalization, until chest computed tomography shows a significant improvement in inflammation. However, since our ten patients were admitted to five different designated hospitals, three of the patients did not receive IVIG because of the lack of that resource in the corresponding hospital at the time.

We agree that underlying diseases are associated with the severity, duration, and prognosis of COVID-19 pneumonia in some patients. We should have emphasized the impact of comorbidities more strongly in our paper. Three of our patients had severe and complex underlying diseases, which contributed to the death of one patient and to severe illness that required treatment in the ICU in another patient. However, the remaining patients without underlying disease (four cases) or with controllable hypertension alone (three cases) still had more severe COVID-19 pneumonia and a longer viral shedding time than the control group did, indicating that immunosuppressive status is the most important factor affecting the clinical progression of COVID-19 in most transplant patients. Although diabetic nephropathy is a common cause of end-stage renal failure, such patients receive simultaneous pancreas-kidney transplantation rather than simple kidney transplantation in China [4], [5]. In our study, none of the ten renal transplant patients had primary diabetic nephropathy or new-onset diabetes mellitus after transplantation. Only one individual (patient 2) experienced transient hyperglycemia during treatment of pneumonia, but the patient’s blood glucose returned to normal shortly after reduction of glucocorticoid treatment.



 Conflicts of interest: The authors have nothing to disclose.