Cyclosporine as a preferred calcineurin inhibitor in renal allograft recipients with COVID-19 infection.

To the editor:

Kidney International recently published 2 series of renal allograft recipients with coronavirus disease 2019 (COVID-19) infection including different approaches to maintenance immunosuppression. Although Alberici et al. report withdrawal of baseline immunosuppression in 20 patients with COVID-19 pneumonia and mainly continuation with methylprednisolone, Banerjee et al. pursued more-gentle reduction of immunosuppression with mainly discontinuation of the antimetabolite in 7 patients with COVID-19 infections of varying severity. However, in 2 of the 7 patients, the calcineurin inhibitor tacrolimus was additionally stopped because of severe respiratory distress syndrome. The corresponding editorial suggests switching to the calcineurin inhibitor cyclosporine as a possible further approach for future exploration, as in vitro data report suppression of viral replication for various coronaviruses at noncytotoxic concentrations regardless of immunosuppressive effects of cyclosporine. In line with this suggestion, we report the first renal allograft recipient converted to cyclosporine during COVID-19 infection. The 45-year-old male had been transplanted 16 years ago. His immunosuppression consisted of only the antimetabolite mycophenolate mofetil. On admission, the patient presented with typical symptoms of COVID-19 pneumonia including fever, cough, dyspnea, and crazy paving pattern in computed tomography scan. The main characteristics are summarized in Table 1 . The therapeutic regimen consisted of withdrawal of the antimetabolite, conversion to low-dose steroid, and introduction of low-dose cyclosporine, azithromycin, and hydroxychloroquine. He required mechanical ventilation for 4 days until his general condition improved significantly, and he was able to be discharged after 17 days with stable allograft function. Therefore, switching to a cyclosporine-based immunosuppression may represent another therapeutic option in the case of COVID-19 infection following kidney transplantation.

Table 1

(According to Banerjee et al.): clinical characteristics, outcome, and blood parameters of first kidney transplant patient converted to cyclosporine during COVID-19 infection

Patient	Age/sex	Tx date	Comorbidities	Respiratory and renal involvement	Baseline creatinine (eGFR ml/min per 1.73 m2)	Baseline immunosuppression and treatment	ACEI or ARB	Outcome
1	45 yr/M	2004	HT/ hypercholisterinemia	Yes, ARDS + AKI (without need for RRT)	124–141 (51–59)	MMFMMF stopped and switch to CyA/Pred	No	Discharged from ITU,now at home,full recovery

ACEI, angiotensin-converting enzyme inhibitor; AKI, acute kidney injury; ARB, angiotensin receptor blocker; ARDS, acute respiratory distress syndrome; Cont., continued; COVID-19, coronavirus disease 2019; CRP, C-reactive protein; CyA, cyclosporine A; D, day after admission; D1, day of admission; eGFR, estimated glomerular filtration rate; HT, hypertension; ITU, intensive therapy unit; LDH, lactate dehydrogenase; M, male; MMF, mycophenolate mofetil; Pred, prednisolone; RRT, renal replacement therapy; Tx, treatment.