Expecting the unexpected: COVID-19 in Kidney Transplant Recipients within United Network for Organ Sharing Region 1.

Dear Editors,

There are numerous case reports and a handful of single [1, 2, 3, 4, 5]‐center studies reporting on COVID‐19 in kidney transplant recipients. Most reports arise from the epicenters of where the SARS‐CoV‐2 virus was first detected such as New York City [1, 2, 5] and Europe [3, 4]. We in UNOS Region 1 experienced COVID‐19 weeks to a month later and questioned whether our experience was different. The programs within UNOS Region 1 have had a long history of sharing information in an attempt to mitigate the effect of viruses on our patients. This was first achieved through the creation of the New England BK Consortium (NEBKCon) to share our clinical experiences and to conduct research in BK virus‐related complications after kidney transplantation. NEBKCon includes the 14 kidney transplant centers in Connecticut, Maine, Massachusetts, New Hampshire, and Rhode Island.

We formulated a 13‐question survey to analyze our experience with kidney transplant recipients who contracted the SARS‐CoV‐2 virus. Thirteen of the 14 centers (93%) in NEBKCon responded to the survey between June 15, 2020, and July 15, 2020. From January 1, 2020 to May 5, 2020, 189 (mean 15, SD ± 11, range 0–41) kidney transplant recipients tested positive for COVID‐19. The 13 centers follow 6,568 patients, suggesting an incidence of 2.88%. Seven patients (3.7%) were asymptomatic. One hundred and thirty‐seven required hospital admission (72.5%). Of those, 46 (24.3%) required ICU admission and 39 (20.6%) required intubation. Kidney dysfunction, as defined by KDIGO guidelines, was reported in 29 (15.3%). Twelve (6.4%) patients required dialysis, and 5 (2.7%) experienced graft loss. Twenty‐three (12.2%) patients died of COVID‐19 or COVID‐19‐related complications. There were 22 (11.6%) transplant recipients diagnosed with COVID‐19 within 1 year of their transplant. Six centers (46%) reported that they were currently altering their deceased donor transplant decisions, offer selection or induction plans due to COVID‐19, and all but one center (92%) was performing living donor kidney transplantation (Table 1).

Table 1

Results from the survey of 13 programs

	COVID‐19‐positive kidney transplant recipients (n = 189)
	No. (%)
Asymptomatic	7 (3.7%)
Hospitalized	137 (72.5%)
ICU Admission	46 (24.3%)
Intubation	39 (20.6%)
Graft Dysfunction	29 (15.3%)
Dialysis	12 (6.4%)
Graft Loss	5 (2.7%)
Died	23 (12.2%)
Within 1 year of transplant	22 (11.6%)

While this survey addresses outcomes and incidence, it lacks the detailed information necessary to make individual management decisions. The results suggest that the incidence and severity of COVID‐19 in kidney transplant recipients in our UNOS Region are lower than those in more densely populated areas. Further, the incidence described in kidney transplant recipients in this study somewhat unexpectedly mimics those reported in the general and pediatric populations.

To our knowledge, this is the largest report of COVID‐19‐infected kidney transplant recipients and their outcomes since the start of the pandemic. Although still high, the cumulative mortality rate in Region 1 was 12.2% which is lower than the 13–30% [1, 2, 3, 4, 5] reported by the initial epicenters. Most importantly, this mortality rate might offer reassurance when compared to the reported mortality rate of maintenance dialysis patients of 28–31% [6, 7, 8]. While comparisons are challenging because of the rapid learning curve and changes in practice patterns as the pandemic has progressed, ongoing regional differences will be likely and individual centers need to make informed decisions based upon their patients’ risk within their specific regions. These decisions would benefit from more robust data through a national prospective registry.

Author contribution

Each author participated in study design, study data collection, and writing the letter.

Funding

The authors have declared no funding.

Conflict of interest

The authors have no conflict of interest to disclose.