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Eleven of the 28 patients admitted to hospital (39%) were so severely ill that they required mechanical ventilation.
Eight patients (22%) were stable enough to be monitored at home, although two of these patients ultimately died.
At a median follow-up of 21 days, 10 of the 36 patients had died, including seven of the 11 patients who required intubation (64%).
“However, with 2 additional weeks of follow-up, the remaining four [intubated] patients are still alive,” Akalin noted.
The two outpatients who died were both recent kidney transplant recipients “who had received antithymocyte globulin within the previous 5 weeks,” the authors note.
Antithymocyte globulin decreases all T-cell subsets for many weeks, and with no T-lymphocytes, “patients can’t mount an immune response to clear the virus,” Akalin explained.
Initial Treatment: Stop Mycophenolate, Trials of Other Drugs
In terms of immunosuppressive therapy, on presentation with COVID-19, 97% of the kidney transplant patients were receiving tacrolimus, 94% prednisone, and 86% were taking mycophenolate mofetil or mycophenolic acid.
Akalin said they “decrease the mycophenolate dose by half or withdraw drug altogether” in the setting of any infection requiring hospital admission, including COVID-19, because transplant patients would never be able to clear the infection with such heavy immunosuppression.
In their 28 hospitalized patients, the dose of mycophenolate was reduced in 14% of the group and was stopped altogether in the remainder of the patients.
Moreover, when the New York team first started tracking their COVID-19-infected transplant patients, there was speculation that the antimalaria drug hydroxychloroquine might help patients recover more quickly, so almost all of their hospitalized patients were treated with that drug.
But since a French study found no difference in outcomes between patients treated with hydroxychloroquine or not, they no longer use it, nor do they use azithromycin, which initially they also felt might benefit COVID-19 recovery in these patients, Akalin explained.
Intriguingly, however, they did treat two patients with the interleukin-6 (IL-6) inhibitor tocilizumab (Actemra, Roche), while six others received the CCR5 inhibitor leronlimab (CytoDyn), both of which blunt high IL-6 levels characteristic of the cytokine storm that can occur in patients with moderate and severe COVID-19.
