COVID-19 AND IMMUNOSUPPRESSION: A CASE OF COVID-19 IN A RENAL TRANSPLANT RECIPIENT

SESSION TITLE: Medical Student/Resident Transplantation Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The United States is currently a global hotspot with more than 1 6 million COVID-19 cases with 5 8% mortality [1] Given its alarming rise, studies were undertaken to determine the clinical course of the illness However, data in the immunosuppressed population, such as solid organ transplant recipients are lacking We report one such case of a renal transplant recipient with COVID-19 pneumonia who had a successful hospital course CASE PRESENTATION: A 65-year-old male with prior history of renal transplantation managed with tacrolimus, mycophenolate mofetil, and prednisone was admitted to the ICU after presenting with shortness of breath, cough, fever, nausea, and diarrhea for 2 weeks He was initially hypotensive and hypoxemic on arrival ultimately requiring intubation and mechanical ventilator support The patient was started on treatment with azithromycin, hydroxychloroquine, lopinavir-ritonavir, and full-dose enoxaparin Initial labs were remarkable for positive COVID-19, elevated inflammatory markers, and worsening creatinine Over the next few days, his inflammatory markers continued to uptrend He was noted to have supra-therapeutic levels of tacrolimus, hence home immunosuppressants were held He was started on Marik’s protocol, which consists of IV methylprednisolone, IV vitamin C, and IV thiamine Within 2 days improvement in respiratory status and inflammatory markers was noted, and he was successfully extubated after 10 days of intubation Ultimately, he was transferred out of the ICU, saturating well on room air, but remained COVID positive 7 weeks after initial detection DISCUSSION: Our case highlights the clinical features and management of COVID-19 in immunosuppressed populations To date, the pathophysiology of COVID in immunosuppressed patients is unclear Some studies suggest a poor prognosis, whereas others suggest a protective mechanism due to attenuated inflammatory response [2] Management strategies proposed include dose reduction or discontinuation of home immunosuppressants and initiation of steroids at various doses [3] The use of Marik's protocol has not been investigated in immunosuppressed population but in our patient, it was associated with a dramatic clinical improvement Other important considerations in transplant patients are monitoring for allograft dysfunction and potential drug interactions CONCLUSIONS: Despite a prolonged hospital course, our patient had a good outcome Marik’s protocol appears to be a potential treatment regimen beneficial in transplant recipients Further studies are required to determine a uniform treatment strategy Reference #1: Coronavirus Disease 2019 (COVID-19) https://www cdc gov/coronavirus/2019-ncov/index html Published May 23, 2020 Accessed May 23, 2020 Reference #2: Zhu L, Gong N, Liu B, et al Coronavirus Disease 2019 Pneumonia in Immunosuppressed Renal Transplant Recipients: A Summary of 10 Confirmed Cases in Wuhan, China [published online ahead of print, 2020 Apr 18] Eur Urol 2020;S0302-2838(20)30214-1 doi:10 1016/j eururo 2020 03 039 Reference #3: Alberici F, Delbarba E, Manenti C, et al A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia [published online ahead of print, 2020 Apr 9] Kidney Int 2020;S0085-2538(20)30365-3 doi:10 1016/j kint 2020 04 002 DISCLOSURES: No relevant relationships by Sukhmani Boparai, source=Web Response no disclosure on file for Rajkamal Hansra;No relevant relationships by Aswani Thurlapati, source=Web Response