Management Strategies and Outcomes in Renal Transplant Recipients Recovering from COVID-19: A Retrospective, Multicentre Study

Background: There is an enormous knowledge gap about the management strategies, clinical outcomes, and follow-up of kidney transplantation (KT) in recipients that have recovered from COVID-19 prior to transplantation.Methods: We conducted a multi-center(n=23), retrospective analysis in Indian transplant centers, and the data between June 26, 2020 to December 1, 2021 for COVID-19 recovered KT was exploited. We calculated for clinical and biopsy-confirmed acute rejection (AR) incidence and used cox-proportional modelling to estimate the multivariate-adjusted hazard ratio (HR) for predictors of AR. Additional outcomes included graft loss, all-cause mortality, waiting time from a positive real-time polymerase test (RT-PCR) to transplant, laboratory parameters, and quality of life in follow-up.Findings: Among 372 KT which included ABO-incompatible (10·2%), sensitized (3·2%), and coexisting donors with COVID-19 history (17·2%), the incidence of AR was 9·1 % with 0·002% graft loss, and 0·01% all-cause mortality over a median (interquartile range) follow-up of median 241 (106-350) days. In a univariable Kaplan Meier analysis, mild COVID-19 illness (Log-Rank (Mantel-Cox); p-value = 0·01), and thymoglobulin (Log-Rank (Mantel-Cox); p-value < 0·01) was associated with lower risk of acute rejection while no induction (Log-Rank (Mantel-Cox); p-value = 0·01) had a higher risk. There was no difference in rejection-free survival analysis for sensitization, ABO incompatibility, and COVID-19 status of the donor. In cox proportional analysis, mild COVID-19 (HR = 0·39(0·14-1·1); p-value = 0·08) had lower risk and no induction (HR = 1·24(0·44-3·51); p-value = 0·68) had higher risk of AR but the difference did not achieve statistical difference. The median duration between RT- PCR negative to transplant was 88 days (overall) and increased from WHO ordinal scale ≤ 3, 4, 5, and 6-7 (88, 65, 110, and 127) days respectively. There was no difference in quality of life, tacrolimus levels, blood counts, and mean serum creatinine assessed in patients with a past COVID infection independent of severity.Interpretation: Our findings support that the outcomes of KT after COVID-19 recovery are comparable to the standard of care for living donation and there is no postulated COVID-19 sequelae in the follow-up. Additionally, there is no need for any change in the induction/immunosuppression regimen based on the severity of COVID-19.Funding: The study was funded by an unrestricted educational grant from SanofiDeclaration of Interest: None to declare. Ethical Approval: The study was approved by the IKDRC-ITS ethical committee.