A Man with Fever and Shortness of Breath after Liver Transplantation

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Posted by Carla Rothaus

Should calcineurin inhibitors be stopped in solid-organ transplant patients with SARS-CoV-2 infection?

Initial presentations of Covid-19 vary in both normal and immunocompromised hosts. Read the NEJM Case Records of the Massachusetts General Hospital Article here.

Clinical Pearls

Q: Do solid-organ transplant patients with Covid-19 uniformly require hospitalization?

A: One important aspect of the Covid-19 pandemic is the finding that more transplant recipients are asymptomatic or mildly symptomatic than in the other coronavirus outbreaks, and the treatment of those patients has been successfully managed on an outpatient basis.

Q: Describe mortality among solid-organ transplant recipients with symptomatic SARS-CoV-2 infection?

A: Mortality is high among symptomatic solid-organ transplant recipients (10 to 28%) and intubated solid-organ transplant recipients (52 to 75%). This may reflect immunosuppression and the preponderance of coexisting risk factors — including older age, obesity, diabetes, cardiovascular disease, and renal dysfunction — for poor outcomes among transplant recipients. The disproportionate burden of severe Covid-19 among Black and Hispanic populations persists among transplant recipients.


Morning Report Questions

Q: Describe a major challenge in the treatment of SARS-CoV-2 infection in patients who have undergone solid-organ transplantation.

A: A major challenge in the treatment of SARS-CoV-2 infection in patients who have undergone solid-organ transplantation is the management of maintenance immunosuppression — a topic that remains controversial. Various approaches have been used, ranging from no change or a minimal reduction in immunosuppressive treatment to stopping all immunosuppressive drugs except for glucocorticoids, which are usually continued at an increased dose. The most controversial issue regarding immunosuppressive treatment in patients with SARS-CoV-2 infection is the appropriate management of glucocorticoids. 

Q: Should calcineurin inhibitors be stopped in solid-organ transplant patients with SARS-CoV-2 infection?

A: In recipients of a non-lifesaving organ who are at risk for the rapid development of severe respiratory impairment despite ongoing maintenance immunosuppressive treatment, the dose of calcineurin inhibitors may be reduced until clinical improvement occurs, at which time the use of other antiinflammatory agents could be considered for controlling lung injury. Temporary discontinuation of calcineurin inhibitors should be considered if the patient is receiving additional antiinflammatory and immunosuppressive drugs. In contrast, continuation of calcineurin inhibitors, even at a reduced dose, is usually recommended in recipients of lifesaving organs (especially organs with the highest immunogenicity, such as the heart and lungs), irrespective of the degree of severity of the viral disease and of any additional immunosuppressive treatment, because of the potential life-threatening consequences of acute rejection.

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