A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia

Abstract

The outcome of SARS-CoV2 infection in patients who have received a kidney allograft and are being treated with immunosuppression is unclear. We describe 20 kidney transplant recipients (median age 59 years [inter quartile range 51-64 years], median age of transplant 13 years [9-20 years], baseline eGFR 36.5 [23-47.5]) with SARS-CoV2 induced pneumonia. At admission, all had immunosuppression withdrawn and were started on methylprednisolone 16 mg/day, all but one was commenced on antiviral therapy and hydroxychloroquine with doses adjusted for kidney function. At baseline, all patients presented fever but only one complained of difficulty in breathing. Half of patients showed chest radiographic evidence of bilateral infiltrates while the other half showed unilateral changes or no infiltrates. During a median follow-up of seven days, 87% experienced a radiological progression and among those 73% required escalation of oxygen therapy. Six patients developed acute kidney injury with one requiring hemodialysis. Six of 12 patients were treated with tocilizumab, a humanized monoclonal antibody to the IL-6 receptor. Overall, five kidney transplant recipients died after a median period of 15 days [15-19] from symptom onset. These preliminary findings describe a rapid clinical deterioration associated with chest radiographic deterioration and escalating oxygen requirement in renal transplant recipients with SARS-Cov2 pneumonia. Thus, in this limited cohort of long-term kidney transplant patients, SARS-CoV-2 induced pneumonia is characterized by high risk of progression and significant mortality. The outcome of SARS-CoV2 infection in patients who have received a kidney allograft and are being treated with immunosuppression is unclear. We describe 20 kidney transplant recipients (median age 59 years [inter quartile range 51-64 years], median age of transplant 13 years [9-20 years], baseline eGFR 36.5 [23-47.5]) with SARS-CoV2 induced pneumonia. At admission, all had immunosuppression withdrawn and were started on methylprednisolone 16 mg/day, all but one was commenced on antiviral therapy and hydroxychloroquine with doses adjusted for kidney function. At baseline, all patients presented fever but only one complained of difficulty in breathing. Half of patients showed chest radiographic evidence of bilateral infiltrates while the other half showed unilateral changes or no infiltrates. During a median follow-up of seven days, 87% experienced a radiological progression and among those 73% required escalation of oxygen therapy. Six patients developed acute kidney injury with one requiring hemodialysis. Six of 12 patients were treated with tocilizumab, a humanized monoclonal antibody to the IL-6 receptor. Overall, five kidney transplant recipients died after a median period of 15 days [15-19] from symptom onset. These preliminary findings describe a rapid clinical deterioration associated with chest radiographic deterioration and escalating oxygen requirement in renal transplant recipients with SARS-Cov2 pneumonia. Thus, in this limited cohort of long-term kidney transplant patients, SARS-CoV-2 induced pneumonia is characterized by high risk of progression and significant mortality. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection is posing challenges to all the health systems in the world. The ideal therapeutic approach is still debated, and data on subgroups of patients at high risk are still scarce.1Cao B, Wang Y, Wen D, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe Covid-19 [e-pub ahead of print]. N Engl J Med. https://doi.org/10.1056/NEJMoa2001282. Accessed March 22, 2020.Google Scholar We have developed an internal treatment protocol for the management of patients with SARS-CoV2 pneumonia who had undergone renal transplantation.2Alberici F. Delbarba E. Manenti C. et al.Management of patients on dialysis and with kidney transplantation during the SARS-CoV-2 (COVID-19) pandemic in Brescia, Italy.Kidney Int Rep. 2020; 5: 580-585Abstract Full Text Full Text PDF PubMed Scopus (201) Google Scholar Since the first days of March 2020, we reorganized our ward to admit patients with SARS-CoV2 pneumonia who had undergone kidney transplantation; we felt this rearrangement was necessary because our center acts as referral for a population of 1200 patients who have had kidney transplantation. Due to the onset of the coronavirus disease 2019 epidemic, acute transplantation surgery was suspended in our center from February 20, 2020. The first admission of a patient with SARS-CoV2 pneumonia who had undergone transplantation occurred on February 27, 2020, the second 6 days later, and subsequently up to March 24, 2020 (when this analysis was performed and patients’ follow-up was censored), an average rate of 1.2 patients who had undergone kidney transplantation were admitted per day. We describe here the clinical course and renal outcomes of the first 20 patients who had undergone kidney transplantation admitted and followed in our unit with pneumonia secondary to SARS-CoV2 infection. In this report, we describe the progress of all patients with SARS-CoV2 pneumonia who had undergone kidney transplantation admitted up to March 24, 2020. These patients had a median inpatient stay of 7 days (interquartile range [IQR], 4–15), and the main baseline clinical characteristics are shown in Tables 1 and 2. Briefly, all patients presented with fever; however, only 1 of the 20 complained of dyspnea; 50% of the patients who had undergone transplantation had radiographic changes of bilateral infiltrates on admission, while the remaining 50% showed unilateral changes or no infiltrates; 7 did not require supplemental oxygen at admission.Table 1Baseline clinical characteristics of 20 patients affected by SARS-CoV2 infection followed in our unit who had undergone kidney transplantationCharacteristicsMale/female (n)16/4Age (yr)59 (51–64)Comorbidities (%) Hypertension85 Ischemic cardiac disease15 Diabetes15 HCV infection10Kidney transplantation age (yr)13 (9–20)Time from symptoms onset to admission (d)5.5 (3.3–8)Baseline serum creatinine (mg/dl)1.95 (1.5–2.8)Baseline eGFR (ml/min)aDetermined with the CKD Epidemiology Collaboration’s CKD-EPI equation.36.5 (23–47.5)Baseline immunosuppression (n) CNIs19/20 MMF14/20 Low-dose glucocorticoidbPrednisone 5 mg/d or methylprednisolone 4 mg/d.13/20 mTORi2/20SARS-CoV2 infection symptoms onset (%) Temperature >37.5 °C100 Cough50 Gastrointestinal symptoms15 Pharyngitis10 Shortness of breath5 Myalgia5Chest X-ray at hospital admission (%) No infiltrates15 Unilateral infiltrates35 Bilateral infiltrates50Blood tests at hospital admission WBCs (NV: 4.00–10.80 × 103/μl)5470 (4115–6193) Neutrophils (NV: 1.50–8.00 × 103/μl)3700 (2280–4500) Lymphocytes (NV: 0.90–4.00 × 103/μl)1170 (620–1305) Platelets (NV: 130–400 × 103/μl)196,000 (119,000–202,000) LDH (NV: 135–225 U/l)231 (190–260) CPK (NV: 39–308 U/l)69 (44–121) AST (NV: 18–54 U/l)37 (26–35) ALT (NV: 10–50 U/l)23 (16–30) Bilirubin (NV: <1.20 mg/dl)0.8 (0.4–0.9) CRP (NV: <5.0 mg/l)49 (19–62) Procalcitonin (NV: <0.5 ng/ml)0.22 (0.1–0.35) Ferritin (NV: 30–400 μg/l)831 (284–882) Fibrinogen (NV: 170–410 mg/d)461 (343–614) D-dimer (NV: <232 ng/ml)279 (277–563) Urea (NV: 17–49 mg/dl)46 (48–106) Creatinine (NV: 0.70–1.20 mg/dl)1.8 (1.7–3.5)Antiviral therapy (n of 19 patients) Lopinavir/ritonavir15 Darunavir + ritonavir4Ventilation requirement at hospital admission No oxygen7 LOR8 HOR5 NIV0 MV0ALT, alanine transaminase; AST, aspartate transaminase; CNI, calcineurin inhibitor; CPK, creatine phosphokinase; CRP, C-reactive protein; eGFR, estimated glomerular filtration rate; HCV, hepatitis C virus; HOR, high oxygen requirement; LDH, lactate dehydrogenase; LOR, low oxygen requirement; MMF, mofetil mycophenolate; mTORi, mammalian target of rapamycin inhibitor; MV, mechanical ventilation; NIV, non-invasive ventilation; NV, normal value; SARS-CoV2, severe acute respiratory syndrome coronavirus 2; WBC, white blood cell.Data are reported as percentages or median (interquartile range) unless otherwise indicated. Unless specified, counts are from the total cohort (N = 20).a Determined with the CKD Epidemiology Collaboration’s CKD-EPI equation.b Prednisone 5 mg/d or methylprednisolone 4 mg/d. Open table in a new tab Table 2Clinical characteristics and outcome of 20 patients with COVID-19 infection who had undergone kidney transplantationPatientAge, yr/sexTx dateComorbiditiesRespiratory and renal involvementBaseline creatinine, μmol/l (eGFR, ml/min per 1.73 m2)Baseline immunosuppression and treatment (± tocilizumab)ACEi or ARBOutcome170/F12/2002HypertensionNIV185 (23)CNI/mTORiCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasoneACEiDischarged247/F3/2011NoneICU, AKI, ARDS282 (16)MMF/CNI/low-dose steroidsCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasoneTocilizumabACEiInpatient371/M1/2007Ischemic cardiac diseaseNIV, ARDS159 (37)MMF/CNI/low-dose steroidsCOVID treatment: no antivirals or hydroxychloroquineDexamethasoneARBDeath457/M8/2018HCV infectionICU, ARDS141 (47)MMF/CNI/low-dose steroidsCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasoneTocilizumab–Death551/M3/1997HypertensionHCV infectionNIV221 (29)MMF/CNICOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasoneTocilizumab–Discharged646/M9/2017HypertensionNIV132 (55)MMF/CNICOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasone–Discharged759/M2/2015HypertensionICU, ARDS256 (23)MMF/CNI/low-dose steroidsCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasoneACEiDeath870/F7/2004HypertensionICU, AKI, ARDS300 (13)CNI/low-dose steroidsCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasoneACEiDeath960/M10/2011HypertensionRoom air150 (43)MMF/CNI/low-dose steroidsCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineACEiInpatient1073/M9/2013HypertensionDiabetesNIV, ARDS132 (46)MMF/CNI/low-dose steroidsCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineACEiInpatient1159/M3/2010HypertensionIschemic cardiac diseaseDiabetesNIV, AKI, ARDS238 (25)MMF/low-dose steroidsCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasoneTocilizumabARBInpatient1263/M8/2004HypertensionNIV, ARDS203 (29)MMF/CNICOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasoneTocilizumab–Death1349/M6/2018HypertensionNIV, AKI, ARDS185 (36)MMF/CNI/low-dose steroidsCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquineDexamethasoneTocilizumab–Inpatient1460/F6/2018HypertensionNIV, ARDS106 (49)MMF/CNI/low-dose steroidsCOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquine–Inpatient1557/M6/2009HypertensionRoom air106 (67)MMF/CNICOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquine–Inpatient1654/M10/2002HypertensionNIV, AKI, ARDS344 (16)CNI/low-dose steroidsCOVID treatment: darunavir, ritonavir, and hydroxychloroquineARBInpatient1760/M4/2007HypertensionIschemic cardiac diseaseRoom air141 (46)CNICOVID treatment: combination of lopinavir and ritonavir, hydroxychloroquine–Inpatient1850/M11/2010HypertensionRoom air123 (58)MMF/CNI/low-dose steroidsCOVID treatment: darunavir, ritonavir, and hydroxychloroquine–Inpatient1969/M7/1998HypertensionDiabetesAKI309 (17)CNI/low-dose steroidsCOVID treatment: darunavir, ritonavir, and hydroxychloroquine–Inpatient2044/M7/2006HypertensionRoom air114 (66)CNI mTORiCOVID treatment: darunavir, ritonavir, and hydroxychloroquine–InpatientACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; ARDS, acute respiratory distress syndrome; AKI, acute kidney injury; CNI, calcineurin inhibitor; COVID-19, coronavirus disease 2019; eGFR, estimated glomerular filtration rate; F, female; HCV, hepatitis C virus; ICU, intensive care unit; M, male, MMF, mycophenolate mofetil; mTORi, mammalian target of rapamycin inhibitor; NIV, non-invasive ventilation; Tx, transplant. Open table in a new tab ALT, alanine transaminase; AST, aspartate transaminase; CNI, calcineurin inhibitor; CPK, creatine phosphokinase; CRP, C-reactive protein; eGFR, estimated glomerular filtration rate; HCV, hepatitis C virus; HOR, high oxygen requirement; LDH, lactate dehydrogenase; LOR, low oxygen requirement; MMF, mofetil mycophenolate; mTORi, mammalian target of rapamycin inhibitor; MV, mechanical ventilation; NIV, non-invasive ventilation; NV, normal value; SARS-CoV2, severe acute respiratory syndrome coronavirus 2; WBC, white blood cell. Data are reported as percentages or median (interquartile range) unless otherwise indicated. Unless specified, counts are from the total cohort (N = 20). ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; ARDS, acute respiratory distress syndrome; AKI, acute kidney injury; CNI, calcineurin inhibitor; COVID-19, coronavirus disease 2019; eGFR, estimated glomerular filtration rate; F, female; HCV, hepatitis C virus; ICU, intensive care unit; M, male, MMF, mycophenolate mofetil; mTORi, mammalian target of rapamycin inhibitor; NIV, non-invasive ventilation; Tx, transplant. All patients had their usual transplant immunosuppression withdrawn and were started on methylprednisolone 16 mg or equivalent dose of prednisone, and 19 of the 20 received antiviral therapy and hydroxychloroquine as per our protocol.2Alberici F. Delbarba E. Manenti C. et al.Management of patients on dialysis and with kidney transplantation during the SARS-CoV-2 (COVID-19) pandemic in Brescia, Italy.Kidney Int Rep. 2020; 5: 580-585Abstract Full Text Full Text PDF PubMed Scopus (201) Google Scholar As antiviral therapy is known to interfere with calcineurin inhibitor metabolism, in 4 patients, tacrolimus levels were monitored after these therapeutic changes were instituted. The median trough values before antiviral therapy were 7.05 ng/ml (IQR, 5.5–8.6): 1 patient had the level rechecked after 3 days with no change compared with baseline; 1 patient had the level rechecked 4 and 5 days after admission (−17% and −18% compared with baseline); 1 was rechecked 6 days after admission (−12% compared with baseline); and 1 was rechecked 8 days after admission (−21% compared with baseline). The median times from symptom onset and admission to these therapeutic changes were, respectively, 5 days (IQR, 3–8.25) for antiviral therapy and 0 days (IQR, 0–0) for hydroxychloroquine. During the follow-up, 1 patient had hydroxychloroquine withdrawn due to toxicity (nausea, vomiting); among the treated patients no prolongation of the cardiac QTc interval compared with baseline or cardiac arrhythmias were observed. Antibiotics were administered to 11 of the 20 patients (55%): cephalosporins in 64%; beta-lactams in 36%; fluoroquinolones in 25%; carbapenems in 10%; and glycopeptides in 5%. During hospitalization, chest radiographs were repeated in 15 patients and radiological findings worsened in 13 of those 15 (87%). In the 13 individuals with worsening radiological findings, 11 (85%) required an escalation of the oxygen supplemental therapy, including 1 patient switched from regular breathing to low oxygen requirement, 3 from regular breathing to high oxygen requirement, 3 from low to high oxygen requirement, 2 from high oxygen requirement to non-invasive ventilation, and 2 from high oxygen requirement to mechanical ventilation. The changes of the main blood tests compared with baseline are shown in Supplementary Figure S1. Additional anti-inflammatory therapy with dexamethasone or tocilizumab, respectively, was given to 11 (55%) and 6 of the 20 patients (30%) (see Supplementary Methods for protocol details); in these patients, respectively, 4 (36%) and 2 (33%) subsequently died. The characteristics of the patients treated with tocilizumab are shown in Table 3; among these 6 patients, 3 (50%) experienced a reduction of the oxygen requirements and 2 (33%) showed amelioration of the radiological findings. Two patients who were treated with tocilizumab eventually died and 1 was discharged from hospital 9 days after the administration of tocilizumab.Table 3Characteristics of 6 patients with SARS-CoV2 pneumonia who had undergone kidney transplantation treated with tocilizumab and outcome after treatmentPatientDay of tocilizumab administrationOxygen requirement at tocilizumabFollow-up after tocilizumab (d)Oxygen requirement after tocilizumabChest X-ray improvementOutcome16NIV11HORNoInpatient26HOR10MVNoDeath37LOR9Room airNoDischarged43HOR4HORYesInpatient55NIV3NIVN/ADeath64HOR3LORYesInpatientHOR, high-flux oxygen; LOR, low-flux oxygen; MV, mechanical ventilation; N/A, not available; NIV, non-invasive ventilation; SARS-CoV2, severe acute respiratory syndrome coronavirus 2. Open table in a new tab HOR, high-flux oxygen; LOR, low-flux oxygen; MV, mechanical ventilation; N/A, not available; NIV, non-invasive ventilation; SARS-CoV2, severe acute respiratory syndrome coronavirus 2. In terms of kidney function, the medium creatinine level at admission was +17% (IQR, 12%–26%; range, 0%–143%) compared with baseline, and the highest creatinine level observed during the follow-up was +33% (IQR, 13%–59%; range, 0%–157%) compared with baseline; 6 of 20 patients developed acute kidney injury and 1 of those 6 required hemodialysis. During follow-up of the 20 patients, 4 (20%) required intensive care and 3 of these individuals subsequently died. Overall, 5 patients died after a median of 11 days from admission (IQR, 11–14 days) and 15 days (IQR, 15–19 days) from symptom onset; of these 5 patients, 4 died from complications of the respiratory failure secondary to SARS-CoV2 infection and 1 died of probable bacterial sepsis (fever, rise of C-reactive protein, and procalcitonin) despite a satisfactory recovery from SARS-CoV2 pneumonia–induced respiratory failure, need for intensive care unit care, and treatment with dexamethasone and tocilizumab. Three patients were discharged, after 7 days in 1 case and after 16 in the 2 remaining cases; at discharge, creatinine levels compared with baseline were 3.6 versus 2.1, 2.3 versus 2.5, and 2.1 versus 1.5 mg/dl. In terms of immunosuppressive therapy, 2 patients were discharged receiving methylprednisolone 16 mg/d and 1 with methylprednisolone 12 mg/d. SARS-CoV2 infection is challenging health care systems around the world. The mortality of the disease has been proposed to be around the 2.3% with age and comorbidities such as cardiovascular diseases, diabetes, chronic respiratory diseases, hypertension, and cancer being associated with worse prognoses.3The Novel Coronavirus Pneumoniae Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus disease (COVID-19)—China. Available at: http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51. Accessed March 22, 2020.Google Scholar,4Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395: 497-506Abstract Full Text Full Text PDF PubMed Scopus (33286) Google Scholar Immunosuppression and chronic kidney disease may represent additional risk factors, although specific data are not available at the moment. Here we reported the clinical characteristics and the outcomes of the first 20 patients affected by SARS-CoV2 pneumonia at our center who had received kidney transplantation. Despite on average a relatively benign onset of the disease, a large proportion of the patients displayed worsening chest radiographs and required an escalation of the supplemental oxygen. Of note, 25% of the patients died despite an aggressive approach to immunosuppression withdrawal and early commencement of antiviral therapy. The role of lopinavir/ritonavir in SARS-CoV2 management is debated, with some data supporting a greater benefit with early start compared with a delayed commencement;1Cao B, Wang Y, Wen D, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe Covid-19 [e-pub ahead of print]. N Engl J Med. https://doi.org/10.1056/NEJMoa2001282. Accessed March 22, 2020.Google Scholar our cohort was started on antiviral therapy a median of 5.5 days after symptom onset. Lopinavir/ritonavir may interact with calcineurin inhibitors impacting on their level: the 4 patients of our cohort with serial calcineurin inhibitor monitoring confirmed that; of note none of these patients died and 3 have been discharged. a role for hydroxychloroquine treatment in the et al. and as a treatment of of an clinical trial [e-pub ahead of print]. Int J Accessed March 2020.Google Scholar In our 19 patients received this although toxicity to treatment withdrawal in 1 and lopinavir/ritonavir may interact a prolongation of the cardiac QTc however, none of the patients in this experienced this data and of the of the pneumonia secondary to SARS-CoV2 infection a role of in the rapid clinical deterioration in with worsening chest radiographs and escalating oxygen requirement, observed in an average of 7 to days from the symptom syndrome with 2019; Full Text Full Text PDF PubMed Scopus Google Scholar In this with or tocilizumab have been to be a therapeutic Y, et al. associated with acute respiratory distress syndrome and in patients with coronavirus disease 2019 pneumonia in Wuhan, [e-pub ahead of print]. Med. Accessed March 22, 2020.Google Scholar of patients treated by this approach experienced a although in terms of were observed in the patients treated with 50% oxygen therapy requirement and of radiological Despite 2 patients died. are preliminary and the to The high mortality rate of this population aggressive management is for patients with SARS-CoV2 infection who had received kidney in early be in case of pneumonia. treatment need to be has the is and the median follow-up is our findings are preliminary and need to be confirmed in with follow-up may be as in the approach and the of the clinical treatment In patients with SARS-CoV2 pneumonia who had undergone kidney transplantation may with an disease course and a is required and chest are management to be to have an on the of these All the patients with SARS-CoV2 infection admitted in the of the of who had undergone kidney transplantation have been The therapeutic approach followed our protocol.2Alberici F. Delbarba E. Manenti C. et al.Management of patients on dialysis and with kidney transplantation during the SARS-CoV-2 (COVID-19) pandemic in Brescia, Italy.Kidney Int Rep. 2020; 5: 580-585Abstract Full Text Full Text PDF PubMed Scopus (201) Google Scholar In all admitted patients had withdrawn and were commenced on methylprednisolone 16 mg/d. therapy with lopinavir/ritonavir hydroxychloroquine adjusted for kidney was in all patients not In case of of and have been (see the Supplementary clinical deterioration after at 7 days from symptom onset or no for but with escalating oxygen requirements or progression of the chest and no of bacterial infection were for dexamethasone mg/d for 5 days, mg/d for 5 days) and up to 2 tocilizumab at of 12 to of dose per on the for dexamethasone and tocilizumab have been in the Supplementary requirements have been as no oxygen low oxygen requirement, from up to with of high oxygen requirement, including with of with oxygen at 15 and ventilation; non-invasive ventilation; and mechanical ventilation. kidney injury was as per clinical for acute kidney PubMed Scopus Google Scholar the of lopinavir/ritonavir and hydroxychloroquine on the cardiac QTc were performed 2 to 3 In case of prolongation compared with baseline, dose reduction was Due to the only have been are as for and median and for to the for the has been All the no with Supplementary COVID-19 infection in kidney transplant March 2020 to the novel coronavirus SARS-CoV-2 had affected from and reported is known and outcomes of SARS-CoV-2 (COVID-19) infection in kidney transplantation who may be at due to long-term and chronic kidney COVID-19 is a respiratory disease, in severe kidney and PDF Open with COVID-19 in kidney this of we 2 of patients who had undergone kidney transplantation during the coronavirus disease 2019 (COVID-19) pandemic have to transplant immunosuppressive therapy and antiviral treatment in the early days of the pandemic in the and The first of 7 of COVID-19 infection in patients who had undergone kidney transplantation from and in and the second of 20 from in Brescia, PDF Open as a calcineurin inhibitor in renal allograft recipients with COVID-19 2 of renal allograft recipients with coronavirus disease 2019 (COVID-19) infection including to et withdrawal of baseline immunosuppression in 20 patients with COVID-19 pneumonia and with et reduction of immunosuppression with of the in 7 patients with COVID-19 of PDF

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