Response to "Is the outcome of SARS-CoV-2 infection in solid organ transplant recipients really similar to that of the general population?"

Abstract

To the Editor, We read with great interest the letter titled “Is the outcome of SARS-CoV-2 infection in solid organ transplant recipients really similar to that of the general population?” by Mendoza et al.1Mendoza MA, Raja M, Villavicencio A, Anjan S, Natori Y. Is the outcome of SARS-CoV-2 infection in solid organ transplant recipients really similar to that of the general population?. Am J Transplant. 2020. https://doi.org/10.1111/ajt.16370Google Scholar regarding our recently published paper.2Molnar MZ Bhalla A Azhar A et al.Outcomes of critically ill solid organ transplant patients with COVID-19 in the United States.Am J Transplant. 2020; 20: 3061-3071Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar We agree with the authors that based on current data we can only speculate that once admitted to the hospital or intensive care unit (ICU), clinical outcomes of solid organ transplant (SOT) recipients and non-SOT recipients are comparable,2Molnar MZ Bhalla A Azhar A et al.Outcomes of critically ill solid organ transplant patients with COVID-19 in the United States.Am J Transplant. 2020; 20: 3061-3071Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar,3Chaudhry ZS Williams JD Vahia A et al.Clinical characteristics and outcomes of COVID-19 in solid organ transplant recipients: a case-control study.Am J Transplant. 2020; 20: 3051-3060Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar but it is still unclear whether SOT recipients have similar outcomes to COVID-19-infected patients in the outpatient setting. However, we would like to emphasize that we never concluded that “transplant status is not associated with higher mortality or other related outcomes” as stated in this letter.1Mendoza MA, Raja M, Villavicencio A, Anjan S, Natori Y. Is the outcome of SARS-CoV-2 infection in solid organ transplant recipients really similar to that of the general population?. Am J Transplant. 2020. https://doi.org/10.1111/ajt.16370Google Scholar Our study indicated that death and organ support requirement were similar between critically ill SOT and non-SOT patients with COVID-19.2Molnar MZ Bhalla A Azhar A et al.Outcomes of critically ill solid organ transplant patients with COVID-19 in the United States.Am J Transplant. 2020; 20: 3061-3071Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Data indicate that the rate of transplantation has declined considerably in both Europe and the United States during the pandemic,4Loupy A Aubert O Reese PP Bastien O Bayer F Jacquelinet C. Organ procurement and transplantation during the COVID-19 pandemic.Lancet. 2020; 395: e95-e96Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar perhaps due to concern regarding early reports of high mortality rates in SOT patients with COVID-19.5Alberici 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.Kidney Int. 2020; 97: 1083-1088Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar, 6Fernandez-Ruiz M Andres A Loinaz C et al.COVID-19 in solid organ transplant recipients: a single-center case series from Spain.Am J Transplant. 2020; 20: 1849-1858Abstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar, 7Banerjee D Popoola J Shah S Ster IC Quan V Phanish M. COVID-19 infection in kidney transplant recipients.Kidney Int. 2020; 97: 1076-1082Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar, 8Hoek RAS, Manintveld OC, Betjes MGH, et al. Covid-19 in solid organ transplant recipients: a single center experience. Transpl Int. 2020. https://doi.org/10.1111/tri.13662Google Scholar, 9Kates OS Haydel BM Florman SS et al.COVID-19 in solid organ transplant: a multi-center cohort study.Clin Infect Dis. 2020; (https://doi.org/10.1093/cid/ciaa1097): ciaa1097Crossref PubMed Scopus (221) Google Scholar However, these initial reports included only SOT patients without properly matched control groups,5Alberici 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.Kidney Int. 2020; 97: 1083-1088Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar, 6Fernandez-Ruiz M Andres A Loinaz C et al.COVID-19 in solid organ transplant recipients: a single-center case series from Spain.Am J Transplant. 2020; 20: 1849-1858Abstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar, 7Banerjee D Popoola J Shah S Ster IC Quan V Phanish M. COVID-19 infection in kidney transplant recipients.Kidney Int. 2020; 97: 1076-1082Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar, 8Hoek RAS, Manintveld OC, Betjes MGH, et al. Covid-19 in solid organ transplant recipients: a single center experience. Transpl Int. 2020. https://doi.org/10.1111/tri.13662Google Scholar, 9Kates OS Haydel BM Florman SS et al.COVID-19 in solid organ transplant: a multi-center cohort study.Clin Infect Dis. 2020; (https://doi.org/10.1093/cid/ciaa1097): ciaa1097Crossref PubMed Scopus (221) Google Scholar which makes it impossible to determine the risk attributable to transplantation status or associated risk factors. Furthermore, results from European registries indicated that kidney transplant recipients with COVID-19 had a 28% higher risk of 28-day mortality compared to dialysis patients with COVID-19.10Jager KJ Kramer A Chesnaye NC et al.Results from the ERA-EDTA Registry indicate a high mortality due to COVID-19 in dialysis patients and kidney transplant recipients across Europe.Kidney Int. 2020; 98: 1540-1548Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar Notwithstanding the advantage of using dialysis patients as comparators, the aforementioned study failed to match patients on several important confounders, such as comorbidities or dialysis vintage.10Jager KJ Kramer A Chesnaye NC et al.Results from the ERA-EDTA Registry indicate a high mortality due to COVID-19 in dialysis patients and kidney transplant recipients across Europe.Kidney Int. 2020; 98: 1540-1548Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar These studies suggested that factors associated with transplantation status were the cause of these worse outcomes. Our results cast doubt on these conclusions, and suggest that the results of earlier studies may have been biased by unmeasured confounders. Kidney transplant recipients have in fact similar risk of in-hospital or ICU-death as nontransplanted patients with similar clinical characteristics. While we agree that further studies are needed to determine the relative risk of death and other clinically relevant endpoints according to SOT status in noncritically ill patients, we believe that our findings question withholding or delaying the processes leading to transplantation, such as waitlisting, for fear of worsening outcomes. In fact, a recent study showed that waitlisted patients were more likely to require hospitalization (82% vs 65%, p = .03) and had a higher risk of mortality (34% vs 16%, p = .02) than kidney transplant recipients.11Craig-Schapiro R, Salinas T, Lubetzky M, et al. COVID-19 outcomes in patients waitlisted for kidney transplantation and kidney transplant recipients. Am J Transplant. 2020. https://doi.org/10.1111/ajt.16351Google Scholar Our study, along with others, sheds light on whether transplanted patients have similar in-hospital and ICU-related outcomes as clinically similar patients from the general population. We agree with the authors of the letter that additional data and studies with well-matched control groups are needed to determine if outcomes are indeed similar across other clinical settings. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.