Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guidelines
Image in Nephrology
Images in Nephrology
Letter to Editor
Letter to the Editor
Letters to Editor
Literature Review
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guidelines
Image in Nephrology
Images in Nephrology
Letter to Editor
Letter to the Editor
Letters to Editor
Literature Review
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
View/Download PDF

Translate this page into:

Research Letter
33 (
5
); 371-372
doi:
10.4103/ijn.ijn_300_22

Efficacy of Casirivimab/Imdevimab in Kidney Transplant Recipients Admitted with Mild-to-Moderate COVID-19: A Case Series

Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
Address for correspondence: Dr. Siddhavinayak Suryakant Rajmane, Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India. E-mail: siddhu.rajmane@gmail.com
Licence
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Disclaimer:
This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.

Kidney transplant recipients (KTRs) are at a high risk of developing graft dysfunction and mortality after contracting the coronavirus disease 2019 (COVID-19). Most approved COVID-19 therapies are intended for hospitalized patients with advanced disease. Casirivimab/imdevimab—a monoclonal antibody that targets the SARS-CoV-2 spike protein—has been studied as an outpatient treatment for mild-to-moderate COVID-19.[12]

There is little information on the use of these monoclonal antibodies and their side effects in KTRs. This study reports the treatment of seven KTRs having mild-to-moderate COVID-19 with casirivimab/imdevimab.

The clinical characteristics and laboratory data are shown in Table 1. The median (interquartile [IQR]) age of the KTRs was 53 (37–67) years; all were men and the median (IQR) duration from transplant to COVID-19 infection was 4 (2–6) years. All were on triple immunosuppressants consisting of mycophenolate, prednisolone, and either tacrolimus, sirolimus, or cyclosporine.

Table 1 Clinical characteristics of the patients at baseline
Characteristic Frequency
Age, median (IQR), years 53 (37–67)
Duration of stay, median (IQR), days 10 (5–14)
Time since transplant, median (IQR), years 4 (2–6)
Duration between hospitalization and monoclonal antibodies treatment, median (IQR), days 4 (3–5)
Immunosuppression
 Tacrolimus 4 (57.1%)
 Sirolimus 2 (28.6%)
 Cyclosporine 1 (14.3%)
 Mycophenolate mofetil 7 (100.0%)
Severity of Disease on CT Score
 Mild 5 (71.4%)
 Moderate 2 (28.6%)
Clinical Status During First admission
 Oxygen (O2) required 2 (28.6%)
Clinical Status at Follow-Up
 ICU required 1 (14.3%)
 Infection at follow-up (UTI) 1 (14.3%)
Outcome
 Discharge 7 (100.0%)
 Death 0 (0.0%)
 Rejection 0 (0.0%)

ICU=Intensive care unit, IQR=Interquartile range, O2=Oxygen, UTI=Urinary tract infection

Two patients were completely vaccinated (one with two doses of Covishield and another with three doses of Pfizer-BioNTech), two had received a single dose of Covaxin, and three were unvaccinated. None had taken booster dose as booster doses were not available at that time. The diagnosis of SARS-CoV-2 infection was confirmed by nasopharyngeal reverse transcription polymerase chain reaction (RT-PCR) test. On the chest high-resolution computed tomography (HRCT), only two KTRs showed moderate CT score, whereas all of the remaining KTRs showed mild involvement. All patients presented with fever. One patient each had breathlessness and cough on presentation. Two patients required supplemental oxygen by face mask.

Treatment was started according to guidelines of the AIIMS/ICMR-COVID-19 National Task Force/Joint Monitoring Group, Government of India, dated May 19, 2021. Mild disease was defined as upper respiratory tract symptoms (and/or fever) without shortness of breath or hypoxia and moderate disease as any one of the following: (1) respiratory rate >24 breaths/min, breathlessness; (2) SpO2 of 90% to <93% on room air. Immunosuppression modification was individualized based on the infection and rejection risk.

As per institutional protocol, five patients underwent tacrolimus dose reduction to maintain trough level close to 5 ng/ml, and their antiproliferative agent was stopped. In the other two patients, only the dose of mycophenolate mofetil was reduced. Two patients received remdesivir, and one patient received intravenous methylprednisolone.

Within five days of their hospitalization, all patients were started on monoclonal antibodies in the dose of half vial of Ronapreve, that is, casirivimab (600 mg) and imdevimab (600 mg), intravenously. Median (IQR) serum creatinine significantly decreased (P < 0.01) from 1.78 (1.71–2.88) mg/dl at admission to 1.47 (1.14–2) mg/dl at discharge. There was no evidence of allograft dysfunction after use of Ronapreve. Elevated D-dimer (630 [550–880] ng/ml) levels also significantly decreased (15 [15–23] ng/ml, P < 0.01) at discharge.

After a median (IQR) duration of 10 (5–14) days in the hospital, all patients were discharged. All have been followed up for 14 months from discharge. One patient developed urinary tract infection after one month and another needed admission for breathlessness due to post-COVID-19 pulmonary fibrosis one month after discharge.

In this series, we found that casirivimab/imdevimab combined with immunosuppression reduction for the treatment of mild-to-moderate COVID-19 in KTRs was safe and associated with good outcomes. COVID-19 in KTRs may be severe and require intensive care admission.[3] Immunosuppression imposes a serious challenge in managing KTRs with COVID-19, and treatment options are limited.

In this series, we noticed a rapid and clear improvement following introduction of the antibodies. Elevated D-dimer levels normalized, and serum creatinine reduced at discharge. Only two patients had moderate HRCT score, and all recovered fully. In our study, the median duration of hospitalization was 10 (5–14) days.

The safety data of the study were encouraging—with only one patient experiencing nausea—and were in line with other studies.[145] We did not encounter any episode of acute rejection, change in tacrolimus level, or increase in creatinine at the 30-day follow-up visit.

To our knowledge, this is the first Indian study on the use of monoclonal antibodies in KTRs with COVID-19 infection. However, this study has a very small sample size, making it impossible to draw any firm conclusions. Additionally, there was no control group, and donor-specific antibodies were not tested.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , , , , , , . AProgrammatic response, including bamlanivimab or casirivimab-imdevimab administration, reduces hospitalization and death in COVID-19 positive abdominal transplant recipients. Transplantation. 2022;106:e153-7.
    [Google Scholar]
  2. , , , , , , . Treatment with monoclonal antibodies minimize severity of covid-19 illness among kidney transplant recipients. J Am Soc Nephrol. 2021;32:640.
    [Google Scholar]
  3. , , , , , , . Clinical profile and outcome of COVID-19 in 250 kidney transplant recipients: A multicenter cohort study from India. Transplantation. 2021;105:851-60.
    [Google Scholar]
  4. , , , , , , . Monoclonal antibody treatment for COVID-19 in solid organ transplant recipients. Transpl Infect Dis. 2022;24:e13759.
    [Google Scholar]
  5. , , , , , , . Monoclonal antibody therapy for COVID-19 in solid organ transplant recipients. Open Forum Infect Dis. 2021;8:ofab255.
    [Google Scholar]
Show Sections