Kidney Transplant Recipients and Omicron: Outcomes, effect of vaccines and the efficacy and safety of novel treatments
Sarah Gleeson, Paul Martin, Tina Thomson, Amarpreet Thind, Maria Prendecki, Katrina J Spensley, Candice L Clarke, Candice Roufosse, Graham Pickard, David Thomas, Stephen P Mcadoo, Liz Lightstone, Peter Kelleher, Dr Michelle Willicombe
doi:10.1101/2022.05.03.22274524
We aimed to describe the outcomes of Omicron infection in kidney transplant recipients (KTR), compare the efficacy of the community therapeutic interventions and report the safety profile of molnupiravir. From 142 KTRs diagnosed with COVID-19 infection after Omicron had become the dominant variant in the UK, 116 (78.9%) cases were diagnosed in the community; 47 receiving sotrovimab, 21 molnupiravir and 48 no treatment. 10 (20.8%) non-treated patients were hospitalised following infection, which was significantly higher than the sotrovimab group (2.1%), p=0.0048, but not the molnupiravir treated group (14.3%), p=0.47. The only admission following sotrovimab occurred in a patient infected with BA.2. One patient from the molnupiravir and no-treatment groups required ICU support, and both subsequently died, with one other death in the no-treatment group. No patient receiving sotrovimab died. 6/116 (5.2%) patients required dialysis following their diagnosis; 2 (9.5%) patients receiving molnupiravir and 4 (8.3%) no-treatment. This requirement was significantly higher in the molnupiravir group compared with the sotrovimab treated patients, in whom no patient required dialysis, p=0.035. Both molnupiravir treated patients requiring dialysis had features of systemic thrombotic microangiopathy. Post-vaccination serostatus was available in 110 patients. Seropositive patients were less likely to require hospital admission compared with seronegative patients, 6 (7.0%) and 6 (25.0%) respectively, p=0.023. Seropositive patients were also less likely to require dialysis therapy, p=0.016. In conclusion, sotrovimab treatment in the community was associated with superior patient and transplant outcomes; it's clinical efficacy against the BA.2 variant requires a rapid review. The treatment benefit of molnupiravir was not evident, and wider safety reporting in transplant patients is needed.
risk group with poor infection outcomes, immunosuppressed people often with significant comorbidities, have been excluded from policy informing studies from the start of the pandemic. Relying on extrapolating data from these studies to inform management of transplant recipients, may and has led to suboptimal outcomes.
References
Benotmane, Pre-exposure prophylaxis with Evusheldโข elicits limited neutralizing activity against the omicron variant in kidney transplant patients, medRxiv
Bernal, Molnupiravir for Oral Treatment of Covid-19 in Nonhospitalized Patients, N Engl J Med
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Callaghan, Real-world Effectiveness of the Pfizer-BioNTech BNT162b2 and Oxford-AstraZeneca ChAdOx1-S Vaccines Against SARS-CoV-2 in Solid Organ and Islet Transplant Recipients, Transplantation
Chavarot, Early treatment with sotrovimab monoclonal antibody in kidney transplant recipients with Omicron infection
Extance, Covid-19: What is the evidence for the antiviral molnupiravir?, BMJ
Gupta, Early Treatment for Covid-19 with SARS-CoV-2 Neutralizing Antibody Sotrovimab, N Engl J Med
Iketani, Antibody evasion properties of SARS-CoV-2 Omicron sublineages, Nature
Kemp, SARS-CoV-2 evolution during treatment of chronic infection, Nature
Prendecki, Immunological responses to SARS-CoV-2 vaccines in kidney transplant recipients, Lancet
Villanego, Trends in COVID-19 Outcomes in Kidney Transplant Recipients During the Period of Omicron Variant Predominance, Transplantation
Willicombe, Scanlon, Miranda, Loud, Lightstone, Should we be clinically assessing antibody responses to covid vaccines in immunocompromised people?, BMJ
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