The use of convalescent plasma, dexamethasone and remdesivir in a renal transplant patient infected with COVID-19

Abstract

Background Immunocompromised patients, such as renal transplant recipients, are a high-risk population for coronavirus disease 2019 (COVID-19) infection and complications. The evidence to support specific treatment of COVID-19 in this group of patients remains very limited. We present the first case in West Texas of a renal transplant patient who received combined therapy with convalescent plasma, dexamethasone, and remdesivir for the treatment of COVID-19.

Case summary We report a female patient who received a deceased donor kidney transplant approximately 2 years prior. She was admitted to our institution with respiratory distress with symptomatic COVID-19 infection. Her baseline renal allograft function per serum creatinine was 0.9 mg/dL, and she was on maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and prednisone. Throughout her hospitalization, her mycophenolate mofetil was maintained, the prednisone was switched for dexamethasone, and her tacrolimus dosage required multiple adjustments secondary to interactions with the azithromycin used to treat an atypical pneumonia upon admission to the hospital. The patient eventually required supplemental oxygen with a venti-mask at 50% FiO2 and transfer to the medical intensive care unit. She received convalescent plasma from a COVID-19 recovered patient, in addition to dexamethasone and then remdesivir for 5 days, with clinical improvement. She was discharged on 3 L per minute supplemental oxygen by nasal cannula from the hospital on day 17 of hospitalization.

Conclusion This renal transplant patient in West Texas with symptomatic COVID-19 infection was treated with convalescent plasma, remdesivir, and dexamethasone with a good outcome. This case also shows the common and often missed drug interactions between tacrolimus and azithromycin and describes a safe way of lowering immunosuppression without compromising renal allograft function.

Keywords: COVID-19, coronavirus, renal transplant, immunosuppression, convalescent plasma, dexamethasone, remdesivir, tacrolimus, mycophenolate mofetil.