Patients undergoing kidney transplant are at risk of severe COVID-19. Our single-center retrospective analysis evaluated the outcomes of kidney transplant outpatients with COVID-19 who were managed with reduced immunosuppression and treatment with molnupiravir. Between January 2022 and May 2023, we included 93 patients (62 men, average age 56 years), serum creatinine 127 (101-153) µmol/L. Molnupiravir was administered, and immunosuppressive therapy was reduced immediately following the confirmation of SARS-CoV-2 infection by PCR, which was 2 (1-3) days after the onset of symptoms. Only three (3.2%) patients required hospitalization, and one patient died. Acute kidney injury was observed in two patients. During the follow-up period of 19 (15-22) months, there was no significant increase in proteinuria, no acute or new chronic graft rejection, and kidney graft function remained stable; serum creatinine was 124 (106-159) µmol/L post-COVID-19 infection and 128 (101-161) µmol/L at the end of the follow-up period. Our results demonstrate that early initiation of molnupiravir treatment combined with a temporary reduction in immunosuppressive therapy results in favorable clinical outcomes in patients with COVID-19, with preservation of good graft function and no episodes of graft rejection.

Department of Nephrology University Hospital Hradec Kralove Hradec Králové Czechia

Department of Surgery University Hospital Hradec Kralove Hradec Králové Czechia

Department of Urology University Hospital Hradec Kralove Hradec Králové Czechia

Hospital Pharmacy University Hospital Hradec Kralove Hradec Králové Czechia

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Jager KJ, Kramer A, Chesnaye NC, Couchoud C, Sánchez-Álvarez JE, Garneata L, 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) 98:1540–8. 10.1016/j.kint.2020.09.006 PubMed DOI PMC

Cochran W, Shah P, Barker L, Langlee J, Freed K, Boyer L, et al. COVID-19 Clinical Outcomes in Solid Organ Transplant Recipients During the Omicron Surge. Transplantation (2022) 106(7):e346–e347. 10.1097/TP.0000000000004162 PubMed DOI PMC

Gandolfini I, Crespo M, Hellemans R, Maggiore U, Mariat C, Mjoen G, et al. Issues Regarding COVID-19 in Kidney Transplantation in the ERA of the Omicron Variant: A Commentary by the ERA Descartes Working Group. Nephrol Dial Transpl (2022) 37(10):1824–9. 10.1093/ndt/gfac203 PubMed DOI PMC

Jayk BA, Gomes da Silva MM, Musungaie DB, Kovalchuk E, Gonzalez A, Delos RV, et al. Molnupiravir for Oral Treatment of COVID-19 in Nonhospitalized Patients. N Engl J Med (2022) 386(6):509–20. 10.1056/NEJMoa2116044 PubMed DOI PMC

Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Inter, Suppl (2012)(2) 1–138. 10.1038/kisup.2012.6 DOI

Poznanski P, Augustyniak-Bartosik H, Magiera-Zak A, Skalec KJ, Jakuszko K, Mazanowska O, et al. Molnupiravir When Used Alone Seems to Be Safe and Effective as Outpatient COVID-19 Therapy for Hemodialyzed Patients and Kidney Transplant Recipients. Viruses (2022) 14:2224. 10.3390/v14102224 PubMed DOI PMC

Cho WJ, Harden D, Moreno D, Dinulos JE, Hanna PE, Wang Q, et al. Oral Antiviral Therapies for COVID-19 in Patients With Advanced Chronic Kidney Disease or Kidney Failure. Nephrol Dial Transpl (2023) 38:1912–4. 10.1093/ndt/gfad058 PubMed DOI PMC

Villamarín M, Márquez-Algaba E, Esperalba J, Perelló M, Los Arcos I, Campany D, et al. Preliminary Clinical Experience of Molnupiravir to Prevent Progression of COVID-19 in Kidney Transplant Recipients. Transplantation (2022) 106(11):2200–4. 10.1097/TP.0000000000004306 PubMed DOI

Radcliffe C, Palacios CF, Azar MM, Cohen E, Malinis M. Real-World Experience With Available, Outpatient COVID-19 Therapies in Solid Organ Transplant Recipients During the Omicron Surge. Am J Transpl (2022) 22(10):2458–63. 10.1111/ajt.17098 PubMed DOI PMC

Johnson MG, Strizki JM, Brown ML, Wan H, Shamsuddin HH, Ramgopal M, et al. Molnupiravir for the Treatment of COVID-19 in Immunocompromised Participants: Efficacy, Safety, and Virology Results From the Phase 3 Randomized, Placebo-Controlled MOVe-OUT Trial. Infection (2023) 51:1273–84. 10.1007/s15010-022-01959-9 PubMed DOI PMC

Guermazi D, Avanitis P, Farmakiotis D. Molnupiravir Efficacy Among Immunocompromised Patients With COVID-19: No Proof of Concept. Infection (2023) 51:1593–5. 10.1007/s15010-023-02027-6 PubMed DOI PMC

Czarnecka K, Czarnecka P, Tronina O, Durlik M. Molnupiravir Outpatient Treatment for Adults With COVID-19 in a Real-World Setting – A Single Center Experience. J Clin Med (2022) 11:6464. 10.3390/jcm11216464 PubMed DOI PMC

Standing JF, Buggiotti L, Guerra-Assuncao JA, Woodall M, Ellis S, Agyeman AA, et al. Randomized Controlled Trial of Molnupiravir SARS-CoV-2 Viral and Antibody Response in At-Risk Adult Outpatients. Nat Commun (2024) 15(1):1652. 10.1038/s41467-024-45641-0 PubMed DOI PMC

Fountain-Jones NM, Vanhaeften R, Williamson J, Maskell J, I-Ly JC, Charleston M, et al. Effect of Molnupiravir on SARS-CoV-2 Evolution in Immunocompromised Patients: A Retrospective Observational Study. Lancet Microbe (2024) 5:e452–58. 10.1016/S2666-5247(23)00393-2 PubMed DOI

Mallapaty S, Callaway E, Kozlov M, Ledford H, Pickrell J, Noorden R, et al. How COVID Vaccines Shaped 2021 in Eight Powerful Charts. Nature (2021) 600:580–3. 10.1038/d41586-021-03686-x PubMed DOI

Watschinger C, Stampfel G, Zollner A, Hoog AM, Rössler A, Reiter S, et al. B and T Cell Responses to SARS-CoV-2 Vaccination in Kidney and Liver Transplant Recipients With and Without Previous COVID-19. Viruses (2023) 16(1):1. 10.3390/v16010001 PubMed DOI PMC

Huh K, Kang M, Kim YE, Choi Y, An SJ, Seong J, et al. Risk of Severe COVID-19 and Protective Effectiveness of Vaccination Among Solid Organ Transplant Recipients. J Infect Dis (2023) 229:1026–34. 10.1093/infdis/jiad501 PubMed DOI

Manothummetha K, Chuleerarux N, Sanguankeo A, Kates OS, Hirankarn N, Thongkam A, et al. Immunogenicity and Risk Factors Associated With Poor Humoral Immune Response of SARS-CoV-2 Vaccines in Recipients of Solid Organ Transplant: A Systematic Review and Meta-Analysis. JAMA Netw Open (2022) 5(4):e226822. 10.1001/jamanetworkopen.2022.6822 PubMed DOI PMC

Solera JT, Árbol BG, Mittal A, Hall VG, Marinelli T, Bahinskaya I, et al. COVID-19 Reinfection Has Better Outcomes Than the First Infection in Solid Organ Transplant Recipients. Transplantation (2024) 108:1249–56. 10.1097/TP.0000000000004902 PubMed DOI

Vankova B, Mala-Ladova K, Kubena AA, Maly J, Sulkova SD. Immunosuppressive Therapy Related Adherence, Beliefs and Self-Management in Kidney Transplant Outpatients. Patient Prefer Adherence (2018) 12:2605–13. 10.2147/PPA.S184166 PubMed DOI PMC

Elec AD, Oltean M, Goldis P, Cismaru C, Lupse M, Muntean A, et al. COVID-19 After Kidney Transplantation: Early Outcomes and Renal Function Following Antiviral Treatment. Int J Infect Dis (2021) 104:426–32. 10.1016/j.ijid.2021.01.023 PubMed DOI PMC

Chen TY, Farghaly S, Cham S, Ttem LL, Sin JH, Rauda R, et al. COVID-19 Pneumonia in Kidney Transplant Recipients: Focus on Immunosuppression Management. Transpl Infect Dis (2020) 22(5):e13378. 10.1111/tid.13378 PubMed DOI PMC

Demir E, Ucar ZA, Dheir H, Danis R, Yelken B, Uyar M, et al. COVID-19 in Kidney Transplant Recipients: A Multicenter Experience From the First Two Waves of Pandemic. BMC Nephrol (2022) 23(1):183. 10.1186/s12882-022-02784-w PubMed DOI PMC

Bajpai D, Deb S, Bose S, Gandhi C, Modi T, Katyal A, et al. Recovery of Kidney Function After AKI Because of COVID-19 in Kidney Transplant Recipients. Transpl Int (2021) 34(6):1074–82. 10.1111/tri.13886 PubMed DOI PMC

Defelice G, Giusti S, Jeon H, Killackey M, Paramesh A, Vijay A. Short and Long-Term Outcomes of Kidney Transplant Recipients Diagnosed With COVID-19 Infection: A Single-Center Observational Study. Cureus (2022) 14(11):e31375. 10.7759/cureus.31375 PubMed DOI PMC