Immunomodulatory drugs hold promise for the management of cytokine release syndrome (CRS) in coronavirus disease-2019 (COVID-19) like tocilizumab (1x1Qin, C., Zhou, L., Hu, Z. et al. Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clin Infect Dis. 2020;
Crossref | Scopus (102) | Google ScholarSee all References1, 2x2Zhang, C., Wu, Z., Li, J.W. et al. The cytokine release syndrome (CRS) of severe COVID-19 and Interleukin-6 receptor (IL-6R) antagonist Tocilizumab may be the key to reduce the mortality. Int J Antimicrob Agents. 2020;
Crossref | PubMed | Scopus (47) | Google ScholarSee all References2) However, its clinical utility in immunosuppressed patients is still lacking (3x3Rutherford, A.I., Subesinghe, S., Hyrich, K.L. et al. Serious infection across biologic-treated patients with rheumatoid arthritis: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Ann Rheum Dis. 2018;
PubMed | Google ScholarSee all References3,4x4Fontana, F., Alfano, G., Mori, G. et al. Covid-19 pneumonia in a kidney transplant recipient successfully treated with Tocilizumab and Hydroxychloroquine. Am J Transplant. 2020;
Crossref | PubMed | Scopus (0) | Google ScholarSee all References4). Here, we describe the successful use of tocilizumab in a kidney transplant (KT) recipient with severe COVID-19.
A 69-year-old man received a KT in 2005 because of end-stage renal disease due to membranoproliferative glomerulonephritis complicated by chronic allograft nephropathy. Comorbidities included hypertension and obesity (body mass index: 31 kg/m2). Maintenance immunosuppression consisted of mycophenolic acid (1500 mg) and cyclosporine (120 mg). On April 2, 2020, he was admitted to our unit with dyspnea and hypoxia (blood oxygen saturation of 94% with an oxygen flow rate of 2 L/min). The RT-PCR test for SARS-CoV-2 detection was positive. There was also evidence of acute kidney injury (AKI) Kidney Disease: Improving Global Outcomes stage 1. Immunosuppression reduction consisted of mycophenolic acid withdrawal and reduced-dose cyclosporine. The patient was hydrated and antibiotic prophylaxis was started (Table 1Table 1). Unfortunately, the patient’s respiratory function further deteriorated and laboratory findings were suggestive of a CRS with a remarkably elevated (431 pg/mL) serum IL-6 levels. A single intravenous infusion of tocilizumab (8 mg/kg/day) was attempted. Two days after, oxygen was not longer required (Figure 1Figure 1). The patient was discharged home and completed recovered from AKI.
|April 10||April 11||April 13|
|Days from symptom onset||12||14||15||16||17||19||20||21||23|
|Highest recorded body temperature, °C||36.5||36.7||37.1||36.7||38.5||36.2||36.1||36.3||36.6|
|Percentage of lung infiltration on chest CT||25%||50%|
|Tocilizumab, 680 mg|
|Dexamethasone, 10 mg|
|Serum creatinine, μmol/L||446||380||313||260||249||280||213|
|Serum albumin, g/L||37||34||32||34||36||31|
|C-reactive protein, mg/L||229||112||67||56||133||8.9|
|Lactate dehydrogenase, U/L||243||348|
|High-sensitivity troponin, ng/L||43||42||44|
|Platelet count, ×109/L||229||198||171||182||196||164||121|
Early detection of CRS biomarkers is recommended and should prompt anti-inflammatory interventions. Larger studies are needed to confirm the utility and safety of IL-6 inhibition combined with dexamethasone in KT recipients with COVID-19.