腎移植患者におけるCOVID-19肺炎の低率-感染と免疫反応の戦い？

Low Rate of COVID-19 pneumonia in Kidney Transplant Recipients - A Battle Between Infection and Immune Response?

• Maryam Ghaffari Rahbar
• Mohsen Nafar
• Alireza Khoshdel
• Nooshin Dalili
• Alireza Abrishami
• Ahmad Firouzan
• Fatemeh Poorrezagholi
• Fariba Samadian
• Shadi Ziaie
• Somayeh Fatemizadeh
• Shiva Samavat

抄録

背景:

COVID-19のパンデミックに伴い、腎移植患者への懸念が高まっている。しかし、発症率、臨床経過、転帰、重症度の予測因子は不明瞭である。

BACKGROUND: With COVID-19 pandemic, concerns about kidney transplant recipients are rising. However, the incidence, clinical course, outcome, and predictive factors of disease severity are obscured.

方法:

COVID-19肺炎を発症した腎移植患者の臨床症状、検査所見、放射線所見、臨床経過、最終的な転帰について述べる。

METHODS: We describe clinical and laboratory manifestations, radiologic findings, clinical course, and finally outcome of kidney transplant recipients with COVID-19 pneumonia.

結果:

当院でフォローアップ中の腎移植患者2493例のうち，19例（放射線所見から診断された4例）が入院した。平均年齢は47.6±12.4歳，移植からの平均期間は115.6±70.3ヶ月であった。リンパ減少症は84.2%、好酸球減少症は78.9%であった。9名の患者は入院期間中に生存しなかった。過去12ヶ月間の急性拒絶反応の既往歴、糖尿病、N/L比高値、血小板数低値、N/L×CRP高値、LDH高値、D-ダイマー陽性、トロポニン高値、PT延長は死亡率と関連していた。COVID-19検査陽性の患者では、急性拒絶反応の既往歴、低血小板数、D-ダイマー陽性が予後不良と関連していた。シクロスポリンの治療は臨床転帰の改善と関連していた。

RESULTS: Of 2493 kidney transplant recipients under follow up in our clinic, 19 cases (4 cases diagnosed based on radiologic findings) were admitted. The mean age of patients was 47.6 ± 12.4 years, and the mean time from transplantation was 115.6 ± 70.3 months. Lymphopenia and eosinopenia were 84.2% and 78.9%, respectively. Nine patients did not survive the hospital course. History of acute rejection during the past 12 months, diabetes, higher N/L ratio, lower platelet count, elevated N/L x CRP, higher levels of LDH, positive D-dimer, higher troponin, and prolonged PT were associated with mortality. Among patients with positive COVID-19 test, history of acute rejection, low platelet count, and positive D-dimer were associated with poor outcome. Treatment with cyclosporine was associated with better clinical outcome.

結論:

移植患者の入院率が低いのは、サイトカインストームに対する免疫抑制剤の防御効果や免疫機能の変化によるものかもしれない。我々は、主に死亡リスクの高い患者においてCOVID-19を管理するための指針として、T細胞の数、機能、サイトカインプロファイルを評価することを提案する。

CONCLUSIONS: Low rate of admission in transplant recipients specially in the very first years of transplantation might be due to protective effects of immunosuppressive agents against cytokine storm or modification of immunity function. We suggest evaluation of T cells number, function and cytokine profile as a guide to manage COVID-19 mainly in patients with higher risk of mortality.

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