European Urology

Identification of kidney transplant recipients with COVID-19--Manuscript Draft--

Manuscript Number: EURUROL-D-20-00345R1

Article Type: Fast Track Submission*

Section/Category: Renal Disease (REN)

Keywords: clinical feature; COVID-19; kidney transplant recipient

Corresponding Author: zhendi wang, M.D.Wuhan Union HospitalWuhan, Hubei CHINA

First Author: Hui Zhang, Ph.D

Order of Authors: Hui Zhang, Ph.D

Yan Chen

Quan Yuan

Qiuxiang Xia

Xianpeng Zeng

Jingtao Peng

Jing Liu

Xingyuan Xiao

Guosong Jiang

Hanyu Xiao

Liangbo Xie

Jing Chen

Jiali Liu

Xiong Xiao

Hua Su

Chun Zhang

Xiaoping Zhang

Hua Yang

Heng Li

Zhendi Wang

Abstract: Coronavirus disease 2019 (COVID-19) is a novel and lethal infectious disease, posinga threat to global health security. The number of cases has increased rapidly but nodata concerning kidney transplant (KTx) recipients infected with COVID-19 areavailable. To present the epidemiological, clinical and therapeutic characteristics ofKTx recipients infected with COVID-19, we report on a case series of five patients whowere confirmed as having COVID-19 through by nucleic acid testing (NAT) fromJanuary 1 to February 28, 2020. The most common symptoms on admission tohospital were fever (5, 100%), cough (5, 100%), myalgia or fatigue (3, 60%) andsputum production (3, 60%); serum creatinine or urea nitrogen levels were slightlyhigher than before symptom onset. Four patients received a reduced dose ofmaintenance immunosuppressive therapy during hospitalization. As of March 4, NATwas negative for COVID-19 in three patients twice in succession, and their computedtomography scans showed improved images. Although greater patient numbers andlong-term follow-up data are needed, our series demonstrates that mild COVID-19

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infection in KTx recipients can be managed using symptomatic support therapycombined with adjusted maintenance immunosuppressive therapy.

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Acknowledgment Statement This corresponding author certifies that: • all persons who have made substantial contributions to the work reported in this manuscript (eg, data collection, analysis, or writing or editing assistance) but who do not fulfill the authorship criteria are named with their specific contributions in an Acknowledgment in the manuscript. • all persons named in the Acknowledgment have provided written permission to be named. • if an Acknowledgment section is not included, no other persons have made substantial contributions to this manuscript. Zhen-Di Wang After completing all the required fields above, this form must be uploaded with the manuscript and other required fields at the time of electronic submission.

Identification of kidney transplant recipients with COVID-19

Hui Zhanga*, Yan Chenb*, Quan Yuanc*, Qiu-Xiang Xiaa, Xian-Peng Zenga, Jing-Tao Penga, Jing

Liua, Xing-Yuan Xiaoa, Guo-Song Jianga, HanYu Xiaoa, Liang-Bo Xiea, Jing Chena, Jia-Li Liua,

Xiong Xiaoa, Hua Sud, Chun Zhangd, Xiao-Ping Zhanga, Hua Yange, Heng Lia, Zhen-Di Wanga#

a. Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of

Science and Technology, Wuhan, 430022, China

b. Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of

Science and Technology, Wuhan, 430022, China

c. Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of

Science and Technology, Wuhan, 430022, China

d. Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of

Science and Technology, Wuhan, 430022, China

e. Department of Organ transplantation, Jiangxi Provincial People’s Hospital Affiliated to Nanchang

University, Nanchang, 330000 , China

* Hui Zhang, Quan Yuan and Yan Chen contributed equally to this work and share first

authorship.

#Correspondence: Address reprint requests to Dr. Zhen-Di Wang, Department of

Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and

Technology, Wuhan, 430022, China; Telephone: (86) 27 85351623; Fax: (86) 27

Manuscript

85776343; E-mail: wangzhendi@gmail.com;

Keywords: clinical feature; COVID-19; kidney transplant recipient

Word count of text: 1685

Word count of the abstract: 186

Contributors: Z.D.W. conceived the idea, designed and supervised the study, had full

access to all data and took responsibility for the integrity of the data. H.Z., Y.C. and

Q.Y. collected and analyzed the clinical and laboratory data. Q.X.X., X.P.Z, J.T.P., L.J.,

X.Y.X. and G.S.J. evaluated pulmonary computed tomographic images. H.Y.X., L.B.X,

J.C., J.L.L., X.X., H.S., C.Z. X.P.Z., H.Y. and H.L. analyzed data and performed

statistical analysis. All authors reviewed and approved the final version.

Declaration of interests: All authors declare no competing interests.

Funding: This work was supported by a clinical research trainee grant from Elite

program of China organ transplant development foundation (No.2019JYJH09), the

National Natural Science Foundation of China (No. 81874091), the National Natural

Science Foundation of China (No. 81974396), the National Natural Science Foundation

of China (No. 81772724) and the National Natural Science Foundation of China (No.

81672529).

Acknowledgments: This work was supported by a clinical research trainee grant from

Elite program of China organ transplant development foundation (No.2019JYJH09),

the National Natural Science Foundation of China (No. 81874091), the National

Natural Science Foundation of China (No. 81974396), the National Natural Science

Foundation of China (No. 81772724) and the National Natural Science Foundation of

China (No. 81672529). We thank all the patients and their families involved in the study.

Special thank Dr. Xiao-Shan Wei for her dedication to data entry and verification.

2

Abstract

Coronavirus disease 2019 (COVID-19) is a novel and lethal infectious disease, posing

a threat to global health security. The number of cases has increased rapidly but no data

concerning kidney transplant (KTx) recipients infected with COVID-19 are available.

To present the epidemiological, clinical and therapeutic characteristics of KTx

recipients infected with COVID-19, we report on a case series of five patients who were

confirmed as having COVID-19 through by nucleic acid testing (NAT) from January 1

to February 28, 2020. The most common symptoms on admission to hospital were fever

(5, 100%), cough (5, 100%), myalgia or fatigue (3, 60%) and sputum production (3,

60%); serum creatinine or urea nitrogen levels were slightly higher than before

symptom onset. Four patients received a reduced dose of maintenance

immunosuppressive therapy during hospitalization. As of March 4, NAT was negative

for COVID-19 in three patients twice in succession, and their computed tomography

scans showed improved images. Although greater patient numbers and long-term

follow-up data are needed, our series demonstrates that mild COVID-19 infection in

KTx recipients can be managed using symptomatic support therapy combined with

adjusted maintenance immunosuppressive therapy.

3

1. Case series

1.1. Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus

that causes coronavirus 2019 (COVID-19), which emerged in Wuhan, China in

December 2019, and has become a growing threat to global health security [1].

Clinically, the disease is characterized with fever, cough, lymphopenia, dyspnea, and

eventually respiratory failure and multiple organ damage in severe cases [2].

Immunosuppression after transplantation renders kidney transplant (KTx) recipients

susceptible to a variety of viral pathogens. Several cases of transplant recipients with

SARS-CoV or Middle East respiratory syndrome coronavirus (MERS-CoV) infection

have been reported [3-5]. However, epidemiological and clinical information

characterizing SARS-CoV-2 infections in KTx recipients remains unknown. Here, we

aimed to comprehensively describe epidemiological and clinical features in five KTx

recipients infected with COVID-19. Our study findings are likely to be of considerable

value for diagnosis and treatment of those patients.

1.2. Cases

From January 2015 to December 2019, 803 cases of kidney transplantation were

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performed in our hospital, with 743 KTx recipients were followed up; six cases had

symptoms, of whom five patients were diagnosed as COVID-19 with confirmed SARS-

CoV-2 infection using nucleic acid testing (NAT) from January 1 to February 28, 2020

(Fig. 1) [6]. After the National Health Commission of China gave approval for data

collection (written informed consent was waived as part of a public health outbreak

investigation) and oral consent was obtained from patients, we followed up the five

KTx recipients until March 4, 2020.

The mean age of these five patients was 45 years (standard deviation [SD], 11 years),

and four were male; all patients had undergone donation after cardiac death (DCD)

renal transplants between January 2016 and November 2019; comorbidities included

hypertension (n = 2), diabetes (n = 1), or bladder cancer (n = 1); the most common

symptoms were fever (5, 100%), cough (5, 100%), myalgia or fatigue (3, 60%) and

sputum production (3, 60%) (Table 1). At symptom onset, all patients’ white blood cell

and neutrophil levels were within normal range except in patient 2, but serum creatinine

or urea nitrogen levels were slightly higher than before symptom onset (Fig. 2A, 2B,

2E, and 2F). On admission, five patients developed lymphopenia and an elevated C-

reactive protein (CRP) level; and proteinuria appeared in four patients (Fig. 2C, 2D, 2G,

and Table 2). During hospitalization, all patients received antiviral therapy (oseltamivir

or arbidol); patients 2 and 3 also received antibacterial therapy (cefixime) and

intravenous immunoglobulin respectively. More importantly, triple

immunosuppression with glucocorticoids, mycophenolate mofetil (MMF) and

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calcineurin inhibitors (CNI) had been used in the four recipients prior to symptom onset;

however, after the onset of illness, the immunosuppressant was reduced or stopped in

four patients (Fig. 1). In patients 1 and 3, the second chest computed tomography (CT)

scans showed deterioration, but this had later resolved, as shown in the third CT scans

(Figs. 1 and 3). As of March 4, four patients had improved chest CT findings, with three

having negative NAT results twice in succession (Figs. 1 and 4). All patients’ symptoms

gradually resolved, except in patient 2. None of these five patients required mechanical

ventilation or admission to intensive care units (ICU), and two were discharged while

three remained hospitalized (Fig. 1).

Concerning patient 2, his maintenance immunosuppressive therapy was glucocorticoid,

MMF and rapamycin before symptom onset. On illness day 0, he complained of fever

and anuria, with increased creatinine, white blood cell and neutrophil levels.

Considering his normal chest CT scan, fever, anuria, hypercreatinemia and leukocytosis

at that time (Fig. 1), we regarded patient 2 as having acute transplantation rejection, in

line with authoritative EAU guidelines on renal transplantation [7]. Thus, patient 2 was

treated with methylprednisolone pulse therapy (500 mg, 250 mg, and 250 mg) for 3

days, after which, his fever abated and his urine output and serum creatinine levels

returned to normal. However, a high fever resumed the next day, with a positive NAT

for SARS-CoV-2 confirming that patient 2 had COVID-19. On admission, the urea

(24.34 mmol/L) and creatinine (411.7 μmol/L) levels of patient 2 were the highest

among these five patients and he also had elevated white blood cell, neutrophil, and

6

CRP levels (Fig. 2 and Table 2). After a week of hospitalization, the second CT scan

for patient 2 showed a typical presentation of viral pneumonia. During hospitalization,

despite the gradual disappearance of fever, patient 2 complained of dyspnea on exertion

with normal oxygen saturation and refused to leave the isolation ward for a third CT

scan (Fig. 1).

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2. Discussion

Although recent studies have reported epidemiological and clinical features of COVID-

19 [1], this is the first study to characterize kidney transplant recipients with COVID-

19. After the outbreak of COVID-19, we identified five infected KTx recipients. While

three patients had a suspected history of exposure, the incubation period concerning the

other two patients was unclear (Fig. 1). However, those two patients were residents of

Wuhan, the center of the outbreak, and their infection may have been due to exposure

to undiagnosed, asymptomatic carriers of SARS-CoV-2. Furthermore, specifically

concerning patient 2, he was treated with methylprednisolone pulse therapy, which

involves greater immunosuppression and could be a predisposing factor for SARS-

CoV-2 infection.

Although SARS-CoV-2 nucleic acid reverse transcription polymerase chain reaction

analysis using throat swab specimens can confirm COVID-19 infection, false negatives

are possible due to the sampling techniques, the viral load of the upper respiratory tract

and mutations of the virus gene. For example, on illness day 21, the NAT result of

patient 2 was not definitive, which suggests that trained technicians should conduct

standard multi-sampling in strict accordance with protocols to improve the sensitivity

of specimens. Apart from lower respiratory tract sampling, whole genome sequencing

and detection of serum antibodies should be considered to optimize diagnostic methods.

8

Concerning laboratory findings, lymphocytopenia developed in the five patients on

admission. Although we could not explain this, lymphocytes have been identified as

primary targets of SARS-CoV injury [8]. Notably, the absolute leukocyte and neutrophil

value was increased in patient 2. However, because bacterial culture results were not

available, the presence of bacterial coinfections could not be confirmed. It should also

be noted that glucocorticoids, such as methylprednisolone, and acute rejection can

contribute to increasing leukocytes and neutrophils on initiation [9]. Thus, using the

leukocyte differential could be helpful in determining whether an abnormal number of

leukocytes and neutrophils is due to bacterial coinfections, acute rejection or the

initiation of methylprednisolone.

Apart from symptomatic support therapy, no specific treatment for COVID-19 has been

confirmed, although several ongoing clinical trials may identify some options [10].

Even for KTx recipients infected with SARS and MERS, the treatment options are

limited [3-5]. Therefore, enhancing personal protection precautions, early identification,

and timely management of affected cases are of crucial importance. Despite the lack of

evidence on clinical efficacy, each patient in this study received antiviral therapy, and

patients 2 and 3 also received antibacterial agent and intravenous immunoglobulin

respectively.

Given the extent of lymphocytes shown to be consumed by SARS-CoV-2 [10], MMF

treatment was withdrawn in four patients. Moreover, glucocorticoids and tacrolimus

9

dosages were also adjusted. There is no evidence to confirm the favorable effects of

glucocorticoids in COVID-19 treatment [11]. Furthermore, whether SARS-CoV-2 can

be inhibited by tacrolimus is unclear, although replication of SARS-CoV was

diminished after tacrolimus treatment [12]. Notably, cyclosporine, another CNI drug,

may be used as an option of host-directed therapies for COVID-19 [13]. Strikingly, no

significant kidney impairment was detected except in patient 2, implying that reducing

immunosuppressive therapy for a short period would not lead to acute rejection.

However, the long-term effect is uncertain. For patient 5, immunosuppressant use was

not changed because of the relatively mild symptoms. His satisfactory clinical outcome

suggested that an immunosuppressive maintenance dosage might not compromise the

antiviral immune effect in relatively mild COVID-19 cases. In addition, aggressive

reduction or withdrawal of immunosuppressant should be considered cautiously only

for recipients with severe pneumonia or acute respiratory distress syndrome [14]. More

importantly, renal function should be monitored frequently because renal failure

resulting from acute rejection could make treatment more difficult.

During hospitalization, four patients' symptoms were gradually controlled whereas

patient 2 got worse further, which, in that case, might be related in part to former acute

rejection. Additionally, as COVID-19 progresses, kidney impairment in patients

infected with SARS-CoV-2 might contribute to poor outcomes, similar to SARS-CoV

where pathological findings concerning kidney specimens from patients with SARS-

CoV shows acute tubular necrosis [15, 16]. Moreover, based on recent studies [1], old

10

age and malignancy could be further risk factors for patient 2. However, whether other

factors may affect prognosis could not be determined due to the limited data available.

In conclusion, although the five KTx recipients were immunocompromised, severe

COVID-19 was not found. Mild COVID-19 in KTx recipients can be managed using

symptomatic support therapy combined with adjusted maintenance immunosuppressive

therapy. Meanwhile, physicians should pay attention to the influence of comorbidities

and the possibility of coinfections. More data are needed to gain better understanding

of KTx recipients infected with COVID-19.

11

References

1. Chen, N., M. Zhou, X. Dong, et al. Epidemiological and clinical characteristics of 99 cases of

2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;

395:507-513.

2. Xu, Z., L. Shi, Y. Wang, et al. Pathological findings of COVID-19 associated with acute respiratory

distress syndrome. Lancet Respir Med 2020.

3. Chiu, M.C. Suggested management of immunocompromized kidney patients suffering from

SARS. Pediatr Nephrol 2003; 18:1204-5.

4. AlGhamdi, M., F. Mushtaq, N. Awn and S. Shalhoub MERS CoV infection in two renal transplant

recipients: case report. Am J Transplant 2015; 15:1101-4.

5. Mailles, A., K. Blanckaert, P. Chaud, et al. First cases of Middle East Respiratory Syndrome

Coronavirus (MERS-CoV) infections in France, investigations and implications for the

prevention of human-to-human transmission, France, May 2013. Euro Surveill 2013; 18.

6. Huang, C., Y. Wang, X. Li, et al. Clinical features of patients infected with 2019 novel coronavirus

in Wuhan, China. Lancet 2020; 395:497-506.

7. Rodriguez Faba, O., R. Boissier, K. Budde, et al. European Association of Urology Guidelines on

Renal Transplantation: Update 2018. Eur Urol Focus 2018; 4:208-215.

8. Gu, J., E. Gong, B. Zhang, et al. Multiple organ infection and the pathogenesis of SARS. J Exp

Med 2005; 202:415-24.

9. Nakagawa, M., T. Terashima, Y. D'Yachkova, G.P. Bondy, J.C. Hogg and S.F. van Eeden

Glucocorticoid-induced granulocytosis: contribution of marrow release and demargination of

intravascular granulocytes. Circulation 1998; 98:2307-13.

10. Yang, X., Y. Yu, J. Xu, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-

2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet

Respir Med 2020.

11. Russell, C.D., J.E. Millar and J.K. Baillie Clinical evidence does not support corticosteroid

treatment for 2019-nCoV lung injury. Lancet 2020; 395:473-475.

12. Carbajo-Lozoya, J., M.A. Muller, S. Kallies, V. Thiel, C. Drosten and A. von Brunn Replication of

human coronaviruses SARS-CoV, HCoV-NL63 and HCoV-229E is inhibited by the drug FK506.

Virus Res 2012; 165:112-7.

13. Zumla, A., D.S. Hui, E.I. Azhar, Z.A. Memish and M. Maeurer Reducing mortality from 2019-

nCoV: host-directed therapies should be an option. Lancet 2020; 395:e35-e36.

14. World Health Organization. Clinical management of severe acute respiratory infection when

Novel coronavirus (nCoV) infection is suspected: interim guidance. Accessed February 29, 2020.

15. Cheng, Y., R. Luo, K. Wang, et al. Kidney impairment is associated with in-hospital death of

COVID-19 patients. 2020:2020.02.18.20023242.

16. Chu, K.H., W.K. Tsang, C.S. Tang, et al. Acute renal impairment in coronavirus-associated severe

acute respiratory syndrome. Kidney Int 2005; 67:698-705.

12

Figure Legend

Figure 1. Timeline of epidemiological and clinical characteristics of kidney

transplant recipients infected with COVID-19.

Date of symptoms onset was defined as origin point, and the contact history was

reviewed. Symptoms, CT image, nucleic acid test, hospital stay and adjustment of

immunosuppressive therapy were listed according to day of illness.

Figure 2. Dynamic profiles of clinical laboratory findings.

We chose four time points to record the dynamic profiles of laboratory findings: the

first time point is one month before the symptom onset; the second time point was when

the patient developed symptoms; the third time point was when the patient was admitted

to hospital; and the fourth time point was the patient's latest laboratory test.

Figure 3. Chest CT images of patient 3

Transverse chest CT images from patient 3. (A) showed unilateral ground-glass opacity

(GGO) with sparing of subpleural regions on illness day 1. On illness day 8, CT image

from patient 3 showed larger lesions in the lower lobe of the left lung with partial

consolidation (B).

Figure 4. Chest CT images of patient 4

Transverse chest CT images from patient 4. (A) showed bilateral ground-glass opacity

(GGO) with sparing of subpleural regions on illness day 2. CT image on illness day 15,

showed multiple consolidations and fibrous stripes in both lungs (B).

13

[Date of submission: March 17, 2020]

James Catto

Editor-in-Chief

European Urology

Dear Editor,

Thank you for giving us an opportunity to revise our manuscript “Identification of kidney

transplant recipients with COVID-19 (EURUROL-D-20-00345)”. We have restructured and

rewritten the case series. On behalf of the co-authors of the present study, I wish to submit the

case series for publication in European Urology, titled “Identification of kidney transplant

recipients with COVID-19.”

This study, using data obtained from five kidney transplant recipients infected with COVID-19,

aimed to comprehensively describe their epidemiological and clinical features as no data

concerning these types of patients are available. We believe that our study makes a significant

contribution to the literature because it showed that mild COVID-19 could be managed using

symptomatic support therapy combined with adjusted maintenance immunosuppressive therapy.

Further, we believe that this paper will be of interest to the readership of your journal because

it provides some evidence-based guidance on the treatment of kidney transplant recipients who

may become infected with COVID-19.

This manuscript has not been published or presented elsewhere in part or in entirety and is not

under consideration by another journal. All study participants provided informed consent, and

the study design was approved by the appropriate ethics review board. We have read and

understood your journal’s policies, and we believe that neither the manuscript nor the study

violates any of these. There are no conflicts of interest to declare.

Take Home Message

Thank you for your consideration. I look forward to hearing from you.

Sincerely,

Zhendi, Wang, MD. PhD.

Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of

Science and Technology, Wuhan, 430022, China; Telephone: (86) 27 85351623; Fax: (86) 27

85776343; E-mail: wangzhendi@gmail.com.

[Date of submission: March 17, 2020]

James Catto

Editor-in-Chief

European Urology

Dear Editor:

Thank you for your letter and giving us an opportunity to revise our manuscript

“Identification of kidney transplant recipients with COVID-19 (EURUROL-D-20-

00345)”.

We also appreciated the two reviewers for their high enthusiasms and

comprehensive analyses of our manuscript. The reviewers’ comments are all

valuable and are also very helpful for revising and improving our paper. We

have studied comments carefully and have made corrections which we hope

meet with approval. For your convenience, we now provide our point-by-point

responses to all the concerns as detailed below.

We have restructured and rewritten the case series. We have tried to reduce

the number of words and references on the premise of clear explanation.

Unfortunately, we failed because of the complexity of COVID-19 in kidney

transplant recipients. We apologize for more than 1500 words and more than

10 references in our revised manuscript. Hope that our case series will be of

great value for the diagnosis and treatment of these patients.

Thank you for your consideration. I look forward to hearing from you.

Sincerely yours,

Zhendi Wang, MD, PhD

Wuhan Union Hospital

Urology

Jie fang da dao 1277

Wuhan, Hubei 430022

CHINA

wangzhendi@gmail.com

Revision notes

Responds to the reviewer’s comments:

Reviewer 1:

1. Unfortunately it needs major corrections/alterations, has many

typographical and grammatical errors.

Response 1: We are so sorry for these mistakes, and the manuscript has been

edited by a professional language service.

2. Abstract:

a). replace 'threatening' with 'posing a threat' in the opening sentence

b). next sentence 'with' is missing.

c). results: patient (line 5), remove the s

d). last sentence: rephrase: 'Limitations include the retrospective nature of

the study, small number of patients (n=5), and short follow-up period.'

Response 2: We thank the reviewer for pointing out these. We have checked

the English and corrected amounts of grammatical errors. Meanwhile,

according to the 'case series of the month', we have re-written the Abstract.

3. Introduction: I don't think the manuscript sheds any light on the prevention

of COVID19 infection in kidney transplant recipients. The last sentence

needs to be modified.

Response 3: We agreed that we should modify the sentence, and we have

corrected the mistake.

4. Results: this section is not easy to follow. It may be better to describe each

of the patients individually as a patient journey, and then to summarise

common clinical characteristics. At the moment, it jumps from patient to

patient and variable to variable. The Treatment and clinical outcomes

section needs a significant rewrite.

Response 4: We thank the reviewer’s important suggestions for better

improving our manuscript. According to the 'case series of the month', we have

re-written the Results. We summarized the common clinical features. In

particular, we described patient 2 alone because of the complex patient journey.

5. Discussion: Again, this section needs re-organising, re-writing.

Response 5: As suggested, we have restructured and rewritten the Discussion

section.

6. For example, suggested re-phrasing of one of the sentences: 'Thus, they

could be infected by undetected SARS-Co-V-2 carriers nearby' to: 'A

plausible explanation may be exposure to un-diagnosed, asymptomatic

carriers of SARS-CoV-2.'

Response 6: Thank the reviewer for helping us re-phrase this sentence. We

have also revised the manuscript accordingly.

7. Expand on why treatment with methylprednisolone could be a predisposing

factor for infection?

Response 7: We're sorry that we didn't describe it clearly in the manuscript.

Due to the acute rejection, patient 2 was treated with methylprednisolone pulse

therapy (500mg, 250mg, 250mg) for 3 days. High dose methylprednisolone can

inhibit the immune function, leading to increased susceptibility of the patient.

8. Provide evidence to support the recommendation: 'we recommend that

kidney transplant recipients don't go to public places and wear surgical

masks when they are out.'

Response 8: Given that humans of all ages are generally susceptible (1.

Diagnosis and Treatment Plan of Corona Virus Disease 2019 [Tentative

Seventh Edition] from National Health Commission of China,

http://www.nhc.gov.cn/yzygj/s7653p/202003/46c9294a7dfe4cef80dc7f5912eb

1989/files/ce3e6945832a438eaae415350a8ce964.pdf; 2. Myth-busters from

WHO, https://www.who.int/emergencies/diseases/novel-coronavirus-

2019/advice-for-public/myth-busters), we recommend that people wear surgical

masks when they are out. However, even so, our recommendation is not

rigorous enough, especially in countries or regions without COVID-19. Thus,

when to use a mask can be considered according to advice from WHO

(https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-

for-public/when-and-how-to-use-masks). In view of these aspects, we have

decided to delete the loose suggestions in our manuscript.

9. Discuss the sensitivity and specificity of the RT-PCR testing, to expand on

the possible false negative result.

Response 9: We appreciate this suggestion, and we have analyzed the

possible causes of false negative, for example, the sampling techniques, viral

load of upper respiratory tract and mutations of virus gene.

10. Is there any evidence yet that re-infection is an impossibility?

Response 10: It is no doubt that this is an important issue to be considered.

Recently, it was reported that four non-kidney transplant patients with COVID-

19 who met criteria for hospital discharge or discontinuation of quarantine in

China (absence of clinical symptoms and radiological abnormalities and 2

negative nucleic acid test) had positive nucleic acid test of SARS-Cov-2 5 to 13

days later (doi:10.1001/jama.2020.2783,

https://jamanetwork.com/journals/jama/fullarticle/2762452). That naturally

raises concerns about whether they are still infectious or re-infected. However,

the positive test results may be caused by the fragments of virus gene rather

than the whole virus capable of infecting others. Moreover, COVID-19 infections

could leave recovering patients with at least short-term immunity against the

virus. Anyway, on the basis of our observation, the recovered non-kidney

transplant and kidney transplant patients do not complain of discomforts again.

We acknowledge that there is a possibility of re-infection. But it's a low

probability, especially in that short time. More importantly, we will follow up

these patients.

11. What were 'the initial obvious symptoms' of kidney transplant recipients?

Are the symptoms or incidence of symptoms of fever, cough, malaise much

different to COVID-19 infection of non-kidney transplant patients?

Response 11: 'The initial obvious symptoms' means that a hundred percent of

our patients developed fever or cough. However, we have realized that our

statements are not rigorous. For our cases series, the most common symptoms

on admission to hospital were fever (5, 100%), cough (5, 100%), myalgia or

fatigue (3, 60%) and sputum production (3, 60%). In recent study

(https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30211-

7/fulltext), most patients had fever (83%) or cough (82%). Symptoms are similar

to those of non- kidney transplant recipients. Furthermore, there was no

statistical difference in incidence of symptoms between the two studies.

Moreover, in our study, such a high proportion may be caused by small sample

size. Thus, we have deleted this section in the revised manuscript.

12. The 'lack of bacterial culture results' statement is vague - were they not

done (strange to not do in a pyrexial patient with leucocytosis and

neutrophilia)? or negative?

Response 12: We are sorry for our vague statement. It's really our fault that the

physicians didn't do bacterial culture. Patient 2 is local resident of Wuhan, the

center of the outbreak. At that time, especially in Wuhan, the epidemic

expanded rapidly, the number of patients increased sharply, and medical

resources were limited. We didn't do the bacterial culture in time. Nevertheless,

in addition to antiviral treatment, patient 2 also received antibacterial therapy.

Reviewer 2:

1. Can they estimate the relative risk of COVID-19 in this population? How

many patients do they have with renal transplants?

Response 1: We thank the reviewer for pointing out these. Because humans of

all ages are generally susceptible (Diagnosis and Treatment Plan of Corona

Virus Disease 2019 [Tentative Seventh Edition] from National Health

Commission of China,

http://www.nhc.gov.cn/yzygj/s7653p/202003/46c9294a7dfe4cef80dc7f5912eb

1989/files/ce3e6945832a438eaae415350a8ce964.pdf), we recommend that

kidney transplant recipients enhance personal protection precaution against

exposure to COVID-19. And, from January 2015 to December 2019, 803 cases

of kidney transplantation were performed in our hospital, with 743 patients were

followed up; we have added this to our revised manuscript.

2. Have they started screening other patients at risk?

Response 2: Thank the reviewer for his/her concern for renal transplant

recipients. We are very sorry that we don't have the ability to complete the

screening. First, there are many COVID-19 patients, especially in China.

Second, medical resources are limited. Third, we have many renal transplant

recipients and everyone is susceptible. Thus, we can only screen renal

transplant recipients with symptoms. In the 743 kidney transplant recipients

who were followed up, six cases had symptoms, with five patients were

diagnosed as COVID-19. We collected and reported five cases of renal

transplant recipients. Nevertheless, we will follow up the renal recipients and

pay close attention to their clinical symptoms.

3. Any knowledge from other transplant populations?

Response 3: From January 2015 to December 2019, 803 cases of kidney

transplantation were performed in our hospital, with 743 patients were followed

up; six cases had symptoms, of whom five patients were diagnosed as COVID-

19. We collected and reported 5 cases of renal recipients. So far, no other

kidney recipients have abnormal performance. We thank the reviewer’s

important help for better improving our manuscript, and we have added these

to our revised manuscript.

4. Any examples from related populations - such as hemodialysis?

Response 4: In our five patients with mild illness, hemodialysis was not

performed. However, in MERS (Middle East Respiratory Syndrome) patients,

continuous renal replacement therapy are recommended (Al-Dorzi, H.M., et al.,

The critical care response to a hospital outbreak of Middle East respiratory

syndrome coronavirus (MERS-CoV) infection: an observational study. Ann

Intensive Care, 2016. 6(1): p. 101.). Therefore, we think that continuous renal

replacement therapy is also an option for severe kidney recipients with COVID-

19.

5. Please make this a case series.

Response 5: We appreciate this suggestion, and we have restructured and

rewritten the case series in our revised manuscript.

fig.1 Click here to access/download;Illustration;fig1.tif

fig.2 Click here to access/download;Illustration;fig2.tif

fig.3 Click here to access/download;Illustration;fig3-CT.tif

fig.4 Click here to access/download;Illustration;fig4-CT.tif

Table 1. Clinical characteristic of the five kidney transplant recipients infected

with COVID-19 on admission to hospital*

Patient No.

Summary 1 2 3 4 5

Sex Male Male Female Male Male —

Age (yr) 38 64 37 47 38 45±11

Time of kidney

transplant surgery

Oct.23,

2019

Jan.16,

2016

Aug.19,

2019

Feb.26,

2019

Jul.27,

2017 —

Sources of Donor

Kidneys DCD DCD DCD DCD DCD —

Comorbidities other

than kidney

diseases

Hypertension － － + － + 2+

Diabetes － － － － + 1+

Bladder cancer － + － － － 1+

Fever + + + + + 5+

Cough + + + + + 5+

Sputum production － + － + + 3+

Myalgia or fatigue － + － + + 3+

Dyspnea － － － － － 0

Gastrointestinal

symptoms － － － － － 0

Body

temperature(℃) 38.9 38.3 39 39.8 39.1 39.2±0.5

Oximetry saturation

on room air (%) 99 96 99 98 97 97.8±1.3

* Plus–minus values are means ±SD (standard deviation). A plus sign indicates that the

sign or symptom was present, and a minus sign that it was absent. DCD = donation after

cardiac death.

Table 1&2

Table 2. The laboratory findings of the five kidney transplant recipients infected

with COVID-19 on admission to hospital*

Patient No.

Summary

1 2 3 4 5

White blood cell

count, ×109/L 4.73 17.67 5.67 3.99 6.44 7.70±5.65

Neutrophil count,

×109/L 2.66 16.07 3.93 2.33 3.22 5.64±5.86

Lymphocyte count,

×109/L 0.63 0.55 0.31 0.51 0.91 0.58±0.22

Platelet count, ×109/L 222 136 158 186 228 186±40

Hemoglobin, g/L 99 139 107 85 148 116±27

PT, s 12.3 12.7 13.7 14.0 12.6 13.0±0.7

APTT, s 32.4 37.8 38.2 43.2 36.9 37.7±3.8

D-dimer, mg/L 0.37 1.26 2.03 0.45 0.39 0.90±0.73

CRP, mg/L 6.68 337.11 9.77 13.38 33.72 80.13±144.04

ESR, mm/h 7 >100 17 12 44 >36±39

Albumin, g/L 34.2 29.3 33.6 37.7 45.2 36.0±5.9

Total bilirubin, μmol/L 9.2 14.7 4.6 12.8 10.4 10.3±3.9

Direct bilirubin,

μmol/L 3.1 2.0 1.8 3.9 4.9 3.1±1.3

ALT, U/L 66 21 70 7 20 37±29

AST, U/L 41 31 49 26 21 34±11

LDH, U/L 193 180 160 235 248 203±37

Urea, mmol/L 9.02 24.34 10.30 9.82 5.92 11.88±7.17

Creatinine, μmol/L 98.0 411.7 137.0 146.9 135.4 185.8±127.6

Proteinuria + ++ + + － —

*Plus–minus values are means ±SD. Normal ranges of laboratory findings are as follows: for

white blood cell count, (3.5-9.5) ×109/L; for neutrophil count, (1.8-6.3) × 109/L; for lymphocyte

count, (1.1-3.2) × 109/L; for platelet count, (125-350) × 109/L; for hemoglobin, (130-175) g/L;

for prothrombin time (PT), (11.0-16.0)s; for activated partial thromboplastin time (APTT),

(28.0-43.5)s; for D-dimer, (0-0.5)mg/L; for C-reactive protein (CRP), (0-8)mg/L; for erythrocyte

sedimentation rate (ESR), (0-15)mm/h; for albumin, (35-55)g/L; for total bilirubin, (5.1-19.0)

μmol/L; for direct bilirubin, (1.7-6.8) μmol/L; for alanine aminotransferase (ALT), (5-40) U/L;

for aspartate aminotransferase (AST), (8-40) U/L; for lactate dehydrogenase (LDH), (109-

245) U/L; for urea, (2.9-8.2) mmol/L; for creatinine, (44.0-133.0) μmol/L; for proteinuria, “-”

indicates that protein excretion is less than 10 mg/dL, ”+” indicates that protein excretion is

between (30-100) mg/dL, “++” indicates that protein excretion is between (100-300) mg/dL.