Clinical Profile, Immunosuppressive Management and Outcome in Adult Renal Allograft Recipients with COVID-19 Infection

Abstract

Introduction. Coronavirus disease 2019 (COVID-19) has placed 
considerable strain on healthcare systems worldwide with renal 
allograft recipients (RARs) representing a particularly vulnerable 
group. Lifelong immunosuppression increases susceptibility to 
severe infection and complicates clinical management. Data on 
COVID-19 in RARs from South Asia and other resource-limited 
settings are limited. This study describes the clinical features, 
immunosuppressive adjustments, and outcomes of renal allograft 
recipients with COVID-19.
Methods. We analyzed data from 26 adult RARs with moderate
to-severe COVID-19, confirmed by RT-PCR, who were admitted 
to the Department of Nephrology, Continental Hospital PLC 
(previous United Hospital Limited) Dhaka, Bangladesh, between 
December 2020 and June 2025.
Results. The mean age was 59.6 years (range: 34 to 75 years), 
and 73.1% of patients were male. DM (46.2%), glomerulonephritis 
(23.1%), and hypertensive nephrosclerosis (19.2%) were the most 
common primary renal diseases. The most frequent symptoms 
were cough (96.2%) and fever (88.5%). Immunosuppressive 
therapy was modified in all patients: antimetabolites were 
discontinued, corticosteroids were switched to dexamethasone 
or IV methylprednisolone, and CNIs were withheld in 34.6% or 
halved in 26.9%. Laboratory results showed elevated inflammatory 
markers (CRP 96.4 mg/L, ferritin 854.3 ng/mL, D-dimer 2016.3 
ng/mL). Chest CT revealed ground-glass opacities in 76.9% (most 
commonly bilateral peripheral, 35%) and consolidation in 61.5%, 
with a mean total severity score of 9.6 ± 4.9. Acute kidney injury 
occurred in 26.9%, among them 23.1%required dialysis and 7.7% 
remained dialysis-dependent. Mechanical ventilation was needed 
in 23.1%. Overall mortality was 26.9%, while 65.4% of patients 
recovered and were discharged.
Conclusion. COVID-19 is associated with significant morbidity 
and mortality in RARs. Despite most patients recovering, 
mortality remained significant, highlighting the need for careful 
immunosuppressive adjustment, aggressive infection control, 
and close monitoring in this high-risk population.