Dear Editor,
Thank you very much for the opportunity to contribute to the current discussion on post-transplant patients with COVID-19, by referring to the letter of Anna Drohomirecka and Tomasz Zieliński [1] published in Kardiologia Polska (Kardiol Pol, Polish Heart Journal) as a commentary on our article entitled: “The course and treatment of COVID-19 in heart transplant recipients: A case series from the late phase of the pandemic”. Given the high risk of infectivity and mortality due to COVID-19 in heart transplant recipients and the need to improve the care of our patients, the exchange of institutional experience between transplant centers is of great importance. We believe that Kardiol Pol is an excellent platform for the cardiac and transplant community to share knowledge and experience in this field.
Pulmonary aspergillosis in heart transplant recipients with COVID-19
COVID-19-associated fungal infections, including COVID-19-associated pulmonary aspergillosis (CAPA), have been well described [2] and defined as secondary (fungal-after-viral) infections; however, the data on the prevalence of invasive pulmonary aspergillosis preceding COVID-19 are limited. We described 2 cases of heart transplant recipients with COVID-19 initially infected with aspergillosis. The diagnosis in both cases was established in the early post-transplant period according to the guidelines of the International Society for Heart and Lung Transplantation [3] including clinical and laboratory criteria (positive bronchoalveolar lavage testing for Aspergillus galactomannan) and the results of computed tomography of the chest. Both patients were treated with voriconazole and had a tacrolimus concentration of 17.3 ng/ml and 10.2 ng/ml at the time of COVID-19 diagnosis (compared to the other 2 patients with a tacrolimus concentration of 10.3 ng/ml and 13.3 ng/ml). Referring to the observation of kidney transplant recipients with COVID-19, we also noted a trend towards higher tacrolimus concentrations during COVID-19 compared to earlier periods in our patients.
The management of immunosuppressive regimens during anti-COVID treatment
Treatment of post-transplant patients, especially immunosuppressive management, always requires an individual approach. Moreover, in the absence of established rules, decisions are often made based on individual and institutional clinical experience. During the pandemic, it was common practice to discontinue or reduce the treatment with antimetabolites; however, reports on the effect of mycophenolate on the course of infectious diseases are contradictory. While some studies suggest an impaired immune response to SARS-CoV-2 vaccination in individuals treated with mycophenolate [4], others show a beneficial effect of the drug on the course of COVID-19 and indicate the antiviral properties of mycophenolate itself [5].
Referring to immunosuppressive management during anti-COVID treatment, we considered the actual intensity of immunosuppression, time from transplant or rejection event, and type of anti-COVID treatment (antivirals or biologics). Our overall strategy for early post-transplant patients on antiviral therapy was to maintain background therapy with tacrolimus and mycophenolate mofetil and closely monitor drug levels with dose adjustments. In cases of neutropenia, we temporarily discontinued anti-metabolite treatment.
Article information
Conflict of interest: None declared.
Funding: None.
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