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Volume: 1 Issue: 3 September 2021

FULL TEXT

CASE REPORT
COVID-19 in Kidney Transplant Recipient With Concomitant Burn Injury: A Challenge to Balance Immunosuppression

ABSTRACT

The COVID-19 pandemic has grossly affected the transplant communities with no exception to any geographic area. Burn injury remains an important public health problem, even during the pandemic. The management of concomitant burn in an organ transplant recipient has been rarely described. Here, we report a kidney transplant recipient who was admitted for moderate COVID-19 symptoms and then sustained a second-degree inhalational burn injury at home on day 2 after discharge from COVID-19. The patient was shown to be COVID-19 positive and was isolated initially in the burn unit. After a second negative report on day 3 of hospital admission, the patient was shifted to the general ward. He required a hemodialysis session and modification of immunosuppression, which was done through telemedicine from our center. The wound was complicated by a rejection episode, which was treated by regrafting. He recovered on day 45 after injury with baseline immunosuppression restored. His serum creatinine reached a nadir of 3.2 mg/dL, and he has continued on regular follow-up. In summary, our case highlights the difficulty in managing burn cases during the pandemic. The added problem of balancing immunosuppression in organ transplant recipients with burn injuries is a daunting task for transplant physicians.


KEY WORDS: Flame injury, Organ transplantation, SARS-CoV-2, Telemedicine

INTRODUCTION
Coronavirus disease (COVID-19) has swept the world in innumerable ways and within a short span of time. Organ transplant is a well-known risk factor for adverse outcomes of COVID-19. There have been exhaustive data depicting high morbidity and mortality in organ transplant recipients.1 Although mortality may flatten with time, there have also been considerable reports of breakthrough cases after vaccination, especially in organ transplant recipients, which makes the situation gloomy for this high-risk population. As per the World Health Organization, burns are a major cause of worldwide mortality and morbidity.2 During the time during when COVID-19 has become a major health problem, whether COVID-19 status affects management and prognosis of patients with burns has been largely understudied, with so far limited supporting evidence. Burn injuries in immunosuppressed patients are traditionally difficult to manage, and the additive impact of COVID-19 in this regard has been rarely reported. Challenges in managing the tailoring of immunosuppression during wound healing and during prevention of wound infection are arduous, as any imbalance can lead to graft rejection.

Here, we report the management and course of a kidney transplant recipient who experienced second-degree burns 2 days after discharge from hospitalization with COVID-19. As this was a retrospective report, informed consent from the patient for publication of the report was not taken, and anonymity and patient privacy were ensured during reporting.

CASE REPORT
A 56-year-old male patient who received renal transplant 3 years earlier was admitted for moderate COVID-19 symptoms to our transplant center. The patient received anticoagulation therapy, remdesivir, and low-flow oxygen support. The baseline characteristics of the patient and his COVID-19 course are depicted in Table 1 and Table 2, respectively. The patient was discharged because of sustained clinical improvement, although he still showed positivity with the SARS-CoV-2 real-time polymerase chain reaction (RT-PCR) test. He was advised of home isolation, as his RT-PCR was positive and SARS-CoV-2 antibody was not detected.

On day 2 after discharge, he sustained a flame burn at home while cooking and was admitted to a primary care center. Because the patient had the incident at home, which is far from our transplant center, he contacted our transplant center for further care and the need for transfer. We had a teleconsultation follow-up, as per our protocol for recovered COVID-19 transplant patients. During telephone consultation with the primary health care physician, it was revealed that the patient had a 26% total body surface area burn, which included mixed-depth burns to his right arm and hand, the upper half of chest, upper abdomen, thighs, and right leg. His face, eyes, and genitals were spared in the injury.

Immunosuppression was modified in the form of stopping antimetabolite and continuing calcineurin inhibitors, but at half the dose. On day 1 of hospitalization for the burn injury, the patient had a positive RT-PCR COVID-19 test and hence was isolated. Debridement and allografting were done on day 3 and on day 10. On day 3, the patient had a negative RT-PCR COVID-19 test.

The patient showed increasing creatinine levels, which reached 10 mg/dL with persistent hyperkalemia and breathlessness. By telephone, we advised the patient to receive a hemodialysis session through a temporary internal jugular vein catheter. His creatinine level started to decrease, and the patient showed improvement. On day 15, a skin biopsy was done (Table 3) that showed burn graft rejection. The patient underwent regrafting of his burn wound, which resulted in a gradually improving wound. The patient did not develop any local wound infection or sepsis during the stay.

On day 30 of follow-up, the patient had a serum creatinine level of 4 mg/dL. On day 45 of follow-up, his creatinine reached a nadir of 3.2mg/dL. No renal graft biopsy was performed, as immunosuppression was decreased for a fair amount of time in the process, and his baseline creatinine was 2.1 mg/dL. The patient was asked to continue regular follow-up in person and by telephone.

DISCUSSION
The World Health Organization reports that there are around 180 000 deaths due to burns every year worldwide.2 These numbers are disproportionally higher for low- and middle-income countries like India. Even today, the reported disability-adjusted life years associated with burns are problematic. Since December 2019, when the SARS-CoV-2 pandemic began, all aspects of the health community around the world have been affected. The global impact of COVID-19 on transplant activities has been extensively researched.1 The impact of COVID-19 on kidney transplant recipients in India has also been reported.3,4 Undoubtedly, new challenges have been shown in managing immunosuppression in the COVID-19 era. Theoretically, immunosuppression treatment can delay recovery of burn and other wounds and can complicate the management protocol for COVID-19. In a US cohort of 57 948 patients, 103 of whom were organ transplant recipients, Zhang and colleagues reported an increased incidence of wound infections.5 Hence, extra caution should be practiced in management of burns in such patients. In our patient, however, there were no infections.

So far, there have been no reports of COVID-19 complicated by burn injury in organ transplant recipients. However, in a case series of concomitant burn and COVID-19 from the United States, 3 of the 4 patients required mechanical ventilation, with comorbid conditions resulting in poorer outcomes afterCOVID-19 infection.6 A multicenter study from Tokyo also showed more inhalation and steam injuries due to burns during the pandemic.7 In a major US burn center in Atlanta, Georgia,8 the time to presentation for burn patients with COVID-19 was significantly higher, pointing toward a lesser reach or delay in treatment during the pandemic. In the United Kingdom, burns through steam inhalation in pediatric patients were increased during the COVID-19 peaks.9 A Spanish report highlighted the overall impact of COVID-19 in burn admissions and surgeries, with more adverse effects on pediatric patients.10 However, an Indian study found no major differences in burn patterns and mortality in comparisons before and during the COVID-19 pandemic. In the report, of 18 COVID-19 patients with concomitant burns, there were 2 mortalities.11

A flexible and intelligent approach to management of burn injuries during the pandemic is required, which is so far lacking in the literature. In the initial phases of the pandemic, to curtail the incidence of burns as an occupational hazard among health care workers serving COVID-19 patients, an effective multidimensional tool was developed in China.12 In a report from the United Kingdom, a multidisciplinary approach for burns of <15% total body surface area was applied during the pandemic. The report also stated that telemedicine was an effective tool in minimizing hospital visits and in improving quality of treatment.13 Given travel restrictions and a desperate need to prevent the spread of COVID-19, telemedicine has already emerged as a novel and efficacious tool.14 Telemedicine can help to prioritize patients during COVID-19 surges and may result in fewer priority admissions. Telemedicine has already been utilized on a large scale to manage organ transplant patients during the COVID-19 pandemic.15

To the best of our knowledge, this is the first case report of burn management in a COVID-19-positive organ transplant recipient. The patient was RT-PCR positive at the time of admission to the burn unit, which further complicated his treatment course. Only on day 3, when he had a second negative test, he was shifted to the non-COVID-19 ward. The patient required hemodialysis on day 10 of admission for persistent hyperkalemia. His immunosuppression was further tailored to accelerate wound healing. Throughout the stay, his oxygenation status did not deteriorate. His burn wound was complicated with rejection, which required regrafting, but there were no wound infections during the entire period. On day 30 postinjury, during a follow-up visit to our center, his creatinine level was 4 mg/dL. We decided to restore all immunosuppression, as wound healing was already complete. His serum creatinine reached a nadir of 3.2 mg/dL on day 45 of injury follow-up.

This case highlights the significance of a multidisciplinary action to prevent further deterioration and to improve outcomes of concomitant burn and COVID-19. A dedicated team of primary care physicians, nursing staff, plastic surgeons, nephrologists and transplant physicians, and infectious disease specialists were among those who managed this complicated case.

CONCLUSIONS

We have reported the impact of COVID-19 in real-world practice in the management of burns in a high-risk population, such as the kidney transplant recipient presented here. A meticulous follow-up of renal functions and the modification of immunosuppression are keys to the successful care of burns in an organ transplant recipient. Further reports are needed to delineate the optimal management protocol for such patients

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Volume : 1
Issue : 3
Pages : 107 - 110


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From the Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Centre, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Vivek B. Kute, Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Centre, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
Phone: +91 9099927543
E-mail: drvivekkute@rediffmail.com