Europea Urology - identification of kidney transplant recipient with COVID-19

1. 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 Hospital
Wuhan, 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, 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
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2. infection in KTx recipients can be managed using symptomatic support therapy
combined with adjusted maintenance immunosuppressive therapy.
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3. EUROPEAN UROLOGY Authorship Responsibility, Financial Disclosure, and
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Title Identification of kidney transplant recipients with COVID-19
First Name Zhen-Di
Middle Name
Last Name Wang
Degree Ph.D. (Ph.D., M.D., Jr., etc.)
Primary Phone (86) 27 85351623 (including country code)
Fax Number (86) 27 85776343 (including country code)
E-mail Address wangzhendi@gmail.com
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The authors listed below have made substantial contributions to the intellectual content of
the paper in the various sections described below.
(list appropriate author next to each section – each author must be listed in at least 1 field.
More than 1 author can be listed in each field.)
_ conception and design Zhen-Di Wang
_ acquisition of data Hui Zhang, Yan Chen, Quan Yuan
_ analysis and interpretation of data Qiu-Xiang Xia, Xian-Peng Zeng, Jing-Tao Peng,
Jing Liu, Xing-Yuan Xiao, Guo-Song Jiang, HanYu Xiao, Liang-Bo Xie, Jing Chen, Jia-Li Liu, Xiong
Xiao, Hua Su, Chun Zhang, Xiao-Ping Zhang, Hua Yang, Heng Li
_ drafting of the manuscript Hui Zhang
_ critical revision of the manuscript for
important intellectual content Zhen-Di Wang
_ statistical analysis HanYu Xiao, Liang-Bo Xie, Jing Chen, Jia-Li Liu,
Xiong Xiao, Hua Su, Chun Zhang, Xiao-Ping Zhang, Hua Yang, Heng Li
_ obtaining funding Zhen-Di Wang
_ administrative, technical, or
material support Yan Chen, Quan Yuan
_ supervision Zhen-Di Wang
_ other (specify)
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interests and relationships and affiliations relevant to the subject matter or materials
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and/or work are clearly identified in the manuscript.
The name of the organization or organizations which had a role in sponsoring the data and
material in the study are also listed below:
All funding or other financial support, and material support for this research and/or work, if
any, are clearly identified hereunder:
The specific role of the funding organization or sponsor is as follows:
Design and conduct of the study
Collection of the data
Management of the data
Analysis
Interpretation of the data
Preparation
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6. Acknowledgment Statement
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• all persons who have made substantial contributions to the work reported in this manuscript
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Zhen-Di Wang
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7. 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

8. 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.

9. 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.

10. 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.

11. 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

12. 4
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

13. 5
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

14. 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).

15. 7
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.

16. 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 ofSARS-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

17. 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

18. 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.

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.

20. 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).

21. 13

22. [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

23. 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.

24. [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

25. 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.

26. 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.

27. 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.

28. 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?

29. 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.

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

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

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

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

34. 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

35. 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 + ++ + + － —

36. *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.