Introduction: COVID19 has a devastating effect among renal transplant recipients. This study aimed to look at the clinical profile and outcomes of COVID 19 among renal transplant recipients across the three waves of SARS COV2 infection in South India.

Methods: In this multicentre study conducted across three tertiary care hospitals in South India, we prospectively analysed all renal allograft recipients with microbiologically confirmed SARS CoV2 infection between June 2020 and February 2022. Transplant details, clinical features of severity, outcomes of COVID19 infection and risk factors associated with mortality were studied. The study was cleared by the Institutional Review Board of respective institutions and the guidelines of the Declaration of Helsinki were followed.

Results: We recruited 67 patients in this study with mean age of 44±11.5 years. Males were 67.2% of the cohort, 79.1% of patients were living donor transplant recipients, average transplant vintage was 6.6±5.5years with a mean baseline creatinine of 1.47±0.81mg%. 37.3% of patients were diabetics. 56.7% of patients presented in the first wave,22.4% in the second and 20.9% in the third wave. As per WHO clinical severity, 56.7% of patients had mild or asymptomatic infection, 17.9% had moderate infection and 25.4% had severe infection. The overall mortality was 17.9%. 35.8% of patients developed an AKI and 13.5% of patients required RRT. Severe infection was seen in 15.8% of infections in the first wave, 73.3% in second wave and none in the third wave (p<0.001). Similarly, mortality was 15.8% in the first wave of infection, 40% in the second wave and none in the third wave. (p-0.008). Development of AKI and RRT requirement was higher in the second wave as compared to the first and third wave. (AKI in the first/second/third wave- 36.8%/60%/7.1%, p-0.007, RRT – 10.5%/33.3%/nil, p- 0.017). In univariate analysis factors associated with mortality were severe disease at presentation (HR 89.83, 95%CI 9.8-823.5, p<0.001), AKI (HR14.65, 95%CI 2.85-75.10, p-0.001), the second wave of infection (HR 5.11, 95%CI 1.34- 19.5,p-0.017) and elevated D-Dimer (HR 1.01, 95%CI 1.00-1.02, p-0.46).

Conclusion: Renal transplant patients have higher mortality due to COVID 19 as compared to general population. Patients in the second wave of infection (presumably caused by Delta variant) had more severe disease, greater risk of AKI and higher mortality as compared to the first (Alpha variant) and third wave (Omicron variant) of SARS CoV2 infection.