Introduction: The risk for morbidity and mortality from coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is high in transplant recipients due to the continued immunosuppression regimen for allograft maintenance. While SARS-CoV-2 primarily affects the lungs and causes pulmonary sequelae, evidence suggests that infection by the virus affects other organ systems as well. Simultaneous pancreas-kidney (SPK) transplantation is a treatment for patients with insulin-dependent diabetes and end-stage renal failure. Management of COVID-19 is especially challenging in patients who received SPK transplantation due to the complex interaction between the viral pathogenesis, pancreas and kidney allografts, and immunosuppressive therapies. Therefore, examining the clinical management and recovery process of allograft damage in post-SPK transplant patients who contacted COVID-19 could be valuable in establishing optimal treatment guidelines for this vulnerable population.

Methods: We present a series of patients who contacted COVID-19 and developed allograft damage after receiving SPK transplantation at our institution. The following information was retrieved and collated: demographics, baseline health following transplantation, clinical management of COVID-19 infection and allograft damage.

Results: Out of 10 post-SPK transplant patients who tested positive for COVID-19, 5 patients (50%) also developed elevation of amylase and/or lipase levels 3 times the upper limit of normal. The average AlloSure level of these 5 patients was 5.67% at the time of pancreatic damage. One patient contacted COVID-19 after being admitted for acute rejection and inflammation of the pancreas, and recovered after receiving remdisivir, dexamethasone, plasmapheresis, and high dose prednisone with aggressive diuresis. The other patient was diagnosed with pancreatitis and acute kidney injury on admission and had symptomatic improvements after receiving thymoglobulin induction, IVIG, and rituximab. The patient subsequently contacted COVID-19 after discharge and fully recovered after receiving Bamlanivimab infusion, which occurred concurrently with a precipitous decline in amylase and lipase levels. The remaining 3 patients did not meet the criteria for acute pancreatitis, and they recovered after receiving tixagevimab with cilgavimab, remdisivir with dexamethasone, and Bamlanivimab infusion, respectively, along with supportive treatments.

Conclusion: Damage to the allograft via immunological processes and infectious agents is a recurring concern for patients who received SPK transplantation. Notwithstanding the clinical overlap of COVID-19 infection and allograft damage in the reported patients, it is still unclear if COVID-19 infection directly elicits damage. Further research is required to clarify the relationship between these two phenomena and establish an optimal treatment guideline.