# Management of concurrent severe COVID-19 pneumonia and antibody-mediated rejection following kidney transplantation: a case report

## TL;DR

This case report describes the successful management of a kidney transplant patient who developed severe COVID-19 pneumonia and antibody-mediated rejection at the same time.

## Contribution

The paper presents a novel case of concurrent severe SARS-CoV-2 infection and acute antibody-mediated rejection in a kidney transplant recipient and their treatment.

## Key findings

- Plasma exchange combined with IVIG and rituximab effectively reversed antibody-mediated rejection without worsening SARS-CoV-2 infection.
- Plasma exchange did not significantly reduce SARS-CoV-2 IgG antibody levels.
- Timely antiviral and anti-rejection therapies led to a favorable outcome in this complex case.

## Abstract

Due to its high mutation rate, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has recurrently emerged worldwide in recent years, leading to an increased incidence of rejection following kidney transplantation and a worsened prognosis for recipients. The management of the concomitant occurrence of SARS-CoV-2 infection and rejection in kidney transplant recipients poses significant challenges, with limited available experience on this topic. This study presents a case report highlighting the simultaneous manifestation of severe corona virus disease 2019 (COVID-19) pneumonia and acute antibody-mediated rejection (ABMR) during the early post-transplantation period.

The recipient underwent the renal transplantation from a deceased donor after brain death and received comprehensive management including antiviral therapy, adjustment of immunosuppressive medications, and relevant supportive care during the course of SARS-CoV-2 infection. In the overlapping period of severe COVID-19 pneumonia and ABMR, we implemented plasma exchange (PE) combined with intravenous immunoglobulin (IVIG) and rituximab treatment, while closely monitoring infection-related indicators and elucidate the impact of PE on SARS-CoV-2 antibodies.

The administration of PE did not significantly impact the level of SARS-CoV-2 IgG antibody. Meanwhile, the combination of PE, IVIG, and rituximab treatment effectively reversed ABMR without exacerbating SARS-CoV-2 infection.

The timely administration of antiviral and anti-rejection therapies in the early stage of renal transplant recipient can lead to favorable outcome in case of SARS-CoV-2 infection and concurrent ABMR.