*Purpose: The COVID pandemic has posed a significant challenge among kidney transplant recipients (KTR) due to their immunocompromised states. The effects of COVID vaccination on KTRs are uncertain. We sought to better understand the clinical course, management, and outcomes of KTRs who developed COVID infection during the pre-and post-COVID vaccine rollout periods. We also compared whether there was a difference in patient outcomes or management of COVID infection between the two groups.

*Methods: This was a single-center study of KTRs who were infected with COVID. Baseline demographics, clinical parameters, COVID vaccination status, management, and outcomes were obtained by manual chart abstraction of the electronic medical records.

*Results: We studied a total of 134 KTRs in the pre-vaccination era and 83 KTRs after vaccination rollout who had COVID infections. The mean age of the patients was 54 years in both groups, and there was a greater proportion of African American KTRs in the pre-vaccination rollout era (70% vs. 53%, P=.02). No statistically significant differences were found among sex, BMI, or induction agents. In the pre-vaccination era, KTRs were more likely to present with fever (71% vs. 51%, P<.001). No statistically significant differences were observed in the onset of COVID infection after transplant, ICU admission, the requirement of mechanical ventilation therapy, incidence of AKI (acute kidney injury), requirement of renal replacement therapy (RRT), or incidence of acute rejection. For COVID infection management, KTRs in the post-vaccination rollout era were more likely to be treated with dexamethasone (47% vs. 32%, P=.035) . No statistically significant difference was found in the proportion of patients who required reduction or discontinuation of immunosuppressive agents. In the pre-vaccination era, KTRs were more likely to recover from acute kidney injury (57% vs, 25%, P=.01). No statistically significant difference was found in mortality between groups, but the risk of death was almost twice a high in the post-vaccination rollout era (21% vs. 12%).

*Conclusions: In this single-center case-control study, COVID vaccination rollout did not seem to have an appreciable impact on the incidence of hospitalization, ICU admission, AKI, RRT requirement, or mortality. Mortality risk among KTRs in the post-vaccination rollout era was almost twice as high as it was in the pre-vaccination rollout era, although there was no statistically significant difference, which might be due to low statistical power. The lack of improved outcomes of KTRs in the post-vaccination rollout remains unclear. A combination of suboptimal immunogenic response to vaccination and the Delta variant surge could be a possibility.

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