*Purpose: COVID pandemic has posed a significant challenge among kidney transplant recipients (KTR) due to their immunocompromised state. There is uncertainty on immunosuppression (IS) management among those who have COVID infection. We sought to better understand the clinical course, management, and outcomes of our KTR who developed COVID infection during the period when COVID vaccine was more readily available. We also investigated the impact of vaccination status on COVID infection.

*Methods: Single-center experience of COVID infected KTR. Baseline demographics, clinical data, COVID vaccination status, management, and outcomes were obtained by manual chart abstraction of the EMR.

*Results: 83 KTR had COVID infection. Mean age was 54 years; 57% were males and 53% were African American. 47% of the patients were >3 years post-transplant. Interestingly, the proportion of COVID-infected patients who were unvaccinated and vaccinated with 2 doses were similar (42% vs 39%; p=NS) and the proportion of asymptomatic patients who were unvaccinated and vaccinated were also similar (47% vs. 53%; p=NS). Respiratory symptom was the most common manifestation (69%); 49 patients (59%) required hospitalization. Mean length of stay was 15 days; 19 (23%) required ICU admission and 14 (17%) required mechanical ventilation; 26 developed AKI with about half requiring RRT; only 2 (18%) patients requiring RRT had renal recovery. The majority of admitted patients received dexamethasone and antibiotics. For IS management, 53% had MMF held or reduced while only 11% had CNI dose reduced; 17 patients (20%) died. In multivariable modeling, only age (OR 1.1, 1.02-1.19; p=0.020) and AA race (OR 5.4, 0.73-40.2; p=0.097) were associated with risk of death. Induction, sex, BMI, and vaccination status were not significant predictors. There were no subsequent acute rejections or graft losses in those who recovered.

*Conclusions: KTR represent a vulnerable patient population for COVID infection. Due to their immunocompromised state and often more severe clinical presentation, with majority requiring hospitalization, ICU admission, and mechanical ventilation. In this single center study, COVID vaccination did not seem to have an appreciable impact on the incidence of COVID infection and presentation. It is unclear what impact immunosuppression dose reductions had on the COVID clinical course, but these reductions did not appear to increase risk of rejection or graft loss.

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