*Purpose: Actual and comorbidity-adjusted mortality in hospitalized patients with COVID-19 has declined in the general population during the course of the pandemic. Whether a similar reduction has occurred in solid organ transplant recipients (SOTR) is unknown.

*Methods: We used a multicenter prospective registry of SOTR with laboratory-confirmed COVID-19 to compare 28-day mortality between the early COVID-19 pandemic (3/1/20- 6/19/20) and a late (more recent) period (6/20/20-11/20/20) for those with 28 day follow-up by 11/12/20. A multivariable logistic regression model including previously identified risk factors for mortality (age >65 years, obesity, diabetes mellitus (DM), congestive heart failure (CHF), chronic lung disease, absolute lymphocyte count <0.5 x 10⁹/L, and abnormal chest imaging) was used to adjust for covariates.

*Results: Of 938 SOTR with COVID-19, 638 (68%) were hospitalized; 165 (26%) hospitalized cases occurred in the late (more recent) period and 472 (74%) cases occurred in the early period . The proportion hospitalized was similar in both periods [late: 165/244 (67.6%) vs. early: 472/692 (68.2%])]. The prevalence of several baseline comorbidities was lower in the late cohort: DM [74/165 (44.8%) vs. 251/472 (54.9%), p=0.01), chronic lung disease [5/165 (3.0%) vs. 47/472 (10.0%)], p=0.01), and CHF [5/165 (3.0%) vs. 37/472 (7.8%), p= 0.03). Presenting features were similar between periods (Figure 1), and treatment with remdesivir, convalescent plasma, and corticosteroids was more frequent in the late period (Figure 2). Crude 28-day mortality was lower in the late period (12.7% vs 20.8%, p=0.02), but mortality did not differ significantly from the early period after adjusting for comorbidities (crude OR 0.56 (95% CI 0.33-0.93) vs. adjusted OR 0.62, (95% CI 0.34-1.10), p=0.11.

*Conclusions: There have been shifts in the demographics of SOTR hospitalized for COVID-19 during the course of the pandemic. Although crude mortality was lower in the more recent period, the comorbidity-adjusted mortality has remained constant. Advancements in management strategies shown to reduce mortality in the general population might not be applicable to SOTR.

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