People who have had a transplant are at higher risk for poor outcomes with COVID-19 than the general public. Yet, some transplant recipients have concerns about COVID-19 vaccination safety. There are also concerns about whether the SARS-CoV-2 virus (that causes COVID-19) or the COVID-19 vaccines might interfere with required daily medications for transplant patients.
Learn why transplant recipients are at higher risk for severe COVID-19, the importance of vaccination, and how to stay safe.
Transplant and COVID-19 Risk
The Centers for Disease Control and Prevention (CDC) continually updates its list of associated medical conditions that put people at risk for severe COVID-19 and:
- Being hospitalized
- Needing intensive care
- Needing a ventilator to breathe
Age is still the greatest risk factor for poor COVID-19 outcomes. Furthermore, the risk of developing severe COVID-19 increases as the number of underlying medical conditions increases. Some of these conditions include:
- Coexisting medical conditions, like chronic kidney or liver disease
- The transplant itself
- The need for medications that suppress the immune system
People with a transplant must take medicines that suppress the immune system to prevent donor organ rejection. When a person receives a transplant, the new organ or tissue is considered foreign to the body, and the immune system attacks what it believes is a foreign invader.
The use of immunosuppressant medicines influences this process so that transplant recipients can live longer, healthier lives. However, immunosuppression also puts a person at risk for other infections and severe COVID-19.
High Risks for Transplant Patients
Transplant patients are at higher risk compared to the general population for contracting SARS-CoV-2 given their frequent contact with the healthcare system. COVID-19 symptoms are the same in transplant and non-transplant patients.
Complications of Transplants and COVID-19
The most concerning complication of COVID-19 in anyone is critical illness or death. Critical illness is defined as respiratory failure and/or multiple organ failure.
A national survey conducted in March 2020 of U.S. transplant centers reported the severity of COVID-19 in 148 SOT recipients. COVID-19 was:
- Mild in 54% of recipients
- Moderate in 21% of recipients
- Critical in 25% of recipients
Among transplant recipients hospitalized with COVID-19, the mortality rates have been as high as 28%. This is much higher than the 1%–2% mortality rate in the general population.
Wide Variability of Mortality Rates
The mortality rate in SOT and HSCT patients varies widely across the globe. Researchers continue their evaluations to determine the most accurate risk of death from COVID-19 for people who have had a transplant.
An evaluation of 318 HSCT recipients found a mortality rate of approximately 32%–33% within a month of a COVID-19 diagnosis. This mortality rate was the same whether the transplant was allogeneic, meaning from another person, or autologous, meaning from the recipient themselves.
One study found the mortality rate among heart transplant recipients who contracted COVID-19 to be approximately 25%.
Some Transplant Patients Have Less Risk Than Others
Liver transplant patients may not do as poorly as other transplant patients. It can be challenging to tease out the difference in the likelihood of complications and death among specific transplant patients, for instance, liver vs. kidney vs. lung transplant recipients. However, taken as a whole, transplant patients are at higher risk for adverse outcomes.
Other complications of COVID-19 in transplant recipients include acute kidney injury, damaged organs, and long COVID (ongoing or returning health problems due to the illness).
Acute Kidney Injury
Aside from overall respiratory and organ failure, one of the more frequent complications in hospitalized patients with COVID-19 is acute kidney injury.
This complication can be particularly concerning for kidney transplant recipients. However, it can occur in other types of transplant patients, as well. In one study, approximately 32% of liver transplant recipients required dialysis due to acute kidney injury during hospital admission for COVID-19.
Acute kidney injury can be temporary. Still, one report indicates that 11% of kidney transplant patients suffered graft loss (the loss of the transplanted kidney).
Damage to Transplanted Organs
Other complications in SOT patients are related to injury to the transplanted organ itself.
Researchers found that approximately 76% of heart transplant patients suffered heart injury during the infection.
In a single center in New York City, lung transplant patients were more likely to require intensive care. If they needed mechanical ventilation to help them breathe, they had almost 100% mortality.
Finally, people with a transplant might be more likely to develop long COVID.
Although research is still underway to further understand this chronic disease, some experts think that people with multiple underlying medical problems and those who were hospitalized for COVID-19 might be at a higher risk for developing long COVID.
Researchers are still discovering which groups are at the highest risk for chronic symptoms from COVID-19. One recent study suggests four factors that increase a person’s risk for developing long COVID. These include:
- Underlying type 2 diabetes
- A high SARS-CoV-2 RNA viral load (how much virus is in the body) at the start of the illness
- A reactivation of another virus commonly contracted during childhood called Epstein-Barr virus (which causes infectious mononucleosis, or mono)
- The development of autoantibodies in which a person’s immune system mistakenly attacks body tissues
However, researchers are still discovering what factors put people most at risk for long COVID. The CDC indicates that even people who did not have significant COVID-19 symptoms can develop post-COVID conditions.
Moreover, the initial thought was that people hospitalized with COVID-19 were more likely to develop long COVID. However, it is unclear whether the long-term symptoms are related to the disease itself or to the effects of being hospitalized for an extended period.
Transplant Treatments and COVID-19
Transplant recipients typically continue on treatments that suppress the immune system. These treatments are necessary so that a person’s immune system does not attack the transplanted tissue.
While these treatments effectively prolong life for people who have had transplants, they leave them at risk for developing other infections or severe COVID-19. Therefore, transplant recipients need to pay particular attention to preventing illness through handwashing, social distancing, mask wearing, and vaccination.
Adjusting Immunosuppressive Medication Doses
Should a person who has had a transplant develop COVID-19, they need to discuss further care with their transplant specialist before adjusting immunosuppressive medication. Adjusting the medicines on their own can cause significant problems with the transplant.
Moreover, at this time, it is not completely clear to experts whether patients should continue, reduce, or stop their immunosuppressive therapies. While it makes sense that continuing the treatment hinders a person’s ability to fight COVID-19, there is also some evidence that specific immunosuppressive agents help to prevent severe COVID-19.
Healthcare providers also need to pay special attention to potential drug-drug interactions between specific COVID-19 and immunosuppressive treatments. Medications such as the disease-modifying antirheumatic drug (DMARD) Cellcept (mycophenolate), Protopic (tacrolimus), or cyclosporine can be toxic if the levels in the body are too high.
When new medicines, such as those used to treat COVID-19, are given to people taking immunosuppressants, an interaction between the two can change the blood levels of all drugs. A slowed drug metabolism means the immunosuppressive medications could build up and become toxic since they are not metabolized as quickly.
Alternatively, if the metabolism speeds up, the blood levels of immunosuppressive medications will drop. Then the drugs will not work the way they usually do, putting a person with a transplant at risk for organ rejection.
Drugs used to treat COVID-19 that can alter overall drug metabolism include:
Healthcare providers need to closely monitor blood levels of immunosuppressive therapy when patients are being treated for COVID-19.
Toxicity of COVID-19 Treatments for Transplant Recipients
Moreover, certain COVID-19 treatments can interfere with specific transplant recipients and injure the transplant itself.
For example, Veklury (remdesivir), Actemra (tocilizumab), and Olumiant (baricitinib) are associated with elevated levels of liver enzymes, which can be of particular concern for liver transplant patients.
Finally, some of the COVID-19 treatments are immunosuppressants themselves, such as dexamethasone, Actemra (tocilizumab), and Olumiant (baricitinib). If these agents are used to treat a transplant recipient who has COVID-19, then the patient will be at risk for other infections.
COVID-19 mRNA Vaccines
The currently authorized COVID-19 messenger RNA (mRNA) vaccines are not live vaccines. Therefore, they can be safely administered to people who are immunocompromised. Reducing the dose or holding immunosuppressive therapies before vaccination is not recommended.
How to Stay Safe
In addition to getting vaccinated, the best ways for transplant recipients to stay safe include:
- Washing hands
- Wearing a mask
- Social distancing
- Avoiding large crowds
This guidance also applies to people with a transplant who are already fully vaccinated, since they are unlikely to develop a robust antibody response from vaccination. The vaccination schedule for immunocompromised people includes an extra dose as part of the primary series, and that vaccine timing differs from that of healthy people.
It also is essential for household members and close contacts of transplant recipients to protect themselves from infection by getting vaccinated as soon as possible.
Prolonged Viral Shedding Suspected in Transplant Recipients
There have been reports of prolonged viral shedding (longer duration of the virus) in people with SOT and HSCT, which has implications for preventing the spread of infection.
Researchers have determined that transplant recipients are much more likely to have complications and die from COVID-19 than the general public. They are at higher risk for contracting the virus, too, primarily because of their frequent contact with the healthcare system, their coexisting medical conditions, and their need to take medication to suppress the immune system.
Some complications include acute kidney injury, long COVID, and organ damage. The virus itself is not the only concern since interactions between COVID-19 treatments and required immunosuppressive therapies after a transplant can also damage transplanted organs.
Experts and transplant specialists need to be heavily involved in the care of transplant patients. Vaccination is crucial, particularly with extra booster doses required for transplant patients, since people with a transplant do not develop strong antibody responses with immunization.
A Word From Verywell
Being a transplant recipient is already extremely stressful outside of the COVID-19 pandemic. Treatment regimens are intense, and healthcare provider visits are frequent. Adding another layer of complexity and concern about COVID-19 can be overwhelming.
The most important thing you can do is complete the COVID-19 vaccination series. You must stay in touch with your transplant specialist, especially if you contract COVID-19. Keep your hands clean, wear a mask, and stay away from large crowds indoors.
The information in this article is current as of the date listed. As new research becomes available, we will update this article. For the latest on COVID-19, visit our coronavirus news page
Frequently Asked Questions
If I am a transplant patient and contract COVID-19, what treatments are available to prevent severe illness?
Treating COVID-19 in transplant patients can be challenging due to the transplant itself, coexisting medical conditions, and the need for chronic immunosuppressive therapy. Currently, protocols for managing COVID-19 in transplant patients are the same as for non-transplant patients. However, since transplant patients are at high risk of developing severe illness with COVID-19, they can receive anti-SARS-CoV-2 monoclonal antibodies as treatment or postexposure prophylaxis (medicine to prevent the illness after exposure).
Additionally, people with a transplant can take Veklury (remdesivir), the only antiviral agent approved by the Food and Drug Administration (FDA) to treat COVID-19. There are also other FDA-authorized (though not approved) medications available.
Should I get a COVID-19 vaccine if I have an organ, blood, or bone marrow transplant?
Given the increased risks of worse COVID-19 clinical outcomes in people with a transplant, vaccination is recommended for all transplant recipients. The clinical trials that evaluated the safety and efficacy of the COVID-19 vaccines did not include immunocompromised patients like people with a transplant. However, healthcare providers still recommend COVID-19 vaccination because of its effectiveness in the general population.
How effective are the mRNA vaccines in transplant recipients?
The CDC recommends the mRNA vaccines Moderna or Pfizer-BioNTech because of their effectiveness and lack of concerning side effects. Unfortunately, people with a transplant and those who take immunosuppressive therapy are unlikely to develop a strong antibody response after vaccination. According to one study, only 17% of transplant recipients developed a detectable antibody response after one dose of the vaccine, and 54% of transplant recipients developed a detectable response after two doses of vaccine. Therefore, it’s recommended that transplant recipients, especially those taking immunosuppressive therapy, should receive a third vaccine dose. They should also receive a booster dose at least three months after the primary series.
After completing a two-shot series, the third dose of mRNA vaccine should be given at least four weeks after the second dose to SOT recipients taking immunosuppressive medications and to HSCT recipients who are within two years of transplantation or are taking immunosuppressive medication. The third dose of vaccine helps boost immunity. A different follow-up study showed that antibody levels were detectable in 68% of transplant patients four weeks after the third dose of vaccine.
Vaccination should be completed at least two weeks before SOT or started one month after the transplant. The COVID-19 vaccines can be offered as early as three months after an HSCT.
What happens if I test positive for COVID-19 right before I am supposed to receive my transplant?
If the virus is detected or strongly suspected in a potential transplant candidate, the transplant should be deferred, if possible. A healthcare provider needs to balance the risks of COVID-19 progression vs. mortality if the candidate does not receive the transplant. The amount of time that must pass after SARS-CoV-2 infection before transplantation is unknown.
SOT donors who test positive for SARS-CoV-2 should defer their donation.