Hospital-at-home as a first-line strategy for kidney transplant recipients with coronavirus disease 2019 infection.

Kidney transplant recipients (KTRs) respond suboptimally to severe acute respiratory syndrome coronavirus 2 vaccination and are more susceptible to severe coronavirus disease 2019 (COVID-19) infection.1Caillard S. Chavarot N. Bertrand D. et al.Occurrence of severe COVID-19 in vaccinated transplant patients.Kidney Int. 2021; 100: 477-479https://doi.org/10.1016/j.kint.2021.05.011Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Early administration of therapeutics has been demonstrated to reduce disease progression.2Hilhorst M., Bemelman F.J., Bruchfeld A., et al. Prophylactic and early outpatient treatment of COVID-19 in patients with kidney disease: considerations from the Immunonephrology Working Group of the European Renal Association (ERA-IWG). Nephrol Dial Transplant. Published online 2023. https://doi.org/10.1093/ndt/gfad044.Google Scholar,3Avery R.K. Update on COVID-19 therapeutics for solid organ transplant recipients, including the omicron surge.Transplantation. 2022; 106: 1528-1537https://doi.org/10.1097/TP.0000000000004200Crossref PubMed Scopus (11) Google Scholar Here, we describe our experience in partnering with our institution’s hospital-at-home program4Ko S.Q. Kumar S.K. Jacob J. et al.Technology-enabled virtual ward for COVID management of the elderly and immunocompromised in Singapore: a descriptive cohort.BMC Infect Dis. 2023; 23: 102https://doi.org/10.21203/rs.3.rs-1848108/v1Crossref PubMed Google Scholar to ensure early access to therapeutics across the waves of the pandemic. Newly diagnosed KTRs were assessed for their suitability for the hospital-at-home program. Inclusion criteria were as follows: (1) stable vital signs and an oxygen saturation level of >95%, (2) ability to self-isolate and self-report parameters via a chatbox, and (3) reliably contactable by telephone. Equipment (blood pressure monitors/oximeters) was provided if patients did not own them. After admission to the hospital-at-home program, antimetabolite doses were reduced and mammalian target of rapamycin inhibitors switched to calcineurin inhibitors. Management included regular video consultations by both hospital-at-home and kidney transplant teams, thrice daily remote vitals monitoring, baseline and interval blood tests (including immunosuppression levels), and COVID-19 polymerase chain reaction tests. Patients had round-the-clock direct physician access via an emergency hotline and were transferred to the nearest tertiary hospital when indicated. Therapeutics were administered in accordance with the prevailing National Institutes of Health guidelines adapted to local context. Drugs were prepared in our hospital central pharmacy and transported to the patient’s home for administration by a visiting nurse. Patients who received COVID-19 therapeutics (intravenously/intramuscularly) were monitored at 15-minute intervals for 60 minutes postadministration. Patients were discharged once clinically well and had a cycle threshold (CT) ratio of >25 or when they reached day 21 of illness. From September 28, 2021, to July 20, 2022, 177 KTRs with COVID-19 were managed at home, across 2486 bed days. Of them, 119 (67.2%) KTRs were directly onboarded to the hospital-at-home program; the rest were hospitalized first before transferring to their homes. The mean age of KTRs was 52.6 years, and 49.2% of them were men (Fig. 1). Forty (22.6%) KTRs received sotrovimab only, 1 (0.6%) received both sotrovimab and remdesivir, 21 (11.9%) received tixagevimab-cilgavimab, and 72 (40.7%) received remdesivir only. Of the 134 KTRs who received therapeutics, 87 (65.0%) had them administered at home, with 9 (10.3%) reporting infusion-related, self-limiting adverse events (fever, diarrhea, and rashes). The mean interval between symptom onset and administration of therapeutics at home vs in hospital was similar (2.6 vs 2.2 days, P =.33). Twenty-three (13%) KTRs were transferred back to the hospital—9 (5.1%) for severe pneumonia with hypoxia, of which 5 (2.8%) required intensive care unit (ICU) admission, and 14 (7.9%) for other medical conditions (electrolyte abnormalities and incidental conditions). There were no mortalities; the combined incidence of oxygenation or ICU requirement was low at 5.1%, comparable with the non-KTR cohorts (4.2%-5.3%).5Maghrabi F. Bazaz R. Wilson E. et al.The development and implementation of a virtual discharge ward for patients with COVID-19 pneumonia: data on the first 300 patients.Thorax. 2021; 76: A35-A36https://doi.org/10.1136/thorax-2020-BTSabstracts.62Crossref Google Scholar On multivariable analysis, significant predictors of oxygen requirement included late presentation (odds ratio, 1.34; 95% confidence interval, 1.08-1.68) and an international severe acute respiratory and emerging infections consortium (ISARIC)-4C score of >9 (P =.000019). Obesity was associated with ICU stay (odds ratio, 7.00; 95% confidence interval, 1.04-46.9) . Our experience demonstrates that hospital-at-home program can be a first-line strategy for managing stable KTRs with COVID-19. It permits safe and prompt administration of therapeutics and titration of complex immunosuppressants. Risk stratification can identify patients (eg, obesity, later presentation, and an ISARIC-4C score of >9) for closer monitoring and early referral for hospitalization. Key enablers are patient education for early detection, early notification by KTRs of symptoms or a positive test, permitting early treatment initiation, and clear protocols for monitoring and care escalation. We have no sources of funding to declare.