Journal Club

Back to the Future: COVID-19 Convalescent Plasma in Immunocompromised Patients

By Erica Kaufman West, MD

Solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients have impaired immune systems and also take immunosuppressives further putting them at higher risk for severe disease and death from COVID-19. Remdesivir, dexamethasone and monoclonal antibody (mAb) research has not included many patients with immunocompromising conditions. While new variants have rendered all known mAb therapies useless, pre-Omicron/post-vaccine COVID-19 convalescent plasma (CCP) has retained in vitro neutralization activity against Omicron variants of SARS-CoV-2. 

An observational, retrospective cohort study published in Transplant Infectious Disease looked at 44 adult immunocompromised patients (26 SOT, 10 HCT, 5 hematologic malignancies without HCT, 3 autoimmune disease) who had symptomatic COVID-19 in early 2022 and received high-titer CCP. Donors had prior COVID-19 within 6 months of donating, and all but one donor had received 1 or 2 doses of mRNA COVID-19 vaccine. Forty-one of 44 patients also received remdesivir, and 20 received dexamethasone in addition to CCP.  

The 30-day all-cause mortality was 4.5%, with the 2 patients who died being HCT patients. The 100-day all-cause mortality was 15.9% (3 SOT patients, 4 HCT patients). In looking at the patients with high immunosuppression versus lower immunosuppression, those with higher immunosuppression had longer hospital stays and higher WHO scores, but there was no difference in 30- or 100-day mortality rates. Interestingly, length of symptoms prior to CCP administration did not change mortality or time to discharge.  

One benefit of CCP is that it retains neutralizing capabilities where mAbs fail. CCP is polyclonal and binds a wider range of epitopes that may retain activity against new variants, which would neutralize virus and limit shedding in immunocompromised patients. Post-vaccine CCP in particular has been shown to be effective against variants that emerged after the plasma was donated. Unlike some of our treatments, CCP has the added benefit of being available on the global scale, anywhere plasma can be collected.
(Tayyar et al. Transpl Infect Dis. 2023;25(2):e14055.)