Publication date: Jul 01, 2026
The efficacy and safety of remdesivir for COVID-19 in kidney transplant (KT) recipients across evolving pandemic eras remain unclear. To compare clinical outcomes among adult KT recipients with symptomatic COVID-19 who received early remdesivir vs those who did not receive remdesivir. This retrospective cohort study emulated a target trial using observational data from 5 hospitals within the Johns Hopkins Health System. Adult KT recipients (aged ≥18 years) with a functioning allograft and symptomatic COVID-19 from March 2020 through January 2024 were eligible. Patients who received anti-SARS-CoV-2 monoclonal antibodies, nirmatrelvir-ritonavir, and/or molnupiravir were excluded. Follow-up continued for up to 1 year after COVID-19 diagnosis. Individuals who initiated remdesivir within 7 days of diagnosis and received at least 3 consecutive days of therapy were assigned to the early remdesivir strategy, whereas those who did not receive remdesivir were assigned to the no remdesivir strategy. The primary outcome was all-cause graft loss (ACGL), a composite of graft failure and all-cause mortality. Secondary outcomes included all-cause mortality, cardiovascular events (CVEs), and long COVID. Per-protocol associations were estimated using a clone-censor-weight (CCW) approach with weighted Cox proportional hazards marginal structural regression models and robust SEs to calculate hazard ratios (HRs) and 95% CIs. Among 432 KT recipients with symptomatic COVID-19 (median age, 57 years [IQR, 46-66 years]; 248 [57. 4%] were male), 177 (41. 0%) initiated early remdesivir and 255 (59. 0%) received no remdesivir. Over 1 year of follow-up, early remdesivir initiation vs no remdesivir was associated with a lower risk of ACGL (HR, 0. 53; 95% CI, 0. 31-0. 92) and CVEs (HR, 0. 58; 95% CI, 0. 35-0. 98) after CCW adjustment. There was no significant association between early initiation of remdesivir and lower risk of all-cause mortality (HR, 0. 51; 95% CI, 0. 24-1. 06) or long COVID (HR, 0. 65; 95% CI, 0. 21-2. 05) in the weighted analysis. In this target trial emulation, KT recipients with symptomatic acute COVID-19 who underwent early remdesivir treatment had reduced risk of ACGL and CVEs. These findings suggest that prompt initiation of remdesivir during COVID-19 illness may protect kidney allograft survival and cardiovascular health in this population.
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Semantics
| Type | Source | Name |
|---|---|---|
| disease | MESH | COVID-19 |
| drug | DRUGBANK | Ritonavir |
| disease | MESH | included |
| disease | MESH | long COVID |
| disease | MESH | HRs |
| disease | MESH | Infectious Diseases |
| drug | DRUGBANK | Methylphenidate |
| drug | DRUGBANK | Tacrolimus |
| drug | DRUGBANK | Sirolimus |
| disease | MESH | death |
| drug | DRUGBANK | Oxygen |
| disease | MESH | acute kidney injury |
| disease | MESH | hypertension |
| drug | DRUGBANK | Isoxaflutole |
| disease | MESH | SMDs |
| disease | MESH | infections |
| drug | DRUGBANK | Adenosine phosphate |
| drug | DRUGBANK | L-Alanine |