Remdesivir Shows Lower Graft Loss Risk in Kidney Recipients With COVID-19

Kidney transplant (KT) recipients face elevated risk of severe COVID-19 because of chronic immunosuppression, and remdesivir trials largely excluded patients with significant kidney impairment or transplants, leaving clinicians without clear causal evidence for this population. A new target trial emulation published in JAMA Network Open found that early remdesivir initiation was associated with a significantly lower 1-year risk of all-cause graft loss (ACGL) and cardiovascular events (CVEs) compared with no remdesivir, offering the strongest causal evidence yet for antiviral use in this vulnerable group.¹

Study Design and Population

Investigators from Johns Hopkins University School of Medicine used retrospective observational data from 5 hospitals within the Johns Hopkins Health System to emulate a target trial, a method designed to reduce selection and immortal time bias common in observational antiviral research. The cohort included 432 adult KT recipients with symptomatic COVID-19 diagnosed from March 2020 through January 2024, with a median age of 57 years, and 248 (57.4%) were male. Patients who received anti–SARS-CoV-2 monoclonal antibodies, nirmatrelvir-ritonavir, or molnupiravir were excluded to preserve a clean comparison between early remdesivir and no remdesivir.¹

Early remdesivir was defined as initiation within 7 days of a positive SARS-CoV-2 test with at least 3 consecutive days of therapy; 177 patients (41.0%) met this definition, and 255 (59.0%) received no remdesivir. The primary outcome, ACGL, combined graft failure and all-cause mortality. Secondary outcomes included all-cause mortality, CVEs, and long COVID. Researchers used a clone-censor-weight approach with weighted Cox proportional hazards models to estimate hazard ratios (HRs) while accounting for baseline confounding and treatment-strategy deviations over the year of follow-up.¹

Key Findings

After adjustment, early remdesivir initiation 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). There was no statistically significant association with lower all-cause mortality (HR, 0.51; 95% CI, 0.24-1.06) or long COVID (HR, 0.65; 95% CI, 0.21-2.05).¹

Notably, unweighted analyses initially showed early remdesivir associated with a higher risk of ACGL (HR, 1.78; 95% CI, 1.01-3.13), a reversal that investigators attributed to substantial confounding by indication, since patients selected for remdesivir tended to be older and more severely ill at diagnosis. The E-value for the adjusted ACGL estimate was 3.15, suggesting a strong unmeasured confounder would be needed to fully explain the association away.¹

Subgroup analyses found consistent protective associations with ACGL among patients younger than 65 years (HR, 0.38; 95% CI, 0.16-0.87), those with a body mass index of 30 or greater (HR, 0.32; 95% CI, 0.14-0.72), deceased-donor KT recipients (HR, 0.49; 95% CI, 0.26-0.95), living-donor KT recipients (HR, 0.38; 95% CI, 0.16-0.94), patients with hypertension (HR, 0.58; 95% CI, 0.34-0.99), and those without known coronary artery disease (HR, 0.41; 95% CI, 0.21-0.80).¹

Sensitivity analyses shortening the treatment grace period to 5 days and adjusting weight truncation thresholds produced similar results, reinforcing the robustness of the primary finding.¹

Broader Safety and Delivery-of-Care Context

The findings align with a growing evidence base supporting the overall safety profile of COVID-19 antivirals. A separate systematic review from the Keck School of Medicine of the University of Southern California, which analyzed 54 studies of FDA-authorized COVID-19 treatments, found insufficient evidence linking antiviral therapies, including remdesivir, nirmatrelvir-ritonavir, and molnupiravir, to serious adverse events.²

"With a severe public health emergency like COVID-19, it is critical that there exists a government compensation program for treatment-related injuries that is based on the best scientific evidence. Now, we know with additional certainty that the treatments are safe without a high frequency of serious [adverse] effects," Jeffrey Klausner, MD, MPH, professor of clinical population and public health sciences at the Keck School of Medicine, said in a news release.²

That review did flag a moderate-certainty signal for neutropenia with tocilizumab and increased infection and bleeding risk with convalescent plasma in patients with hematologic cancer, though neither finding applied to remdesivir directly.²

Delivery models for remdesivir have also drawn favorable feedback from patients and clinicians. A survey study published in BMC Infectious Diseases examined advanced medical care at home (AMCAH) programs that integrated remdesivir infusions outside the hospital setting.³

"Our survey results found that with physician guidance, patients were receptive to care at home," the study authors said,³ adding that "high ratings of medical follow-up, telehealth encounters, and low adverse event frequency were consistent with previously reported literature."

Among 536 patient respondents, adherence, defined as completing 100% of therapy, reached 87%, and physicians reported high confidence in supporting pharmacy services (96.3%) and at-home nursing (87%) during infusion courses.³

What This Means for Pharmacists

For pharmacists working in transplant, infectious disease, or ambulatory infusion settings, the JAMA Network Open findings reinforce current CDC and Infectious Diseases Society of America guidance recommending early antiviral therapy for patients at high risk of COVID-19 progression, now with population-specific evidence for KT recipients.¹

Because remdesivir carries known drug-drug interaction considerations with calcineurin inhibitors such as tacrolimus, pharmacists remain central to monitoring and coordinating therapy in this population as antiviral initiation timelines tighten. The complementary safety and at-home care data further support pharmacists' role in counseling patients on adherence, coordinating telehealth-supported infusion schedules, and reassuring patients and caregivers about the overall tolerability of antiviral treatment.^2,3

REFERENCES

1. Srisurapanont K, Manothummetha K, Siriyakorn N, et al. Remdesivir and All-Cause Graft Loss Among Kidney Transplant Recipients With Symptomatic COVID-19. JAMA Network Open. 2026;9(7):e2625591. doi:10.1001/jamanetworkopen.2026.25591

2. Gallagher A. Study finds COVID-19 therapies cause few serious adverse effects. Drug Topics. April 14, 2025. Accessed July 28, 2026. https://www.drugtopics.com/view/study-finds-covid-19-therapies-cause-few-serious-adverse-effects

3. Gallagher A. Providers, patients show favorable perception of remdesivir during COVID-19 pandemic. Drug Topics. October 24, 2025. Accessed July 28, 2026. https://www.drugtopics.com/view/providers-patients-show-favorable-perception-of-remdesivir-during-covid-19-pandemic