**5. Conclusions**

Our SARS-CoV-2 transplant registry demonstrated an almost 10% death rate in the early pandemic era, when vaccinations were not yet available and MAB treatment options were still evolving. Despite a trend for the kidney-transplant recipients being more susceptible to severe disease, particularly at the outset of the pandemic, this did not reach significance, while age prevailed as the mortality predictor, increasing the death hazard by a factor of 10 over the age of 60. Tacrolimus immunomodulation was protective in our patient sample. However, these findings should be interpreted with caution, since they could be inherent to the well-known limitations of a small sample size and retrospective study bias. Randomized trials are needed to elucidate the various immunosuppression modalities' impact on disease progression. This pilot study, which was conducted in a highly endemic area of the disease and on a patient population with overall morbidity and mortality among the highest in the United States, may provide the control group for future high-quality propensity-score-matched studies.

**Author Contributions:** Conceptualization, M.K.R., S.B., L.B. and E.G.; Data curation, H.H., A.W. and E.G.; Investigation, H.H., J.N., T.O., G.K. and D.K.; Methodology, H.H. and E.G.; Project administration, E.G.; Resources, A.W., M.K.R., S.B., L.B. and E.G.; Supervision, E.G.; Writing–original draft, H.H., A.W. and E.G.; Writing–review & editing, H.H., A.W., J.N., T.O., G.K., D.K., M.K.R., S.B., L.B. and E.G.; Final revision and approval of the manuscript: E.G. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) of University of Arkansas for Medical Sciences (protoco l262269, 18 December 2020).

**Informed Consent Statement:** Patient consent was waived with approval from an institutional IRB as this was a chart review study with no direct patient contact, all collected patient data was deidentified, and no identifiable patient information is reported.

**Data Availability Statement:** Not applicable.

**Conflicts of Interest:** The authors declare no conflict of interest.
