POS-067 THE IMPACT OF INFECTION ON KIDNEY ALLOGRAFT FAILURE IN AN UNDER-RESOURCED COUNTRY: THE IRAQI KURDISTAN EXPERIENCE DURING THE COVID-19 PANDEMIC

Abstract

Because of the cost and complexity of dialysis, kidney transplantation is the World's most widely used replacement therapy for end-stage kidney disease. This kidney transplantation is practiced where resources for infection identification and control do not usually meet the standards of developed countries. This is a cross-sectional study of all kidney transplants performed in Sulaimania Governate of Iraq from 2015 through 2019 and followed-up through 2021. There were 656 patients. The average age was 39.2 ± 14.0 years, 68.6% were male, 416 received hemodialysis (HD) for a median of 2 months (IQR 0-5 months), 96% were first-time transplants, all donors were living, and 13.1% of recipients had pre-transplant DSA. Outcomes consisted of return to HD (RHD), death with a functional graft (DWFG), and all graft loss (RHD+DWFG). Infections consisted of pyelonephritis, PCR+ BK viremia (BKV), PCR+ COVID-19, and non-kidney-deep infections (NK-deep infections). NK-deep infections were defined as non-COVID pneumonia, septicemia, gastrointestinal infections, and hepatitis. Breslow proportional hazard functions analyzed outcomes, and logistic regression tested the relationships between infections and outcomes. Results include 95% confidence intervals. Graft failure occurred in 113 patients, 53 with RHD and 50 with DWFG. The 12 and 60 month graft survivals were 97.0% (95.3-98.1%) and 90.0% (86.7-92.5%) for RHD, 97.5% (95.9-98.5%) and 90.3% (87.0-92.8%) for DWFG, and 94.6% (92.5-96.1%) and 81.3% (77.5-84.7%) for all graft loss, with differences between RHD and DWFG being not significant, p=0.46. Seventy-nine patients had pyelonephritis, 37 had BKV, and 211 had COVID, with 9 COVID cases contracted after RHD. There were 11 COVID deaths, 9 causing DWFG and 2 occurring after RHD. Thirty patients had NK-deep infections that involved 13 RHD and 17 DWFG patients. NK-deep infections were the most significant variable associated with all graft loss (OR=222.5, 29.0-1707.9, p>0.001]. BKV adversely affected all graft loss (OR=2.6, 1.1-6.2, p=0.03), but nearly all pyelonephritis resolved with treatment, and its effect on graft survival was not significant (OR=0.53, 0.22-1.26, p=0.15) The one and five-year survivals of this cohort of kidney transplant patients were surprisingly good. Nevertheless, an infection commonly with pneumonia or septicemia contributed to 34.0% of DWFG and 24.5% of RHD. Recovery occurred in 94.8% of COVID-infected patients, but a fatality rate of 5.2% resulted in 18.0% of DWFG. As COVID wanes, a modest improvement in graft survival is expected, but NK-deep infections will remain critical factors influencing 5-year graft loss.