Response to the Letter to the Editor: “Immunosuppressive therapy management during sepsis in kidney transplant recipients: a prospective multicenter study”

Background and Objectives: In the era of the coronavirus disease 2019 (COVID-19) pandemic, the management of immunosuppressive (IS) therapy in kidney transplant (KT) recipients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requires attention. It is not yet understood whether IS therapy may protect from the cytokine storm induced by SARS-CoV-2 infection or a temporary adjustment/withdrawal of IS therapy to restore the immune system may be necessary. We performed a systematic literature review to investigate the current management of IS therapy in KT recipients with COVID-1. Materials and Methods: Out of 71 articles published from 1 February 2020 until 30 October 2020, 554 KT recipients with SARS-CoV-2 infection were identified. Results: Modifications of IS therapy were based on the clinical conditions. For asymptomatic patients or those with mild COVID-19 symptoms, a “wait and see approach” was mostly used; a suspension of antimetabolites drugs (347/461, 75.27%) or mTOR inhibitors (38/48, 79.2%) was adopted in the majority of patients with symptomatic COVID-19 infections. For CNIs, the most frequent attitude was their maintenance (243/502, 48.4%) or dose-reduction (99/502, 19.72%) in patients asymptomatic or with mild COVID-19 symptoms, while drug withdrawal was the preferred choice in severely symptomatic patients (160/450, 31.87%). A discontinuation of all IS drugs was used only in severely symptomatic COVID-19 patients on invasive mechanical ventilation. Renal function remained stable in 422(76.17%) recipients, while 49(8.84%) patients experienced graft loss. Eight (1.44%) patients experienced a worsening of renal function. The overall mortality was 21.84%, and 53(9.56%) patients died with functioning grafts. Conclusion: A tailored approach to the patient has been the preferred strategy for the management of IS therapy in KT recipients, taking into account the clinical conditions of patients and the potential interactions between IS and antiviral drugs, in the attempt to balance the risks of COVID-19-related complications and those due to rejection or graft loss.

COVID-19 in Kidney Transplantation: Outcomes, Immunosuppression Management, and Operational Challenges.

SARS-CoV-2 Vaccines in Kidney Transplant Recipients: Will They Be Safe and Effective and How Will We Know?

SARS-CoV-2 infection in pediatric kidney transplant recipients.

Is COVID-19 infection more severe in kidney transplant recipients?

Impact of Protease Inhibitor-Based Anti-Retroviral Therapy on Outcomes for HIV+ Kidney Transplant Recipients.

Observations on improving COVID-19 vaccination responses in kidney transplant recipients: heterologous vaccination and immunosuppression modulation

Progress in Dermatology: Cutaneous Oncology in Organ Transplant Recipients: Meeting the Challenge of Squamous Cell Carcinoma

BackgroundSepsis is the leading cause of Intensive Care Unit (ICU) admissions in kidney transplant recipients (KTRs). However, the optimal immunosuppressive therapy (IST) management in this context is not well-defined. We aimed to evaluate the impact of IST management in the ICU on mortality rates and kidney graft function 6 months after inclusion in KTRs admitted for sepsis.MethodsWe conducted a multicenter, prospective, observational study over 1 year in 11 French ICUs. Inclusion criteria were all KTRs who have been transplanted for at least 3 months, admitted to the ICU for sepsis. All changes of IST (7 days prior to ICU admission or throughout the ICU stay) were collected. The primary outcome was MAKE 180 (Major Adverse Kidney Event), a composite outcome including mortality, kidney graft dysfunction and dialysis requirement at 180 days after inclusion.ResultsOne hundred and twenty-four patients were included. The main cause of ICU admission was respiratory failure for 78 patients (62.9%). Predominant IST management was mycophenolic acid (MPA) discontinuation for 74 patients (59.7%) and calcineurin inhibitor (CNI) continuation for 63 patients (50.8%). By multivariable analysis, after adjustment for age, non-renal SOFA score at admission, kidney function at admission, sex, and history of cellular rejection we did not find any significant association between MAKE 180 and CNI discontinuation (adjusted OR = 1.05, 95% CI 0.87–1.26, p = 0.6). In contrast, MPA discontinuation was significantly associated with MAKE 180 (adjusted OR = 1.45, 95% CI 1.07–1.96, p = 0.018). No significant association was found between IST discontinuation and ICU-acquired infections (adjusted OR = 1.14, 95% CI 0.95–1.36, p = 0.157). Among ICU survivors, only 2 graft rejections occurred during the year following ICU discharge.ConclusionThis study is the first prospective investigation to suggest an association between MPA discontinuation and adverse outcomes during sepsis in critically-ill KTRs. These findings must be interpreted with caution given the potential confounding introduced by SARS-Cov-2–specific treatment protocols. Further interventional trials are necessary to optimize immunosuppressive drug strategies in KTRs during sepsis.Supplementary InformationThe online version contains supplementary material available at 10.1186/s13613-025-01523-2.

Advance Care Planning and Palliative Care Consultation in Kidney Transplantation

Predictors of severe COVID-19 in kidney transplant recipients in the different epidemic waves: Analysis of the Spanish Registry.

COVID-19 in solid organ transplant recipients: Initial report from the US epicenter.

Introduction Risk-to-benefit ratio of upper extremity allotransplantation (UEA), a non-vital transplantation procedure, remains to be clarified, as concerns have been raised regarding infectious, metabolic and malignant complications of lifelong immunosuppression. The aim of this study was to provide a relevant assessment of the infectious risk in UEA recipients. Infectious complications in UEA recipients were analyzed and compared to that of kidney transplant (KT) recipients who have the lowest rate of infections among the different populations of solid organ transplant recipients. Patients and Methods Matched cohort study among UEA and KT recipients from the prospectively maintained “International Registry on Hand and Composite Tissue Transplantation” (IRHCTT) and the French “Données Informatisées et VAlidées en Transplantation” (DIVAT) database. All UEA recipients reported to the IRHCTT between 1998 and 2016 were matched with KT recipients (1:5), according to age (±5 years), sex, CMV serostatus of donor and recipient and (depleting or not depleting) induction. Incidence and characteristics of all infectious events reported to the databases at three posttransplant periods (0-6 months, 7-12 months, >12 months) were analyzed. Results and Discussion Sixty-one UEA recipients were matched with 305 KT recipients. Mean (±SD) follow-up of UEA and KT recipients was 2583±1876 and 2230±1792 days, respectively (p=0.16). Immunosuppression regimen at 3 months posttransplant was similar. The number of acute rejection episodes during follow-up was higher in UEA recipients than in KT recipients (1.3±1.6 vs 0.4±0.7, p<0.01). During follow-up, 30 (50.8%) UEA recipients presented a total of 61 infectious events while 129 (42.3%) KT recipients presented 243 infectious events. Incidence rate of infectious events was higher in UEA recipients than in KT recipients during the first 6 months posttransplant (3.27 vs 1.95 events/1000 transplant-days, p=0.01). Thereafter, incidence rates of infections did not significantly differ between UEA and KT recipients: 0.61 vs 0.45 events/1000 transplant-days (7th-12th month posttransplant, p=0.5) and 0.15 vs 0.21 events/1000 transplant-days (>12th month posttransplant, p=0.11), respectively. Distribution of sites of infections was significantly different: while mucocutaneous infections predominated among UEA recipients at each of the three posttransplant periods (representing 28.6%, 50% and 30% of infectious events, respectively), urinary tract infections (28.6%, 23.8% and 33.9%) and pneumonia (17.3%, 42.9% and 28.2%) predominated among KT recipients. Conclusion Incidence rate of infectious events is higher in UEA recipients than in KT recipients during the first 6 months posttransplant. After the first 6 months posttransplant, incidence of infections is low, at worst equivalent to the incidence observed in young KT recipients. Distribution of infectious syndromes suggests less severe infections in UEA than in KT recipients.

This study aims to evaluate allograft and patient outcomes among recipients of kidney transplants after non-renal solid organ transplants. We also aim to compare our findings with recipients of a repeat kidney transplant. We performed an analysis on kidney transplant recipients who underwent kidney transplantation after a non-renal solid organ transplant. Survival data were stratified into 2 groups: Group A (n=37) consisted of recipients of a kidney transplant after prior non-renal solid organ transplant, and Group B (n=330) consisted of recipients of a repeat kidney transplant. The 1-,5-, and 10-year graft survival (death-censored) for recipients of a kidney transplant post-non-renal solid organ transplant (Group A) were 97.3%, 91.5%, and 86.9%, compared with 97.9%, 90.2%, and 83.4% for recipients of a repeat kidney transplant (Group B) (p=.32). The 1-, 5-, and 10-year patient survival rates were 97.3%, 82.7%, and 79.1% in Group A compared to 97.9%, 90.2%, and 83.4% in Group B. Unadjusted overall patient survival was significantly lower for Group A (p=.017). Kidney transplant recipients who have undergone a previous non-renal solid organ transplant have similar allograft survival outcomes, but higher long-term mortality rates compared to repeat kidney transplant recipients.

Low immunization rates among kidney transplant recipients who received 2 doses of the mRNA-1273 SARS-CoV-2 vaccine