Infections In Transplant Recipients Research Articles

Development of CMV‐specific cytotoxic T cells (CMV‐Tc) in pediatric renal transplant recipients with CMV viremia

Viral infections are controlled primarily by viral-specific T cells, raising concern for adequate T-cell response to clear CMV infection in transplant recipients receiving lymphocyte-depleting agents (LDA). We examined the rates of CMV viremia and clearance, seroconversion, and CMV-specific CD8+ T cell (CMV-Tc) activity with class of induction agent received. Retrospective review of 45 pediatric renal transplant recipients who received induction with LDA (n=31) or non-LDA (NLDA; n=14) received valganciclovir prophylaxis for 6months post-transplant and CMV-PCR monitoring. CMV-Tc was measured by intracellular IFNγ flow cytometry, when possible, at baseline, 1month after CMV viremia (>5 copies/PCR) and serially until CMV-Tc was positive (≥0.2%). Viremia rates at 1, 2, and 4years post-transplant were higher in LDA vs. NLDA (46.3% vs. 7.2%, 64.2% vs. 7.2%, and 64.2% vs. 7.2%, respectively; p=.002). Viremia rates at these time points in seronegative LDA (50.3%, 71.6%, 71.6%) were significantly or near significantly higher than seronegative NLDA (9.1%, 9.1%, 9.1%; p=.004), seropositive-LDA (22.3%, 22.3%, 22.3%; p=.07), or seropositive NLDA (0%, 0%, 0%; p=.07). Eleven of 17 (64.7%) viremic subjects required valganciclovir dose reduction during the prophylaxis period for leukopenia. All viremic LDA patients developed CMV-Tc. One viremic NLDA patient did not develop CMV-Tc. No patients developed CMV disease. CMV seronegative pediatric renal transplant patients receiving LDA are more likely to have valganciclovir prophylaxis dose reduction and develop subclinical CMV viremia; however, all developed CMV-Tc. Larger prospective studies are needed to further understand the effects of induction agents on CMV-Tc and CMV-Tc's role post-transplant.

Maintaining mask momentum in transplant recipients

The widespread use of facemasks has been a crucial element in the control of the SARS‐CoV‐2 pandemic. With mounting evidence for mask efficacy against respiratory infectious diseases and greater acceptability of this intervention, it is proposed that masking should continue after the pandemic has abated to protect some of our most vulnerable patients, recipients of stem cell and solid organ transplants. This may involve not only masking these high‐risk patients, but possibly their close contacts and the healthcare workers involved in their care. We review the evidence for mask efficacy in prevention of respiratory viruses other than SARS‐CoV‐2 and address the burden of disease in transplant recipients. Although we acknowledge that there are limited data on masking to prevent infection in transplant recipients, we propose a framework for the study and implementation of routine masking as a part of infection prevention interventions after transplantation.

Analysis and Fine Specificity of the HCMV-Specific Cell-Free and Cell-Associated Antibody-Dependent Cellular Phagocytosis (ADCP) Responses in Lung Transplant Recipients.

Human Cytomegalovirus (HCMV) may cause severe infections in transplant recipients. HCMV-replication can be limited by HCMV-specific antibody responses. The impact of the antibody-dependent cellular phagocytosis (ADCP) on inhibition of HCMV-replication in natural infections has not been clarified. Therefore, we investigated the HCMV-specific ADCP response in a study cohort of lung-transplant recipients (LTRs) with different donor (D) and recipient (R) HCMV-serostatus. Follow-up plasma samples from 39 non/low-viremic and 36 highly viremic (>1000 HCMV copies/mL plasma) LTRs were collected for one (R+ LTRs) or two (D+/R− LTRs) years post-transplantation. The HCMV-specific ADCP responses were assessed by focal expansion assays (FEA) and flow-cytometry. In all LTRs, ADCP responses were detected against HCMV-infected cells and cell-free virions. When measured in fibroblasts as well as with cell-free virus, the HCMV-specific ADPC response was higher in LTRs than in HCMV-seropositive healthy controls. In D+/R− LTRs, a significant ADCP response developed over time after the receipt of an HCMV positive lung, and a level of <19 IE+ cells/focus in the FEA on fibroblasts was associated with further protection from high-level viremia. Taken together, a strong HCMV-specific ADCP response is elicited in transplant recipients, which may contribute to protection from high-level viremia in primary HCMV infection.

Letermovir treatment of cytomegalovirus infection or disease in solid organ and hematopoietic cell transplant recipients.

Few options are available for cytomegalovirus (CMV) treatment in transplant recipients resistant, refractory, or intolerant to approved agents. Letermovir (LET) is approved for prophylaxis in hematopoietic cell transplant (HCT) recipients, but little is known about efficacy in CMV infection. We conducted an observational study to determine the patterns of use and outcome of LET treatment of CMV infection in transplant recipients. Patients who received LET for treatment of CMV infection were identified at 13 transplant centers. Demographic and outcome data were collected. Twenty-seven solid organ and 21 HCT recipients (one dual) from 13 medical centers were included. Forty-five of 47 (94%) were treated with other agents prior to LET, and 57% had a history of prior CMV disease. Seventy-seven percent were intolerant to other antivirals; 32% were started on LET because of resistance concerns. Among 37 patients with viral load<1000 international units (IU)/ml at LET initiation, two experienced>1 log rise in viral load by week 12, and no deaths were attributed to CMV. Ten patients had viral load>1000 IU/ml at LET initiation, and six of 10 (60%) had a CMV viral load<1000 IU/ml at completion of therapy or last known value. LET was discontinued in two patients for an adverse event. Patients treated with LET with viral load<1000 IU/ml had good virologic outcomes. Outcomes were mixed when LET was initiated at higher viral loads. Further studies on combination therapy or alternative LET dosing are needed.

Bartonellosis in transplant recipients: A retrospective single center experience.

BACKGROUNDBartonellosis is a rare but challenging condition to diagnose with a spectrum of clinical presentations in the immunocompromised host.AIMTo further characterize the presentation of Bartonella henselae (B. henselae) infections in solid organ and hematopoietic stem cell transplant recipients.METHODSWe conducted a single-center retrospective study of all B. henselae testing for 5012 transplant recipients receiving care at a single institution between 2011 and 2018.RESULTSWe identified 38 patients who underwent testing for B. henselae, and three of 38 were found to have bartonellosis. Two of the patients were renal transplant recipients who presented with visceral bartonellosis and symptoms concerning for post-transplant lymphoproliferative disorder. One autologous stem cell transplant recipient presented with cat scratch disease. We detail the clinical courses of these three cases and review the literature concerning the clinical presentations, differential diagnosis, and limitations of diagnostic tests for B. henselae infections in transplant recipients.CONCLUSIONAlthough the incidence of B. henselae infection in transplant recipients is unknown, it merits inclusion in the differential diagnosis for fever of unknown origin in this population.

Clinical Characteristics and Outcome of Coronavirus Disease 2019 Infection in Patients with Solid Organ Transplants: A Systematic Review and Meta-Analysis

Importance: Although many studies have reported cases of COVID-19 infection in transplant recipients, most of them only involve a small number of patients and narrow geographic areas.Objective: This study aims to investigate the clinical characteristics, morbidity, severity, and mortality of COVID-19 infection among solid organ transplant (SOT) recipients by meta-analysis.Data Sources: We performed a literature search using the databases PubMed, Web of Science, and Google Scholar as of November 26, 2020.Study Selection Pooled incidence proportion (i.e., cumulative incidence) and 95% confidence intervals (CI) were determined to estimate morbidity, severity, and mortality of COVID-19 in SOT recipients as well as clinical symptoms.Data Extraction and Synthesis: Cochrane chi-square test statistic, Q statistic, and Higgin’s I2 statistic were used to evaluate heterogeneity among the studies. Publication bias and sensitivity of the included studies were also tested.Results: Forty-eight studies were included in the meta-analysis. The morbidity rate of COVID-19 in SOT recipients was 2·10% (95% confidence intervals [CI] 1·35-3·01), incidence of severe infection was 22·46% (95% CI 15·74-29·90), and mortality rate was 17·38% (95% CI, 13·72-21·34). In the transplanted organ analysis, the proportion of patients with severe infection was highest in the recipients of two or more transplants (48·85% [95% CI 11·88-86·38]). Further, the mortality rate was highest in lung transplant recipients (25·12% [95% CI 16·94-34·00]). The most common symptoms of COVID-19 in SOT recipients were fever, cough, and respiratory symptoms, which were reported in 73·39%, 58·90%, and 45·77% of patients, respectively. Conclusion and relevance: The SOT was a significant risk factor for worse COVID-19 outcomes, although the morbidity of COVID-19 in SOT recipients was not markedly higher than that in the general population.Funding Statement: The authors received no financial support for the research, authorship, and/or publication of this article.Declaration of Interests: The authors have no conflicts of interest to declare.

Evaluation of latent tuberculosis infection in liver transplant recipients.

Background and Objectives:Tuberculosis is one of the main reasons for mortality in liver transplant recipients. Since Iran is considered as a tuberculosis-endemic country, the present study aims to evaluate the outcome of latent tuberculosis infection in transplant recipients after liver transplantation.Materials and Methods:The present analytical cross-sectional study was performed on transplanted patients in Imam Khomeini Complex Hospital in Tehran Iran from 2006 to 2016. All patients with positive tuberculin skin test were enrolled. Variables including demographic information, therapeutic and outcome data were gathered and analyzed.Results:Among 675 transplant recipients, 100 patients had positive tuberculin skin test (14.8%). Sixty seven percent of recipients were men and the mean age was 72.67 ± 1.3 years. All patients’ received Isoniazid prophylaxis before transplantation. The mean duration of anti-tuberculosis prophylaxis before and after transplant were 2.7 ± 1.9 and 3.6 ± 5.5 months, respectively. Tuberculosis has not been occurred in none of these patients after a mean follow up time of 45.21 ± 3 months. During the study period, four subjects infected by Mycobacterium tuberculosis, while their skin test was negative before transplant.Conclusion:According to our study, tuberculin skin test is a reliable and sensitive test for diagnosis of latent tuberculosis in liver transplant candidates. Isoniazid prophylaxis is well tolerated in patients with end stage liver diseases and liver transplant recipients.

Absorption, Metabolism, Distribution, and Excretion of Letermovir.

Letermovir is approved for prophylaxis of cytomegalovirus infection and disease in cytomegalovirus-seropositive hematopoietic stem-cell transplant (HSCT) recipients. HSCT recipients are required to take many drugs concomitantly. The pharmacokinetics, absorption, distribution, metabolism, and excretion of letermovir and its potential to inhibit metabolizing enzymes and transporters in vitro were investigated to inform on the potential for drug-drug interactions (DDIs). A combination of in vitro and in vivo studies described the absorption, distribution, metabolism, and routes of elimination of letermovir, as well as the enzymes and transporters involved in these processes. The effect of letermovir to inhibit and induce metabolizing enzymes and transporters was evaluated in vitro and its victim and perpetrator DDI potentials were predicted by applying the regulatory guidance for DDI assessment. Letermovir was a substrate of CYP3A4/5 and UGT1A1/3 in vitro. Letermovir showed concentration- dependent uptake into organic anionic transporting polypeptide (OATP)1B1/3-transfected cells and was a substrate of P-glycoprotein (P-gp). In a human ADME study, letermovir was primarily recovered as unchanged drug and minor amounts of a direct glucuronide in feces. Based on the metabolic pathway profiling of letermovir, there were few oxidative metabolites in human matrix. Letermovir inhibited CYP2B6, CYP2C8, CYP3A, and UGT1A1 in vitro, and induced CYP3A4 and CYP2B6 in hepatocytes. Letermovir also inhibited OATP1B1/3, OATP2B1, OAT3, OCT2, BCRP, BSEP, and P-gp. The body of work presented in this manuscript informed on the potential for DDIs when letermovir is administered both intravenously and orally in HSCT recipients.

SARS-CoV2/COVID-19 Infection in Transplant Recipients and in Patients on the Organ Transplant Waiting List in Colombia

To assess our determination to continue transplant activity in Colombia during the coronavirus disease 2019 (COVID-19) pandemic, this study seeks to describe the risk of infection and mortality of transplanted patients vs those on the waiting list. Therefore, a descriptive study of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2)/COVID-19 infection in transplant recipients and patients on the waiting list was conducted. The data sources were the information systems of the Instituto Nacional de Salud of Colombia: National Donation and Transplant Information System, the National Public Health Surveillance System, and the National COVID-19 Data Repository. Characteristics of the patients who tested positive were analyzed, and the mortality rate was determined. An Real Time-PCR test for SARS-CoV-2/COVID-19 was performed in 7% of the transplant recipients included in this study, and 14.8% of those recipients tested positive. Among patients on the waiting list, 15.2% were tested, and 16.7% showed positive results. Overall, 1% (84/8108) of the transplant recipients and 2.5% (74/2926) of patients on the waiting list were infected with SARS-CoV-2/COVID-19. There were no differences in mortality between these groups (P = .8748). In conclusion, with the data obtained so far, the hospital availability, and the adoption of safety protocols in the institutions, our findings can support the continuity of the transplant activities in this country.

Practicing With Uncertainty: Kidney Transplantation During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic required transplant nephrologists, surgeons, and care teams to make decisions about the full spectrum of transplant program operations and clinical practices in the absence of experience or data. Initially, across the country, there was a reduction in kidney transplant procedures and a striking pause in the conduct of living donation and living-donor transplant surgeries. Aspects of candidate evaluation and follow-up rapidly converted to telehealth. Months into the pandemic, much has been learned from experiences worldwide, yet many questions remain. In this Perspective, we reflect on some of the practice decisions made by the transplant community in the initial response to the pandemic and consider lessons learned, including those related to the risks, benefits, and logistical considerations of proceeding with versus delaying deceased-donor transplantation, living donation, and living-donor transplantation during the pandemic. We review the evolution of therapeutic strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their use in transplant recipients, current consensus related to immunosuppression management in infected transplant recipients, and emerging information on vaccination against SARS-CoV-2. We share our thoughts on research priorities, discuss the areas in which we are still practicing with uncertainty, and look ahead to the next phase of the pandemic response.

Fungal infections in transplant recipients: pros and cons of immunosuppressive and antimicrobial treatment

Fungal infections in transplant recipients: pros and cons of immunosuppressive and antimicrobial treatment

Coronavirus Disease 2019 Associated Risk Score, Behavior, and Symptom Prevalence in German Transplant Recipients

BackgroundTransplant recipients are prone to developing severe infections because of immunosuppression. Therefore, studying the manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in transplant recipients is of particular importance. MethodsOne hundred twelve transplant patients consecutively visiting the outpatient department of 2 German transplant centers were included in this study after providing written informed consent. The patients were interviewed about coronavirus disease 2019 (COVID-19) symptoms and history. Nasopharyngeal swabs were analyzed by SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR). SARS-CoV-2 IgG and IgA were measured concomitantly in patient sera by enzyme-linked immunosorbent assay. ResultsThe risk of severe COVID-19 according to 2 recent scores differed among the analyzed patients. All patients were well educated about their presumed higher risk of a severe COVID-19 and described performing self-isolation wherever possible. Nevertheless, 20 patients reported contact with someone suspected of having COVID-19 or who tested positive shortly thereafter (18%). Despite this relatively high exposure, no clinically relevant case of COVID-19 was reported. Though SARS-CoV-2 IgG and IgA were found in 3 patients (3%); 2 patients were asymptomatic and only 1 had mild COVID-19 symptoms and positive RT-PCR 4 weeks earlier. There were no occult SARS-CoV-2 infections, as demonstrated by negative PCR tests. ConclusionDespite the high exposure level, the incidence of COVID-19 remained very low. Because of the differences in COVID-19 risk, balancing risk exposure and quality of life should be recommended.

High mortality associated with gram-negative bacterial bloodstream infection in liver transplant recipients undergoing immunosuppression reduction.

BACKGROUNDImmunosuppression is an important factor in the incidence of infections in transplant recipient. Few studies are available on the management of immunosuppression (IS) treatment in the liver transplant (LT) recipients complicated with infection. The aim of this study is to describe our experience in the management of IS treatment during bacterial bloodstream infection (BSI) in LT recipients and assess the effect of temporary IS withdrawal on 30 d mortality of recipients presenting with severe infection.AIMTo assess the effect of temporary IS withdrawal on 30 d mortality of LT recipients presenting with severe infection.METHODSA retrospective study was conducted with patients diagnosed with BSI after LT in the Department of Liver Surgery, Renji Hospital from January 1, 2016 through December 31, 2017. All recipients diagnosed with BSI after LT were included. Univariate and multivariate Cox regression analysis of risk factors for 30 d mortality was conducted in the LT recipients with Gram-negative bacterial (GNB) infection.RESULTSSeventy-four episodes of BSI were identified in 70 LT recipients, including 45 episodes of Gram-positive bacterial (GPB) infections in 42 patients and 29 episodes of GNB infections in 28 patients. Overall, IS reduction (at least 50% dose reduction or cessation of one or more immunosuppressive agent) was made in 28 (41.2%) cases, specifically, in 5 (11.9%) cases with GPB infections and 23 (82.1%) cases with GNB infections. The 180 d all-cause mortality rate was 18.5% (13/70). The mortality rate in GNB group (39.3%, 11/28) was significantly higher than that in GPB group (4.8%, 2/42) (P = 0.001). All the deaths in GNB group were attributed to worsening infection secondary to IS withdrawal, but the deaths in GPB group were all due to graft-versus-host disease. GNB group was associated with significantly higher incidence of intra-abdominal infection, IS reduction, and complete IS withdrawal than GPB group (P < 0.05). Cox regression showed that rejection (adjusted hazard ratio 7.021, P = 0.001) and complete IS withdrawal (adjusted hazard ratio 12.65, P = 0.019) were independent risk factors for 30 d mortality in patients with GNB infections after LT. CONCLUSIONIS reduction is more frequently associated with GNB infection than GPB infection in LT recipients. Complete IS withdrawal should be cautious due to increased risk of mortality in LT recipients complicated with BSI.IS

Vaccine-Preventable Infections Among Solid Organ Transplant Recipients: A Data-Linked Cohort Study, Australia, 2000-2015

IntroductionRecipients of solid organ transplants are at risk of serious infection due to immunosuppression. Some infections are preventable with vaccination; infection rates vary with immunosuppression, vaccination rates and baseline disease prevalence. Both adherence with and response to vaccination in this population are variable, and optimum vaccination strategies continue to be refined.&#x0D; Objectives and ApproachWe aimed to characterise the incidence and complications of vaccine-preventable infections in transplant recipients. Eligible participants received an organ transplant in New South Wales, Australia, in 2000-2015. Linkage was undertaken between transplant registries and the notifiable conditions information management system. Vaccine-preventable infections were diphtheria, Haemophilus influenzae type b, influenza, invasive pneumococcal disease, measles, mumps, pertussis, poliovirus, rubella and tetanus. Standardized incidence ratios (SIR) were calculated relative to Australian population notification rates, standardizing for gender, age and calendar year.&#x0D; ResultsAmong 3,394 recipients, 399 vaccine-preventable infections affected 339 (10%) recipients. Influenza was the most common vaccine-preventable infection with 352 notifications among 305 recipients. Influenza cases were 8.9 times more common among transplant recipients than the general population (95%CI: 8.0-10.0). In 36 cases (10%), hospitalization was required, and 2 deaths due to influenza were reported.&#x0D; There were 20 notifications of invasive pneumococcal disease (IPD) for 18 recipients. IPD occurred 10.2 times more often among transplant recipients than the general population (95%CI: 6.4-16.2). Most (n=13, 65%) cases were hospitalized, and one patient died from IPD.&#x0D; Cases of pertussis occurred only slightly more often than in the general population (SIR 1.5, 95%CI: 1.0-2.3). Of 26 cases, there was one reported hospitalization and no deaths due to pertussis. Only one case of mumps, and no other vaccine-preventable infections, were reported.&#x0D; ConclusionTransplant recipients have excess cases of influenza and IPD compared to the general population, although this has improved over time. The need for appropriate recipient vaccination is emphasized.

Treatment of invasive IMP-4 Enterobacter cloacae infection in transplant recipients using ceftazidime/avibactam with aztreonam: A case series and literature review.

Infections caused by carbapenemase-producing Enterobacteriaceae (CPE) are an emerging threat in both solid organ and stem cell transplant recipients. Invasive CPE infections in transplant recipients are associated with a high mortality, often due to limited therapeutic options and antibacterial toxicities. One of the most therapeutically challenging group of CPE are the metallo-β-lactamase (MBL)-producing Gram-negative bacteria, which are now found worldwide, and often need treatment with older, highly toxic antimicrobial regimens. Newer β-lactamase inhibitors such as avibactam have well-established activity against certain carbapenemases such as Klebsiella pneumoniae carbapenemases (KPC), but have no activity against MBL-producing organisms. Conversely, aztreonam has activity against MBL-producing organisms but is often inactivated by other co-existing β-lactamases. Here, we report four cases of invasive MBL-CPE infections in transplant recipients caused by IMP-4-producing Enterobacter cloacae who were successfully treated with a new, mechanism-driven antimicrobial combination of ceftazidime/avibactam with aztreonam. This novel antimicrobial combination offers a useful treatment option for high-risk patients with CPE infection, with reduced drug interactions and toxicity.

Determining the therapeutic range for ribavirin in transplant recipients with chronic hepatitis E virus infection.

The aim of this study was to define the therapeutic range for ribavirin (RBV) in transplant recipients with chronic hepatitis E virus (HEV) infection. In this retrospective multicentre cohort study, data of adult transplant recipients with chronic HEV infection, who had been treated with RBV monotherapy between 01‐3‐2008 and 01‐08‐2018, were included. ROC curve analyses were performed, and the half‐maximal effective RBV concentration was calculated to determine a representative therapeutic range. In 96 patients, RBV monotherapy for a median of three months resulted in a sustained virologic response in 63.5% of the patients, while 88.5% of the patients developed anaemia. RBV plasma concentrations at steady state were significantly higher in clinical responders compared with clinical non‐responders: median 1.96 (IQR 1.81‐2.70) versus 0.49 (IQR 0.45‐0.73) mg/L, P = .0004. RBV caused a dose‐dependent haemoglobin reduction with higher RBV plasma concentrations resulting in more haemoglobin reduction. The therapeutic range for RBV for chronic HEV infection in transplant recipients ranges between 1.8 and 2.3 mg/L.

Mortality Rates in Transplant Recipients and Transplantation Candidates in a High-prevalence COVID-19 Environment.

The risk of COVID-19 infection in transplant recipients (TRs) is unknown. Patients on dialysis may be exposed to greater risk of infection due to an inability to isolate. Consideration of these competing risks is important before restarting suspended transplant programs. This study compared outcomes in kidney and kidney/pancreas TRs with those on the waiting list, following admission with COVID-19 in a high-prevalence region. Audit data from all 6 London transplant centers were amalgamated. Demographic and laboratory data were collected and outcomes included mortality, intensive care (ITU) admission, and ventilation. Adult patients who had undergone a kidney or kidney/pancreas transplant, and those active on the transplant waiting list at the start of the pandemic were included. One hundred twenty-one TRs and 52 waiting list patients (WL) were admitted to hospital with COVID-19. Thirty-six TR died (30%), while 14 WL patients died (27% P = 0.71). There was no difference in rates of admission to ITU or ventilation. Twenty-four percent of TR required renal replacement therapy, and 12% lost their grafts. Lymphocyte nadir and D-dimer peak showed no difference in those who did and did not die. No other comorbidities or demographic factors were associated with mortality, except for age (odds ratio of 4.3 [95% CI 1.8-10.2] for mortality if aged over 60 y) in TR. TRs and waiting list patients have similar mortality rates after hospital admission with COVID-19. Mortality was higher in older TRs. These data should inform decisions about transplantation in the COVID era.

Organ Donation and Transplantation During the COVID-19 Pandemic: A Summary of the Spanish Experience.

Spain has been amongst the countries most affected by the COVID-19 pandemic, which has posed significant challenges to the donation and transplantation program. Despite a dramatic decrease of donation and transplantation activities during the critical early weeks of the outbreak, the program has recovered and is learning to cope with COVID-19. We describe the 4 pillars upon which the Spanish donation and transplantation program has been rebuilt. (1) Standards have been developed and progressively updated for the evaluation and selection of potential donors and recipients with regards to SARS-CoV-2 infection. (2) Spain has been actively generating evidence to assess the validity of our standards and to understand the natural history of the infection in transplant recipients. No case of donor-derived COVID-19 has been reported to date. COVID-19 has been more frequent and has had a more aggressive course in recipients of solid organ transplants than in the general population, but this seems largely explained by the demographics and comorbidity of transplant patients. (3) As a result of this evidence and experience, recommendations have been issued for the management of COVID-19 in solid organ transplant recipients and candidates on the waiting list. (4) Finally, concrete guidance has been issued for centers to manage the donation and transplantation programs in relation to a dynamic and heterogeneous epidemiologic scenario. The Spanish experience confronting the impact of COVID-19 upon donation and transplantation may help serve the needs of a broader community in other countries.

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

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2, has led to the death of hundreds of thousands of people worldwide. If infected, older individuals and those with diabetes, hypertension, cardiovascular disease, and compromised immune systems are at higher risk for unfavorable outcomes. These comorbidities are prevalent in patients with kidney disease, hence the significant burden of COVID-19 on kidney transplant programs. Multiple case series of kidney transplant recipients with COVID-19 have shown increased mortality compared to nontransplant patients. To date, we do not have high-level evidence to inform immunosuppression minimization strategies in infected transplant recipients. Most centers however have adopted early antimetabolite withdrawal in addition to other interventions. This review summarizes the published COVID-19 literature as it relates to outcomes and immunosuppression management in kidney transplant recipients. It also discusses challenges pertaining to pretransplant evaluation and wait-listed patients.

SARS-CoV2 and immunosuppression: A double-edged sword.

Severe acute respiratory syndrome Coronavirus 2 (SARS‐Cov2) outbreak has caused a pandemic rapidly impacting on the way of life of the entire world. This impact in the specific setting of transplantation and immunosuppression has been poorly explored to date. Discordant data exist on the impact of previous coronavirus outbreaks on immunosuppressed patients. Overall, only a very limited number of cases have been reported in literature, suggesting that transplanted patients not necessarily present an increased risk of severe SARS‐Cov2‐related disease compared to the general population. We conducted a literature review related to the impact of immunosuppression on coronavirus infections including case reports and series describing immunosuppression management in transplant recipients. The role of steroids, calcineurin inhibitors, and mycophenolic acid has been explored more in detail. A point‐in‐time snapshot of the yet released literature and some considerations in relation to the use of immunosuppression in SARS‐Cov2 infected transplant recipients are provided here for the physicians dealing with immunocompromised patients.