Kidney Transplant Patients Research Articles

Hybrid Immunity Protects against Antibody Fading after SARS-CoV-2mRNA Vaccination in Kidney Transplant Recipients, Dialysis Patients, and Medical Personnel: 9 Months Data from the Prospective, Observational Dia-Vacc Study.

(1) Background: Compared to medical personnel, SARS-CoV-2mRNA vaccination-related positive immunity rates, levels, and preservation over time in dialysis and kidney transplant patients are reduced. We hypothesized that COVID-19 pre-exposure influences both vaccination-dependent immunity development and preservation in a group-dependent manner. (2) Methods: We evaluated 2- and 9-month follow-up data in our observational Dia-Vacc study, exploring specific cellular (interferon-γ release assay = IGRA) and/or humoral immune responses (IgA/IgG/RBD antibodies) after two SARS-CoV-2mRNA vaccinations in 2630 participants, including medical personnel (301-MP), dialysis patients (1841-DP), and kidney transplant recipients (488-KTR). Study participants were also separated into COVID-19 pre-exposure (hybrid immunity) positive (n = 407) versus negative (n = 2223) groups. (3) Results: COVID-19 pre-exposure improved most vaccination-related positive immunity rates in KTR and DP at 2 months but not in MP, where rates reached almost 100% independent of hybrid immunity. In the COVID-19-negative study, patients' immunity faded between two and nine months, evaluated via the percentage of patients with an RBD antibody decrease >50%, and was markedly group- (MP-17.8%, DP-52.2%, and KTR-38.6%) and vaccine type-dependent. In contrast, in all patient groups with COVID-19, pre-exposure RBD antibody decreases of >50% were similarly rare (MP-4.3%, DP-7.2%, and KTR-0%) but still vaccine type-dependent, with numerically reduced numbers in mRNA-1273- versus BNT162b2mRNA-treated patients. Multivariable regression analysis of RBD antibody changes between two and nine months by interval scale categorization confirmed COVID-19 pre-exposure as a factor in inhibiting strong RBD Ab fading. COVID-19 pre-exposure in MP and DP also numerically reduced T-cell immunity fading. In DP, symptomatic (versus asymptomatic) COVID-19 pre-exposure was identified as a factor in reducing strong RBD Ab fading after vaccination. (4) Conclusions: After mRNA vaccination, immunity positivity rates in DP and KTR but not MP, as well as immunity preservation in MP/DP/KTR, are markedly improved via prior COVID-19 infection. In DP, prior symptomatic compared to asymptomatic COVID-19 disease was particularly effective in blocking immunity fading after mRNA vaccination.

Subclinical rejection and allograft survival in kidney transplantation: protocol for a systematic review and meta-analysis

IntroductionSubclinical rejection (SCR) refers to the presence of acute rejection without accompanying kidney allograft dysfunction. The impact of SCR on long-term graft survival remains a subject of ongoing debate.Methods and...

Community Point of Care Testing in Diagnosing and Managing Chronic Kidney Disease.

Chronic kidney disease (CKD) poses a significant global health challenge with increasing prevalence and associated morbidity. Point-of-care testing (POCT) provides an opportunity to improve CKD management and outcomes through early detection and targeted interventions, particularly in underserved communities. This review evaluates the roles of POCT in CKD, focusing on utility (through screening programs, monitoring of kidney function, and assessing participants on renally excreted medications), accuracy, and acceptability. Screening programs employing POCT have demonstrated promising outcomes, with improved rates of CKD diagnosis in groups with disparate health outcomes, offering a vital avenue for early intervention in high-risk populations. These have been conducted in rural and urban community or pharmacy settings, highlighting convenience and accessibility as important facilitators for participants. In addition, POCT holds significant promise in the monitoring of CKD, particularly in groups requiring frequent testing, such as kidney transplant recipients and patients on renin-angiotensin-aldosterone inhibitors. The consideration of the variable analytical performance of different devices remains crucial in assessing the utility of a POCT intervention for CKD. While the convenience and improved accessibility of home self-testing versus healthcare professional management is important, it must be balanced with acceptable levels of accuracy and precision to maintain patient and clinical confidence. Despite challenges including variability in accuracy and the user-friendliness of devices, patient feedback has generally remained positive, with studies reporting increased patient satisfaction and engagement. However, challenges regarding wider uptake are limited by healthcare professional confidence (in test reliability), the potential for increased workload, and early prohibitive costs. In conclusion, POCT represents a growing and valuable tool in enhancing CKD care, particularly in resource-limited settings, but careful consideration of device selection and implementation strategies is essential to achieve desired outcomes.

Magnesium matters: unveiling hidden risks in kidney transplant patients through total and ionized magnesium profiling.

In kidney transplant (KT) patients, magnesium (Mg2+) deficiency is widespread. It is often encountered early after KT, may persist longer, and is frequently promoted by calcineurin inhibitors (CNIs) and tubular leakage. Studies demonstrated an association between post-KT hypomagnesemia and allograft dysfunction. The concentration of the active form, the ionized Mg2+ (iMg2+), is not measured clinically, and total Mg2+ (tMg2+) and iMg2+ correlations are conflicting. We assess the cross-sectional prevalence of hypomagnesemia in KT patients. The correlation of demographic and anthropometric parameters was also studied. A prospective, single-center analysis of KT patients was conducted at the University Hospital of Bern, Switzerland (March 2023-August 2023). Blood samples were collected at least twice for the majority of patients. tMg2+ has been quantified from a plasma sample at the Clinical Chemistry Department of the University Hospital of Bern. The PRIME® ES analyzer (Nova Biomedical, USA) provided results for iMg2+. The following co-variables were considered: age, comorbidities, kidney disease, KT history, estimated glomerular filtration rate (eGFR), and treatment (including Mg2+ supplementation and immunosuppression). A total of 208 measurements in 104 patients were performed [once in 9/104 patients (8.7%), twice in 86/104 (82.7%), and three times in 9/104 (8.7%)]. Compared to that in healthy volunteers (51 measurements in 51 participants), mean iMg2+ was significantly lower in KT patients {KT: 0.46 mmol/L [interquartile range (IQR): 0.40-0.50], volunteers: 0.57 mmol/L (IQR 0.54-0.61), p < 0.01}. Overall, iMg2+ and tMg2+ showed strong category agreement (r2 = 0.93, p < 0.01). In linear regression, low iMg2+ correlated with CNI exposure. For 110/208 measurements (52.9%), a reduced iMg2+ (cutoff: 0.42 mmol/L) was shown. In 58/208 (27.9%), both values were reduced, and 52/208 (25%) had isolated reduced iMg2+. In principal component analysis, patients with isolated low iMg2+ clustered with patients with low iMg2+ and tMg2+. iMg2+ and tMg2+ were strongly correlated. A substantial proportion of patients show isolated low iMg2+. Currently, it is unclear if these patients suffer from Mg2+ deficiency.

The impact of obesity on body surface area adjusted estimated glomerular filtration rate in patients with chronic kidney disease.

Assessment of kidney function is necessary for prescribing renally excreted drugs. The estimated glomerular filtration rate (eGFR) routinely reported by laboratories is indexed to a body surface area (BSA) of 1.73 m2. In obese patients, the indexed eGFR may underestimate directly measured GFR. To determine the prevalence of obesity in patients with chronic kidney disease (CKD) and examine the effect of adjusting the indexed eGFR for patient BSA (deindexing) across CKD Stages 2-5. We conducted a cross-sectional study of 575 adults with stable CKD from two general nephrology clinics over 6 months. Dialysis and kidney transplant patients were excluded. We used four equations (Mosteller, Dubois, Haycock and Schlich) to determine BSA based on actual body weight and applied Bland-Altman plots and piecewise linear regression to examine the relationship between deindexed and indexed eGFR. The median age was 68 years (58% male). The prevalence of overweight and obesity was 31% and 47% respectively. Mean body mass index was 29.7 kg/m2. The Schlich equation for BSA produced the smallest adjustment in eGFR, while the Haycock equation produced the largest adjustment. Males experienced the largest change in eGFR from deindexing because of larger BSAs. Although bias became increasingly positive with higher eGFR, the linear regression stratified by CKD stage indicated that deindexing had little impact with eGFR <45 mL/min/1.73 m2. In CKD, deindexing the Chronic Kidney Disease Epidemiology Collaboration eGFR may not be necessary when the eGFR is <45 mL/min/1.73 m2, particularly if the patient is female.

Unveiling systemic responses in kidney transplantation: interplay between the allograft transcriptome and serum proteins.

Immunity, as defined by systems biology, encompasses a holistic response throughout the body, characterized by intricate connections with various tissues and compartments. However, this concept has been rarely explored in kidney transplantation. In this proof-of-concept study, we investigated a direct association between the allograft phenotype and serum protein signatures. Time-matched samples of graft biopsies and blood serum were collected in a heterogeneous cohort of kidney-transplanted patients (n = 15) for bulk RNA sequencing and proteomics, respectively. RNA transcripts exhibit distinct and reproducible, coregulated gene networks with specific functional profiles. We measured 159 serum proteins and investigated correlations with gene expression networks. Two opposing axes-one related to metabolism and the other to inflammation-were identified. They may represent a biological continuum between the allograft and the serum and correlate with allograft function, but not with interstitial fibrosis or proteinuria. For signature validation, we used two independent proteomic data sets (n = 21). Our findings establish a biological link between the allograft transcriptome and the blood serum proteome, highlighting systemic immune effects in kidney transplantation and offering a promising framework for developing allograft-linked biomarkers.

The wane and wax of sleep apnea in kidney transplant patients.

The wane and wax of sleep apnea in kidney transplant patients.

Radiologic evaluation of the kidney transplant donor and recipient.

The kidney is the most common solid organ transplant globally and rates continue to climb, driven by the increasing prevalence of end stage renal disease (ESRD). Compounded by advancements in surgical techniques and immunosuppression leading to longer graft survival, radiologists evermore commonly evaluate kidney transplant patients and candidates, underscoring their role along the transplant process. Multiphase computed tomography (CT) with multiplanar and 3D reformatting is the primary method for evaluating renal donor candidates, detailing renal size, vascular/collecting system anatomy, and identifying significant pathologies such as renal vascular diseases and nephrolithiasis. Ultrasound is the preferred initial postoperative imaging modality for graft evaluation due to its low cost, accessibility, noninvasiveness, and lack of radiation. CT and magnetic resonance imaging (MRI) may be useful adjunctive imaging techniques in diagnosing transplant pathology when ultrasound alone is not diagnostic. Kidney transplant complications are categorized by an approximate timeline framework, aiding in differential diagnosis based on onset, duration, and severity and include perinephric fluid collections, graft compression, iatrogenic injuries, vascular compromise, graft rejection, and neoplastic processes. This review discusses imaging strategies and important findings along the transplant timeline, from donor assessment to long-term recipient complications.

Contraceptive Counselling and Uptake Among Female Kidney Transplant Recipients in Ethiopia

ABSTRACTBackgroundContraceptive counselling and utilization for kidney transplant patients is a vital component of their kidney transplant care. The use of standardized information on contraceptive methods to prevent unplanned post‐transplant pregnancies in Africa in general is less studied. This study aimed to describe contraceptive counselling and uptake among kidney transplant recipients at a kidney transplant centre in Ethiopia.MethodsA descriptive study on contraceptive counselling and uptake among female Ethiopian kidney transplant recipients was conducted at St. Paul's Hospital Millennium Medical College (Ethiopia) from April 15 to July 15, 2023. Data on women's sociodemographic, renal transplantation and contraceptive counselling and use were collected through interviewing the participants using a structured questionnaire. Data were analyzed on SPSS 23 using simple descriptive analysis. Percentages and frequencies were used to present the results.ResultsA total of 60 participants were included in the final analysis. The mean age of the participants was 33.7 ± 8.4 years. The median duration from the time of renal transplant was 19 months. Most (49/60, 81.7%) of the participants reported that they did not receive family planning counselling on contraceptive methods in the early post‐transplant phase. The rate of contraceptive uptake was 8.3% (5/60) with two patients being copper IUD users, and Implanon, tubal ligation and combined oral contraceptives each utilized by a single kidney transplant patient.ConclusionContraceptive counselling and uptake rates among female kidney transplant recipients in this study were very low, which is consistent with findings from previous studies. Increasing female kidney transplant patients’ awareness on safe and effective contraceptive use through adequate contraceptive counselling is essential.

Impact of COVID-19 Infection in Kidney Transplant Patients: A Review

Managing COVID-19 in kidney transplant patients is complex due to limited data on its severity, treatment, and management. Conflicting information from studies necessitates case-by-case treatment decisions. Atypical symptoms can lead to misdiagnosis, so a thorough evaluation is crucial. Immunosuppressants and comorbidities can worsen the disease, leading to the controversial approach of discontinuing or reducing immunosuppressive drugs. Kidney transplantation is challenging due to the surgical procedure’s sensitivity and high risk of transmission. While vaccines offer protection, their efficacy may be altered by immunosuppressive drugs in these patients. This review summarizes the management of COVID-19 in kidney transplant patients, addressing these complexities. Kidney transplant patients face unique COVID-19 challenges due to weakened immunity. They are at higher risk for severe illness and complications from both the virus and immunosuppressant medications. Early identification and intervention are crucial, including antiviral treatment like remdesivir in severe cases. Managing immunosuppressants is critical to balancing the risk of transplant rejection with COVID-19 severity. Drug interactions with COVID-19 treatments require careful consideration, potentially necessitating dose adjustments or alternative medications. The pandemic has disrupted transplant services, highlighting the need for prioritized vaccination and safe access to care. Telemedicine can help minimize virus exposure during post-transplant follow-up. While immunosuppression may impact vaccine responses, vaccination remains crucial to reducing the severe COVID-19 risk. Booster doses and continued precautions are important. Mental health support is essential to address pandemic-related anxiety, depression, and social isolation. More data is needed on the safety and effectiveness of COVID-19 treatments and vaccines in this population. A multidisciplinary approach, including close monitoring, careful medication management, vaccination, and psychosocial support is needed to optimize management and improve outcomes.

416 The Impact of Pancreas Transplantation on Secondary Diabetic Complications: A Systematic Review

Abstract Aim Pancreas transplantation (PT) provides diabetic cure for patients with complicated Type 1 Diabetes Mellitus (T1DM). We aimed to examine the impact of PT on secondary diabetic complications, including retinopathy, neuropathy, and cardiovascular disease. Method A database search using MedLINE for publications up to April 2023 was conducted employing MeSH terms ‘Pancreas Transplantation’ AND ‘Diabetes Mellitus, Type 1’ AND ‘Diabetic Retinopathy’ OR ‘Heart Disease’ OR ‘Cardiovascular Diseases’ OR ‘Peripheral Vascular Disease’ OR “Amputation’ OR ‘Neuropathy.” Results 223 articles were screened, with 172 excluded as per study design (total included 51). 64.7% (n=33) of studies were retrospective case control studies, 35.3% (n=18) of studies were retrospective cohort studies. A total of 5616 patients with a mean of 99.1 (SD± 262.4) simultaneous kidney transplant (SPK) patients and 48.2 (SD± 262.4) pancreas transplant alone (PTA) patients per article were studied. All articles examining diabetic retinopathy concluded that retinopathy improved or stabilized. 69% (n=11) of papers demonstrated no significant change to visual acuity. An equal number of articles (n=4) demonstrated increased peripheral nerve conduction velocity after SPK and PTA. 40% (n=2) of articles examining vibration perception studies demonstrated an increase post-transplantation. Improvements in cardiac events incidence, metabolic factors, and heart structure were seen in 79% (n=15) of cardiovascular articles. Conclusions Despite significant heterogeneity in outcome measures observed, PT provides benefits in mitigating the complication profile of T1DM. Standardised outcome measurement should be adopted to allow assessment of the impact of beta-cell replacement with the potential for objective evidence reversibility of secondary complications.

Brincidofovir inhibits polyomavirus infection in vivo.

Widespread in the human population and able to persist asymptomatically for the life of an individual, polyomavirus infections cause a significant disease burden in the immunocompromised. Individuals undergoing immune suppression, such as kidney transplant patients or those treated for autoimmune diseases, are particularly at high risk for polyomavirus-associated diseases. Because no antiviral agent exists for treating polyomavirus infections, management of polyomavirus-associated diseases typically involves reducing or discontinuing immunomodulatory therapy. This can be perilous due to the risk of transplant rejection and the potential development of adverse immune reactions. Thus, there is a pressing need for the development of antivirals targeting polyomaviruses. Here, we investigate the effects of brincidofovir, an FDA-approved antiviral, on polyomavirus infection in vivo using mouse polyomavirus. We show that the drug is well-tolerated in mice, reduces infectious viral titers, and limits viral pathology, indicating the potential of brincidofovir as an anti-polyomavirus therapeutic.

Cognitive profile of kidney transplant patients and impact of deceased vs. living donor transplantation

BackgroundIt is important to learn more about the prevalence, severity and characteristics (i.e., which cognitive abilities are especially affected) of cognitive impairment in kidney transplant patients. Furthermore, the impact of living vs. deceased donor renal transplantation on cognitive outcome in this patient group needs further studies.MethodsFifty-nine patients (43 men, age 55 ± 13 years) who received a deceased donor or living donor kidney transplant, completed a comprehensive neuropsychological test assessment. Neuropsychological tests explored the cognitive domains of verbal and visual memory, attention, and executive functions.ResultsFifteen percent of the patients had mild, 25% moderate, and 15% severe cognitive impairment. The level of domain-specific cognitive deficit differed between verbal memory, attention, and executive functions (χ2(2) = 7.11, p = 0.029). On average, patients showed the highest deficit in executive functions, and the lowest deficit in verbal memory. Patients who received a kidney graft from a deceased donor were more likely to have a cognitive impairment than those who received a kidney graft from a living donor (OR = 3.03, 95% CI [0.99,9.32], Wald χ2(1) = 3.74, p = 0.053). This effect was independent of time on dialysis as well as of creatinine levels, or creatinine clearance.ConclusionsOur results show that in kidney transplant patients with cognitive impairment, the cognitive domain of executive functions is the most affected one. This might be detrimental for quality of life. The fact that patients who received living donor kidneys seem to do better in terms of cognition than patients with deceased donor kidneys deserves more attention in future research.Graphical abstract

A comparative analysis of kidney allograft outcomes in steroid use versus steroid discontinuation after basiliximab and ATG induction: AUNOS database study.

The relative safety and efficacy of early steroid withdrawal in kidney transplant patients after basiliximab compared to anti-thymocyte globulin (ATG) induction therapy is unknown. We aimed to compare kidney allograft outcomes in steroid use versus steroid discontinuation after basiliximab and ATG induction from the United Network for Organ Sharing (UNOS) database. We conducted a retrospective cohort analysis of the UNOS database and included first kidney transplant recipients who received ATG or basiliximab induction therapy. We compared graft and patient outcomes in those who received steroid maintenance and those who were discharged off steroids. Of 106,061 patients, 25,344 (86.7%) received basiliximab induction and were maintained on steroids (B-Sm), and 3,880 (13.3%) were on a steroid-free regimen (B-Sf). Graft failure rate was significantly higher in the B-Sf compared to B-Sm at 1-year (4.1 vs. 1.8%, p<0.001), 3-year (6.0 vs. 4.3%, p<0.001) and 5-year follow-up (7.7 vs. 6.4%, p=0.0004). The mortality rate was significantly higher in B-Sf at 1-year (3.3 vs. 2.4%, p=0.0005), 3-year (7.6 vs. 5.5%, p<0.001) and 5-year follow-up (11.5 vs. 8.8%, p<0.001) when compared to the B-Sm. 76,837 recipients received ATG induction therapy, 51,745 (72.4%) were on steroid maintenance therapy (A-Sm) and 25,092 (32.6%) were on a steroid-free regimen (A-Sf). The graft failure rate was significantly higher in A-Sf compared to A-Sm at 1-year follow-up (2.6 vs. 2.3%, p=0.0006), however, there was no difference at 3-year (5.0 vs. 5.0%, p=0.53) or 5-year follow-up (7.2 vs. 8.1%, p=0.17). There was no difference in mortality rates between A-Sf vs. A-Sm at 1 year (2.5 vs. 2.4%, p=0.98) and at 3 years (5.5 vs. 5.4%, p=0.45), respectively. Patients who were maintained on steroids after basiliximab induction had better 5-year allograft survival and patient survival compared to those who were not maintained on steroids. However, steroid maintenance conferred no additional benefit after ATG induction and was associated with higher mortality.

Postoperative Care and Outcomes in Solid-Organ Transplant Patients Undergoing Lower Extremity Fracture Treatment.

To determine the postoperative outcomes in solid-organ transplant (SOT) patients undergoing operative treatment of lower extremity fractures. Retrospective comparative study. Academic Level 1 trauma center. Patients who underwent SOT and operative treatment of lower extremity fracture from 2013 to 2021 were identified, excluding pathologic fractures. Postoperative complications, length of stay, time to death, 90-day and 1-year readmission rates, readmission causes, discharge location, and immunosuppressive regiments. Sixty-one patients with an average age of 67 years (range 29-88) were included. The mortality rate was 37.7%. The average follow-up was 15.2 months (range of 2 weeks-10 years). The majority of patients (32.8%) had received a liver transplant, and femoral neck fractures constituted the largest fracture group. The average length of stay was 10 days, with the shortest being 1 day and the longest being 126 days (SD 18). The majority of patients (57.3%) were not discharged home. Only 2 suffered from a postoperative complication requiring another procedure: hardware removal and liner exchange for periprosthetic joint infection, respectively. There was a 27.9% 90-day readmission rate with 2 deaths within that period with the most common being altered mental status (29.4%), genitourinary infections (17.6%), repeat falls (11.8%), and low hemoglobin requiring transfusion (11.8%). The longest average time to death analyzed by transplant type was found among lung transplant patients (1076 days, 62.5% mortality), followed by liver transplant patients (949 days, 35.0% mortality), and then kidney transplant patients (834 days, 38.9% mortality). The shortest time to death was 71 days from index procedure. Family members of SOT patients undergoing operative treatment of lower extremity fractures should be made aware of the high risk for 90-day readmission postoperatively (27.9%) and overall mortality (12.5%). Providers should be aware of the need for multidisciplinary involvement for inpatient care, monitoring postoperative complications, and facilitating discharge planning. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Are drain essentials in kidney transplantation? Analysis of risk factors affecting the postoperative drainage

ObjectiveThe routine drain placement following renal transplantation is currently under debate. Its benefit is uncertain and may cause complications, particularly infectious ones. Some renal transplant patients have low-productive drains, that might be unnecessary. The objective of this study is to bring to light factors influencing drain volume in kidney transplantation. Materials and methodsAll kidney transplant patients in Tours between 2019 and 2020 were included. The characteristics of the two groups were analyzed: patients with low-productive redons (quantification less than 100mL/24h,) and patients with productive redons (≥ 100mL/24h). Univariate and multivariate analyses by logistic regression were performed to look for risk factors associated with productive drainage. ResultsOne hundred and eighty-nine patients were included (67 in the low-productive group and 122 in the productive group). The results in the productive group showed a significantly higher proportion of retransplantation (P=0.015), overweight (P=0.012), low residual diuresis (P=0.041), and a significantly lower proportion of preemptive transplantation (P=0.008) and peritoneal dialysis (P=0.037). After an adjustment, the following variables remained significantly associated with greater drainage: overweight (OR=2.42, P=0.014; 95% CI [1.2–4.94]); retransplantation (OR=3.98, P=0.027; 95% CI [1.27–15.45]), and preemptive transplant (OR=0.22, P=0.013; 95% CI [0.06–0.7]). ConclusionThe non-implementation of a redon in renal transplantation could be considered, in a selected population of non-overweight patients, with significant residual diuresis for a first transplantation which should be preemptive. This could lead to a randomized controlled trial to determine the real benefits of a routine drain replacement in kidney transplantation. Level of evidenceIV.

Mediating role of inner strength in the relationship between medication literacy and medication adherence among kidney transplant patients.

Compared with long-term renal replacement therapy, kidney transplantation is the ideal treatment for end-stage renal disease (ESRD), significantly extending patient life and improving quality of life. Kidney transplant patients need to adhere to lifelong immunosuppressive medication regimens, but their medication adherence is generally poor compared with other organ transplant recipients. Medication adherence is closely related to medication literacy and psychological status, yet related studies are limited. This study aims to investigate the current status of medication adherence, inner strength, and medication literacy in kidney transplant patients, analyze the relationships among these 3 factors, and explore the mediating role of inner strength in the relationship between medication literacy and medication adherence. A cross-sectional survey was conducted from March to October 2023 involving 421 patients aged≥18 years who visited kidney transplantation outpatient clinics at 4 tertiary hospitals in Hunan Province. The inner strength, medication literacy, and medication adherence of kidney transplant patients were investigated using the Inner Strength Scale (ISS), the Chinese version of the Medication Literacy Assessment in Spanish and English (MedLitRxSE), and the Chinese version of the Morisky Medication Adherence Scale-8 (C-MMAS-8), respectively. Univariate analysis was performed to examine the effects of demographic and clinical data on medication adherence. Correlation analysis was conducted to explore the relationships among medication literacy, medication adherence, and inner strength. Significant variables from univariate and correlation analyses were further analyzed using multiple linear regression, and the mediating effect of inner strength was explored. Among the 421 questionnaires collected, 408 were valid, with an effective rate of 96.91%. The scores of C-MMAS-8, MedLitRxSE, and ISS were 6.64±1.16, 100.63±14.67, and 8.47±4.03, respectively. Among the 408 patients, only 86 (21.08%) patients had a high level of medication adherence, whereas 230 (56.37%) patients had a medium level of medication adherence, and 92 (22.55%) patients had poor medication adherence. Univariate analysis indicated that the kidney transplant patients' age, marital status, education levels, years since their kidney transplant operation, number of hospitalizations after the kidney transplant, and adverse drug reactions showed significant differences in medication adherence (all P<0.05). Correlation analysis showed that inner strength positively correlated with both medication literacy (r=0.183, P<0.001) and medication adherence (r=0.201, P<0.001). Additionally, there was a positive correlation between medication adherence and medication literacy (r=0.236, P<0.001). Inner strength accounted for 13.22% of the total effect in the mediating role between medication literacy and medication adherence. The level of medication adherence among kidney transplant patients needs improvement, and targeted intervention measures are essential. Inner strength mediates the relationship between medication literacy and medication adherence in these patients. Healthcare professionals should focus on enhancing medication literacy and supporting patients' inner strength to improve medication adherence.

Prevalence of proteinuria after living donor kidney transplantation and related risk factors: A retrospective cohort study from Syria

Introductionproteinuria is associated with poor allograft and patient survival in kidney transplant recipients (KTRs). This study aims to investigate the prevalence and risk factors of proteinuria in KTRs and its impact on kidney function during the first two years after kidney transplantation (KT). Materials and methods200 KTRs were included in this retrospective cohort study from living donors, performed in two University hospitals in Syria, from January 2018 to March 2021. Demographic and immunological characteristics were analyzed depending on the 24 h urine protein (Up) excretion that was classified into three groups: Up I (150–500 mg/day), Up II between (0.5–1 g/day), and Up III (>1 g/day). ResultsUp was increased subsequently as the transplant progressed, where the greatest excretion of the Up was reported 2 years after KT. At 6 months after KT; the cold ischemic time (CIT), serum creatinine (Cr), using angiotensin-converting enzyme inhibitors (ACEIs)/ angiotensin II receptor blockers (ARBs), and GFR showed strong significant differences between Up groups (P = 0.00003, 0.0001, 0.00001, and 0.026; respectively). The CIT and Cr were higher in the Up III group compared to Up I and UP II groups. At 12 months after KT; Cr, using ACEIs/ARBs, and GFR showed strong significant differences between Up groups (P = 0.00009, <0.0001, and <0.0001; respectively). The mean Cr was higher in Up II and Up III groups (1.7 mg/dL; for each) compared to the Up I group (1.0 mg/dL). At 24 months after KT; CIT, using ACEIs/ARBs, Cr, and GFR showed strong significant differences between Up groups (P = 0.02, <0.0001, 0.00008, and <0.0001; respectively). ConclusionThis is the first study from Syria that conducted in KT patients. The prevalence and amount of proteinuria showed subsequently increased as the transplant progressed. Serum Cr, GFR, CIT, and using ACEIs/ARBs showed differences between Up groups at 6 months, 1 year, and 2 years after KT. Our data suggest that the use of ACEIs/ARBs is not a contraindication in early posttransplant period. Due to several known cardiovascular and renal benefits of ACEIs/ARBs future studied in KT population should investigated to determine if these drugs could give beneficial effects on grafts and patients survival.

Silent Hearing Loss in Kidney Transplant Patients Receiving Tacrolimus: A Fact or a Myth?

Background: It has been claimed that tacrolimus may have harmful effects on the auditory system, where it has been linked to ototoxicity and sensorineural hearing loss (SNHL). We evaluated silent SNHL in kidney transplant recipients (KTRs) receiving tacrolimus and the different factors affecting it compared to healthy controls. Materials and Methods: In this case control study, hearing functions were studied in 42 KTRs receiving tacrolimus as maintenance immunosuppressive therapy for more than 3 months in comparison to 27 age- and gender-matched healthy subjects using tympanometry, pure-tone audiometry (PTA), extended high frequency audiometry (EHFA), and transient evoked oto-acoustic emissions (TEOAEs). Also, different factors were studied in relation to SNHL. Results: PTA showed that 23.8%, 21.4%, and 4.8% had mild, moderate, and severe SNHL, respectively. One-fifth of KTRs had severe SNHL, according to EHFA. According to TEOAEs, 28.6% of KTRs had abnormal hearing. There was a significant positive correlation between the tacrolimus trough levels and the results of both the PTA (P = 0.002) and EHFA (P = 0.035) tests. Conclusion: SNHL was detected in about half of the studied KTRs. Silent SNHL in KTRs might be associated with higher tacrolimus trough levels.

Safe immunosuppression. New tool for personalized immunosuppressant treatment in renal transplantation. A case report

Background: The adjustment of immunosuppressive therapy after kidney transplantation (KT) to avoid graft rejection remains an important challenge for clinicians. It is difficult to achieve a good balance between under-immunosuppression (with an increased risk of graft rejection) and over-immunosuppression (with an increased risk of side effects) by only relying on the available information about immunosuppressive drugs (IMS). Immunobiogram® (IMBG) is a novel in vitro diagnostic test that provides clinicians with information about the patient’s sensitivity to individual IMS. Objective: To present a case report of a patient with renal transplant in the maintenance phase who presented several complications probably related to the immunosuppression during the follow-up, where the use of IMBG as complementary information helped clinicians to guide the therapeutical decision. Methods: IMBG is a first-in-class in vitro immunoassay that involves the culture of the patient peripheral blood mononuclear cells (PBMCs) in a semi-solid 3D matrix, then submitted to immune stimulation. It reveals the capacity of an IMS over a gradient to inhibit the activation of immune cells. The read-out allows the building of a dose-response curve per IMS tested, which is mathematically analyzed by a software using the key curve parameters and finally to be translated into a sensitivity map to IMS. Findings: We present a case report of a 72-year-old patient with a cadaveric donor kidney transplant receiving standard immunosuppressive treatment with mycophenolate, tacrolimus, and corticosteroids. The patient presented several episodes of infections during the follow-up (SARS-CoV2, Cytomegalovirus, spondylodisquitis by Staphylococcus aureus, and emphysematous cystitis) which were managed with different treatment adjustments such as de-escalation of mycophenolate and switching to mTOR. The information provided by the IMBG showed a lack of sensitivity to mTOR which allowed to confirm the final adjustment to a treatment with tacrolimus and corticosteroids, remaining the patient stable since then. Discussion: Despite various adjustments to the immunosuppressive therapy during the follow-up, the patient continued experiencing adverse effects that could be related to an over-immunosuppression state. The IMBG provided pharmacodynamic information that complemented the clinical and pharmacokinetic data available, facilitating the individualization of the treatment. Conclusion: The case highlights the potential of the IMBG as a complementary clinical tool for personalized treatment of kidney transplant patient management.