Management Of Kidney Transplant Recipients Research Articles

The Role of Vitamin D Metabolism Genes and Their Genomic Background in Shaping Cyclosporine A Dosage Parameters after Kidney Transplantation.

Background: Kidney transplantation is followed by immunosuppressive therapy involving calcineurin inhibitors (CNIs) such as cyclosporin A. However, long-term high CNIs doses can lead to vitamin D deficiency, and genetic variations influencing vitamin D levels can indirectly impact the necessary CNIs dosage. This study investigates the impact of genetic variations of vitamin D binding protein (DBP) rs2282679 and CYP2R1 hydroxylase rs10741657 polymorphisms on the cyclosporin A dosage in kidney transplant recipients. Additional polymorphisims of genes that are predicted to influence the pharmacogenetic profile were included. Methods: Gene polymorphisms in 177 kidney transplant recipients were analyzed using data mining techniques, including the Random Forest algorithm and Classification and Regression Trees (C&RT). The relationship between the concentration/dose (C/D) ratio of cyclosporin A and genetic profiles was assessed to determine the predictive value of DBP rs2282679 and CYP2R1 rs10741657 polymorphisms. Results: Polymorphic variants of the DBP (rs2282679) demonstrated a strong predictive value for the cyclosporin A C/D ratio in post-kidney transplantation patients. By contrast, the CYP2R1 polymorphism (rs10741657) did not show predictive significance. Additionally, the immune response genes rs231775 CTLA4 and rs1800896 IL10 were identified as predictors of cyclosporin A response, though these did not result in statistically significant differences. Conclusions:DBP rs2282679 polymorphisms can significantly predict the cyclosporin A C/D ratio, potentially enhancing the accuracy of CNI dosing. This can help identify patient groups at risk of vitamin D deficiency, ultimately improving the management of kidney transplant recipients. Understanding these genetic influences allows for more personalized and effective treatment strategies, contributing to better long-term outcomes for patients.

Interstitial Foci Expression of Indoleamine 2,3-Dioxygenase 1: A Potential Biomarker for Kidney Transplant Rejection.

(1) Background: Kidney transplantation is the best therapy for patients with end-stage renal disease, but the risk of rejection complicates it. Indoleamine 2,3-dioxygenase 1 (IDO1), an enzyme involved in immune response modulation, has been suggested to play a role in transplant immunological injury. The aim of the study was to explore the expression of IDO1 in the interstitial foci of transplanted kidneys and its potential association with rejection episodes. (2) Methods: This retrospective study analysed kidney transplant biopsies from 121 patients, focusing on IDO1 expression in interstitial foci. Immunohistochemistry was used to detect IDO1, and patients were categorised based on IDO1 presence (IDO1-IF positive or negative). The incidence of rejection was compared between these groups. (3) Results: Patients with IDO1 expression in interstitial foci (IDO1-IF(+)) exhibited higher incidences of rejection 46/80 (57.5%) vs. 10/41 (24.34%) patients compared to IDO1-IF(-) patients, which was statistically significant with p = 0.0005. The analysis of antibody-mediated rejection showed that IDO1-IF(+) patients developed AMR at 12/80 (15%), while only 1 IDO1-IF(-) negative patient did (2,44%), with p = 0.035. T-cell-mediated rejection was also more common in IDO1-IF(+) patients 43/80 (53.75%) than in IDO1-IF(-) patients 7/41 (17.07%), with p = 0.0001. (4) Conclusions: IDO1 expression in interstitial foci of renal transplant biopsies is associated with a higher incidence of rejection, suggesting that IDO1 could serve as a potential biomarker for transplant rejection. These findings highlight the importance of IDO1 in immune regulation and its potential utility in improving the management of kidney transplant recipients.

Management of kidney transplant recipients for primary care practitioners.

Patients with kidney transplants have a significant co-morbidity index, due to a high number of pre-existing conditions and use of immunosuppression medications. These patients are at higher risk of developing conditions such as hypertension, dyslipidemia, post-transplant diabetes, cardiovascular events, and anemia. Moreover, they are particularly susceptible to infections such as urinary tract infections or pyelonephritis, cancers, and gastrointestinal complications such as diarrhea, which in turn may be attributed to medication adverse effects or infectious causes. Along with these concerns, meticulous management of electrolytes and allograft function is essential. Prior to prescribing any new medications, it is imperative to exercise caution in identifying potential interactions with immunosuppression drugs. This review aims to equip primary care practitioners to address these complex issues and appropriate methods of delivering care to this rapidly growing highly susceptible group.

Study of therapeutic patient education practices in French renal transplantation centres

ObjectivesTherapeutic patient education (TPE) plays a critical role in the management of kidney transplant recipients. However, discrepancies exist in the guidance provided regarding the usage of immunosuppressants across different kidney...

Outcomes and management of kidney transplant recipients with Fabry disease: a review.

Fabry disease is an X-linked inheritable lysosomal storage disease caused by various mutations of the galactosidase α gene resulting in α-galactosidase deficiency. Chronic kidney disease (CKD) is one of the most significant consequences of Fabry disease,with risk of end-stage kidney disease (ESKD) in this population. Like forother patients with ESKD, kidney transplant is the optimal treatment for Fabry disease patients with ESKD. However, enzyme replacement therapy and newer Fabry disease treatments remain important to mitigate other end organ damage such as cardiomyopathy post transplantation. This review is a primer on Fabry disease, which examines the outcomes of disease in the context of kidney transplant prior to, and during, the enzyme replacement treatment era, medical treatment of kidney transplant recipients with Fabry disease, and progress in screening studies.

The Use of Diffusion Tensor Imaging in the Identification of Acute Rejection and Chronic Allograft Nephropathy After Renal Transplantation.

Identifying the cause of renal allograft dysfunction is important for the clinical management of kidney transplant recipients. To evaluate the diagnostic efficiency of diffusion tensor imaging (DTI) for identifying allografts with acute rejection (AR) and chronic allograft nephropathy (CAN). Prospective. Seventy-seven renal transplant patients (aged 42.5 ± 9.5 years), including 29 patients with well-functioning stable allografts (Control group), 25 patients diagnosed with acute rejection (AR group), and 23 patients diagnosed with chronic allograft nephropathy (CAN group). 1.5 T/T2-weighted imaging and DTI. The serum creatinine, proteinuria, pathologic results, and fractional anisotropy (FA) values were obtained and compared among the three groups. One-way analysis of variance; correlation analysis; independent-sample t-test; intraclass correlation coefficients and receiver operating characteristic curves. Statistical significance was set to a P-value <0.05. The AR and CAN groups presented with significantly elevated serum creatinine as compared with the Control group (191.8 ± 181.0 and 163.1 ± 115.8 μmol/L vs. 82.3 ± 20.9 μmol/L). FA decreased in AR group (cortical/medullary: 0.13 ± 0.02/0.31 ± 0.07) and CAN group (cortical/medullary: 0.11 ± 0.02/0.27 ± 0.06), compared with the Control group (cortical/medullary: 0.15 ± 0.02/0.35 ± 0.05). Cortical FA in the AR group was higher than in the CAN group. The area under the curve (AUC) for identifying AR from normal allografts was 0.756 and 0.744 by cortical FA and medullary FA, respectively. The AUC of cortical FA and medullary FA for differentiating CAN from normal allografts was 0.907 and 0.830, respectively. The AUC of cortical FA and medullary FA for distinguishing AR and CAN from normal allografts was 0.828 and 0.785, respectively. Cortical FA was able to distinguish between AR and CAN with an AUC of 0.728. DTI was able to detect patients with dysfunctional allografts. Cortical FA can further distinguish between AR and CAN. 2 TECHNICAL EFFICACY: Stage 2.

COVID-19 Infection in Kidney Transplant Recipients: Single-Center Study

Introduction : Renal transplant recipients receiving chronic immunosuppression have been considered a population at high risk for infections, complications and death related to COVID-19 infection. Results: The average age of the patients was 37.3 ± 12.1 years, with a male predominance (65.9%). At least one comorbidity was observed in 41% of patients; obese (27.3%), diabetics (20.5%), cardiovascular diseases (6.8%), and cancers (2.2%). 90.1% of patients were hospitalized, of which 10% were admitted to the intensive care unit. Of the hospitalized patients, 10% died. Antimetabolites were reduced in 91% and stopped in 9% of patients. Calcineurin inhibitors were discontinued in 11.3% of patients. Hydroxychloroquine was administered in 23 patients (52.3%), antivirals in one patient (2.3%) and antibiotics in 56.8% of cases. Conclusion: Close monitoring of kidney transplant recipients is required during a pandemic due to a high mortality rate. The management of kidney transplant recipients has been difficult for clinicians and strategies are not based on high quality evidence.

Torque teno virus viremia and QuantiFERON®-CMV assay in prediction of cytomegalovirus reactivation in R+ kidney transplant recipients.

Cytomegalovirus (CMV) is the most frequent infectious complication following solid organ transplantation. Torque teno viruses (TTV) viremia has been proposed as a biomarker of functional immunity in the management of kidney transplant recipients (KTR). The QuantiFERON®-CMV (QF-CMV) is a commercially available assay that allows the assessment of CD8+ T-cell responses in routine diagnostic laboratories. In a prospective national multicenter cohort of 64 CMV-seropositive (R+) KTR, we analyzed the value of TTV load and the two markers of the QF-CMV assay [QF-Ag (CMV-specific T-cell responses) and QF-Mg (overall T-cell responses)], alone and in combination, in prediction of CMV reactivation (≥3 log10 IU/ ml) in the first post-transplant year. We compared previously published cut-offs and specific cut-offs optimized from ROC curves for our population. Using the conventional cut-off (3.45 log10 copies/ml), TTV load at D0 [inclusion visit on the day of transplantation before induction (D0)], or at M1 (1-month post-transplant visit) perform better in predicting CMV viremia control than CMV reactivation. Survival analyses suggest a better performance of our optimized TTV cut-offs (3.78 log10 copies/ml at D0 and 4.23 log10 copies/ml at M1) for risk stratification of CMV reactivation in our R+ KTR cohort. The QF-CMV (QF-Ag = 0.2 IU/ml, and QF-Mg = 0.5 IU/ml) also appears to better predict CMV viremia control than CMV reactivation. Moreover, survival analyses suggest that the QF-Mg would perform better than the QF-Ag in stratifying the risk of CMV reactivation. The use of our optimized QF-Mg cut-off (1.27 IU/ml) at M1 further improved risk stratification of CMV reactivation. Using conventional cut-offs, the combination of TTV load and QF-Ag or TTV load and QF-Mg did not improve prediction of CMV viremia control compared to separate analysis of each marker but resulted in an increase of positive predictive values. The use of our cut-offs slightly improved risk prediction of CMV reactivation. The combination of TTV load and QF-Ag or TTV load and QF-Mg could be useful in stratifying the risk of CMV reactivation in R+ KTR during the first post-transplant year and thereby have an impact on the duration of prophylaxis in these patients. ClinicalTrials.gov registry, identifier NCT02064699.

Continuous Erector Spinae Plane Analgesia in Kidney Transplant Recipients: A Quality Improvement Project.

Introduction Pain management in patients with chronic kidney disease is challenging. Due to impaired kidney function, analgesic options are limited.Postoperative analgesia in transplant recipients is further complicated by their vulnerability to infections, titrated fluid managementand optimal haemodynamics to maintain graft function.Erector spinae plane (ESP) blocks have been used successfully in a variety of surgeries. This study is a quality improvement project aiming to assess the efficacy ofcontinuous erector spinae plane catheter analgesia in the postoperative management of kidney transplant recipients. Methods We conducted an initial audit over a period of three months. All patients who underwent kidney transplantation under general anaesthesia with erector spinae plane catheters were included. Erector spinae plane catheters were secured prior to induction, and continuous local anaesthetic infusion was maintained postoperatively. Pain scores using the numerical rating scale (NRS) were recorded at intervals in the first 24 hours postoperatively, and supplementary analgesicsgiven were noted.Following satisfactory results from the initial audit, we implemented erector spinae planecatheters as part of multimodal analgesia in transplant patients in our centre. We re-audited all transplants done over the next year to reassess the quality of postoperative analgesia. Results Five patients were audited during the initial audit.The average NRS score ranged from 0 at rest to a maximum of 5 during mobilisation. All patients were given only paracetamol to supplement analgesia, and none required opioids.During the re-audit, data was collected on postoperative pain management in 13 subsequent transplants conducted over the nextyear.The NRS scores ranged from 0 at rest to 6 on mobilisation. Two patients required boluses of fentanyl 25 mcg via the catheter, and the rest reported satisfactory analgesia with paracetamol as needed. Conclusion This quality improvement project changed our centre's practice in managing postoperative pain in kidney transplantations. We switched from securing epidural catheters to erector spinae plane catheters due to better safety profile, minimal use of opioids and lesser adverse effects. We shall continue to re-audit our practices for the best outcomes.

ODP191 Efficacy of Protocol Based Insulin Dosing in Post-Surgical Hyperglycemia Management of Kidney Transplant Recipients

Abstract Background Post-operative renal transplant recipients with diabetes mellitus are managed by ad hoc insulin regimen which is highly variable among providers and transplant centers. We implemented a standardized insulin dosing protocol after renal transplantation based on several key variables particularly post-transplant steroid use. Methods The standardized insulin dosing protocol was implemented on July 1st, 2020. Patients with a history of diabetes mellitus who underwent renal transplants from July 2020-July 2021 were reviewed. After being seen by the endocrinology consultation service, a weight-based insulin dosing protocol based on corticosteroid dose was started and continued for 5 days postoperatively. As a control, data from patients who underwent renal transplantation between January 2019 to December 2019, and were seen by endocrinology for post-op hyperglycemia management, was collected in an identical fashion. Results The post protocol implementation group (N=39) had an average age of 59.6 and of BMI 31 kg/m2 with the majority being type II diabetes mellitus (84%). The control group (N=40) had an average age of 60.4 and BMI of 33 kg/m2. Type II diabetes mellitus similarly represented at 82%. Post-op inpatient target blood glucose was 101-180. Fasting and postprandial blood glucose (BG) data were gathered after chart review. Five hundred fifty-five fasting blood glucose (FSBG) checks were included for post protocol group vs 628 for the control group. Blood glucose was within the target range 37.8% for the protocol group and 28.9% for the control group. There were 8 (1.4%) hypoglycemic episodes (BG &amp;lt;70) in intervention group vs 5 (0.79%) in control group. Hyperglycemia was stratified into 3 tiers: 181-220, 221-300, &amp;gt;300. Hyperglycemia (BG 241-300) was observed 14.9% in the post protocol group vs 22.7%. Severe hyperglycemia (BG&amp;gt;300)was documented in 7.3% post protocol vs 15.6%. Among the post protocol group, no patient was started on insulin drip whereas 5 patients were started on insulin drip in the control groups. Conclusion Renal transplantation patients are susceptible to hypo- and hyperglycemic events leading to poor graft outcomes. Glycemic control is central in reducing event rates. Post renal transplantation diabetes management using a graded insulin protocol in accordance with steroid dosing was highly efficacious in our academic medical center. Using a standardized insulin protocol patients demonstrated superior glucose control and less IV insulin usage. Presentation: No date and time listed

P2.03: Dynamic Kidney Rejection Risk Prediction Using Serial Donor Derived Cell Free DNA.

Background: Donor-derived cell free DNA (ddcfDNA) has evolved as a non-invasive biomarker for monitoring kidney transplant patients for rejection. Trends in ddcfDNA over time may help predict important outcomes for the allograft. We examined samples from subjects enrolled in the CTOT08 clinical trial (NCT01289717) to determine the ability of joint modeling to dynamically predict rejection episodes (clinical and subclinical) in kidney transplant recipients. Methods: Serial blood samples collected in the first two years post-transplant were analyzed for ddcfDNA using the TRAC test (Eurofins – Viracor, Lees Summit, MO). We used the joint modeling method to model the trend of serial ddcfDNA scores to predict the 2-year rejection-free probability. We pre-defined 4 time points post-transplant and dynamically plotted two illustrative patient’s 2-year event-free probability via the joint modeling method. Results: The figures depicting the predicted event-free probability are presented as below. The two patients have very similar predicted 2-year event-free probability based on their serial TRAC score up to 0.17-years post transplant. Moving forward in time, the predicted probability starts to diverge for these two patients. One patient has stable ddcfDNA scores below 0.5% up to year 0.75. The patient’s predicted 2-year event-free probability increases over time. At 0.5-year post transplant, the predicted event-free probability is 0.621 [0.503, 0.737]. While for the other patient, their ddcfDNA score is relatively high and continues to increase. The second patient has a lower 2-year event-free probability. At 0.5-year post transplant, the predicted event-free probability is 0.548 [0.360, 0.702]. The second patient went on to have a rejection episode at 0.86 months post-transplant. Discussion: Plasma ddcfDNA is evolving as both a diagnostic and a prognostic biomarker in the management of kidney transplant recipients. Using joint modeling, we were able to develop a dynamic risk prediction model for future rejection episodes in patients. Future applications include further validation and eventually defined interventions such as immunosuppression titration to reduce the risk of future rejection episodes.

Costs of Treatment of Acute Antibody-Mediated Rejection in Kidney Transplant Recipients

Antibody-mediated rejection (AMR) remains challenging in kidney transplant recipients. It may negatively impact the graft survival, and its treatment is associated to relatively high expenses. The aim of our study was to assess the costs of treatment of acute AMR in the Polish settings. A total of 11 kidney transplant recipients with acute AMR diagnosed between September 2016 and August 2019 and treated in our center were included. Direct costs of inpatient and outpatient care in the first year after AMR diagnosis from the perspective of a transplant center were retrospectively calculated. The costs of treatment of acute AMR were considerably high, with a mean 1-month cost of treatment 12,718 PLN (∼€2925; ∼3307 US dollars). That means that costs of management of kidney transplant recipients with acute AMR are almost 2-fold higher than hemodialysis. Intravenous immunoglobulin was responsible for the majority (55%) of costs. Treatment of acute AMR increases the costs of post-kidney transplant care in involved patients. Therefore, efforts should be made to minimize the risk for acute AMR. Despite its potential clinical benefits, management of acute AMR is even more expensive than dialysis. Therefore, further cost-effectiveness analyses are needed to justify the spending and to establish the best treatment regimens.

Coronavirus disease 2019 and renal transplantation.

Ever since the severe acute respiratory syndrome virus causing coronavirus disease 2019 (COVID-19) struck the world, global health strategies have changed significantly. According to the Centers for Disease Control and Prevention, kidney transplant recipients are stratified as being high risk of developing fatal illness from COVID-19 infection. Kidney transplant is the gold-standard treatment for end-stage kidney disease subjects. During the pandemic, significant concerns have emerged regarding continuation of kidney transplant surgeries and management of kidney transplant recipients post-transplant. The added risk of immunosuppression in this cohort was and remains a theoretical concern, posing a potential risk of transplantation rather than benefit. This comprehensive review aims to cover most of the faced challenges in kidney transplantation in different stages of the pandemic. In addition, it will elucidate the epidemiology, nature, course of the disease, surgical consideration in donors and recipients as well as role of immunosuppression and management of COVID-19 infected kidney transplant recipients during these extraordinary circumstances.

SARS-CoV-2 Infection After Full Vaccination in Kidney Transplant Recipients.

Since the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), several vaccines have been developed and approved for human use in the United States and Europe.1 In our center, coronavirus disease 2019 (COVID-19) vaccination of kidney transplant recipients (KTRs) started in February 2021, with about 800 KTRs fully vaccinated in May 2021. Among the different vaccines, mRNA vaccines BNT162b2 (Pfizer/BioNTech) and mRNA-1273 (Moderna) have demonstrated an effectiveness of up to 95% in preventing COVID-19 in immunocompetent population. However, the effectiveness in KTRs to induce an immunological response has been reported to be significantly lower (up to 65%), and information about the risk and severity of a postvaccination COVID-19 is scarce in these patients.1-6 Herein, we describe 21 cases of KTRs (20 KTRs and 1 simultaneous pancreas-kidney recipient) who developed a polymerase chain reaction–proven COVID-19 after a full vaccination course. The study was approved by the ethics committee from our center. From the 21 KTRs, 2 patients (9%) received a 2-dose regimen of the BNT162b2 vaccine and 19 (91%) the mRNA-1273 vaccine. Only 1 patient (5%) developed SARS-CoV-2 immunoglobulin G antibodies after vaccination (which were assessed >15 d after the second dose). All patients were diagnosed with COVID-19 through a nasopharyngeal swab after a mean time of 84.71 ± 27.43 d from the second vaccine dose (52% with pneumonia). SARS-CoV-2 variants could be determined in 5 patients: 2 patients were infected with the Alpha variant and 3 with the Delta one. Table 1 summarizes demographic, transplantation immunosuppression, and COVID-19 characteristics of the analyzed patients. Two patients (9%) were asymptomatic. TABLE 1. - Demographic, transplantation, and COVID-19 characteristics of the analyzed patients Kidney transplant recipients (n = 21) Gender, male 9 (43) Age at COVID-19 diagnosis, y 57.61 ± 11.96 Transplant type Kidney transplant 20 (95) Simultaneous pancreas-kidney transplant 1 (5) Time from transplant to COVID-19 diagnosis, y 3.79 (1.83–13.12) Induction immunosuppression No induction 6 (29) Basiliximab 6 (29) Thymoglobulin 9 (42) Maintenance immunosuppression Tacrolimus 21 (100) Mycophenolate 15 (71) Everolimus 6 (29) Prednisone 21 (100) SARS-CoV-2 vaccine BNT162b2, Pfizer/BioNTech 2 (9) mRNA-1273, Moderna 19 (91) SARS-CoV-2 IgG antibodies after vaccination, yes 1 (5) Time from second vaccine dose to COVID-19 diagnosis, d 84.71 ± 27.43 SARS-CoV-2 variant Alpha 2 (9) Delta 3 (14) Symptoms at COVID-19 diagnosis Asymptomatic 2 (9) Fever 16 (76) Cough 11 (52) Dyspnea 8 (38) Diarrhea 4 (19) Patient hospital admission, yes 11 (52) ICU admission with MV, yes 6 (29) COVID-19 treatment Dexamethasone 6 (29) Remdesivir 5 (24) Remdesivir plus baricitinib 1 (5) Remdesivir plus anakinra 1 (5) Tocilizumab 3 (14) ≥1 immunosuppressant withdrawn, yes 16 (76) Patient outcomes Discharged 13 (62) Dead 1 (5) Hospital stay, d 11 (7–20) Data are presented as mean ± SD, median (IQR), or n (%), unless otherwise specified.COVID-19, coronavirus disease 2019; ICU, intensive care unit; IgG, immunoglobulin G; IQR, interquartile range; MV, mechanical ventilation; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. Regarding patient management, 11 patients (52%) required hospital admission, and 7 (33%) required intensive care unit (ICU) admission with the need for mechanical ventilation in 6. Ten (48%) were managed as outpatients (Table 1). Of the 21 patients, 1 (5%) died, 7 (33%) are still admitted (5 of them in the ICU), and 13 (62%) have been already discharged. Current median hospital stay is 11 (7–20) d. With this letter, we would like to provide preliminary information about a single-center kidney transplant population in Spain after a full COVID-19 vaccination regimen and reinforce the apparently less efficient immunization effect that COVID-19 vaccines provide in KTRs and the need to vaccinate their close relatives, as well as to still maintain precautions against COVID-19 in this population (especially against the Delta variant), even after full vaccination course. Nevertheless, actual hospital and ICU admission rates are lower compared with a nonvaccinated cohort of KTRs (79% and 52% for hospital and ICU admission, respectively) from our center. Larger studies are needed to provide robust information on the prognosis and management of KTRs with COVID-19 after vaccination, as well as the potential need for a third dose to increase the immunization rate.

Prevalence and causes of graft dysfunction in first 3 months after kidney transplantation in Erbil transplant center

Graft dysfunction after kidney transplantation occur due to different causes. Diagnosis of graft dysfunction is a key component in the management of kidney transplant recipients. The aim of this study was to identify the causes of graft dysfunction in the first 3 months after kidney transplant by kidney biopsy for better graft survival. A total number of 250 patients who underwent renal transplantation at the Erbil teaching center from January 2020 to December 2020 were considered for this study. 50 biopsies were performed due to renal graft dysfunction in the first 3 months post-transplant. Descriptive statistics were analyzed using IBM SPSS Statistics software version 22.0. The biopsy results showed that acute cellular rejection (ACR) was observed in 21 patients (42%), acute interstitial nephritis (AIN) was found in 16 patients (32%), acute tubular necrosis (ATN) was occurred in 9 patients (18%), calcineurin inhibitor toxicity (CNI) was observed in 2 patients (4%), acute humoral rejection (AHR) was found in 1 patient (2%) and thrombotic microangiopathy (TMA) was occurred in 1 patient (2%). As a conclusion, the most important causes of graft dysfunction were ACR, AIN and ATN, respectively. Also, glomerulonephritis, diabetes and hypertension are the most risk factor for ESRD. In addition, the results of this study showed that Anti-HLA cross match can be used as an indicator for predicting the result of transplantation. Keywords: graft dysfunction, Kidney transplantation, acute cellular rejection, acute interstitial nephritis

Early perioperative fluid overload is associated with adverse outcomes in deceased donor kidney transplantation.

Kidney transplant recipients are often treated with a large volume of infusion to attain adequate graft perfusion in the early perioperative period. However, it remains unknown whether this fluid therapy is renal responsive or a contributing factor to fluid overload complications. We conducted a retrospective cohort analysis of all recipients who received deceased donor kidney transplantation at an academic teaching hospital from January 2015 to April 2019. Our exposure of interest was early perioperative fluid balance. The primary outcome was graft function at 1, 6, and 12months after transplantation. The secondary outcome was cardiopulmonary and gastrointestinal complications. Fluid balance was not significantly correlated with graft function in short- or long-term periods. Postoperative complications were higher in recipients with increased fluid balance. Delayed graft function was significantly related to cardiopulmonary and gastrointestinal complications. Cardiovascular disease and high BMI of recipients were strong risk factors for cardiopulmonary complications. Fluid overload was prevalent in the early perioperative period of kidney transplantation. It did not promote renal recovery, but was associated with a high risk of complications. Our findings might be a useful indicator to optimize the perioperative fluid management of kidney transplant recipients.

Liquid biopsies: donor-derived cell-free DNA for the detection of kidney allograft injury.

In kidney transplantation, the use of minimally invasive damage biomarkers that are more sensitive and specific than plasma creatinine will be crucial to enable early, actionable detection or exclusion of structural kidney damage due to acute or chronic rejection. Donor-derived cell-free DNA (dd-cfDNA), which can be quantified, for example, through next-generation sequencing, droplet digital PCR and quantitative PCR, is a candidate biomarker with great potential for enabling comprehensive monitoring of allograft injury. dd-cfDNA has a favourable overall diagnostic performance for the detection of rejection and its high negative predictive value might be especially useful for avoiding unnecessary biopsies. Elevated dd-cfDNA levels have been shown to be detectable before graft injury can be clinically identified using current diagnostic methods. Moreover, dd-cfDNA falls rapidly to baseline levels after successful treatment for rejection owing to its short half-life. dd-cfDNA can detect graft injury caused by immune activation owing to insufficient immunosuppression and might therefore also help guide immunosuppression dosing. The fractional abundance of dd-cfDNA can be affected by changes in the recipient cfDNA (for example, due to infection or physical exercise) but the use of absolute quantification of dd-cfDNA overcomes this limitation. Serial dd-cfDNA determinations might therefore facilitate cost-effective personalized clinical management of kidney transplant recipients to reduce premature graft loss.

Coronavirus Disease 2019 and Kidney Transplantation in Saudi Arabia: Outcomes and Future Opportunities.

BackgroundKidney transplant services all over the world were severely impacted by the coronavirus disease 2019 pandemic. The optimum management of kidney transplant recipients with coronavirus disease 2019 remains uncertain.Material/MethodsWe conducted a multicenter cohort study of kidney transplant recipients with coronavirus disease 2019 infection in Saudi Arabia. Multivariable Cox regression analysis was used to study predictors of graft and patient outcomes at 28 days after coronavirus disease 2019 diagnosis.ResultsWe included 130 kidney transplant recipients, with a mean age of 48.7(±14.4) years. Fifty-nine patients were managed at home with daily follow-up utilizing a dedicated clinic, while 71 (54.6%) required hospital admission. Acute kidney injury occurred in 35 (26.9%) patients. Secondary infections occurred in 38 (29.2%) patients. SARS-CoV-2 antibodies testing was carried out in 84 patients, of whom 70 tested positive for IgG and/or IgM. Fourteen patients died (10.8%). A multivariable Cox regression analysis showed that age, creatinine at presentation, acute kidney injury, and use of azithromycin were significantly associated with worse patient survival. Graft loss was associated with requiring renal replacement therapy and development of secondary infections.ConclusionsDespite kidney transplant recipients with coronavirus disease 2019 infection having higher rate of hospital admission and mortality compared to the general population, a significant number of them can be managed using a telemedicine clinic. Most kidney transplant patients seem to mount an antibody response following coronavirus disease 2019 infection, and it remains to be seen if they will have a similar response to the incoming vaccines.

Prevalence and predictors of SARS-CoV-2 antibodies among solid organ transplant recipients with confirmed infection.

It remains uncertain whether immunocompromised patients including solid organ transplant (SOT) recipients will have a robust antibody response to SARS‐CoV‐2 infection. We enrolled all adult SOT recipients at our center with confirmed SARS‐CoV‐2 infection who underwent antibody testing with a single commercially available anti‐nucleocapsid antibody test at least 7 days after diagnosis in a retrospective cohort. Seventy SOT recipients were studied (56% kidney, 19% lung, 14% liver ± kidney, and 11% heart ± kidney recipients). Thirty‐six (51%) had positive anti‐nucleocapsid antibody testing, and 34 (49%) were negative. Recipients of a kidney allograft were less likely to have positive antibody testing compared to those who did not receive a kidney (p = .04). In the final multivariable model, the years from transplant to diagnosis (OR 1.26, p = .002) and baseline immunosuppression with more than two agents (OR 0.26, p = .03) were significantly associated with the antibody test result, controlling for kidney transplantation. In conclusion, among SOT recipients with confirmed infection, only 51% of patients had detectable anti‐nucleocapsid antibodies, and transplant‐related variables including the level and nature of immunosuppression were important predictors. These findings raise the concern that SOT recipients with COVID‐19 may be less likely to form SARS‐CoV‐2 antibodies.

Challenges in the management of kidney transplant recipients in a centre without a kidney transplant program: A single centre experience

Objective: This study is aimed at highlighting the challenges associated with the management of kidney transplant recipients in a centre without a transplant program.Methods: This is a retrospective study that enrolled all post renal transplant patients seen at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, North-western Nigeria between October 2010 and June 2019. Data obtained included cause of renal disease, pre-transplant dialysis details, type of donor, country of the kidney transplant, sponsor, type of maintenance immunosuppression, frequency of follow up, complications and outcome of the kidney transplant. Data obtained was analysed using statistical package for the social sciences software (SPSS) version 25 (IBM Inc. 2010).Results: Of the 16 patients who were enrolled in this study, 10 (62.5%) were males with a mean age of 36.5 ± 13.2 years. Twelve (75%) subjects reported challenges in obtaining their post-transplant immunosuppressants. Only one (6.25%) subject had allograft biopsy despite the fact that 5 (71.4%) out of the 7 patients that died had allograft dysfunction. The majority of the participants (81.3%) had no serum tacrolimus level test done throughout their follow up period.Conclusions: The management of post-transplant recipients in our centre is associated with challenges ranging from difficulty in procurement of post-transplant medications, poor laboratory support for monitoring of drug levels and inadequate facilities for management of allograft dysfunction.&#x0D; Keywords: Kidney transplant; End-stage renal disease; follow-up &#x0D; French Title: Défis dans la prise en charge des receveurs de transplantation rénale dans un centre sans programme de transplantation rénale: Une expérience dans un seul centreIntroduction : Cette étude vise à mettre en évidence les défis associés à la prise en charge des greffés rénaux dans un centre sans programme de transplantation.Méthode de l'étude : Il s'agit d'une étude rétrospective qui a recruté tous les patients après transplantation rénale vus à l'hôpital universitaire Usmanu Danfodiyo (HUUD), Sokoto, dans le nord-ouest du Nigéria entre octobre 2010 et juin 2019. Les données obtenues comprenaient la cause de la maladie rénale, les détails de la dialyse de pré-transplantation, le type du donner, du pays de la transplantation rénale, du promoteur et d'immunosuppression. Les données obtenues ont été analysées à l'aide du progiciel statistique du logiciel de sciences sociales (PSLSS) version 25 (IBM Inc. 2010).Résultat de l'étude : Sur les 16 patients inclus dans cette étude, 10 (62,5%) étaient des hommes avec un âge moyen de 36,5 ± 13,2 ans. Douze (75%) sujets ont signalé des difficultés à obtenir leurs immunosuppresseurs après la transplantation. Un seul sujet (6,25%) a eu une biopsie d'allogreffe malgré le fait que 5 (71,4%) des 7 patients décédés avaient un dysfonctionnement de l'allogreffe. La majorité des participants (81,3%) n'ont eu aucun test du taux de tacrolimus sérique effectué tout au long de leur période de suivi.Conclusion : La gestion des receveurs post-transplantation dans notre centre est associée à des défis allant de la difficulté à se procurer des médicaments post-transplantation, un soutien de laboratoire médiocre pour la surveillance des niveaux de médicaments et des installations inadéquates pour la gestion du dysfonctionnement des allogreffes.&#x0D; Mots-clés: Greffe de rein, phase terminale de la maladie rénale