Outcomes In Kidney Transplant Recipients Research Articles

Elevated Donor-Derived Cell-Free DNA (dd-cfDNA) in the Early Post-Transplant Period Is Associated With an Increased Incidence of Adverse Clinical Outcomes in Kidney Transplant Recipients

Elevated Donor-Derived Cell-Free DNA (dd-cfDNA) in the Early Post-Transplant Period Is Associated With an Increased Incidence of Adverse Clinical Outcomes in Kidney Transplant Recipients

Outcomes in Kidney Transplant Recipients With COVID-19 Illness in the Era of Vaccines

Outcomes in Kidney Transplant Recipients With COVID-19 Illness in the Era of Vaccines

Effect of Carbapenem-Resistant Klebsiella pneumoniae Infection on the Clinical Outcomes of Kidney Transplant Recipients.

Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection has proven to be difficult to control and typically presents with devastating effects. This retrospective study was conducted on the renal recipients at our institution between January 2021 to January 2022. Clinical data was collected to identify factors associated with CRKP infection and clinical outcomes. There were 104 cases out of 186 total renal recipients who presented with at least one infection within 3 months after KT, and 14 cases developed unfavorable clinical outcomes. We identified 16 confirmed CRKP infected cases with the incidence of 8.60%. Possible donor derived infection (DDI) (OR = 6.743; 95% CI: 1.477-30.786; P = 0.014) were independent risk factors for the occurrence of CRKP infection of renal recipients in our analysis, CRKP infection (OR = 20.723; 95% CI: 3.448-124.547; P = 0.001) and pneumonia (OR = 28.458; 95% CI: 1.956-413.984 P = 0.014) were independent risk factors for the occurrence of unfavorable clinical outcomes following KT, and the occurrence of unfavorable clinical outcomes following KT were significantly associated with CRKP infection (r = 0.535; P < 0.001) and antibiotic regimen containing ceftazidime/avibactam (CZA) (r = -0.655; P = 0.006). The use of CZA was significantly different in the comparison of antibiotic regimens between the CRKP infected renal recipients with unfavorable outcomes and CRKP infected patients with favorable outcomes. It is possible that DDI can lead to CRKP infection, and CRKP infection and pneumonia were closely correlated with poor prognosis. The use of CZA may play a role in avoiding the unfavorable outcomes of CRKP infected recipients.

The Immunohistochemical Expression of the Von Willebrand Factor: A Potential Tool to Predict Kidney Allograft Outcomes.

Few reports assessed endothelial activation biomarkers in kidney allograft biopsies using immunohistochemistry. This retrospective cohort study evaluated the association between posttransplant outcomes and the immunohistochemistry expression of Caveolin-1, Von Willebrand Factor (Vwf), and T-Cadherin in for-cause biopsies diagnosed as interstitial fibrosis and tubular atrophy of unknown etiology. Samples with antibody-mediated changes were excluded. The patients were followed for 3 years after the biopsy or until graft loss/death. Seventy-one (71) samples from 66 patients were included. Eighteen (25.4%) patients lost their grafts, mainly due to chronic rejection (33.3%). Caveolin-1 and T-Cadherin were not associated with graft loss. Vwf had good accuracy in predicting graft failure (AUC 0.637, 95% CI 0.486 to 0.788 P =0.101). The presence of more than 10% of Vwf positivity in the microvasculature (Vwf >10%) was associated with reduced death-censored graft survival (58.2% vs. 85.4% P =0.006), and this result was also observed in the subgroup presenting mild interstitial fibrosis (ci=1) (65.7% vs. 88.6% P =0.033). The multivariate analysis showed that Vwf >10% was an independent risk factor for graft loss (HR=2.88, 95% CI 1.03 to 8.02 P =0.043). In conclusion, Vwf might be an additional tool to predict allograft outcomes in kidney transplant recipients with interstitial fibrosis and tubular atrophy of unknown etiology, probably reflecting immune endothelial activation.

Infection by Carbapenemase-Producing Klebsiella pneumoniae in Renal Transplant Recipients

Abstract: There is a tendency to increase the number of cases of infection by multidrug-resistant bacteria, in view of the indiscriminate and sometimes excessive use of broad-spectrum antibiotics in the hospital environment. These infections have generated great impact, especially in immunosuppressed patients undergoing solid organ transplantation. National data revealed a significant increase in the rates of infections by multidrug-resistant bacteria. The present study aimed to evaluate the incidence and demographics of health care-related infections by carbapenemase-producing K. pneumoniae (KPC). This is an observational, retrospective, descriptive study conducted at a single center (Kidney Hospital) with evaluation of the outcomes of kidney transplant recipients with KPC infection between November 2009 and December 2015. In our center, KPC bloodstream infection had the highest prevalence, followed by urinary tract infection. The overall 30-day mortality was 36%, similar to that found in the international literature. Infection with multidrug-resistant bacteria is a serious clinical condition in transplant patients and poses a therapeutic challenge.

Allograft function and muscle mass evolution after kidney transplantation.

Advanced chronic kidney disease is associated with muscle wasting, but how glomerular filtration rate (GFR) recovery after kidney transplantation is associated with muscle mass is unknown. We took advantage of the simultaneous measurement of GFR (using iohexol plasma clearance; ioGFR) and creatinine excretion rate (a surrogate marker of muscle mass; CER) performed 3months after transplantation and at a later time point at our institution to investigate the interplay between allograft function, muscle mass, and outcome in kidney transplant recipients. Between June 2005 and October 2019, 1319 successive kidney transplant recipients (mean age 50.4±14.6; 38.7% female) underwent GFR measurement at our institution 3months after kidney transplantation. CER (CER3 ) and ioGFR (ioGFR3 ) were 7.7±2.6μmol/min and 53±17.1mL/min/1.73m2 , respectively. Multivariable analysis identified female gender, older donor and recipient age, reduced body mass index, coronary disease, dialysis history, proteinuria, and reduced ioGFR3 as independent predictors of low CER3 (ioGFR3 : β coefficient 0.19 [95% confidence interval 0.14 to 0.24]). A total of 1165 patients had a subsequent CER measurement after a median follow-up of 9.5months. Of them, 373 (32%) experienced an increase in CER>10%, while 222 (19%) showed a CER decrease of more than 10%. Multivariable analysis adjusted for CER3 and other confounders identified ioGFR3 as an independent predictor of CER at follow-up (β coefficient 0.11 [95% confidence interval 0.07 to 0.16]). In multivariable Cox analysis, reduced CER at 3months or at follow-up were consistently associated with mortality (hazard ratio [95% confidence interval] at 3months: 0.82 [0.74 to 0.91]; at follow-up: 0.79 [0.69 to 0.99]) but not with graft loss. Glomerular filtration rate recovery is a determinant of muscle mass variation after kidney transplantation. Early interventions targeting muscle mass gain may be beneficial for kidney transplant recipients.

Outcome of Kidney Transplant Recipients During Covid-19 Pandemic

Background: Kidney recipients constitute a vulnerable group of population and may have high risk of morbidity and mortality when infected with COVID-19. Objective: To a assess the overall outcome as well as the incidence and impact of COVID-19 among recipients who underwent transplantation during the pandemic Methods: A pre-designed follow up protocol was set to prospectively analyse the data obtaining from the recipients who underwent renal transplantation since 8 March 2010, the first appearance of COVID-19 in Bangladesh till 31 December, 2020. Outcome parameters were renal functional status; surgical, urological, immunological and medical complications; and incidence of COVID-19 and its outcome during the first 12 weeks post-transplant period. Results: Out of 100 patients, 82.0% were male and 18.0% were female. Serum creatinine levels (μmol/L) at 4, 8 and 12 weeks post-transplant were 200 in 6.0%, 5.0% and 6.0% respectively. Graft nephrectomy was done in 3 cases due to vascular complications. Five (5.0%) patients presented with symptoms of COVID-19, among them, 2 cases were confirmed with RT-PCR. There were 6 death cases, and septicaemia was the most common cause of death. The overall mortality rate was 6.0% in our study population but in COVID-19 confirmed cases it was 50.0%. Conclusion: During this pandemic, the overall outcome of renal transplantation was excellent and the incidence of symptomatic COVID-19 among transplant recipients was not higher than the incidence observed in general population of Bangladesh. But among the COVID-19 confirmed recipients, mortality rate was significantly higher. Bangladesh Med Res Counc Bull 2022; 48(1): 33-40

316.14: Impact of Donor Hepatic Steatosis on Kidney Transplant Recipient Outcomes

Introduction: Increasing evidence suggests an independent association of hepatic steatosis with chronic kidney disease, kidney function decline and risk of cardiovascular (CV) disease. Whether the presence or severity of an organ donor’s hepatic steatosis impacts on kidney transplant recipient (KTR) outcomes has not been studied. Methods: We performed a retrospective cohort study of deceased liver donors, matched to their KTR, in New South Wales (NSW), Australia from 2006-2020. We linked data from the Australian and New Zealand Dialysis and Transplantation (ANZDATA) and Organ Donation (ANZOD) registries with biopsy results of donor livers evaluated or utilised for transplantation at the NSW state-wide liver transplant unit. Donor hepatic steatosis was graded contemporaneously by histopathologists as S0 (<5%), S1 (5-33%), S2 (>33-66%) or S3 (>66%). Standard donor and recipient characteristics were collected. All-cause death, cardiovascular (CV) death, graft loss (death-censored), delayed graft function (DGF), graft function decline (assessed by eGFR) and post-transplant CV events (composite of coronary artery, peripheral vascular or cerebrovascular disease) were compared among recipients according to their presence and severity of hepatic steatosis. Results: 751 donors with liver biopsies were matched to 1,263 KTRs (8,043 person-years follow-up). Donor hepatic steatosis grades were: S0 453 (60%), S1 195 (26%), S2 71 (9%), S3 32 (4%). Donors with hepatic steatosis (S1-3) were significantly older (median age 53 vs 46 years) than those without steatosis and had worse metabolic profiles: higher body mass index (median 27 vs 25kg/m2), diabetes (9% vs 6%), hypertension (35% vs 25%). KTR of donors with and without hepatic steatosis had similar baseline characteristics. Presence of hepatic steatosis (vs no steatosis) and steatosis severity (S3 vs S0-2) did not impact on all-cause- or CV-death, graft loss, or DGF in the multivariable analysis. Univariable analysis suggested that decline in graft function was greater in recipients from donors with steatosis compared to recipients of donors without steatosis, but this no longer remained significant on multivariable analysis after adjusting for other variables. There was an increased risk of CV events on univariable (HR 1.42, 95%CI 1.00-2.02, p=0.05) and multivariable analysis (HR 1.47, 95%CI 1.03-2.10, p=0.04, Table 1) among recipients of donors with severe (S3) steatosis versus those with no/less donor steatosis. Conclusion: In this retrospective analysis, neither the presence nor severity of biopsy-proven donor hepatic steatosis appeared to impact kidney transplant recipient outcomes. Recipients from donors with severe hepatic steatosis may be at higher risk of cardiovascular events.

P8.141: Prevalence and Outcome of Kidney Transplant Recipients Infected With BK Polyoma Virus at National Kidney And Transplant Institute From 2016 to 2021

Background: BK polyoma virus (BKV) infection is an evolving challenge in kidney transplant recipients as untreated infections often lead to allograft dysfunction or graft loss. The virus is ubiquitous with viruria and viremia being detected in 30% and >10% of patients, respectively. Decreasing the immunosuppression has been established as the mainstay of treatment, however, screening protocols vary between institutions. Objective: This study aims to describe the prevalence and outcomes of kidney transplant recipients with BKV at the National Kidney and Transplant Institute (NKTI) for the last 5 years. Methods: This is a retrospective study conducted at the NKTI wherein chart review was performed. Age, gender, native kidney disease, viral loads (urine and blood), graft biopsy results were reviewed. Clinical outcomes such as graft failure, early complications, and readmission were also determined. Results: There were 1057 kidney transplants and 12 BKV cases from 2016-2021 with a prevalence of 1.1%. The mean age of recipients was 39 (range 17-66) years, majority of which were males (58%) (Table 1). Half of the recipients had chronic glomerulonephritis with anti-thymocyte globulin being the most common induction agent (67%). Majority (88%) did not have urinary stents. Of the identified cases, viruria (41%) and viremia (33%) were present with 50% having biopsy-proven BKV nephropathy. Most cases presented >6 months from transplant (66%) and viral loads were above 500 copies/ml in 83% of cases. One patient was highly sensitized (8%) and two patients had graft loss (17%). No graft loss and retransplants were done for BKV. Conclusion: The low prevalence of BKV infection in our center reflects the varying practice of clinicians in the management of transplant recipients. Reduction of immunosuppression remains to be the treatment of choice. Early detection may prevent morbidity and graft loss. Routine screening for BKV has been recommended however, it has yet to gain acceptance among our transplant physicians.

P8.112: Pregnancy Outcomes in Kidney Transplant Recipients And Their Newborns

P8.112: Pregnancy Outcomes in Kidney Transplant Recipients And Their Newborns

P8.071: Outcomes in Kidney Transplant Recipients With Allograft Failure Who Return to Dialysis

Background: Kidney transplant recipients (KTR) who return to dialysis (RTD) have high morbidity. Whether to continue immunosuppression (IS) after RTD remains uncertain and involves balancing IS-related risks with preventing terminal rejection and allo-sensitization that may preclude re-transplantation. Objectives: We conducted a quality improvement study to characterize IS practices following RTD, and determine incidence of potential IS-related complications, catastrophic IS-related events, and re-transplantation for patients in whom IS was weaned early vs. late. Methods: We identified all adult KTR who RTD and survived >6 months between January 2015-June 2020 at a large Canadian transplant center using this center’s transplant and dialysis databases. Comorbidities, medications, and outcomes were captured from electronic charts on pre-specified forms from RTD until death, re-transplantation, or Aug 2021. Early IS weaning was defined as discontinuing at least one agent excluding prednisone within 6 months of RTD. Results: Of 49 included patients, 27(55%) discontinued one IS agent by 6 months, while 22(45%) were maintained on two for a median of 34 months (range 7-78 months). During median follow-up of 29 months (range 3-78), there were no between-group differences in the proportion of patients who experienced all-cause (16/27 vs. 12/22) or infection-related (8/27 vs. 7/22) hospitalisations, ICU admission (5/27 vs. 5/22), malignancy (3/27 vs. 2/22), death (6/27 vs.4/22), terminal rejection (3/27 vs. 2/22), or re-transplantation (7/27 vs. 5/22). Median baseline PRA was significantly higher in early vs. late groups, suggesting confounding by indication. Two catastrophic IS events (disseminated tuberculosis, PTLD) occurred in late weaners. Conclusion: Almost half of KTR continued long-term double IS after RTD, and retransplantation rates were low. Cancer and death were not increased in late vs. early IS weaners, but catastrophic infection and PTLD occurred only in late weaners. Early discontinuation of one IS agent did not result in lower probability of re-transplantation and should be considered to reduce infectious complications.

331.3: Characteristics, Demographics and Outcomes of Kidney Transplant Recipients With Extreme Dialysis Vintage &gt; 10 Years. A National UNOS Database Review 2000-2021

Introduction: Prolonged dialysis times (DT) have been associated with inferior outcomes. Nevertheless, rarely suitable candidates with extreme dialysis vintage are transplanted. We aimed to review the characteristics, demographics and outcomes of such patients. Methods: We used United Network for Organ Sharing registry data to assess outcomes for patients who were on dialytic therapy for a minimum of 10 years, who received a kidney alone transplant from Jan 1 2000 – Dec 31 2021. Pediatrics, multi-organ transplants and those without a confirmed dialysis start date were excluded. Results: During the study period, a total of 361,029 kidney alone transplants were performed, of which 70.3% were patients who were on dialysis at the time of transplant. Out of the 253,841 dialysis patients, transplanted, 962 (0.37%) patients met our criteria. The majority of transplants (78.7%) in these 962 cases were performed after Dec, 2014 when the new KAS allocation which credits waitlist time from chronic dialysis initiation was implemented. There was no difference in graft survival for race, gender, but DM and DGF were independant predictors of inferior survival (p<0.05). Conclusions: The present study is the first to look at the granular details of this unique group of patients who receive a transplant after a minimum of 10 years of dialysis. Although outcomes may be somewhat inferior to standard outcomes of patients with shorter dialysis times, carefully selected candidates can still have reasonable successful outcomes. - Recipient Characteristics Mean Age at Time of Transplant (yrs) 49.9+/-10.5 (18-75) Race (AA/Whites/Hispanics) (%) 41.9/ 21.1/ 24.7 Gender (M/F) (%) 53.5/ 38.5 Re-Transplants (%) 38.5 Deceased Donor/ Living Donor Transplants (%) 97.3/ 2.7 Etiology of ESRD (DM/HTN/Other) (%) 24.8/ 20.7/ 54.5 CPRA (0-20, 20-80, 80-97, 98-100) (%) 31.8/ 19.6/ 12.7/ 35.9 Zero Mismatch (%) 5.7 PVD (%) 5.2 MedianDialysis Time (yrs) 12.4 (10-32) Dialysis Time (10-15yrs/ 15-20yrs/ > 20 yrs) (%) 76.7/ 16.4/ 6.8 Donor Characteristics Mean Donor Age (yrs) 36.4 +/-13.9 (1-69) Donor Race (Whites/AA/Hispanics) (%) 52/ 18.6/ 22.6 Donor Gender (M/F) (%) 61.9/ 38.1 DCD (%) 16.4 ECD (%) 6.3 KDPI Median 38 KDPI > 85 (%) 1.8 Donor HTN/ DM (%) 21.5/ 4.3 Median Cold Ischemia Time (hrs) 16 Kidneys Pumped (%) 34.5 Donor PHS Increased Risk (%) 15 Transplant Outcomes DGF (%) 34.7 Acute Rejection within 1 year (%) 9.8 Mean Length of Stay (days) 7.7+/- 9.1 Patient Death within 30 days n (%) 8 (0.8) Graft Failure Within 30 days n (%) 25 (2.5) Graft Survival (%) 1yr/ 3yr/ 5yr/ 10 yr 92/ 80/ 70/ 41 Patient Survival (%) 1yr/ 3yr/ 5yr/ 10yr 96/ 88/ 80/ 50

412.7: Pre-transplant Hyperparathyroidism and Adverse Posttransplant Outcomes in Kidney Transplant Recipients

Introduction: Whether correction of severe hyperparathyroidism (HPT) is required before kidney transplantation is subject of debate, as previous studies investigating the impact of pretransplant HPT on graft and patient outcomes showed conflicting results. We aimed to assess whether pretransplant serum PTH levels are associated with the risk of delayed graft function (DGF), death censored graft failure (DCGF), or mortality. Additionally, we focused on a subgroup of patients with very high pre-transplant PTH levels (≥81 pmol/L; ≥764 pg/mL). Methods: We performed a single-center cohort study including patients who underwent kidney transplantation between 1986 and 2020. Donor and recipient demographic data, medical information and routine laboratory measurements were extracted from the local transplant registry. We performed multivariable logistic regression and Cox regression analyses to study associations between PTH and DGF (persisting dialysis requirement for up to 7 days post-transplant), DCGF (return to dialysis or re-transplantation), or all-cause mortality, respectively. We also compared these outcomes for patients in the highest vs. lowest PTH decile for each endpoint. Results: A total of 1576 kidney transplant recipients (KTRs) (51.6 ± 14.0 years-old, 42.7% male) were included. Donor age was 51.2 ± 13.5 years, 785 (49.8%) patients received a graft from a living donor, and 535 (33.9%) patients underwent a pre-emptive transplantation. Median (IQR) pretransplant serum PTH concentration was 24.3 (12.8 – 44.6) pmol/L. Corrected calcium increased while PTH and corrected phosphate decreased within the first 3 months post-transplant, even in patients with pre-transplant PTH >81 pmol/L (Figure 1A-C). Pre-transplant PTH was not associated with DGF (Table 1). During median follow-up of 5.0 (2.2 – 8.4) years, 201 (12.8%) patients developed DCGF. In fully adjusted Cox regression analyses, PTH was not associated with DCGF (Table 1). Additionally, patients with PTH >81 pmol/L (N=121) did not have an increased risk of DGF (HR 1.67 [95% CI 0.62 – 4.55], P=0.65) or DCGF (HR 0.86 [95% CI 0.47 – 1.61], P=0.65), compared with those in the lowest PTH decile. During median follow-up of 5.2 (2.9 – 9.0) years, 474 (30.1%) patients deceased. In age- and sex-adjusted analyses, a higher serum PTH was associated with an increased risk of all-cause mortality, but this association lost significance upon multivariable adjustment (Table 1). When comparing KTRs with PTH levels in the highest vs. lowest decile, there was also no association with mortality (HR 0.96 [95% CI 0.62 – 1.48], P=0.65). Conclusion: In this cohort study, pre-transplant serum PTH was not associated with an increased risk of DGF, DCGF or mortality after transplantation. Subgroup analyses in patients with severe HPT yielded similar results. Our data do not support the requirement of pre-transplant parathyroidectomy in patients with (severe) hyperparathyroidism to improve graft or patient survival.

216.7: The Immunohistochemical Expression of Endothelial Activation Biomarkers Is a Potential Tool to Predict Kidney Allograft Outcomes

Background and Objective: Few reports assessed biomarkers of endothelial activation in kidney allograft biopsies using immunohistochemistry (IHC). This study aimed to analyze the IHC expression of Caveolin-1 (Cav), Von Willebrand Factor (Vwf), and T-Cadherin (Cad) in for-cause allograft biopsies diagnosed as Interstitial Fibrosis and Tubular Atrophy (IF/TA) of unknown etiology and evaluate its association with graft loss. Methods: This was a retrospective single-center cohort study including kidney biopsies performed in a single center between January 2013 and December 2017, whose histological, laboratory and clinical analysis concluded for IF/TA of unknown etiology. Samples with antibody-mediated changes were excluded. Patients were followed for three years after the biopsy or until graft loss/death. Results: Seventy-one (71) samples from 66 patients were included. Eighteen (25.4%) patients lost their grafts, mainly due to chronic rejection (33.3%). Cav and Cad were not associated with graft loss. Vwf had good accuracy to predict graft failure (AUC 0.637, 95%CI 0.486-0.788, p = 0.101). The presence of more than 10% of Vwf positivity in the microvasculature (Vwf > 10%) was associated with reduced death-censored graft survival (58.2% versus 85.4%, p = 0.006). The multivariate analysis showed that Vwf > 10% was an independent risk factor for graft loss (HR = 2.88, 95%CI 1.03-8.02, p = 0.043). Conclusion: Vwf might be an additional tool to predict allograft outcomes in kidney transplant recipients with IF/TA of unknown etiology, probably reflecting immune endothelial activation.

249.12: The Impact of Monoclonal Antibody Against SARS-COV2 And Vaccination on Outcomes in Kidney Transplant Recipients With COVID-19

249.12: The Impact of Monoclonal Antibody Against SARS-COV2 And Vaccination on Outcomes in Kidney Transplant Recipients With COVID-19

P16.37: Outcomes of COVID-19 Vaccination Among Kidney Transplant Recipients Admitted for COVID-19 at the National Kidney And Transplant Institute: A Retrospective Study

Background: Kidney transplant recipients are immunocompromised hosts of COVID-19 with a higher risk of infection and severe disease due to underlying CKD and long-term immunosuppression, thus vaccination against COVID is strongly recommended. However, studies indicate that transplant recipients mount lower antibody responses following vaccination compared with healthy individuals. Due to limited information on the outcomes of COVID-19 vaccination on transplant recipients, this study will examine the efficacy of vaccination in preventing severe to critical COVID in this immunocompromised population. Objective: To determine the outcomes of kidney transplant recipients admitted for COVID-19 at the National Kidney and Transplant Institute and the impact of COVID-19 vaccination status on their survival. Methods and Materials: A retrospective study of 131 kidney transplant recipients admitted for COVID-19 from March 2020 to December 2021. Descriptive statistics were used to summarize the clinical characteristics and outcomes of the participants. Results: The median age was 51 years old with a male gender distribution of 54.5%. Chronic glomerulonephritis was the most common primary renal disease. Diabetes, hypertension, and cardiovascular disease were the most common co-morbidities. Patients belonging to the critical COVID group were observed to have older kidney allografts with a median age of 120 months. Among 131 kidney transplant recipients, 24.8% were fully vaccinated and 74.2% were either unvaccinated or partially vaccinated. Of the 32 patients in the vaccinated group, 3 were vaccinated with Astra Zeneca, 5 received Janssen, 7 from Moderna, 10 from Pfizer, 1 received Sputnik and 12 received Coronavac (Sinovac). Among the vaccinated group, those who received Moderna and Pfizer vaccines were observed to have moderate COVID-19 disease progression only with 57.1% from the Moderna group and 40% from the Pfizer group. Among patients who progressed to critical COVID-19, it was observed that a significant number of them came from the Coronavac group. The need for oxygenation was observed in 64% of patients, of which 65.5% were unvaccinated. Acute kidney injury was reported in 43.5% of the overall population, 63.2% of which were observed in the unvaccinated group. Of the 16% who had graft loss during COVID-19 admission, 57.1% were unvaccinated. The incidence of death was lower among fully vaccinated than those in the partial and unvaccinated groups. Likewise, the probability of survival is highest among fully vaccinated than those partially vaccinated and unvaccinated. Renal graft biopsy on patients with COVID-19 has not been practiced at NKTI thus rendering rates of biopsy-proven acute rejection a limitation of the study. Conclusion: Our experience shows that lack of COVID-19 vaccination among kidney transplant recipients demonstrates a higher rate of mortality associated with COVID-19. Key words: COVID-19, renal transplantation, survival, Philippines.

336.2: Elevated Donor-Derived Cell-Free DNA (Dd-cfDNA) in the Early Post-transplant Period Is Associated With an Increased Incidence of Adverse Clinical Outcomes in Kidney Transplant Recipients

Introduction: Early post-transplant elevations in dd-cfDNA, even in the absence of histologic rejection or other overt pathology, have been suggested to carry a riskof adverse outcomes among solid organ transplant recipients. We investigated this association among kidney transplant recipients enrolled in the Kidneyallograft Outcomes AlloSure Registry (KOAR, NCT03326076). Methods: To assess the impact of early post-transplant dd-cfDNA elevations, we evaluated the incidence of a clinical composite that included biopsy-provenrejection (BPAR), detection of de novo donor specific antibodies (dnDSA) and return to dialysis in patients with and without median dd-cfDNA >1% over the first100 days post-transplant. Patients with events before day 100 were excluded. Univariate and multivariate analyses were performed. Results: 51 of 1296 patients (3.9%) had a median dd-cfDNA ≥1.0% during the first 100 days post-transplant. In a univariate model, these patients had asignificantly higher risk of the experiencing both the composite outcome and each individual component during the first post-transplant year (Figure 1). In a multivariate Cox proportional hazards model that included recipient age, delayed graft function, donor type (living vs deceased), and recipient sensitization,only 100-day median dd-cfDNA elevation ≥1.0% was a statistically significant predictor of the composite outcome, with a hazard ratio of 2.99 (95% CI: 1.59 -5.61, p < 0.005) (Table 1). Conclusions: Our findings suggest that early post-transplant elevations in dd-cfDNA among kidney transplant recipients, even in the absence of clearimmunologic or histologic correlates, identify a population of patients at risk for adverse clinical outcomes during the first post-transplant year. Molecular risk-stratification using dd-cfDNA may have implications for clinical surveillance and therapeutic management of these patients.

Outcomes of kidney transplant recipients who underwent pre-transplant bariatric surgery for severe obesity: a long-term follow-up study.

BackgroundKidney transplantation (KT) is the preferred therapy for end-stage renal disease (ESRD). While a major cause for ESRD, obesity is also a key obstacle to candidacy for KT. Bariatric surgery, particularly sleeve gastrectomy (SG), is increasingly used to improve access to KT in patients with obesity, but the literature especially on outcomes post-KT remains lacking. We aimed to provide a long-term follow-up analysis of efficacy and outcomes of a previously described cohort of patients with obesity, who had SG as a means for access to KT.MethodsThis is a single-center retrospective follow-up study of 32 patients with advanced chronic kidney disease or ESRD, who were referred and underwent SG between 2013 and 2018 as an access strategy to KT. The primary outcome was successful KT. Ninety-day outcomes, long-term graft function, and changes in weight and obesity-related comorbidities after KT were assessed. Descriptive statistics are presented as count (percentage) or median (interquartile range).ResultsAt baseline, 18 (56%) were male with a median age and BMI of 51 (11) years and 42.3 (5.2) kg/m2, respectively. Median follow-up time post-SG was 53 (58) months. At last follow-up, 23 (72%) patients received KT. Median time to KT was 16 (20) months and BMI was 34.0 (5.1) kg/m2 at time of transplant. At KT, 13 (57%) and 20 (87%) had diabetes and hypertension, respectively. Median follow-up post-KT was 16 (47) months. There was one graft loss requiring return to dialysis. At 5-year post-KT, median serum creatinine was 136 (66) µmol/l. At last follow-up post-KT, median BMI remained at 33.7 (7.6) kg/m2. Among patients with diabetes and hypertension, 7/13 (54%) and 5/20 (25%) had either improvement or remission of their comorbidities, respectively.ConclusionSG is an effective strategy to improve access to KT in patients with severe obesity. Transplant recipients also continue to benefit from sustained weight loss and improved related comorbidities that may positively impact their graft function after KT.Graphical abstract

Use of hepatitis B viremic donors in kidney transplant recipients: A single center experience.

Utilization of Hepatitis B virus (HBV)-infected kidney allografts represents an opportunity to bridge the gap between organ supply and demand. Highly efficacious vaccines and antiviral therapies allow these allografts to be transplanted with negligible risk to the recipient. The purpose of this study was to describe the prophylactic strategies and related clinical outcomes of kidney transplant recipients who received a kidney from an HBV viremic donor. Eight patients received an allograft from an HBV viremic deceased kidney donor between January 1, 2017 and December 4, 2020. All recipients were immune to hepatitis B with a surface antibody titer greater than or equal to 10mIU/ml (range: 12->1000 mIU/ml). After transplant, 62.5% demonstrated HBV core antibody seroconversion at an average of 47.4 ± 28.5 days post-transplant. Anti-viral prophylaxis was initiated in 87.5% of patients; 62.5% preemptively during the transplant admission (range 1-3 days post-transplant) and 25% following HBcAb seroconversion (range 45-304 days post-transplant). Of the four patients who were started on entecavir preemptively, two subsequently core converted. These two patients had an HBV surface antibody less than 100 mIU/ml at the time of transplant. None of the recipients converted to HBV surface antigen positivity. The average estimated glomerular filtration rate was 41 ± 19ml/min/1.73m2 , and there were no significant elevations in liver enzymes through one year post-transplant. The use of HBV viremic kidney allografts may represent an additional source of transplant organs; however, more studies are needed to better elucidate the optimal protective strategies for these recipients.

Cardiovascular Outcomes in Kidney Transplant Recipients With ADPKD

IntroductionCardiovascular disease leads to high morbidity and mortality in patients with kidney failure. Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a systemic disease with various cardiac abnormalities. Details on the cardiovascular profile of patients with ADPKD who are undergoing kidney transplantation (KT) and its progression are limited.MethodsEchocardiographic data within 2 years before KT (1993–2020), and major adverse cardiovascular events (MACEs) after transplantation were retrieved. The primary outcome is to assess cardiovascular abnormalities on echocardiography at the time of transplantation in ADPKD as compared with patients without ADPKD matched by sex (male, 59.4%) and age at transplantation (57.2 ± 8.8 years).ResultsCompared with diabetic nephropathy (DN, n = 271) and nondiabetic, patients without ADPKD (NDNA) (n = 271) at the time of KT, patients with ADPKD (n = 271) had lower rates of left ventricular hypertrophy (LVH) (39.4% vs. 66.4% vs. 48.6%), mitral (2.7% vs. 6.3% vs. 7.45) and tricuspid regurgitations (1.8% vs. 6.6% vs. 7.2%). Patients with ADPKD had less diastolic (25.3%) and systolic (5.6%) dysfunction at time of transplantation. Patients with ADPKD had the most favorable post-transplantation survival (median 18.7 years vs. 12.0 for diabetic nephropathy [DN] and 13.8 years for nondiabetic non-ADPKD [NDNA]; P < 0.01) and the most favorable MACE-free survival rate (hazard ratio = 0.51, P < 0.001). Patients with ADPKD had worsening of their valvular function and an increase in the sinus of Valsalva diameter post-transplantation (38.2 vs. 39.9 mm, P < 0.01).ConclusionADPKD transplant recipients have the most favorable cardiac profile pretransplantation with better patient survival and MACE-free survival rates but worsening valvular function and increasing sinus of Valsalva diameter, as compared with patients with other kidney diseases.