Positive Recipients Research Articles

Better outcome of COVID-19 positive kidney transplant recipients during the unremitting stage with optimized anticoagulation and immunosuppression.

IntroductionCOVID‐19 is an ongoing pandemic with high morbidity and mortality and with a reported high risk of severe disease in kidney transplant recipients (KTR).AimWe aimed to report the largest number of COVID‐19‐positive cases in KTR in a single center and to discuss their demographics, management, and evolution.MethodsWe enrolled all the two thousand KTR followed up in our center in Kuwait and collected the data of all COVID‐19‐positive KTR (104) from the start of the outbreak till the end of July 2020 and have reported the clinical features, management details, and both patient and graft outcomes.ResultsOut of the one hundred and four cases reported, most of them were males aged 49.3 ± 14.7 years. Eighty‐two of them needed hospitalization, of which thirty‐one were managed in the intensive care unit (ICU). Main comorbidities among these patients were hypertension in 64.4%, diabetes in 51%, and ischemic heart disease in 20.2%. Management strategies included anticoagulation in 56.7%, withdrawal of antimetabolites in 54.8%, calcineurin inhibitor (CNI) withdrawal in 33.7%, the addition of antibiotics in 57.7%, Tocilizumab in 8.7%, and antivirals in 16.3%. During a follow‐up of 30 days, the reported number of acute kidney injury (AKI) was 28.7%, respiratory failure requiring oxygen therapy 46.2%, and overall mortality rate was 10.6% with hospital mortality of 13.4% including an ICU mortality rate of 35.5%.ConclusionBetter outcome of COVID‐19‐positive KTR in our cohort during this unremitting stage could be due to the younger age of patients and early optimized management of anticoagulation, modification of immunosuppression, and prompt treatment of secondary bacterial infections. Mild cases can successfully be managed at home without any change in immunosuppression.

POS-721 COVID-19 INFECTION IN KIDNEY TRANSPLANT RECIPIENTS : A RETROSPECTIVE STUDY

The novel coronavirus was first identified toward the end of 2019 ,designated as coronavirus disease 2019(COVID-19).The morbidity and mortality from COVID are particularly high among patients with underlying health conditions and chronic diseases.Kidney-transplant recipients appear to be at particularly high risk for critical Covid illness due to chronic immunosuppression and coexisting conditionsThe outcome of covid 19 infection in transplant patients is unclear. Hence we have retrospectively analysed covid positive transplant recipients to assess the clinical profile,Outcomes and Management.

Impact of Cytomegalovirus Mismatch on Outcome after Heart Transplantation

Purpose Cytomegalovirus (CMV) is correlated with a number of complications following heart transplantation (HTx). The impact of a serologic mismatch between donor and recipient is still controversially discussed. Especially the necessity of prophylactic virostatic medication is a matter of concern. Therefore, we aimed to analyse the impact of preoperative CMV matching on perioperative morbidity and mortality after HTx. Methods We retrospectively reviewed all 178 patients, which underwent HTx between 2010 and 2020 in our department. Patients were divided with regard to their pretransplant CMV matching. The recipients could be categorized into 4 groups depending on their serologic CMV matching (Group 1: donor and recipient CMV-IgG positive (=D+/R+), n=52; Group 2: (D+/R-), n=31; Group 3: (D-/R+), n=49; Group 4: (D-/R-), n=34). The remaining patients were excluded due to missing information about the donors CMV status. Patients and donors were comparable concerning co-morbidities and risk factors for impaired posttransplant outcome. Results Incidence of primary graft dysfunction (PGD), perioperative neurological events, bleeding complications, severe infections and early graft rejection (>1R) were comparable between all groups (p>0.05). In contrast, the incidence of postoperative acute kidney injury with need for hemodialysis was significantly increased in Group 3 (73.9%) compared to the other groups (57.7% in Group 1, 40.0% in Group 2 and 52.9% in Group 4, p=0.03). Posttransplant CMV viremia was observed in serologic positive recipients only (Group 1: 13.3%, Group 2: 0.0%, Group 3: 25.0%, Group 4: 0.0%, p Conclusion Except for kidney function, we did not observe any differences in perioperative morbidity and mortality regarding CMV matching in our cohort. Seropositive recipients carry the most important risk factor of posttransplant CMV viremia. In contrast, the so-called “high-risk” CMV configuration (D+/R-) showed no impairments of postoperative outcome compared to “low-risk” (D-/R-), which may be related to positive effects of regularly administered prophylactic virostatic medication in the “high-risk” cohort.

Removal of Anti-Thymocyte Globulin by Plasma Exchange in ABO-Incompatible and Positive Crossmatch Kidney Transplant Recipients

BackgroundRecipients of ABO-incompatible (ABOI) and positive crossmatch (PXM) kidney transplants are at high risk for antibody-mediated acute rejection. Despite aggressive immunosuppression in high-risk patients, the incidence of acute rejection remains considerably higher than in other groups. No published studies have examined plasma concentrations of anti-thymocyte globulin (ATG) in patients undergoing plasma exchange. The objectives of this study were to compare plasma ATG concentrations before and after plasma exchange in ABOI and PXM kidney transplant patients to determine the amount removed. Materials and MethodsThis prospective pharmacokinetic evaluation enrolled 10 patients undergoing ABOI or PXM kidney transplant at an academic medical center. Blood and waste plasma samples from 5 patients were assayed for total and active ATG concentrations. Patient records were monitored for renal function and rejection rates in the first 6 months post-transplant. ResultsTotal ATG concentrations decreased a mean of 59.78 ± 13.91% after each plasma exchange session, and active ATG levels decreased a mean of 56.8 ± 17.08%. Mean daily concentrations reflect a lack of expected ATG accumulation. Only 1 of 4 patients had detectable ATG concentrations after 30 days. After 6 months, the incidence of acute rejection in this sample was 44% and graft survival was 89%. ConclusionsThis is the first study to show that plasma exchange removes a substantial amount of ATG in high-risk kidney transplant patients. Based on these results, we believe these high-risk patients have been traditionally underdosed.

Outcomes of hepatitis C virus seropositive donors to hepatitis C virus seronegative liver recipients: A large single center analysis

Introduction and objectivesThe success of direct-acting antivirals (DAA) has transformed the management of hepatitis C virus (HCV) infection and has led to the expansion of the deceased donor organ pool for liver transplantation. Material and methodsWe present a single center retrospective review of liver transplantations performed on HCV-seronegative recipients from HCV-seropositive organs from 11/2017 to 05/2020. HCV nucleic acid testing (NAT) was performed on HCV-seropositive donors to assess active HCV infection. Results42 HCV-seronegative recipients underwent a liver transplant from a HCV-seropositive donor, including 21 NAT negative (20 liver, 1 simultaneous liver kidney transplant) and 21 NAT positive liver transplants. Two (9.5%) HCV antibody positive/NAT negative recipients developed HCV viremia and achieved sustained virologic response with DAA therapy. The remaining patients with available data (19 patients) remained polymerase chain reaction (PCR) negative at 6 months. 20 (95%) of HCV antibody positive/NAT positive recipients had a confirmed HCV viremia. 100% of patients with available data (15 patients) achieved SVR. Observed events include 1 mortality and graft loss and equivalent rates of post-transplant complications between NAT positive and NAT negative recipients. ConclusionsHCV-seropositive organs can be safely transplanted into HCV-seronegative patients with minimal complications post-transplant.

Immunogenicity of Two COVID-19 Vaccines Currently Used in India: Experience in Health Care Workers From a Tertiary Care Hospital

Background: Being a long-term preventive measure, COVID-19 vaccines are used in global populations. In India, country-wide immunization drive was initiated in January 2021.Methods: To assess immune response of health-care-workers to COVISHIELD(n=187) and COVAXIN(n=21), blood samples collected pre-vaccination and 1month-post-1/post-2 dose, administered 28days apart, were tested for IgG-anti-SARS-CoV-2 (ELISA) and neutralizing (Nab, PRNT50) antibodies. Spike protein-specific T cells were quantitated by IFN-γ ELISPOT and Flow-cytometry-based Intra-cellular-secretion (ICS) for IFN-γ/IL2.Findings: Among pre-vaccination-antibody negative (pre-negatives, n=120) and positive (pre-positives, n=67) COVISHIELD recipients, %Nab seroconversion and median (IQR) Nab titers were 55.1%/95.6% and 16(IQR 2.5-36.3)/(64.5, IQR 34.5-154.2, pst dose, but declined to 1740(911-3116, pnd dose. Though the number of COVAXIN recipients was small, post-2nd dose humoral response was lower than COVISHIELD (50% seroconversion and median titer 6.75, IQR 2.5-24.75, pInterpretation: This first-time, systematic, real-world assessment revealed stronger humoral (COVISHIELD) and cellular (COVAXIN) immune responses respectively. Relation of dose interval and post-2nd decline in Nab titers in pre-positives (COVISHIELD) needs evaluation. Immunogenicity/efficacy of vaccines will change with the progression of the pandemic and needs to be assessed in field-setting.Funding Information: Biotechnology Industry Research Assistance Council (BIRAC), Grant/Award Number: BIRAC/BT/NBM0095/02/18. Declaration of Interests: Authors declare no any commercial or financial conflict of interest.Ethics Approval Statement: The study was approved by the “Human Ethics Committee” of BVDUMCH. Written informed consent was obtained from all the participants.

Outcome of 69 allogeneic stem cell transplantations for Fanconi anemia using HLA-matched unrelated donors: a study on behalf of the European Group for Blood and Marrow Transplantation

Allogeneic stem cell transplantation is the only treatment that can restore a normal hematopoiesis in Fanconi anemia (FA). In this retrospective multicenter study, we analyzed the results of this approach using HLA-matched unrelated bone marrow donors, and tried to identify covariates predicting the outcome of the transplant. From January 1985 to June 1998, 69 FA patients were transplanted with unrelated HLA-matched donors. Patients' characteristics before and after transplant were provided by the European group blood and marrow transplant registry and were analyzed in collaboration with the European Fanconi Anemia Registry. The 3-year probability of survival was 33%. Extensive malformations, a positive recipient cytomegalovirus serology, the use of androgens before transplant, and female donors were associated with a worse outcome. Primary graft failures were observed more frequently when female donors were used, mainly because the grafts contained lower nucleated cell doses per kilogram of recipient body weight compared with grafts coming from male donors. The probability of grade III-IV acute graft-versus-host disease (GVHD) was 34%. Elevated serum alanine/aspartate transaminases before transplantation; limb, urogenital tract, or nephrologic malformations; and non-T-cell-depleted grafts were predictors of severe acute GVHD. This study shows the dramatic impact of preexisting congenital malformations on the outcome of FA patients transplanted with HLA-matched unrelated donors. If the use of T-cell depletion has led to a dramatic reduction of acute GVHD incidence, no significant outcome improvement was observed with this approach, mainly because of an increased risk of graft failure. (Blood. 2000;95:422-429)

Long-term outcome after prevention of de novo hepatitis B in recipients of core antibody-positive livers with hepatitis B immunoglobulin only

Background: Anti-HBc positive donors represent an important source of organs in hepatitis B virus (HBV) endemic areas despite the risk of occult HBV infection. We analyzed long-term outcome of prevention for de novo HBV with hepatitis B immunoglobulin (HBIG) only after liver transplantation (LT) using core-positive grafts. Methods: We retrospectively reviewed the prospective collected data of 1,479 recipients between 1988 and 2018 at Seoul Nation al University Hospital. 1,458 were eligible and enrolled. If either donor or recipient had core antibody, HBIG 4000 IU was adminis trated 4 times until postoperative day 3. Results: Of 1,458 LTs, 478 (32.8%) used anti-HBc positive grafts. Three hundred twenty-six (68.2%) was allocated to hepatitis B surface antigen (HBsAg)-positive recipients, with 152 (31.8%) to HBs-negative recipients. 21 (13.8%) of de novo HBV infection occurred in 152 core-positive grafts. One (25%), 11 (22.4%), 0, 9 (9.2%) was diagnosed of de novo HBV infection in 4 of hepatitis B surface antigen (HBcAb) and HBsAb negative, 49 of HBcAb-negative and HBsAb-positive, 1 of HBcAb-positive and HBsAb-neg ative, 98 of HBcAb and HBsAb positive recipients respectively. Anti-HBc negative recipients were more likely to develop de novo HBV infection compared with anti-HBc positive recipients (22.6% vs. 9.1%, P=0.021). Incidence of de novo HBV infection did not differ by recipient HBsAb status (P=0.530). The median follow-up time was 69 months (range, 29-165 months). The median time to detection of HBsAg seropositivity was 18 months (range, 8-55 months). Two had no treatment, twelve were treated with nu cleoside analogs (NA) monotherapy, and seven were treated with NA plus HBIG. The median treatment duration was 41 months. Seven acquired seroconversion. There were 42 (8.8%) of graft losses in study period. The 1-, 5-, 10-year patient survival with an ti-HBc positive liver were 97.5%, 93.2%, and 90.5%. No patient died of de novo HBV infection. Conclusions: De novo HBV did not affect patient survival. However, HBIG only prophylaxis was not enough to prevent de novo HBV development in the era of NA.

Abstract 12659: Improved Heart Transplant Outcomes Among Patients With Hepatitis C Virus Infection in the Era of Direct-acting Antiviral Agents

Introduction: The effect of hepatitis C virus (HCV) infection in recipients or donors on heart transplants is less known in the era after the introduction of direct-acting antiviral agents (DAAs). Methods: Using the United Network for Organ Sharing registry, 25,581 adult heart transplant recipients between 2005 and 2019 were identified. The trend in prevalence of HCV infected recipients and in utilization of HCV infected donors and their effect on the transplant outcomes were investigated in the pre-DAAs era versus the DAAs era separated by May 13, 2011, using Cox proportional hazard regression. Results: HCV antibody positive recipients (n=532, 2.1%) had stable prevalence ( P =0.18) with a higher mortality risk in the pre-DAAs era (50.8% versus 38.8% at 10 years; hazard ratio (HR), 1.50; 95% confidence interval (CI), 1.22-1.85; P <0.001), however not in the DAAs era (25.3% versus 28.4% at 7 years; HR, 0.96; 95% CI, 0.72-1.28; P =0.79) ( P interaction<0.001). Organ use from HCV antibody positive donors (n=375, 1.5%) was exclusively concentrated in the recent years ( P <0.001) and provided the similar mortality up to 2 years (15.7% versus 12.4%; HR, 0.96; 95% CI, 0.65-1.43; P =0.84) regardless of the recipient HCV antibody status. The similar findings were confirmed with a subgroup cohort with positive nucleic acid amplification test (NAT). Conclusions: In the DAAs era, positive HCV antibody in recipients did not adversely affect the long-term transplant outcomes. Graft utilization from positive HCV antibody or NAT positive donors are rapidly more prevalent and appeared to be promising up to 2 years post-transplant.

Management of lung transplantation in the COVID-19 era-An international survey.

It is unknown if solid organ transplant recipients are at higher risk for severe COVID-19. The management of a lung transplantation (LTx) program and the therapeutic strategies to adapt the immunosuppressive regimen and antiviral measures is a major issue in the COVID-19 era, but little is known about worldwide practice. We sent out to 180 LTx centers worldwide in June 2020 a survey with 63 questions, both regarding the management of a LTx program in the COVID-19 era and the therapeutic strategies to treat COVID-19 LTx recipients. We received a total of 78 responses from 15 countries. Among participants, 81% declared a reduction of the activity and 47% restricted LTx for urgent cases only. Sixteen centers observed deaths on waiting listed patients and eight centers performed LTx for COVID-19 disease. In 62% of the centers, COVID-19 was diagnosed in LTx recipients, most of them not severe cases. The most common immunosuppressive management included a decreased dose or pausing of the cell cycle inhibitors. Remdesivir, hydroxychloroquine, and azithromycin were the most proposed antiviral strategies. Most of the centers have been affected by the COVID-19 pandemic and proposed an active therapeutic strategy to treat LTx recipients with COVID-19.

Post-Transplant Lymphoproliferative Disorder after Solid Organ Transplant in the Pediatric Population: A Systematic Review

Background: Post-transplant lymphoproliferative disease (PTLD), is one of the major complications after organ transplantation. The aim of this study is to study the incidence, risk factors especially EBV status, histopathological types, management, and outcomes of PTLD in the pediatric groups. Methods: Following the PRISMA guideline, we performed a comprehensive literature search on PubMed, Cochrane Library, Embase, and clinicaltrials.gov from the past ten years on May 04, 2020. We used the MeSH terms of organ transplantation and lymphoproliferative disorders. The initial search revealed 1741 articles. We excluded all case reports, case series, pre-clinical trials, review articles, and meta-analysis. We found twenty-eight studies. We extracted the data for baseline characteristics, recipient & donor EBV status, immunosuppression used, type & stage of PTLD, organ system involved, duration between transplant and PTLD diagnosis, treatment, and mortality. Results: We included 32 studies with a total (n) of 15597 pediatric patients after a solid organ transplant. 1210 (7.75%) patients developed PTLD, out of which 609 (50.33%) were male participants, 453 (37.4%) female, and 148 (12.23%) the gender was unknown. (Table 1) Data from 19 studies showed that among PTLD patients, 115 recipients & 76 donors tested positive for Epstein-Barr Virus (EBV), 187 recipients were seronegative and the rest were unknown at the time of transplant. Immunosuppressive drugs used after organ transplantation included; cyclosporine, tacrolimus, sirolimus, azathioprine, mycophenolate, prednisone, mTOR inhibitors, induction therapy with OKT3, IL-2 inhibitors (basiliximab, daclizumab) and anti-thymocyte/anti-lymphocyte globulin. In two studies, antiviral prophylaxis with ganciclovir/valganciclovir was achieved. Data from nine studies showed the median age at PTLD diagnosis was 6.8 years. L'Huillier et al. stated that the median duration for EBV positive recipients to develop PTLD was 1.92 years (0.35-3.09 years), compared to EBV negative recipients, which was 0.95 years (2.48-2.92 years). Overall, the median duration from organ transplant to the diagnosis of PTLD among 15 studies was 29.1 months, ranging from 0.9 months to 186 months. The histopathology of PTLD was confirmed via biopsy specimen showing predominance in monomorphic type, i.e; 265/1210 (21.9%), followed by polymorphic type with 140/1210 (11.5%), an early lesion with 46/1210 (3.80%), Non-Hodgkin lymphoma 28/1210 (2.3%), Hodgkin lymphoma 33/1210 (2.72%) and mixed type (polymorphic & monomorphic) 4/1210 (0.33%). Histopathological data for 694 patients were not available. Treatment of PTLD was achieved with reduction or complete cessation of immunosuppressive therapy, anti-CD20 antibody (rituximab), antiviral treatment with ganciclovir/valganciclovir, lymphoma treatment with chemotherapeutic agents, radiotherapy, and surgical resection. Gajarski et al. concluded that patients who received induction therapy [OKT3, IL-2 antagonists (basiliximab, daclizumab) and anti-thymocyte globulin] had significantly less PTLD development as compared to those who did not receive induction therapy, i.e., (2.9% vs. 4.9%) among 2374 total patients. According to Hayes Jr. et al., recipient EBV seronegativity continued to be associated with lower mortality hazard (HR 0.715; 95 % CI 0.547, 0.935; p = 0.014). Data from 19 studies showed the mortality rate among 494 PTLD diagnosed patients was 22.7% (112) with an overall survival of 84.2% respectively from three studies. Data from five studies showed that direct PTLD related mortality accounted for 63% (17/27) of deaths in PTLD diagnosed patients. Conclusion: Our analysis shows that post-transplant EBV positive recipients who undergo multiorgan transplants are more likely to develop PTLD compared to EBV positive recipients with single organ transplantation. The median duration from organ transplants to the diagnosis of PTLD ranged from months to years, however, this duration was reported to be less in EBV negative recipients compared to EBV positive recipients with organ transplants. The most common histological type of PTLD among pediatric groups was monomorphic and the least common was Classic Hodgkin lymphoma. Rituximab use in the treatment of PTLD was associated with a decreased use of alkylating agents and as a result, the side effects associated with these agents were reduced. Disclosures Anwer: Incyte, Seattle Genetics, Acetylon Pharmaceuticals, AbbVie Pharma, Astellas Pharma, Celegene, Millennium Pharmaceuticals.: Honoraria, Research Funding, Speakers Bureau.

The fraction of sensitization among lung transplant recipients in a transplant center in Japan

BackgroundAnti-human leukocyte antigen (HLA) antibody testing was approved by the Japanese government in 2018. As such, there was no longitudinal data regarding the HLA-sensitization of lung transplant (LTX) patients in Japan. We therefore set out to measure anti-HLA antibodies from all our LTX patients during their annual follow-up to characterize the sensitization status in the Japanese population.MethodsThe cross-sectional study was conducted for consecutive LTX recipients who underwent transplantation from January 2000 to January 2020 at Tohoku University Hospital (TUH). The serum from the recipients was screened for anti-HLA antibody with the panel-reactive assay (PRA) and the donor-specific antibodies (DSA).ResultsSensitization was reviewed in 93 LTX recipients, showing 23 positive (24.7%) and 70 negative (75.3%) PRA. More sensitized recipients were found in recent transplantations (60.9% (14/23), ≤5 years post LTX) than in older transplantations (17.4% (4/23), 5–10 years or 21.7% (5/23), ≥10 years post LTX) (p = 0.04). Even fewer recipients had DSA (5.4%, 5/93), among whom 4/5 (80%) were recently transplanted.ConclusionThe rate of PRA positive LTX recipients in our population was lower compared with those in previous reports from US and Europe. More sensitized LTRs were found in recent transplantations than the older cohort, and DSA was identified primarily in the recent recipients. Due to several limitations, it is still unclear whether the sensitization would be related the development of CLAD or survival, yet this study would be fundamental to the future anti-HLA body study in Japanese population.

Evidence of potent humoral immune activity in COVID-19-infected kidney transplant recipients.

Whether kidney transplant recipients are capable of mounting an effective anti‐severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) adaptive immune response despite chronic immunosuppression is unknown and has important implications for therapy. Herein, we analyzed peripheral blood cell surface and intracellular cytokine phenotyping by flow cytometry along with serum antibody testing in 18 kidney transplant recipients with active coronavirus disease 2019 (COVID‐19) infection and 36 matched, transplanted controls without COVID‐19. We observed significantly fewer total lymphocytes and fewer circulating memory CD4+ and CD8+ T cells in the COVID‐19 subjects. We also showed fewer anergic and senescent CD8+ T cells in COVID‐19 individuals, but no differences in exhausted CD8+ T cells, nor in any of these CD4+ T cell subsets between groups. We also observed greater frequencies of activated B cells in the COVID‐19 patients. Sixteen of 18 COVID‐19 subjects tested for anti‐SARS‐CoV‐2 serum antibodies showed positive immunoglobulin M or immunoglobulin G titers. Additional analyses showed no significant correlation among immune phenotypes and degrees of COVID‐19 disease severity. Our findings indicate that immunosuppressed kidney transplant recipients admitted to the hospital with acute COVID‐19 infection can mount SARS‐CoV‐2‐reactive adaptive immune responses. The findings raise the possibility that empiric reductions in immunosuppressive therapy for all kidney transplant recipients with active COVID‐19 may not be required.

Evolving Impact of COVID-19 on Transplant Center Practices and Policies in the United States.

In our first survey of transplant centers in March 2020, >75% of kidney and liver programs were either suspended or operating under restrictions. To safely resume transplantation, we must understand the evolving impact of COVID-19 on transplant recipients and center-level practices. We therefore conducted a six-week follow-up survey May 7-15, 2020, and linked responses to the COVID-19 incidence map, with a response rate of 84%. Suspension of live donor transplantation decreased from 72% in March to 30% in May for kidneys and from 68% to 52% for livers. Restrictions/suspension of deceased donor transplantation decreased from 84% to 58% for kidneys and from 73% to 42% for livers. Resuming transplantation at normal capacity was envisioned by 83% of programs by August 2020. Exclusively using local recovery teams for deceased donor procurement was reported by 28%. Respondents reported caring for a total of 1166 COVID-19-positive transplant recipients; 25% were critically ill. Telemedicine challenges were reported by 81%. There was a lack of consensus regarding management of potential living donors or candidates with SARS-CoV-2. Our findings demonstrate persistent heterogeneity in center-level response to COVID-19 even as transplant activity resumes, making ongoing national data collection and real-time analysis critical to inform best practices.

Heart Transplantation Survival Outcomes of HIV Positive and Negative Recipients

In the era of antiretroviral therapy, HIV-positive patients have reduced mortality from HIV infection and increased morbidity from end-stage heart failure. The number of HIV-positive heart transplantation recipients remains scant. Long-term survival has not been rigorously studied. We compared survival outcomes of heart transplantation in HIV-positive recipients with those of HIV-negative recipients. Clinical data from all adult heart transplantations were extracted from the United Network for Organ Sharing dataset. The impact of recipient HIV status was analyzed with Cox proportional hazards modeling, 1:3 propensity score matching, and Kaplan-Meier survival analysis. Seventy-five HIV-positive recipients and 29,848 HIV-negative recipients were identified. Race distributions differed between the recipient groups, with black patients comprising a larger proportion of the HIV-positive recipient group (46.7% vs 20.9%, P < .001). The mean year of transplant was significantly later in the HIV-positive recipient group. The rate of acute rejection in the HIV-positive group was higher than in the HIV-negative group (38.7% vs 17.7%, P < .001), as was rate of antirejection treatment administration such as intravenous immunoglobulin or plasmapheresis (26.7% vs 10.4%, P < .001). There was no difference in 30-day, 1-year, and 5-year survival of HIV-positive recipients vs HIV-negative recipients. Recipient HIV infection was not a significant covariate in predicting survival in a Cox proportional hazards model. Short-term and moderate-term survival after heart transplantation is similar for HIV-positive recipients and HIV-negative recipients, although data are very limited. This finding suggests that HIV-positive recipients should not be excluded from transplant candidacy solely based on HIV serostatus.

Positive Crossmatch Kidney Transplantation: State of the Art and Future Perspectives

The organ shortage for kidney transplantation remains a challenging issue worldwide. Incompatibility between donor-recipient pairs, commonly occurring among transplant candidates who were sensitized from prior antigen exposure, serves as a significant barrier to kidney transplantation. In efforts to overcome this obstacle, living and deceased donor kidney transplantation across human leukocyte antigen barriers following desensitization has been pursued via positive crossmatch transplantation. The goal of desensitization therapy is to remove or denigrate donor-specific alloantibodies prior to transplantation in order to permit transplantation across the human leukocyte antigen barrier and prevent rejection. Various desensitization regimens have been utilized, including the use of plasmapheresis, intravenous immunoglobulin, and or immunoadsorption. Although long-term allograft outcomes for positive crossmatch kidney transplantation following desensitization therapy have been shown to be inferior to compatible transplantation, particularly with increasing strength of the crossmatch, there is an established survival benefit for positive crossmatch transplant recipients compared with remaining on the transplant waitlist. However, positive crossmatch transplantation may confer higher risks of infection and malignancy. Despite the fact that some of these heightened risks, positive crossmatch transplantation has also been demonstrated to have cost-savings compared with remaining on dialysis and may, therefore, be a cost-effective treatment option for sensitized patients who would face long waiting times and may never be able to achieve compatible transplantation. This review highlights both the risks and benefits of positive crossmatch transplantation and its role in the broader field of kidney transplantation.

ABO-Incompatible Living Donor Kidney Transplantation in a Human Immunodeficiency Virus–Positive Recipient From a Human Immunodeficiency Virus–Positive Donor: A Case Report

A human immunodeficiency virus (HIV) infection is no longer an absolute contraindication for solid organ transplantation, yet such a setting is still challenging and little explored because of general reservations and medical difficulties. We describe a 51-year-old man with end-stage renal failure due to polycystic kidney disease who underwent an ABO-incompatible kidney transplantation from his 49-year-old male partner. Early postoperative course revealed an episode of suspected acute rejection, which was successfully managed with a steroid pulse. Both donor and recipient continued to have an undetectable viral load after adjusting antiretroviral medication to renal function. To the best of our knowledge, this is the first report of a successful ABO-incompatible living donor kidney transplantation from an HIV-positive donor in an HIV-positive recipient, and this case seems to be a valuable approach with favorable results.

Cytomegalovirus Infection in Postrenal Transplant Recipients: 18 Years’ Experience From a Tertiary Referral Center

BackgroundCytomegalovirus (CMV) reactivation or infection is one of the most important infectious complications in transplant recipient leading to significant morbidity and mortality. Its early detection and prompt treatment is imperative to improve transplant outcome. The present study estimated the frequency of CMV in renal transplant recipients (RTR). Various aspects of pp65Ag assay and quantitative real-time polymerase chain reaction (qRT-PCR) were evaluated in relation to the recent guidelines for CMV detection and treatment. MethodsRetrospectively, data of clinically suspected cases of CMV (1610 out of total 2681 renal transplants) were analyzed along with a comparison of pp65Ag assay and qRT-PCR. ResultsThe overall incidence of CMV syndrome was 14.25%; however, the incidence of CMV viremia in the clinically suspected group was 23.73%. The proportion of positive cases with pp65Ag assay and qRT-PCR were 13.6% (95% CI; 7.9-22.3) and 19.3% (95% CI; 12.4-28.8) with a substantial agreement (Cohen’s kappa = 0.632) between the 2 techniques. CMV positive recipients were treated with ganciclovir until their viral count was negative or up to 3 weeks, followed by 3 months of prophylaxis with valganciclovir. No graft failure or mortality was reported secondary to CMV infection until 3 to 5 years of follow-up. ResultsCMV infection is quite prevalent in RTR, and early detection and immediate treatment or prophylaxis is of utmost importance. qRT-PCR is the gold standard and preferred over other methods; however pp65Ag assay still holds its importance in low-economic countries and populations where CMV infection is more prevalent and financial constraints are a major limitation.

Can HCV Viremic Organs Be Used in Liver Transplantation to HCV Negative Recipients?

Liver transplantation has steadily increased worldwide resulting in a large number of patients on the waiting list. Due to the opioid epidemic in the US, the pool of Hepatitis C seropositive donors increased significantly in recent years. Direct acting antivirals played an instrumental role in making liver transplantation with hepatitis C positive allograft an acceptable option. Although hepatitis C positive liver transplantation to hepatitis C positive recipients is a common practice, there is limited data and agreement on hepatitis C positive liver transplant to hepatitis C negative recipient. Thus, we review the current literature on this topic.

Evaluation of Universal versus Preemptive Antifungal Prophylaxis in Lung Transplantation

Infections from various fungi are increasingly recognized in the setting of lung transplant and guidelines do not distinguish one superior strategy between universal or preemptive. Limited studies exist comparing the two approaches and this study aims to evaluate the incidence mold infections post lung transplant (LTx) before and after the implementation of a protocol change. Our institution's PRE-protocol (PRE) included a pre-emptive prophylaxis for high risk IMI (invasive mold infection) with positive donor or recipient mold colonizations. POST-protocol implementation, a universal prophylaxis approach using itraconazole 200mg PO BID for lifetime post-transplant was employed. A single-center, retrospective chart review was conducted on adult LTx recipients. Patients receiving LTx between 1/2012-5/2016 were included in the PRE cohort and those between 8/2016-5/2019 were included in the POST cohort. A total of 150 patients were included in the PRE cohort and 127 in the POST cohort. Baseline demographics were similar among the cohorts in regards to mean age, gender, bilateral transplant and race. Incidence of IMI or disseminated fungal disease was n=13 (9%) vs n=1 (1%) in the PRE vs POST cohort; p=0.002. A total of 94/150 (63%) vs 51/127 (40%); p=.001 patients developed post LTx fungal colonization. The distribution of types of mold (Table 1) show that there was significantly less BAL colonization with aspergillus with the universal prophylaxis protocol (POST) 33 vs 64%. Median time to first fungal colonization was similar in both groups 108 vs 109 days in the respective PRE and POST groups. Discontinuation rates of itraconazole was n=28 (22%) among the POST cohort. While fungal colonization is ubiquitous, invasive and disseminated fungal infections can result in detrimental outcomes post lung transplant. The strategy of lifelong universal prophylaxis for molds may confer decreased colonization rates and in turn lower incidence if invasive and disseminated disease.