The outcome of SARS-CoV2 infection in patients who have received a kidney allograft and are being treated with immunosuppression is unclear. We describe 20 kidney transplant recipients (median age 59 ...years inter quartile range 51-64 years, median age of transplant 13 years 9-20 years, baseline eGFR 36.5 23-47.5) with SARS-CoV2 induced pneumonia. At admission, all had immunosuppression withdrawn and were started on methylprednisolone 16 mg/day, all but one was commenced on antiviral therapy and hydroxychloroquine with doses adjusted for kidney function. At baseline, all patients presented fever but only one complained of difficulty in breathing. Half of patients showed chest radiographic evidence of bilateral infiltrates while the other half showed unilateral changes or no infiltrates. During a median follow-up of seven days, 87% experienced a radiological progression and among those 73% required escalation of oxygen therapy. Six patients developed acute kidney injury with one requiring hemodialysis. Six of 12 patients were treated with tocilizumab, a humanized monoclonal antibody to the IL-6 receptor. Overall, five kidney transplant recipients died after a median period of 15 days 15-19 from symptom onset. These preliminary findings describe a rapid clinical deterioration associated with chest radiographic deterioration and escalating oxygen requirement in renal transplant recipients with SARS-Cov2 pneumonia. Thus, in this limited cohort of long-term kidney transplant patients, SARS-CoV-2 induced pneumonia is characterized by high risk of progression and significant mortality.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as coronavirus disease (COVID-19), is a major pandemic challenging health care systems around the world. The optimal ...management of patients infected with COVID-19 is still unclear, although the consensus is moving toward the need of a biphasic approach. During the first phase of the disease (from onset of the symptoms up to 7–10 days) viral-induced effects are prominent, with the opportunity to institute antiviral therapy. In the second inflammatory phase of the disease, immunosuppressive strategies (for example with glucocorticoids or anticytokine drugs) may be considered. This latter stage is characterized by the development of progressive lung involvement with increasing oxygen requirements and occasionally signs of the hemophagocytic syndrome. The management of the disease in patients with kidney disease is even more challenging, especially in those who are immunosuppressed or with severe comorbidities. Here we present the therapeutic approach used in Brescia (Italy) for managing patients infected with COVID-19 who underwent kidney transplantation and are receiving hemodialysis. Furthermore, we provide some clinical and physiopathological background, as well as preliminary outcome data of our cohort, to better clarify the pathogenesis of the disease and clinical management.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The outcome of kidney transplant patients with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection is still unclear. Here we describe the clinical characteristics, disease outcome, ...and risk factors for acute respiratory distress syndrome (ARDS) and death of a cohort of 53 kidney transplant patients with coronavirus disease 2019 (COVID‐19). Eight of 53 have been handled as outpatients because of mild disease, on average with immunosuppression reduction and the addition of hydroxychloroquine and azithromycin; no patients required admission, developed ARDS, or died. Because of severe symptoms, 45/53 required admission: this cohort has been managed with immunosuppression withdrawal, methylprednisolone 16 mg/d, hydroxychloroquine, and antiviral drugs. Dexamethasone and tocilizumab were considered in case of ARDS. About 33% of the patients developed acute kidney injury, 60% ARDS, and 33% died. In this group, thrombocytopenia was associated to ARDS whereas lymphopenia at the baseline, higher D‐dimer, and lack of C‐reactive protein reduction were associated with risk of death. In the overall population, dyspnea was associated with the risk of ARDS and age older than 60 years and dyspnea were associated with the risk of death with only a trend toward an increased risk of death for patients on tacrolimus. In conclusion, SARS‐CoV‐2 infection may have a variable outcome in renal transplant patients, with higher risk of ARDS and death in the ones requiring admission.
Findings from an Italian cohort of kidney transplant patients with COVID‐19 support heterogenous disease courses with higher risks of acute respiratory distress syndrome and death in the subgroup with severe disease.
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BFBNIB, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract
Background and Aims
Encapsulating peritoneal sclerosis (EPS) is a rare but severe complication of peritoneal dialysis (PD). Its prevalence, ranging from 0.7 to 3.3%, and its reported ...mortality is 25-55%. Post-transplantation encapsulating peritoneal sclerosis (PT-EPS) usually occurs within two years from PD interruption due to kidney transplantation. Calcineurin inhibitors are thought to be involved in the pathogenesis of PT-EPS.
Method
This is a retrospective, single-center study: all the patients who received PD for 2 or more months before kidney transplantation between 1979 and 2018 in our unit were enrolled. All PD patients diagnosed with EPS after transplantation were identified, and their data were compared with those of non-transplanted PD patients (NT-PD).
Results
Data from a total of 1014 PD patients were examined; 215 underwent kidney transplantation and 799 remained on PD. PT-EPS occurred in 5/215 patients (2.3%), a prevalence not significantly different from that of NT-PD (21/799= 2.6%; P = 0.39) (Table 1). Calcineurin inhibitors were administered to 178/215 (83%) patients without EPS and all 5 patients with PT-EPS (P = 0.68). Calcineurin inhibitors were associated with corticosteroids (41%), mycophenolate mofetil (34%), or both (42%). Inhibitors of mammalian targets of rapamycin were used in association with calcineurin inhibitors in 25%, with calcineurin inhibitors and steroids in 24% and steroids alone in 7%. Mortality due to PT-EPS was 4.3% vs 1.2% in NT-PD (P = 0.38) (Figure 1).
Conclusion
The prevalence of PT-EPS was similar to that of EPS in NT-PD. Therapy with calcineurin inhibitors did not appear to be a crucial risk key in the development of PT-EPS.
Table 1.
Encapsulating peritoneal sclerosis (C-EPS) vs those with post-transplantation encapsulating Comparison of characteristics between the non-transplanted PD patients (NT-PD) vs those transplanted (KT-PD) and between the patients with classic peritoneal sclerosis (PT-EPS)
NT-PD
KT-PD
p
Number of patients (%)
799 (78.9)
215 (21.2)
--
Male/female
444/355
125/90
0.56
Total time on PD* (months) (median, IQR)
26 (10-44)
27 (16-46)
0.38
Deceased for all causes (%)
662 (82.8)
47 (21.9)
<0.001
Deceased for EPS (%)
8 (1.2)
2 (4.3)
0.38
C-EPS
PT-EPS
P
Cases of EPS (%)
21 (2.6)
5 (2.3)
0.39
Age at EPS diagnosis (M±SD)
64±12
55±7
0.08
Months spent on PD at diagnosis* (median, IQR)
103 (42-156)
79 (54-97)
0.33
Months from diagnosis to the end of observation# (median, IQR)
22 (5-75)
62 (46-114)
0.13
Deceased due to EPS (%)
8 (38.1)
2 (40.0)
0.94
*
For all treatments. #Dead or lost to follow-up
Figure 1.
Comparative cumulative survival from EPS in the 215 KT-PD patients (continuous line) vs the 799 NT-PD patients (dotted line) (log-rank test: p=0.38).
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