COVID‐19 is novel infectious disease with an evolving understanding of its epidemiology and clinical manifestations. Immunocompromised patients often present atypical presentations of viral diseases. ...Herein we report a case of a COVID‐19 infection in a solid organ transplant recipient, in which the first clinical symptoms were of gastrointestinal viral disease and fever, which further progressed to respiratory symptoms in 48 hours. In these high risk populations, protocols for screening for SARS‐Cov2 may be needed to be re‐evaluated.
The authors report an atypical presentation of COVID‐19 infection in a kidney transplant recipient, demonstrating the relevance of screening in a high risk population.
According to preliminary data, seroconversion after mRNA SARS‐CoV‐2 vaccination might be unsatisfactory in Kidney Transplant Recipients (KTRs). However, it is unknown if seronegative patients develop ...at least a cellular response that could offer a certain grade of protection against SARS‐CoV‐2. To answer this question, we prospectively studied 148 recipients of either kidney (133) or kidney‐pancreas (15) grafts with assessment of IgM/IgG spike (S) antibodies and ELISpot against the nucleocapside (N) and the S protein at baseline and 2 weeks after receiving the second dose of the mRNA‐1273 (Moderna) vaccine. At baseline, 31 patients (20.9%) had either IgM/IgG or ELISpot positivity and were considered to be SARS‐CoV‐2‐pre‐immunized, while 117 (79.1%) patients had no signs of either cellular or humoral response and were considered SARS‐CoV‐2‐naïve. After vaccination, naïve patients who developed either humoral or cellular response were finally 65.0%, of which 29.9% developed either IgG or IgM and 35.0% S‐ELISpot positivity. Factors associated with vaccine unresponsiveness were diabetes and treatment with antithymocytes globulins during the last year. Side effects were consistent with that of the pivotal trial and no DSAs developed after vaccination. In conclusion, mRNA‐1273 SARS‐CoV‐2 vaccine elicits either cellular or humoral response in almost two thirds of KTRs.
Stable kidney or kidney‐pancreas transplant recipients exhibit lower than expected rates of cellular and humoral responses to the
Kidney transplant recipients might be at higher risk for severe coronavirus disease 2019 (COVID‐19). However, risk factors for relevant outcomes remain uncertain in this population. This is a ...multicentric kidney transplant cohort including 104 hospitalized patients between March 4 and April 17, 2020. Risk factors for death and acute respiratory distress syndrome (ARDS) were investigated, and clinical and laboratory data were analyzed. The mean age was 60 years. Forty‐seven patients (54.8%) developed ARDS. Obesity was associated to ARDS development (OR 2.63; P = .04). Significant age differences were not found among patients developing and not developing ARDS (61.3 vs 57.8 years, P = .16). Seventy‐six (73%) patients were discharged, and 28 (27%) died. Death was more common among the elderly (55 and 70.8 years, P < .001) and those with preexisting pulmonary disease (OR 2.89, P = .009). At admission, higher baseline lactate dehydrogenase (257 vs 358 IU/mL, P = .001) or ARDS conferred higher risk of death (HR 2.09, P = .044). In our cohort, ARDS was equally present among young and old kidney recipients. However, the elderly might be at higher risk of death, along with those showing higher baseline LDH at admission.
This multicenter study of kidney transplant recipients with COVID‐19 analyzes the clinical course and immunosuppression adjustments during infection and investigates risk factors for severe forms.
Recipients of simultaneous liver‐kidney transplantations (SLKTs) have a lower risk of rejection compared with recipients of kidney transplants alone. However, there is disagreement about the impact ...of pretransplant anti–human leukocyte antigen sensitization on patient and kidney graft survival in the long term. The aim of the study was to evaluate the impact of the recipient immunological risk and comorbidities in renal graft outcomes on SLKT. We reviewed the SLKTs performed in our center from May 1993 until September 2017. Patient and graft survival were analyzed according to the immunological risk, comorbidities, liver and kidney rejection episodes, immunosuppression, and infections. A total of 20 recipients of SLKT were considered in the high immunological risk (HIR) group, and 68 recipients were included in the low immunological risk (LIR) control group. The prevalence of hepatitis C virus infection, second renal transplant, and time on dialysis prior to transplantation were significantly higher in the HIR group. The incidence of acute kidney rejection was higher in the HIR group (P<0.01). However, death‐censored kidney graft survival as well as the estimated glomerular filtration rate at follow‐up were not different between the 2 groups. Comorbidities, but not the immunological risk, impact negatively on patient survival. Despite the higher incidence of rejection in the HIR SLKT group, longterm renal function and graft survival were similar to the LIR group.
The dialysis‐based definition of Delayed Graft Function (dDGF) is not necessarily objective as it depends on the individual physician’s decision. The functional definition of DGF (fDGF, the failure ...of serum creatinine to decrease by at least 10% daily on 3 consecutive days during the first week post‐transplant), may be more sensitive to reflect recovery after the ischemia‐reperfusion injury. We retrospectively analyzed both definitions in 253 deceased donor kidney transplant recipients for predicting death‐censored graft failure as primary outcome, using eGFR < 25 ml/min/1.73 m2 as a surrogate end‐point for graft failure. Secondary outcome was a composite outcome that included graft failure as above and also patient’s death. Median follow‐up was 3.22 2.38–4.21 years. Seventy‐nine patients developed dDGF (31.2%) and 127 developed fDGF (50.2%). Sixty‐three patients fulfilled criteria for both definitions (24.9%). At multivariable analysis, the two definitions were significantly associated with the primary HR (95%CI) 2.07 (1.09–3.94), P = 0.026 for fDGF and HR (95%CI) 2.41 (1.33–4.37), P = 0.004 for dDGF and the secondary composite outcome HR (95%CI) 1.58 (1.01–2.51), P = 0.047 for fDGF and HR (95%CI) 1.67 (1.05–2.66), P = 0.028 for dDGF. Patients who met criteria for both definitions had the worst prognosis, with a three‐year estimates (95%CI) of survival from the primary and secondary outcomes of 2.31 (2.02–2.59) and 2.20 (1.91–2.49) years for fDGF+/dDGF+, in comparison with the other groups (P < 0.01 for trend). fDGF provides supplementary information about graft outcomes on top of the dDGF definition in a modern series of kidney transplantation.
Summary
Enteric complications remain a major cause of morbidity in the post‐transplant period of pancreas transplantation despite improvements surgical technique. The aim of this single‐center study ...was to analyze retrospectively the early intestinal complications and their potential relation with vascular events. From 2000 to 2016, 337 pancreas transplants were performed with systemic venous drainage. For exocrine secretion, intestinal drainage was done with hand‐sewn anastomosis duodenojejunostomy. Twenty‐three patients (6.8%) had early intestinal complications. Median age was 39 years (male: 65.2%). Median cold ischemia time was 11 h IQR: 9–12.4. Intestinal complications were intestinal obstruction (n = 7); paralytic ileus (n = 5); intestinal fistula without anastomotic dehiscence (n = 3); ischemic graft duodenum (n = 3); dehiscence of duodenojejunostomy (n = 4); and anastomotic dehiscence in jejunum after pancreas transplantectomy (n = 1). Eighteen cases required relaparotomy: adhesiolysis (n = 6); repeated laparotomy without findings (n = 1); transplantectomy (n = 6); primary leak closure (n = 3); re‐positioning of the graft (n = 1); and intestinal resection (n = 1). Of the intestinal complications, 4 were associated with vascular thrombosis, resulting in two pancreatic graft losses. Enteric drainage with duodenum–jejunum anastomosis is safe and feasible, with a low rate of intra‐abdominal complications. Vascular thrombosis associated with intestinal complications presents a risk factor for the viability of pancreatic grafts, so prevention and early detection is vital.
Chronic active antibody-mediated rejection (c-aABMR) is an important cause of allograft failure and graft loss in long-term kidney transplants.
To determine the efficacy and safety of combined ...therapy with rituximab, plasma exchange (PE) and intravenous immunoglobulins (IVIG), a cohort of patients with transplant glomerulopathy (TG) that met criteria of active cABMR, according to BANFF'17 classification, was identified.
We identified 62 patients with active c-aABMR and TG (cg ≥ 1). Twenty-three patients were treated with the combination therapy and, 39 patients did not receive treatment and were considered the control group. There were no significant differences in the graft survival between the two groups. The number of graft losses at 12 and 24 months and the decline of eGFR were not different and independent of the treatment. A decrease of eGFR≥13 ml/min between 6 months before and c-aABMR diagnosis, was an independent risk factor for graft loss at 24 months (OR = 5; P = 0.01). Infections that required hospitalization during the first year after c-aABMR diagnosis were significantly more frequent in treated patients (OR = 4.22; P = 0.013), with a ratio infection/patient-year of 0.65 and 0.20 respectively.
Treatment with rituximab, PE, and IVIG in kidney transplants with c-aABMR did not improve graft survival and was associated with a significant increase in severe infectious complications.
Agencia Española de Medicametos y Productos Sanitarios (AEMPS): 14566/RG 24161. Study code: UTR-INM-2017-01.
Introduction
Nonantigen‐specific immunoadsorption (IA) has proven to be effective in acute antibody‐mediated rejection (aAMR). However, there is a lack of solid studies evaluating the safety and ...efficacy of IA with antihuman Ig‐columns in aAMR. For chronic‐active AMR (cAMR), no studies have evaluated the efficacy of nonantingen‐specific IA with antihuman Ig‐columns. The purpose of this study was to evaluate the role of nonantigen‐specific IA with antihuman Ig‐columns in the treatment of both aAMR and cAMR in kidney transplantation.
Material and Methods
In retrospective and observational study, kidney graft and recipient survival rates were assessed after treatment of aAMR and cAMR with nonantigen‐specific IA with Ig‐Flex columns (Therasorb) between January 2012 and May 2018. Protocols included nonantigen‐specific IA, rituximab, intravenous immunoglobulin, and rescue plasma exchange, if necessary.
Results
The study included 14 patients with AMR (acute in 9, chronic active in 5). For aAMR, mean follow‐up was 13 ± 6 months, and patient and graft survival were, respectively, of 100% and 83%, with a mean increase in estimated glomerular filtration rate (eGFR) of 7.98 ± 12.96, 10.18 ± 16.71, and 11.43 ± 13.85 mL/min/1.72 m2 (P > .05) at 3, 12 months after treatment, and at the end of follow‐up, respectively. For cAMR, mean follow‐up was 14 ± 8 months, and patient and graft survival were, respectively, of 100% and 60%, with an average increase in eGFR of 4.30 ± 7.86, 5.64 ± 10.47, and 14.5 ± 7.86 mL/min/m2 (P > .05) at 3, 12 months after IA treatment, and at the end of the follow‐up, respectively, although 40% did not respond and required chronic hemodialysis.
Conclusion
Nonantigen‐specific IA with Ig‐Flex columns was safe and effective for aAMR treatment in kidney transplantation. In cAMR, IA with Ig‐Flex columns was associated with a satisfactory kidney graft survival, suggesting that IA could potentially offer some benefits supporting its indication in cAMR.
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