Clinical course, management and outcomes of COVID-19 in HIV-infected renal transplant recipients: A case series.

BACKGROUND: HIV-infected kidney transplant recipients with COVID-19 are at increased risk of acute illness and death owing to their underlying comorbidities and chronic immunosuppression. OBJECTIVES: To describe the incidence, clinical presentation and course of COVID-19, vaccination status, and SARS-CoV-2 antibody positivity rate among HIV-infected-to-HIV-infected kidney transplant recipients in South Africa (SA). METHODS: This retrospective study reports on rates of SARS-CoV-2 infection, COVID-19 and mortality among SA HIV-infected kidney transplant recipients who received organs from HIV-infected donors (HIV positive to HIV positive), before and after vaccination. Patient demographics, clinical presentation, course, management and disease outcomes were analysed. Antibody serology tests were performed between May and September 2022. RESULTS: Among 39 HIV-positive-to-HIV-positive transplant recipients, 11 cases of COVID-19 were diagnosed from March 2020 to September 2022. Six patients (55%) required hospitalisation, of whom 3 were admitted to a high-care unit or intensive care unit. Two patients required mechanical ventilation, and 2 received acute dialysis. One patient was declined access to intensive care. Four patients (10%) died of COVID-19 pneumonia. All the COVID-19-positive patients had at least one comorbidity. Vaccination data were available for 24 patients, of whom 5 had refused SARS-CoV-2 vaccination. SARS-CoV-2 antibody data were available for 20 patients; 4 vaccinated patients had a negative nucleocapsid protein antibody test and a positive spike protein antibody test, suggesting vaccination-acquired immunity. The remaining 16 patients demonstrated immunity that was probably due to COVID infection, and of these, 14 were also vaccinated. Of the 11 COVID-19 cases, only 1 was observed after vaccination. CONCLUSION: In our case series, ~10% of the HIV-positive-to-HIV-positive transplant recipients died of COVID-19 pneumonia. This mortality rate appears higher than figures reported in other transplant cohorts. However, it is likely that the actual number of cases of SARS-CoV-2 infection was much higher, as the study only included polymerase chain reaction-confirmed cases. It remains unclear whether HIV infection, transplant or the combination of the two drives poorer outcomes, and larger studies adjusting for important demographic and biological factors may isolate these effects.

A tale of two kidneys, and the case for machine perfusion in South Africa.

Extended-criteria donors (ECDs) are seen as a means of addressing the shortfall in solid-organ availability for transplant. However, the use of ECD kidneys is associated with a greater risk of primary non-function compared with standard-criteria donor kidneys, and a higher discard rate has been described internationally. There seems to be a lack of consensus in the consideration of ECD kidneys for transplant, with reliance often placed on the subjective assessment of individual clinicians. The following case examines the difference in the institutional decision-making process applied to two kidneys from a single donor, and provides an argument for the use of hypothermic machine perfusion in low- to middle-income countries as an efficacious and objective means of assessing ECD kidney suitability.

Kidney transplant utilising donors after circulatory death: The first report from the African continent.

BACKGROUND: At Groote Schuur Hospital in Cape Town, South Africa, the number of deceased organ donors has declined over the past 2 decades, necessitating a more liberal approach to donor selection. In 2007, measures to expand the deceased kidney donor pool were implemented, including an HIV positive-to-positive transplant programme and the utilisation of extended-criteria donors as well as donors after circulatory death (DCDs). OBJECTIVES: To report on our institutional experience with DCD kidney transplants and to encourage this approach among other African centres to improve access to transplantation. METHODS: An observational cohort study of consecutive DCD kidney transplants at Groote Schuur Hospital over a 17-year period was performed. Primary endpoints were 1-, 2- and 5-year graft and patient survival. Secondary endpoints included the incidence of delayed graft function (DGF), 30-day morbidity, length of stay, and donor and recipient clinical characteristics. RESULTS: Fifteen DCD procurements were performed, with no kidneys discarded. Thirty kidney transplants were performed, with a median (interquartile range) cold ischaemic time of 11.5 (8 - 14) hours. The incidence of DGF was 60.0%, and 30-day morbidity (other than DGF) was 20.0%. Graft survival at 1, 2 and 5 years was 100%, 96.0% and 73.7%, respectively. Patient survival at 1, 2 and 5 years was 93.3%, 93.3% and 88.4%, respectively. CONCLUSION: Long-term graft and patient survival was comparable with the international literature. DCD may present a unique opportunity to expand deceased donation throughout Africa, particularly in areas affected by a lack of brain death legislation and religious or cultural objections to donation after brain death.

Estimating the surgical backlog from the COVID-19 lockdown in South Africa: A retrospective analysis of six government hospitals.

BACKGROUND: The COVID-19 pandemic reached South Africa (SA) in March 2020. A national lockdown began on 27 March 2020, and health facilities reduced non-essential activity, including many surgical services. PRIMARY OBJECTIVE: to estimate the COVID-19 surgical backlog in Western Cape Province, SA, by comparing 2019 and 2020 general surgery operative volume and proportion at six district and regional hospitals. SECONDARY OBJECTIVE: to compare the operative volume of appendicectomy, laparoscopic cholecystectomy, cancer and trauma between the 2 years. METHODS: This was a retrospective study of general surgery operations from six SA government hospitals in the Western Cape. Data were obtained from electronic operative databases or operative theatre logbooks from 1 April to 31 July 2019 and 1 April to 31 July 2020. RESULTS: Total general surgery operations decreased by 44% between 2019 (n=3 247) and 2020 (n=1 810) (p<0.001). Elective operations decreased by 74% (n=1 379 v. n=362; p<0.001), and one common elective procedure, laparoscopic cholecystectomy, decreased by 68% (p<0.001). Emergency operations decreased by 22% (n=1 868 v. n=1 448; p<0.001) and trauma operations by 42% (n=325 v. n=190; p<0.001). However, non-trauma emergency operations such as appendicectomy and cancer did not decrease. The surgical backlog for elective operations after 4 months from these six hospitals is 1 017 cases, which will take between 4 and 14 months to address if each hospital can do one additional operation per weekday. CONCLUSIONS: The COVID-19 pandemic has created large backlogs of elective operations that will need to be addressed urgently. Clear and structured guidelines need to be developed in order to streamline the reintroduction of full surgical healthcare services as SA slowly recovers from this unprecedented pandemic.