The Transplant Experience for Undocumented Immigrant Patients Formerly Receiving Emergency Dialysis and Caregivers.

Importance: Individuals of undocumented immigration status with kidney failure face barriers to receiving transplants due to lack of health insurance despite no regulatory barriers. Little is known about the perspectives on kidney transplant among individuals with undocumented immigration status with kidney failure who relied on emergency hemodialysis. Objective: To examine the overall experiences of transplant among transplant recipients of undocumented immigration status who previously relied on emergency hemodialysis and their family caregivers. Design, Setting, and Participants: In this qualitative study, semistructured 1-to-1 interviews were conducted with transplant recipients who had previously received emergency hemodialysis and transitioned to scheduled dialysis and their primary caregivers living in Denver, Colorado, between May 1, 2022, and March 31, 2023, in English or Spanish. Main Outcomes and Measures: Themes and subthemes regarding the experience of transplant as an undocumented immigrant previously receiving emergency hemodialysis were identified. Interview transcripts were translated, deidentified, and then analyzed using thematic analysis. Results: A total of 25 participants including 15 transplant recipients (5 [33.3%] female and 10 [66.7%] male; mean [SD] age, 49.5 [9.8] years) and 10 caregivers (7 [70.0%] female and 3 [30.0%] male; mean [SD] age, 44.5 [22.3] years) participated. Six themes were reported: limited kidney replacement therapy education while receiving emergency hemodialysis (lack of awareness of kidney disease and treatment options and discriminatory kidney replacement therapy education due to immigration status), hope for transplant once receiving scheduled dialysis (prospect of transplant through scheduled dialysis, family and quality of life as transplant motivators), transplant education and health insurance after transition to scheduled dialysis (inadequate transplant education in dialysis clinic, peer-to-peer transplant education, and peer-to-peer communication regarding availability of private health insurance), uncertainty during transplant evaluation (difficulty navigating the evaluation and wait-listing process, lack of communication regarding timeline, and concern for family limiting living donation), posttransplant improvements (ability to work after transplant is critically important given immigration status, autonomy with transplant improves mental health, and vigilance in maintaining transplant), and transplant facilitators (self-advocacy, spirituality and optimism, and peer support). Conclusions and Relevance: This qualitative study of transplant recipients of undocumented immigration status and their caregivers found that individuals formerly receiving emergency dialysis are excluded from education and access to transplant, and peer support throughout the transplant process helped with education and motivation to pursue transplant. These findings may be used to implement improvements in access to support and education for patients of undocumented immigration status with kidney failure, especially in areas where scheduled dialysis is not available.

Short and Long-Term Outcomes of Kidney Transplant Recipients Diagnosed With COVID-19 Infection: A Single-Center Observational Study.

PURPOSE: Kidney transplant recipients (KTRs) are at an increased risk of severe disease and death caused by coronavirus disease 2019 (COVID-19) infection. There is a paucity of information on the evolution of graft function among hospitalized KTRs who overcome the infection. METHODS: The study included adult KTRs at a single transplant institute who were diagnosed with COVID-19 and needed hospitalization between March 15, 2020, and January 15, 2021. We analyzed patient demographics, comorbid risk factors, and inpatient clinical courses for patients who were able to recover from the infection. Kidney function was analyzed pre-infection, during initial hospitalization, and up to 12 months post-infection. RESULTS: We identified 48 KTRs who were diagnosed with COVID-19 infection during the study period. Eighteen KTRs among these needed hospitalization for symptoms of fever and respiratory distress. Four patients died of COVID-19 infection-related complications and were excluded from the study. The 14 remaining patients in the study were predominantly of the Black race (85.7%), with a median time since transplant of four years. Of the patients, 64.3% developed acute kidney injury (AKI), with an average peak serum creatinine (sCr) of 2.6 mg/dl and a glomerular filtration rate (GFR) of 35. The mean sCr and GFR of the group were 2 mg/dl and 44 at baseline (prior to infection). This represented an increase in their sCr and GFR of 34% and 29%, respectively. The median follow-up post-infection was 14.5 months. sCr and GFR were 1.87 mg/dl and 47 at three to six months, and 1.89 mg/dl and 48 at nine to 12 months post-infection. New onset proteinuria was noted in five out of 14 patients (36%), with complete resolution of the same in all at three to six months follow-up. Of patients with AKI, 78% had complete recovery at three to six months follow-up. The mean baseline sCr and GFR of patients who had incomplete recovery was 2.35 and 31.5 with pre-existing proteinuria. Of our entire cohort, there was only one patient who experienced graft loss. This patient had a baseline sCr and GFR of 3.8 mg/dl and 22, existing proteinuria on urinalysis, and a history of biopsy-proven rejection. CONCLUSION: AKI is common among KTRs who are hospitalized with COVID-19 infection. Most of these recovered, although we noted that patients with baseline lower kidney function and existing proteinuria had a lower recovery rate.

Resolution of Disseminated Angiosarcoma in a Kidney Transplant Recipient After Treatment With Sirolimus: A Case Report.

Angiosarcoma is a rare, almost universally fatal malignant neoplasm in kidney transplant recipients. No evidence-based guidelines are available for disseminated disease. Here, we report a case of a 66-year-old woman who developed disseminated angiosarcoma 4 months after living nonrelated kidney transplant. She underwent only 2 rounds of chemotherapy because of intolerable adverse effects. Her mycophenolic acid and tacrolimus were withdrawn and sirolimus use was started. In addition to its immunosuppressant effects, sirolimus has been shown to have antineoplastic properties. Remarkably, at almost 2 years post-transplant, the patient has had complete resolution of all gross metastatic disease with only immunosuppressant medication changes. This case highlights the interesting possibility that sirolimus is an effective adjunct treatment for disseminated angiosarcoma in kidney transplant recipients.

The Effect of Proton Pump Inhibitor Use on the Course of Kidney Function in Patients with Chronic Kidney Disease Stages G3a to G4.

BACKGROUND: Proton pump inhibitors (PPI) are widely used and implicated in the progression of chronic kidney disease (CKD). We evaluated the relation between chronic PPI use in veterans with CKD G3a to G4 and the rate of decline in renal function. METHODS: We accessed the Veteran Affairs Informatics and Computing Infrastructure national database to evaluate the relation between chronic PPI use and rate of decline in renal function in veterans with CKD (eGFR <60 ml/min1.73 m2). We applied Propensity Score Matching to match the PPI group and the no-PPI control group on age, sex, race, and Charlson Comorbidity Index. The final sample included 1406 patients (age: 62.07±7.82, 62.02% Caucasian) in the PPI cohort with a median 4.7 years follow-up and 1425 patients (age: 65.45±6.58, 71.16% Caucasian) in the control cohort with a median 3.9 years follow-up. Kaplan-Meier curve and Cox regression were performed to analyze the associations of PPI use with dialysis, all-cause mortality, metabolic acidosis, and CKD progression. RESULTS: The PPI group had a significantly increased risk of CKD progression, dialysis and all-cause mortality (aHR, 1.83; 95% CI, 1.53 to 2.19; aHR, 1.84; 95% CI, 1.26 to 2.67; and aHR, 1.34; 95% CI, 1.08 to 1.65, respectively). The PPI cohort also had a trend for development of metabolic acidosis (aHR, 1.34; 95% CI, 0.998 to 1.80), although the difference was not statistically significant. CONCLUSIONS: The data suggest that chronic PPI use accelerates progression of kidney disease and is associated with increased mortality in CKD patients.

Observational Study of the Clinical Characteristics and Short-Term Outcomes of Kidney Transplant Recipients Diagnosed With COVID-19 Infection (SARS-CoV-2) Requiring Hospitalization in New Orleans.

Background: Kidney transplant recipients are at increased risk of severe disease and death caused by coronavirus disease 2019 (COVID-19) infection. The role of immunosuppressive medications in the clinical presentation, disease course, and outcomes is not well understood. Methods: We analyzed kidney transplant recipients diagnosed with COVID-19 and requiring hospitalization during the initial infection surge at 2 large transplant centers in New Orleans, Louisiana, between February 1, 2020 and April 30, 2020. Patient presentation, clinical course, kidney transplant function, and postdischarge details are included in this analysis. Results: Twenty-three kidney transplant recipients hospitalized with COVID-19 were included in the study. The majority of patients were Black (95.7%). Diabetes, hypertension, and obesity were present in more than 50% of the patients. The most common presenting symptom was fever, present in 52.2% of patients. All patients were managed with reduction in immunosuppression. Patients received azithromycin (60.9%), hydroxychloroquine (47.8%), remdesivir (8.7%), and intravenous methylprednisolone pulse (8.7%). The average length of stay was 4.5 days (range, 2-18 days). In this study population, 73.9% of the patients sustained acute kidney injury, with an average peak serum creatinine of 3.81 mg/dL. Twenty-six percent of the patients required renal replacement therapy. Seventy-seven percent of patients developed proteinuria (at least 1+ proteinuria on urinalysis). Of the patients in this population who required mechanical ventilation (39.1%), 77.8% died. Overall, 30.4% of patients died of COVID-19-related complications during admission. Of the 16 patients discharged, the average serum creatinine at discharge was 2.09 mg/dL compared with an average preadmission serum creatinine of 1.8 mg/dL. Conclusion: During the initial COVID-19 infection surge in New Orleans, we noted that kidney transplant recipients had initial symptoms similar to the general population. However, we recorded a higher incidence of acute kidney injury and death compared to nontransplant patients. Patients who required mechanical ventilation had a high mortality rate. Black patients are overrepresented in our study.

Antibody-Mediated Rejection: A Review.

BACKGROUND: Chronic antibody injury is a serious threat to allograft outcomes and is therefore the center of active research. In the continuum of allograft rejection, the development of antibodies plays a critical role. In recent years, an increased recognition of molecular and histologic changes has provided a better understanding of antibody-mediated rejection (AMR), as well as potential therapeutic interventions. However, several pathways are still unknown, which accounts for the lack of efficacy of some of the currently available agents that are used to treat rejection. METHODS: We review the current diagnostic criteria for AMR; AMR paradigms; and desensitization, treatment, and prevention strategies. RESULTS: Chronic antibody-mediated endothelial injury results in transplant glomerulopathy, manifested as glomerular basement membrane duplication, double contouring, or splitting. Clinical manifestations of AMR include proteinuria and a rise in serum creatinine. Current strategies for the treatment of AMR include antibody depletion with plasmapheresis (PLEX), immunoadsorption (IA), immunomodulation with intravenous immunoglobulin (IVIG), and T cell- or B cell-depleting agents. Some treatment benefits have been found in using PLEX and IA, and some small nonrandomized trials have identified some benefits in using rituximab and the proteasome inhibitor-based therapy bortezomib. More recent histologic follow-ups of patients treated with bortezomib have not shown significant benefits in terms of allograft outcomes. Furthermore, no specific treatment approaches have been approved by the US Food and Drug Administration. Other agents used for more difficult rejections include bortezomib and eculizumab (an anti-C5 monoclonal antibody). CONCLUSION: AMR is a fascinating field with ample opportunities for research and progress in the future. Despite the use of advanced techniques for the detection of human leukocyte antigen (HLA) or non-HLA donor-specific antibodies, alloimmune response remains an important barrier for successful long-term allograft function. Treatment of AMR with currently available therapies has produced a variety of results, some of them suboptimal, precluding the development of standardized protocols. New therapies are promising, but randomized controlled trials are needed to find surrogate markers and improve the efficacy of therapy.