Complications of rabbit anti-thymocyte globulin induction immunosuppression in HIV-infected kidney transplant recipients.

Background: Kidney transplantation in HIV-infected individuals with end-stage kidney disease is associated with improved survival compared to dialysis. Rabbit anti-thymocyte globulin (rATG) induction in HIV-infected kidney transplant recipients has been associated with a lower risk of acute rejection, but data on the rates of de novo malignancy and BK viremia in these patients is lacking. Methods: We performed a single-center retrospective cohort study of adult HIV-infected individuals who underwent kidney transplantation with rATG induction between January 2006 and December 2016. The primary outcome was the development of de novo malignancy. Secondary outcomes included the development of BK viremia, infections requiring hospitalization, HIV progression, biopsy-proven acute rejection, and patient and allograft survival. Results: Twenty-seven HIV-infected individuals with end-stage kidney disease received deceased (n=23) or living (n=4) donor kidney transplants. The cumulative rate of malignancy at five years was 29%, of whom 29% died because of advanced malignancy. BK viremia was detected in six participants (22%), of whom one had biopsy-proven BK virus-associated nephropathy and all of whom cleared the BK viremia. Five-year acute rejection rates, patient survival and death-censored allograft survival were 17%, 85% and 80% respectively. Conclusion: rATG induction in HIV-infected kidney transplant recipients was associated with a low risk of acute rejection, but a potentially higher risk of de novo malignancies and BK viremia in this cohort. Screening strategies to closely monitor for BK virus infection and malignancy post-transplantation may improve outcomes in HIV-infected kidney transplant recipients receiving rATG induction.

Sublingual administration of tacrolimus: current trends and available evidence.

Widespread anecdotal use of sublingual tacrolimus administration has arisen, although little literature exists to guide practice. Given the paucity of data, we conducted a survey to evaluate the practice of sublingual tacrolimus administration at transplant centers across the United States and evaluated the literature that is currently available. A 10-question online survey assessing the current state of sublingual tacrolimus use was distributed to pharmacists at transplant centers that each performed more than 100 solid organ transplantations in 2013. In addition, a literature review was performed by searching the PubMed database to identify available evidence for the sublingual administration of tacrolimus. The online survey was completed by 59 (65.6%) of the 90 targeted transplant centers, representing 51.3% of all solid organ transplantations performed in 2013. Sublingual administration of tacrolimus was used in all solid organ transplant populations, with ~67% of lung transplant centers using this route for tacrolimus. The most common dose conversion was 2 mg oral to 1 mg sublingual, with 92% of centers opening oral capsules and administering the contents sublingually. Home use of sublingual administration and use in the pediatric population was uncommon. Seven peer-reviewed reports and one abstract were identified in the literature review. Seven of the eight publications reported favorably on sublingual administration, although no consistent dose conversion or method of administration was elucidated. The majority of the transplant centers surveyed found sublingual tacrolimus a viable alternative when oral administration is unavailable. A large robust prospective evaluation of sublingual administration of tacrolimus is imperative to provide the most effective care to solid organ transplant recipients and to ensure optimal safety for both patients and providers who administer the drug.