Apheresis medicine education during the early phase of the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic introduced challenges and disruption across healthcare, including apheresis medicine (AM). In this study, we report findings from a survey conducted among American Society for Apheresis Physician Committee (ASFA-PC) members to describe the impact of the COVID-19 pandemic on AM education practices. STUDY DESIGN AND METHODS: A voluntary, anonymous, 24-question, institutional review board-approved survey regarding AM teaching during the pandemic was distributed to ASFA-PC members in the United States between December 1, 2020, and December 15, 2020. Descriptive analyses were reported as number and frequency of respondents for each question. Free text responses were summarized. RESULTS: Responses were received from 14/31 (45%) of ASFA-PC members, of whom 12 practiced at academic institutions. Among these, 11/12 (92%) transitioned to virtual platform for AM trainee conferences during the pandemic. A variety of resources were employed to support independent AM learning. While 7/12 (58%) respondents did not change the informed consent process for AM procedures, others delegated this process or introduced remote alternatives. The most common method respondents used to conduct AM patient rounding was a hybrid in-person/virtual model. CONCLUSION: This survey describes the adaptations and changes AM practitioners made to trainee education in response to the early phase of the COVID-19 pandemic. The transition to virtual and/or hybrid trainee learning and AM rounds underscores the importance of digital AM resources. Further study of the effects of the pandemic and its impact on AM trainee education, as well as patient care is warranted.

Benefit of B7-1 staining and abatacept for treatment-resistant post-transplant focal segmental glomerulosclerosis in a predominantly pediatric cohort: time for a reappraisal.

BACKGROUND: Primary FSGS manifests with nephrotic syndrome and may recur following KT. Failure to respond to conventional therapy after recurrence results in poor outcomes. Evaluation of podocyte B7-1 expression and treatment with abatacept (a B7-1 antagonist) has shown promise but remains controversial. METHODS: From 2012 to 2020, twelve patients developed post-KT FSGS with nephrotic range proteinuria, failed conventional therapy, and were treated with abatacept. Nine/twelve (< 21 years old) experienced recurrent FSGS; three adults developed de novo FSGS, occurring from immediately, up to 8 years after KT. KT biopsies were stained for B7-1. RESULTS: Nine KTRs (75%) responded to abatacept. Seven of nine KTRs were B7-1 positive and responded with improvement/resolution of proteinuria. Two patients with rFSGS without biopsies resolved proteinuria after abatacept. Pre-treatment UPCR was 27.0 ± 20.4 (median 13, range 8-56); follow-up UPCR was 0.8 ± 1.3 (median 0.2, range 0.07-3.9, p < 0.004). Two patients who were B7-1 negative on multiple KT biopsies did not respond to abatacept and lost graft function. One patient developed proteinuria while receiving belatacept, stained B7-1 positive, but did not respond to abatacept. CONCLUSIONS: Podocyte B7-1 staining in biopsies of KTRs with post-transplant FSGS identifies a subset of patients who may benefit from abatacept. A higher resolution version of the Graphical abstract is available as Supplementary information.

Percutaneous Ultrasound-Guided Kidney Transplant Biopsy Outcomes: From the Nephrologist to the Radiologist Standpoint.

Background: Kidney transplant biopsies are the gold standard for evaluating allograft dysfunction. These biopsies are performed by nephrologists and radiologists under real-time ultrasound guidance. A few studies have examined the outcomes of ultrasound-guided kidney transplant biopsy in transplant recipients; however, none have compared these outcomes between both specialties. Methods: We retrospectively analyzed a cohort of 678 biopsies performed in a single center during a 44-month study period. Biopsies were stratified into two groups based upon the specialist performing the procedure: interventional radiology (IR; N=447) and transplant nephrology (TN; N=231). Results: There were 55 (8%) complications related to biopsies in the entire cohort: 37 (8.2%) in the IR group and 18 (7.7%) in the TN group, without statistical difference between the groups (P=0.94). Blood pressure control and prior use of anticoagulation were significant predictors of complicated biopsies (P=0.004 and 0.02, respectively). Being a woman and prior use of anticoagulation were significant predictors of transfusion of blood products (P=0.01 and 0.01, respectively). Being a woman and blood pressure control were significant predictors of overall perinephric hematoma (P=0.01 and 0.01, respectively), and Black race was a significant predictor of perinephric hematoma without worsening of renal function (P=0.005). The specialist team performing the procedure was not a statistically significant predictor of biopsy complications, transfusion of blood products, or perinephric hematoma with comparable sample yield. Conclusions: Percutaneous ultrasound-guided kidney transplant biopsy performed by transplant nephrologists have similar complication rates when compared with interventional radiologists in an academic center.

Kidney transplantation during coronavirus 2019 pandemic at a large hospital in Miami.

BACKGROUND: Coronavirus 2019 (COVID-19) pandemic has resulted in more than 350 000 deaths worldwide. The number of kidney transplants has declined during the pandemic. We describe our deceased donor kidney transplantation (DDKT) experience during the pandemic. METHODS: A retrospective study was conducted to evaluate the safety of DDKT during the COVID-19 pandemic. Multiple preventive measures were implemented. Adult patients that underwent DDKT from 3/1/20 to 4/30/20 were included. COVID-19 clinical manifestations from donors and recipients, and post-transplant outcomes (COVID-19 infections, readmissions, allograft rejection, and mortality) were obtained. The kidney transplant (KT) recipients were followed until 5/31/20. RESULTS: Seventy-six patients received kidneys from 57 donors. Fever, dyspnea, and cough were reported in 1, 2, and 1 donor, respectively. Thirty-eight (66.6%) donors were tested for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) prior to donation (mainly by nasopharyngeal or bronchoalveolar lavage polymerase chain reaction [PCR]) and 36 (47.3%) KT recipients were tested at the time of DDKT by nasopharyngeal PCR; all of these were negative. Our recipients were followed for a median of 63 (range: 33-91) days. A total of 42 (55.3%) recipients were tested post-transplant for SARS-CoV2 by nasopharyngeal PCR including 12 patients that became symptomatic; all tests were negative except for one that was inconclusive, but it was repeated and came back negative. Forty (52.6%) KT recipients were readmitted, and 7 (9.2%) had biopsy-proven rejection during the follow-up. None of the KT recipients transplanted during this period died. CONCLUSIONS: Our cohort demonstrated that DDKT can be safely performed during the COVID-19 pandemic when preventive measures are implemented.

Roux-en-Y gastric bypass is an effective bridge to kidney transplantation: Results from a single center.

Body mass index (BMI) > 35-40 kg/m2 is often a contraindication, while Roux-en-Y gastric bypass (RYGB) is performed to enable kidney transplantation. This single-center retrospective study evaluated pre- and post-transplant outcomes of 31 morbidly obese patients with end-stage renal disease having RYGB before kidney transplantation between July 2009 and June 2014. Fourteen RYGB patients were subsequently transplanted. Nineteen recipients not having GB with a BMI ≥ 36 kg/m2 at transplantation were used as historical controls. Mean BMI (±SE) before RYGB was 43.5 ± 0.7 kg/m2 (range: 35.4-50.5 kg/m2 ); 87.1% (27/31) achieved a BMI < 35 kg/m2 . The percentage having improved diabetes/hypertension control was 29.0% (9/31); 25.8% (8/31) had complications (mostly minor) after RYGB. Among transplanted patients, blacks/Hispanics comprised 78.6% (11/14) and 84.2% (16/19) of RYGB and controls; 57.1% (8/14) and 63.2% (12/19) had a (mostly long-standing) pretransplant history of diabetes. While biopsy-proven acute rejection (BPAR) occurred significantly higher among RYGB vs control patients (6/14 vs 3/19, P = .03), patients developing T-cell BPAR were also significantly more likely to have a tacrolimus (TAC) trough level < 4.0 ng/mL within 3 weeks of T-cell BPAR (P = .0007). In Cox's model, the impact of having a TAC level < 4.0 ng/mg remained significant (P = .007) while the effect of RYGB was no longer significant (P = .13). Infections, graft, and patient survival were not significantly different. Despite obvious effectiveness in achieving weight loss, RYGB will need more careful post-transplant monitoring given the observed higher BPAR rate.

Highly Sensitized Patients: Miami Transplant Institute Experience.

BACKGROUND: Transplantation continues to be challenging in highly sensitized patients. Herein, we compared induction immunosuppression (IS) based on immunologic risk stratification and desensitization with intravenous immunoglobulin (IVIG). METHODS: Of the 42 highly sensitized kidney and 3 kidney-pancreas transplant recipients who underwent IVIG for desensitization from 2008-2014, 10 (Control group) received standard induction IS with antithymocyte globulin, basiliximab, and methylprednisolone, and 35 (Rituximab group) received standard IS with rituximab ± IVIG ± plasmapheresis. Immunologic risk stratification was based on donor specific antibodies (DSA), flow crossmatch ratio, and calculated panel reactive antibody. All patients received tacrolimus, mycophenolate, and steroids for maintenance IS. Unacceptable antigen cut-offs for class I and II DSA were 6000 and 9000 mean fluorescence intensity and 2.0 and 4.4 channel shift ratios for T and B cell flow cytometry crossmatch, respectively. All complement dependent cytotoxicity T cell crossmatch negative patients were transplanted. RESULTS: Characteristics between groups, including high risk level, previous transplantation rate, number of human leukocyte antigen mismatches, delayed graft function rate, rejection rate, serum creatinine, and estimated glomerular filtration rate at 1 year (1.48 ± 0.6 and 50 ± 17 versus 1.1 ± 0.4 mg/dl and 66 25 ml/min) were not statistically significant between the Control and the Rituximab groups, respectively. Waiting time for the Control group was 6.4 years versus 4.1 years for the Rituximab group (p = 0.009). The cumulative proportion of patients who remain free of death or allograft failure was significantly higher in the Rituximab (87%) versus the Control group (60%) (p = 0.047). CONCLUSIONS: In highly sensitized patients who received desensitization with IVIG, the addition of Rituximab to our standard IS (and/or IVIG and plasmapheresis as per the immunologic risk stratification model) resulted in higher cumulative patient and graft survival.

Evaluación clínica del acceso vascular / Clinical evaluation of the vascular access

La evaluación del paciente para la confección del acceso vascular se debe iniciar en el período de IRC, con la antelación suficiente para permitir la reacción del acceso vascular de elección como es la FAV nativa, y para permitir que ésta madure en forma correcta. Hay que tener en cuenta la importancia que tiene el interrogatorio para recabar los antecedentes del paciente y sistematizar la evaluación clínica para no pasar por alto ningún paso de la misma. Se puede obtener información muy útil y detalles de suma importancia en sólo "usar la punta de los dedos" y "escuchar todo lo que el acceso vascular del paciente nos puede decir". Se sugiere sistematizar de la siguiente forma el exámen físico para la confección del acceso vascular: 1)Examinar el sistema arterial del brazo no dominante (chequear los pulsos, realizar el Test de Allen. Si se encuentra alguna alteración, examinar el brazo dominante. 2)Comparar las presiones en ambos brazos. Si se encuentran anormalidades, chequear el brazo dominante. 3)Examinar el sistema venoso evaluando la anatomía venosa del brazo y del antebrazo. 4)Usar torniquete o lazo para ponerlas en evidencia. Si no es satisfactoria examinar el brazo dominante o evaluar con Doppler. 5)Enviar al paciente a realizarse una fístula nativa. (AU)(Esta monografía fue presentada para la aprobación del "Curso formativo para residentes en Nefrología" dictado en el Instituto Universitario CEMIC durante el año 1998)

Evaluación clínica del acceso vascular / Clinical evaluation of the vascular access

La evaluación del paciente para la confección del acceso vascular se debe iniciar en el período de IRC, con la antelación suficiente para permitir la reacción del acceso vascular de elección como es la FAV nativa, y para permitir que ésta madure en forma correcta. Hay que tener en cuenta la importancia que tiene el interrogatorio para recabar los antecedentes del paciente y sistematizar la evaluación clínica para no pasar por alto ningún paso de la misma. Se puede obtener información muy útil y detalles de suma importancia en sólo "usar la punta de los dedos" y "escuchar todo lo que el acceso vascular del paciente nos puede decir". Se sugiere sistematizar de la siguiente forma el exámen físico para la confección del acceso vascular: 1)Examinar el sistema arterial del brazo no dominante (chequear los pulsos, realizar el Test de Allen. Si se encuentra alguna alteración, examinar el brazo dominante. 2)Comparar las presiones en ambos brazos. Si se encuentran anormalidades, chequear el brazo dominante. 3)Examinar el sistema venoso evaluando la anatomía venosa del brazo y del antebrazo. 4)Usar torniquete o lazo para ponerlas en evidencia. Si no es satisfactoria examinar el brazo dominante o evaluar con Doppler. 5)Enviar al paciente a realizarse una fístula nativa. (AU)(Esta monografía fue presentada para la aprobación del "Curso formativo para residentes en Nefrología" dictado en el Instituto Universitario CEMIC durante el año 1998)