Better outcome of COVID-19 positive kidney transplant recipients during the unremitting stage with optimized anticoagulation and immunosuppression.

INTRODUCTION: COVID-19 is an ongoing pandemic with high morbidity and mortality and with a reported high risk of severe disease in kidney transplant recipients (KTR). AIM: We aimed to report the largest number of COVID-19-positive cases in KTR in a single center and to discuss their demographics, management, and evolution. METHODS: We enrolled all the two thousand KTR followed up in our center in Kuwait and collected the data of all COVID-19-positive KTR (104) from the start of the outbreak till the end of July 2020 and have reported the clinical features, management details, and both patient and graft outcomes. RESULTS: Out of the one hundred and four cases reported, most of them were males aged 49.3 ± 14.7 years. Eighty-two of them needed hospitalization, of which thirty-one were managed in the intensive care unit (ICU). Main comorbidities among these patients were hypertension in 64.4%, diabetes in 51%, and ischemic heart disease in 20.2%. Management strategies included anticoagulation in 56.7%, withdrawal of antimetabolites in 54.8%, calcineurin inhibitor (CNI) withdrawal in 33.7%, the addition of antibiotics in 57.7%, Tocilizumab in 8.7%, and antivirals in 16.3%. During a follow-up of 30 days, the reported number of acute kidney injury (AKI) was 28.7%, respiratory failure requiring oxygen therapy 46.2%, and overall mortality rate was 10.6% with hospital mortality of 13.4% including an ICU mortality rate of 35.5%. CONCLUSION: Better outcome of COVID-19-positive KTR in our cohort during this unremitting stage could be due to the younger age of patients and early optimized management of anticoagulation, modification of immunosuppression, and prompt treatment of secondary bacterial infections. Mild cases can successfully be managed at home without any change in immunosuppression.

Pregnancy After Renal Transplant: Single Center Experience From the Middle East in Patients Using Different Calcineurin Inhibitors.

OBJECTIVES: Pregnancy after kidney transplant has a high risk for maternal and fetal complications; however, it can be successful if patients are properly selected. Here, we studied outcomes and complications of pregnancies in kidney transplant recipients who received calcineurin inhibitor-based immunosuppression. MATERIALS AND METHODS: In this case control study, we reviewed patients who became pregnant between 2004 and 2017. For this analysis, each pregnancy was considered an event. We divided pregnancies into 2 groups according to calcineurin inhibitor-based maintenance immunosuppression: group 1 (49 pregnancies) received cyclosporine, and group 2 (33 pregnancies) received tacrolimus. Patients also received steroids and azathioprine. Patients had regular antenatal follow-up at the Hamed Alessa Organ Transplant Center (Kuwait) and in the maternity hospital (monthly until month 7 and then weekly until delivery). RESULTS: Of 750 female kidney transplant recipients within childbearing potential, there were 82 pregnancies (10.9%) in 49 recipients (6.5%). Seventy-eight pregnancies were planned, and 4 pregnancies occurred while women were using contraception. There was 1 triple pregnancy, 5 double, and 76 single pregnancies. Two women had preeclampsia as maternal complication, 2 had uncontrolled hypertension, and 7 developed graft dysfunction. Forty-seven women (57.3%) had caesarean section, and the remaining had vaginal deliveries. Of 89 babies, 86 were viable (1 intrauterine fetal death and 2 abortions). Eight babies were delivered prematurely with low birth weight, and 2 needed incubators. Mean serum creatinine levels were 97.9 ± 24, 109 ± 38, 100 ± 39, 120 ± 46, and 115 ± 57 µmol/L at baseline, first, second, and third trimesters, and postpartum, respectively. Twelve patients showed high panel reactive antibodies but without donor-specific antibodies. CONCLUSIONS: Posttransplant pregnancy can be successful in most renal allograft recipients, but the increased risk of fetal and maternal complications, including low birth weight, spontaneous abortus, and preeclampsia, should be considered.

Extended Efficacy of Low-Dose Valganciclovir for Prevention of Cytomegalovirus Disease in Intermediate-Risk Kidney Transplant Recipients: Two-Year Follow-Up.

OBJECTIVES: In a previous study, we evaluated 1-year outcomes of using low-dose valganciclovir prophylaxis for cytomegalovirus infection in intermediate-risk kidney transplant recipients. Whether this effect persists in the long term is unknown. We aimed to evaluate the 2-year follow up of such adopted prophylaxis. MATERIALS AND METHODS: We randomized 2 matched groups of kidney transplant recipients (1:1) to receive valganciclovir as 450 mg daily (group 1) or 900 mg daily (group 2) for the first 6 months after kidney transplant. The final analysis included 196 patients as intermediate-risk patients (98 in each treatment group) after exclusion of 5 high-risk patients. Serologically, all patients were at moderate risk for cytomegalovirus infection. Long-term outcomes including cytomegalovirus disease, acute rejection, new-onset diabetes after transplant, graft loss, and patient survival were assessed. RESULTS: Through year 2 of follow-up, cytomegalovirus infection was reported in only 1 patient in group 1 (at month 13) and 1 patient in group 2 (at month 19) (not significant). Biopsy-proven acute rejection episodes were not statistically different between the groups (2 episodes in group 1 and 6 in group 2; P = .431). New-onset diabetes posttransplant was reported in 8.1% in group 1 and 13.2% in group 2 (P = .535). Graft failure was equal in both groups (1 in each group) at 2 years of follow up (not significant). Patient survival was comparable in both groups (100% in group 1 versus 97.9% in group 2; P = .661). The total number of cytomegalovirus infections at 2 years was numerically less in group 1 (P = .128). CONCLUSIONS: Low-dose valganciclovir prophylaxis for 6 months was associated with sustained reduction of cytomegalovirus infection up to 2 years after kidney transplant without significant impact on the acute rejection, new-onset diabetes posttransplant, or patient and graft outcomes.

Impact of accidental discovery of renal cell carcinoma at time of renal transplantation on patient or graft survival.

BACKGROUND: Renal tumors are common in the pretransplant end-stage renal disease population. Their impact on transplant outcome has not been well addressed. METHODS: This study is a retrospective follow-up observational study conducted in 258 renal transplant recipients. All patients had an ipsilateral native nephrectomy at the time of transplantation. We reviewed the histopathology of all native nephrectomies to gauge the prevalence of renal cell carcinoma (RCC) and to investigate the impact of accidental discovery of RCC on graft and patient outcome. RESULTS: RCC was found in 12 patients (4.7%): clear type in 9 patients, and chromophobe and combined clear and papillary type in 1 and 2 patients, respectively. There was no significant difference in human leukocyte antigen mismatch, primary immunosuppression, occurrence of rejection, graft function, and patient and graft survival between patients with or without RCC. RCC presented in the other native kidney in three patients (25%) posttransplantation and one of them developed metastasis 4 years after renal transplantation in the RCC group in comparison with eight patients in the control group (3.3%; P<0.001). The median follow-up period was 56 months for the RCC group and 65 months for the control group. CONCLUSIONS: We found that renal transplant outcome and patient survival were not adversely affected by the presence of accidently discovered RCC at the time of transplantation. These patients seem to be at significantly higher risk of the occurrence of RCC in the remaining native kidney. Further studies are warranted to confirm our results.