Direct Oral Anticoagulants vs. Warfarin in Hemodialysis Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Background: The use of Direct Oral Anticoagulants (DOACs) in patients who have both atrial fibrillation (AF) and end-stage renal disease (ESRD) requiring hemodialysis remains controversial, with warfarin remaining the mainstay of the treatment. As hemodialysis patients were excluded from most clinical DOACs trials, the evidence of their efficacy and safety is lacking in this cohort of patients. Aim: To review the current evidence investigating safety profile and the efficacy of DOACs in comparison with warfarin in patients with AF and end-stage renal disease (ESRD) requiring hemodialysis. Methods and Results: We included five studies with a total of 34,516 patients in our meta-analysis. The outcomes were major bleeding, ischemic stroke, systemic embolization, hemorrhagic stroke, gastrointestinal bleeding, minor bleeding, and death. Of these patients, 31,472 (92.14%) received warfarin and 3,044 patients received DOACs (8.91%). No significant differences in the incidence of hemorrhagic stroke, major bleeding, hemodialysis access site bleeding, ischemic stroke, and GI bleeding were found between DOACs and warfarin. However, there were higher rates of systemic embolization, minor bleeding, and death events in patients who received DOACs than in the warfarin group (3.39% vs. 1.97%, P-value = 0.02), (6.78% vs. 2.2%, P-value 0.02), and (11.38% vs. 5.12%, P-value < 0.006) respectively. Conclusion: In patients on dialysis who require anticoagulation for AF, warfarin could be associated with a significant reduction in minor bleeding, systemic embolization, and death compared to DOACs. These findings need to be validated by further prospective studies to address the best strategy to deal with the increased thrombotic and bleeding risks in such patients.

Pretransplant donor-specific anti-human leukocyte antigen antibodies despite a negative complement-dependent lymphocytotoxicity crossmatch: Is it wise to desensitize before kidney transplant?

The significance of pretransplant donor-specific antibodies (DSAs) despite negative complement-dependent lymphocytotoxicity crossmatch (CDC-XM) would be useful for clinical decision-making. Hence, we aimed to determine the impact of pretransplant DSA despite negative crossmatch on the outcome of kidney transplantation. One hundred and eleven kidney recipients were prospectively enrolled in this study after being transplanted at Hamed Al-Essa Organ Transplant Center of Kuwait between January 2011 and December 2013. Of them, 50 recipients with positive DSA at the time of transplant were subjected to desensitization (Group 1). Three local protocols were utilized; first included plasma exchange, high-dose intravenous immunoglobulin (IVIG), and rituximab; second included immunoadsorption plus RTX, and the third included high-dose IVIG and rituximab. The second group included 61 recipients with negative DSA. All recipients had negative CDC-XM and flow cytometry crossmatch at the time of transplant. Panel-reactive antibody (±DSA) levels with mean fluorescence intensity and graft function were monitored along the first 24 months for all patients. There were no statistically significant differences between the two groups regarding early posttransplant graft function, patient and graft survivals. Pretransplant DSA with negative CXM carries a minimal clinical risk with optimized immunosuppression.

Screening for BK Viremia/Viruria and the Impact of Management of BK Virus Nephropathy in Renal Transplant Recipients.

OBJECTIVES: The prevalence of BK-induced nephritis in renal transplant recipients is estimated to be 1% to 10%; the rate of graft loss within 1 year is 30% to 65%. We conducted this study to evaluate screening of BK virus in blood and/or urine among renal transplant recipients and to assess the effects of different therapeutic modalities in renal transplant recipients with BK nephropathy. MATERIALS AND METHODS: Kidney transplant recipients were screened at the time of transplant and then at 1, 2, 3, 6, 9, 12, 18, and 24 months posttransplant. Fiftynine patients were diagnosed with BK virus viremia. Patients were divided into 2 groups according to treatment: group 1 (n = 29) received an active treatment and group 2 (n = 30) received minimized immunosuppression. RESULTS: Most patients required graft biopsies to confirm diagnosis (86.2% in group 1 vs 50% in group 2; P = .03). Both groups were comparable regarding demographic data. Initial posttransplant graft function was significantly better in group 1 (P = .017); ultimately, there was no significant difference between both groups regarding graft survival (P= .51). Fifty percent of patients had biopsy-proven acute T-cell-mediated rejection before BK virus-associated nephropathy diagnosis (significantly higher in group 1). Serum creatinine levels were significantly better in group 2 at 3, 4, and 5 years after BK nephropathy (P = .001, .017, and .003, respectively). CONCLUSIONS: The prevalence of BK nephropathy in our renal transplant recipients was 5.9% with a rate of graft loss ranging from 43% to 51%. Regular screening, less intensive immunosuppressive therapy, and early intervention by reduction of immunosuppressive medications are advisable to obtain early diagnosis and to have better outcomes of BK virus-associated nephropathy with antiviral agents.

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.

Annual Data for Kidney Transplant Services in Kuwait (2015).

OBJECTIVES: Renal transplant services have been provided by the Hamed Al-Essa Organ Transplant Center in Ibn Sina Hospital since 1979 for Kuwaitis and non-Kuwaiti citizens residing in Kuwait. We aimed to monitor the activity and outcome of annual renal transplants in 2015. MATERIALS AND METHODS: Data on transplant patients were collected from hospital records from January 1, 2015, through December 31, 2015, at Ibn Sina Hospital. RESULTS: Eighty-one patients underwent a renal transplant in Kuwait in 2015; 46 patients (56.8%) were male and 35 (43.2%) were female. Of these 81 patients, 24 (29.6%) received a kidney from a deceased donor, 19 (23.5%) received a kidney from a living-unrelated donor, and 38 (46.9%) received a kidney from a living-related donor. Thirty-four patients (41.98%) who were highly sensitized immunologically underwent successful desensitization before transplant according the local protocol; 13 (38.2%) of these patients were male and 21 (61.8%) were female. Two patients (2.47%) experienced acute rejection within the first week after transplant. One diabetic female patient underwent a successful simultaneous deceased-donor kidney and pancreas transplant. Seventy-nine patients who underwent a transplant outside of Kuwait in 2015 were added to the follow-up list; 62 (78%) of these patients were male and 17 (22%) were female. Of these 79 patients, 31 patients (39%) received a kidney from a living-related donor, 45 (57%) received a kidney from a living-unrelated donor, and 3 (4%) received a kidney from a deceased donor. In addition, 303 patients were assessed for fitness for kidney transplant; 204 (67.3%) of these patients were male and 99 (32.7%) were female. Eight (2.6%) patients were not placed on the waiting list for a kidney transplant for medical reasons. CONCLUSIONS: A total of 81 patients underwent a renal transplant in Kuwait in 2015, only 2 (2.47%) of whom experienced acute rejection in the first week after transplant.