ABSTRACT
Introduction: A significant reduction of acute rejection rates was observed after using Mycophenolate mofetil (MMF) in renal transplant recipients (RTR). However, side-effects like hematological and gastrointestinal intolerance often occur when MMF is used in routine doses.MMF dose reduction is required during its side-effects or co-existing infection in RTR.The outcome of MMF dose modulation in RTR is not well established. COVID-19 pandemic has given an opportunity to study the effect of MMF dose modulation on graft function as large number of RTR who had Covid19 received MMF dose reduction or discontinuation. This study's objective was to determine whether MMF dose reduction or discontinuation was associated with the effect on allograft function after renal transplantation. We included all RTR who had an infection with SARS-CoV2 and received MMF dose reduction or discontinuation Methods: We prospectively collected data of Renal transplant recipients developing covid 19 infection during the first and second covid waves. Management including decision on admission, immunosuppression modulation, antibiotics were done based on clinician's discretion subject to logistics and the prevailing guidelines by the ISOT. All patients were followed up for minimum 15 months for graft dysfunction, biopsy rate, biopsy proven acute rejection ( BPAR). The effect of immunosuppression modulation - MMF cessation (Group A) Vs MMF reduction/no manipulation (Group B) and its bearing on the incidence of rejection and was compared. Additional factors such as follow - up sub therapeutic CNI levels, development of DSA ( when done ), steroid increment were studied regression model. Kaplan - meier survival curves for 24 months drawn. Result(s): Among 251 renal transplant patients with SARS-CoV2 infection, 38 patients died during Index admission. 45 patients has not completed for 15 months.168 patients completed 15 month follow - up. Among them, anti-metabolite were reduced in 115 ( 68.5%), stopped in 42 (25%), not manipulated in 5 ( 3%) and 6 patients were not on anti-metabolites and hence excluded from present analysis. Of the 162 patients, MMF had been stopped for 2 weeks or until presumed clinical recovery in 42 patients ( Group A) and the rest in 120 patients ( Group B). Mean age was 41.18 ( +/- 12.8) and 75.6 % had mild COVID. Median duration of follow-up was 18 months ( 14q1-22q3 months). Total Readmission rate was 66 ( 40.7%) (Group A 21( 50%) Vs Group B 45 ( 37.5 %). Graft Biopsy was done in 16% of patients. 9.3 % patients had acute rejection ( 11.9% Vs 8.3%, p 0.05). Among those who had rejection, ABMR was seen in 2, ACR in 3, CABMR in 5 and combined rejection in 1. Conclusion(s): MMF dose modulation to tackle an infectious episode may be associated with graft dysfunction and rejection on follow-up and close follow up is needed in any patient in whom MMF dose in manipulated No conflict of interestCopyright © 2023
ABSTRACT
Cellular and humoral responses are required for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) eradication. Antigen-presenting cells load SARS-CoV-2 peptides on human leukocyte antigen (HLA) with different avidities and present to T- and B-cells for imposing humoral and cellular responses. Due to immunosuppression, renal transplant recipient (RTR) patients are speculated to poorly form the antibody against the SARS-CoV-2. Therefore, determining the association of specific HLA alleles with anti-SARS-CoV-2 spike protein antibody formation will be helpful in managing the RTR having specific HLA alleles from SARS-CoV-2 infection and vaccination. Material(s) and Method(s): In this study, anti-SARS-CoV-2 spike protein antibody in 161 RTRs was determined by the chemiluminescent microparticle immunoassay methods, and HLA alleles were determined by the polymerase chain reaction-single-strand oligonucleotide methods and analyzed to study the HLA allele association with anti-SARS-CoV-2 spike protein-specific humoral response and severity of COVID-19 symptoms in recently SARS-CoV-2-infected RTRs. Result(s): The anti-SARS-CoV-2 spike protein specific antibody seroconversion rate in RTRs was 90.06% with a median titer of 751.80 AU/ml. The HLA class I alleles, A*11 in 22.1%, A*24 in 21.37%, A*33 in 20.68%, HLA B*15 in 11%, B*07 in 8.27%, HLA-C*30 in 20.93%, C*70 in 23.25% and HLA Class II alleles, DRB1*07 in 18.62%, DRB1*04 in 13.8%, HLA-DRB1*10 in 14.48%, HLA-DQA1*50 in 32.55% of RTRs were associated with the seroconversion. The mean SARS-CoV-2 clearance time was 18.25 +/- 8.14 days. Conclusion(s): RTRs with SARS-CoV-2 infection developed a robust seroconversion rate of 90.0% and different alleles of HLA-B, DRB1, and DQA1 were significantly associated with the seroconversion. Copyright © 2022 Indian Journal of Transplantation.
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BACKGROUND: Different vaccines have been developed against SARS nCoV 19 and deployed in mass immunization campaigns across the world. In India, Covishield (ChAdOx1 nCoV-19) manufactured by Serum Institute of India) and Covaxin (BBV152) manufactured by Bharat Biotech are two such vaccines that have been made available. The former is a replication-deficient adenovirus vaccine while the latter is an inactivated whole virion vaccine. There has been many case reports of new onset or relapse of glomerular disease occurring after Covid-19 vaccination. This is attributed to heighten off target effect of immune response of the vaccine. AIM OF THE STUDY: We present a case series of four patients where glomerular disease manifested for the first time after Covid-19 vaccination in our center. METHOD(S): We have included in our case series those patients whose clinical features manifested for the first time within 1 month of Covid-19 vaccination and whose renal biopsy showed glomerular pathology. RESULT(S): Case 1: A 12-year-old male presented to us with abrupt onset of edema leading to anasarca on 30/4/2022. He had received first dose of Covid-19 vaccine (Covaxin) on 26/4/2022. His labs showed urine protein of 3+ and nil RBC, serum creatinine 0.7 mg/dl, serum albumin 1.9 mg/dl, and dyslipidemia (total cholesterol 378 mg/dl, triglycerides 191 mg/ dl). He underwent renal biopsy in view of nephrotic syndrome. It was suggestive of minimal change disease. He was started on prednisolone at 2 mg/kg/day. Case 2: A 39-year-old female presented to us with abrupt onset of maculopapular rash, fever, and bilateral lower limb swelling on 25/1/2022. She had received second dose of Covid-19 vaccine (Covishield) on the same day in the morning. She was found to have hypertension with BP of 160/100 mm Hg. Her labs showed urine protein of 2+ and 18-20 RBC/high power field, serum creatinine 1.9 mg/dl, serum albumin 3.7 mg/dl, negative ANA and ANCA, and normal complement levels. She underwent renal biopsy in view of renal failure with active urinary sediments. It was suggestive of focal and segmental glomerulosclerosis (FSGS). Case 3: A 37-year-old male patient with history of hypertension (on irregular treatment) presented to us with history of gross hematuria without passage of clots in May 2022 about three days after receiving booster dose of Covishield vaccine. He did not have edema, rash, joint pain, or decreased urine output. His labs showed urine protein of 2+ and 5-6 RBC/high power field, serum creatinine 2.0 mg/dl, serum albumin 4.0 mg/dl, negative ANA and ANCA, and normal complement levels. He underwent renal biopsy in view of renal failure with active urinary sediments. It was suggestive of IgA nephropathy (M1E0S1T1C0). Case 4: An 18-year-old female with family history of nail patella syndrome presented to us with history of abrupt onset of edema of both lower limbs on 21/11/2021. She also had rash at the time of presentation. She had received first dose of Covid-19 vaccine (Covaxin) on 20/11/2021. Her labs showed urine protein of 2+ and numerous RBC/high power field, serum creatinine 1.4 mg/dl, serum albumin 2.98 mg/dl, negative ANA, and dsDNA and low complement levels (C3 14.1 mg/dl, C4 10.1 mg/dl: both being low). She underwent renal biopsy in view of renal failure with active urinary sediments. It was suggestive of membranoproliferative glomerulonephritis (MPGN). She was started on prednisolone at 1 mg/kg/day. CONCLUSION(S): Different vaccines have different mechanisms of action, but their target remains the spike protein of the SARS Cov2 virus. Glomerular disease has mostly been reported with mRNA-based vaccines. Here we have reported glomerular disease occurring in close temporal relation to Covishield and Covaxin which have different mechanism of action. There have been reports of IgA nephropathy, minimal change disease and FSGS which manifested soon after vaccination. MPGN after Covid-19 vaccination is rarely seen. Thus, this case series shows that post- Covid vaccination glomerular disease can have varied pathologies.
ABSTRACT
BACKGROUND: A significant reduction of acute rejection rates was observed after using Mycophenolate mofetil (MMF) in renal transplant recipients (RTR). However side-effects like hematological and gastrointestinal intolerance often occur when MMF is used in routine doses. MMF dose reduction is required during its side-effects or coexisting infection in RTR. The outcome of MMF dose modulation in RTR is not well established AIM OF THE STUDY: COVID-19 pandemic has given an opportunity to study the effect of MMF dose modulation on graft function as large number of RTR who had COVID-19 received MMF dose reduction or discontinuation. This study's objective was to determine whether MMF dose reduction or discontinuation was associated with the effect on allograft function after renal transplantation. We included all RTR who had an infection with SARS-CoV2 and received MMF dose reduction or discontinuation METHODS: We prospectively collected data of renal transplant recipients developing COVID-19 infection during the first and second covid waves. Management including decision on admission immunosuppression modulation antibiotics were done based on clinician'S discretion subject to logistics and the prevailing guidelines by the ISOT. All patients were followed up for minimum 15 months for graft dysfunction biopsy rate biopsy-proven acute rejection ( BPAR). The effect of immunosuppression modulation - MMF cessation (Group A) Vs MMF reduction/no manipulation (Group B) and its bearing on the incidence of rejection and was compared. Additional factors such as follow - up sub therapeutic CNI levels development of DSA ( when done ) steroid increment were studied regression model. Kaplan - Meier survival curves for 24 months drawn. RESULT(S): Among 251 renal transplant patients with SARSCoV2 infection, 38 patients died during Index admission. 45 patients have not completed for 15 months. 168 patients completed 15 month follow - up. Among them, antimetabolite were reduced in 115 (68.5%), stopped in 42 (25%), not manipulated in 5 ( 3%) and 6 patients were not on anti-metabolites and hence excluded from present analysis. Of the 162 patients, MMF had been stopped for 2 weeks or until presumed clinical recovery in 42 patients ( Group A) and the rest in 120 patients ( Group B). Mean age was 41.18 ( i' +/- 12.8), and 75.6% had mild COVID. Median duration of followup was 18 months ( 14q1-22q3 months). Total readmission rate was 66 (40.7%) (Group A 21 (50%) Vs Group B 45 (37.5%). Graft biopsy was done in 16% of patients. 9.3% patients had acute rejection (11.9% Vs 8.3%, p 0.05). Among those who had rejection, ABMR was seen in 2, ACR in 3, CABMR in 5 and combined rejection in 1 CONCLUSION(S): MMF dose modulation to tackle an infectious episode may be associated with graft dysfunction and rejection on follow-up and close follow-up is needed in any patient in whom MMF dose in manipulated.
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Introduction: The direct and indirect impact of SARS COVID 19 on the health of children was unprecedented. This study was conducted to compare the changing pattern of pediatric disease dynamics and the use of healthcare system before and after the SARS-CoV2 outbreak in a tertiary care hospital. Methodology: This retrospective, observational study was conducted by collecting data from medical records during COVID 19 pandemic from March 2020 till August 2020. This was compared with the data of 2019 during similar months. The impact of COVID 19 on use of paediatric health care service units like outpatient department, casualty, intensive care and immunization clinic were assessed. Results: There was a significant decline in routine OPD (68%) attendance during the COVID 19 period as compared to pre-COVID period. Paediatric ward admissions and PICU admissions were decreased by 55% and 42% respectively. We also observed a significant 43% decline in the number of children attending immunization clinic in the year 2020. Conclusion: The fear of COVID 19 pandemic and the measures taken to control the pandemic has affected the health seeking behaviour of patients. This evaluation of trends in healthcare use may help in planning the delivery of healthcare service delivery in future. @ The Journal retains the copyrights of this article.
ABSTRACT
Coronavirus disease-19 (COVID-19) affected everyone on the globe, including renal transplant recipients who are at increased risk of infection. The clinical manifestations, immunosuppressive modifications, and treatment protocol are not well defined. We are reporting a case of renal transplant recipient and reviewed all case reports and series (a total of 100 patients) published to date to comprehend the clinical manifestations, immunosuppression modifications, treatment given, and outcomes of the patients. A 57-year-old male kidney transplant recipient had a fever, headache, weakness, and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. He became asymptomatic with the treatment of hydroxychloroquine, azithromycin, and oseltamivir. However, he remained persistently positive by reverse transcriptase-polymerase chain reaction for SARS-CoV-2 for 4 weeks and became negative only after Ivermectin therapy, a safer medicine than antivirals/antiretrovirals used for COVID therapy in renal transplant recipients. Of the 100 patients review of case series, fever was noted in 85%, cough 71%, diarrhea 10%, and radiographic abnormalities in 75% of cases. Only in 3% of cases, steroid was stopped, and in the rest of the cases, 63% either continued in the same doses or changed to methylprednisolone in 34%. Calcineurin inhibitors were temporarily stopped in 42% of cases, reduced in 9% of cases, and continued in the same doses in 49% of cases. The anti-metabolites were discontinued in 83%, reduced in 9% of cases, and not changed in 8% of cases. SARI was observed in 18% and acute kidney injury (AKI) in 26% of cases. Of all the AKI, 11% required renal replacement therapy. Mortality was observed in 21% of cases. COVID in renal transplant recipients may show an unusually longer positivity. Ivermectin may be used in the absence of any conclusive SARS-CoV-2 antivirals. Mortality is high in renal transplant recipients.