ABSTRACT
Purpose: Primary focal segmental glomerulosclerosis (FSGS) recurs after kidney transplantation (KT) in 30-50% of recipients with a median time of 1.5 months post- KT. Recurrence is associated with early graft loss in 60% of cases. The aim of this study is to assess the efficacy of pre-emptive therapeutic plasma exchange (TPE) and rituximab for the prevention of FSGS recurrence post-KT. Method(s): This single-center, retrospective study included patients receiving KT for primary FSGS between May 2016 and August 2021. Living-donor KT recipients received three sessions of TPE prior to scheduled transplant. Recipients of both living and deceased donor KT received 3 postoperative sessions of TPE followed by one dose of 375 mg/m2 rituximab with or without intravenous immune globulin (IVIG) 0.5 g/kg. Recipients underwent protocol biopsy at one month to screen for FSGS recurrence. The primary endpoint was a composite for disease recurrence including proteinuria (>=1 g/day) or/and biopsy-proven FSGS within one month. Result(s): 54 patients received KT for FSGS during the study period using the TPE/ rituximab protocol. 5 patients (9%) experienced FSGS recurrence within one month of transplant. A total of 10 patients (19%) were found to have disease recurrence within a year, with median (IQR) time to recurrence of 37 days (27-66). White race and history of hypertension were independent risk factors for recurrence, whereas African American race and diabetes were associated with a reduced risk of recurrence. 31 patients (57%) also received IVIG prior to discharge due to concerns for hypogammaglobulinemia. There were 18 documented infections in 13 patients (24%) within 3 months of transplant. Patients who received IVIG had significantly fewer cases of infection (3 cases: 1 viral and 2 COVID-19) compared to patients who did not receive IVIG (15 cases: 4 bacterial, 9 viral, 1 fungal, and 1 COVID-19), p<0.001. At one year, 9 patients (19%) had biopsy-proven rejection (5 acute cellular rejection, 1 antibody-mediated rejection, and 3 mixed rejection). There were no instances of graft loss or mortality observed at one year. Conclusion(s): The utilization of plasma exchange and rituximab may prevent early disease recurrence of FSGS without significant rates of infection, graft loss, or mortality.
ABSTRACT
Purpose: Although rare, infection and vaccination have been reported to result in human leukocyte antibodies (HLA). We analyzed the effect of SARS-CoV2 infection, or COVID-19 vaccination on HLA antibodies. Method(s): Multicenter study of waitlisted renal transplant patients (pts) either infected with SARS-CoV2, or fully vaccinated against it with single antigen testing within 3 months prior, and 3 months after. Demographics and infection/vaccination details were collected. If the calculated panel reactive antibody (cPRA) changed specificities were collected. Pts with cPRA change were adjudicated by each center's HLA laboratory director and coordinating center's lab director. Result(s): Data from 5 centers, 409 pts with single antigen testing before and after infection or vaccination was analyzed. 282 pts had an initial cPRA of 0%, and 72 had an initial cPRA>80%. 30 pts (7.0%) had a change in cPRA, 17 (3.9%) had an increase and 13 (3.0%) a decrease. After adjudication no pts with a clinically significant HLA antibody specificity increase were identified. The differences have been largely influenced by one or two specificities with subtle fluctuations around the borderline of the participating centers' mean fluorescence intensity cutoff for unacceptable antigen listing. Conclusion(s): To date, no clinically significant change in cPRA was seen in pts who were infected with SARS-CoV2 and recovered, nor pts fully vaccinated against COVID-19. This has implications for crossmatching at the time of organ offer after SARS-CoV2 infection or vaccination. Also, vaccination appears to be safe for waitlisted pts, even if they are sensitized. (Figure Presented).
ABSTRACT
Purpose: The transplant community faces ongoing challenges regarding the conduct of organ transplantation during the COVID-19 pandemic, and patient treatment preferences during the pandemic require consideration. Methods: To determine waitlisted end-stage kidney disease patients willingness to accept an organ during the pandemic, we conducted an online survey of patients with available email addresses (n=1068);responses were received between May 29 and July 2, 2020.Patients were asked 12 questions, including two open-ended question to understand any concerns related to 1) quality and source of donor kidney and 2) impact of COVID-19 on kidney transplantation in general. Results: The majority of respondents indicated they would accept an organ during the pandemic and respondents almost universally indicated their comfort with transplant if their physician thought they should. Table 1 shows the questions and the aggregated responses;the response rate was 22% (n=232, with an average response per question of 76% (n=176). There were 113 responses to the open-ended questions that were classified into following emergent themes: “clinical concerns”, “COVID concerns”, “trust”, and “no concern” if the latter was explicitly stated, with a fifth category for “other” responses. The open response comments highlighted candidates' concerns about the pandemic lengthening their wait time, contracting COVID-19 after transplantation, and balancing risk of infection versus remaining on the list (Table 2). Conclusions: These results indicate that kidney transplant candidates heavily support continued transplantation during the pandemic, suggesting that patients may perceive the need for transplantation to outweigh the risks associated with COVID-19. Balancing patient treatment preferences with clinical capacity (e.g., testing availability, personal protective equipment, and overall hospital beds) requires ongoing reassessment in the face of fluctuating incidence of COVID-19. (Table Presented).