One-Year Outcomes in Kidney Transplant Recipients with Acute Kidney Injury and COVID-19

Purpose: Acute kidney injury (AKI) occurs in more than half of kidney transplant recipients (KTRs) with COVID-19. The longitudinal trajectory of kidney function is unclear. To study this, we compare mortality outcomes and long-term allograft function as measured by the change in serum creatinine (SCR) after hospital discharge between kidney transplant patients with SARS CoV-2 who experienced in-hospital AKI with who did not have AKI. Method(s): In this retrospective, multi-center study, we identified 149 KTRs who tested positive for SARS-CoV-2 between March 1st, 2020 and March 31st, 2021. Data from electronic medical records were retrieved and compared between KTRs without AKI and KTRs with AKI who were hospitalized with COVID-19. Creatinine was trended at 0,1,3,6, and 12 months. Result(s): A total of 149 COVID-19 infected KTRs were hospitalized. Of them, 102 (69%) had AKI with 45 (44.1%) in Stage 1, 9 (8.8%) in Stage 2 and 41 (40.2%) in Stage 3. Thirty-three patients died and 97% of them was in AKI group. Patients in AKI group had median survival time of 1.18 months, compared to more than 8 months in non-AKI group (p=0.002), Figure 1. Regression analysis for Intercept and slope were estimated by AKI groups, showing mild improvement in mean SCR over the 1 year at 2.2 mg/dL from peak SCR of 3.6 mg/dL, lowest eGFR 23.9 (SD 14.39) but didn't reach pre-AKI baseline in patients with AKI (1.8mg/dL), Figure 2. Conclusion(s): Patients in AKI group had higher mortality most of which was in the early period. There was mild improvement in creatinine over the following 12 months in AKI group but SCR didn't return to baseline. There with no significant change in slope of creatinine for non-AKI COVID patients.

Covid vs non covid pneumonia in kidney transplant recipients

Purpose: Compare clinical characteristics and outcomes in kidney transplant recipients (KTRs) hospitalized with COVID vs Non COVID Pneumonia. Methods: This is a retrospective case-control study examining epidemiologic, laboratory and clinical characteristics of KTRs hospitalized with COVID vs Non COVID pneumonia. Cases were determined by consecutive KTRs diagnosed with COVID-19 from March 20, 2020 through April 25, 2020. Data were censored on April 30th, 2020. 39 patients had COVID, 11 were excluded because they did not have pneumonia. All patients with pneumonia were hospitalized. Controls were determined by searching the EMR for hospital admissions by diagnosis codes for pneumonia and kidney transplant status from January 1,2019 to October 30, 2019. 49 patients were identified, out of which 22 were excluded due to misclassification of pneumonia, dual organ transplantation and failed kidney transplant. Primary end point was progression to respiratory failure requiring mechanical ventilation, ICU admission or in-hospital all-cause mortality. Secondary end points were ARDS, shock and AKI requiring RRT. Results: Demographics, comorbidities and laboratory findings in 28 KTRs with COVID and 27 KTRs with Non COVID pneumonia are shown in Patients with COVID pneumonia were more likely to be leukopenic, lymphopenic and present with bilateral infiltrates. KTRs with COVID were more likely to be black. (trend towards significance p=0.058). Outcomes are summarized in KTRs with COVID pneumonia had higher odds of death (OR=6.94), ICU admission (OR=4.44), developing ARDS(OR=22.53) and shock(OR=5.92) as compared to KTRs with Non-COVID pneumonia. Conclusions: KTRs with COVID 19 pneumonia present with more leukopenia, lymphopenia , bilateral infiltrates , and tend to have higher mortality , ICU admission, ARDS and shock as compared to non COVID pneumonia. These results help us have a higher index of suspicion for COVID-19 pneumonia in KTRs who present with leukopenia, lymphopenia and bilateral infiltrates, in the setting of negative RTPCR (95% sensitivity)or in KTRs in whom results are still awaited, so that timely treatment can be provided.

Early effects of acuity circle-based liver allocation during COVID-19 pandemic in the United States

Purpose: One month before the COVID-19 pandemic was declared, liver transplant (LT) allocation in the US was updated (February 4th, 2020), by introducing the acuity circle (AC)-based model. This study evaluated the early effects of the AC-based allocation on waitlist outcomes. Methods: Adult candidates listed between January 1st, 2019, and June 30th, 2020, were evaluated. Two periods were defined according to the listing date (pre- and post-AC), and 90-day waitlist outcomes were compared. Data was censored if none of the events had occurred before the end of the period. The median transplant MELD score of each state was calculated, and states were defined as low-(<25th%ile), mid- (25th-75th%ile), and high-(>75th%ile) MELD regions. In addition, transplanted patients were categorized into 3 groups according to their final MELD score (6-14, 15-28, 29+). Organ sharing and donor characteristics were compared between eras. Results: 12,546 and 3,932 candidates in pre and post-AC eras were eligible. The post-AC era was associated with significantly lower 90-day waitlist mortality (HR=0.75, 95%CI=0.62-0.90;p=0.002) and higher transplant probability (HR=1.19, 95%CI=1.10-1.29;p<0.001). When outcomes were assessed in each MELD region group, improvement in outcomes was significant in mid-MELD regions, but not in other MELD regions. Among 5,971 and 772 transplanted in the pre and post- AC eras, national sharing significantly increased in all groups (overall: 7.4% to 32.5%, P<0.001). In contrast, a significant increase and decrease in the proportion of donation-after-circulatory-death (DCD)-LT was observed in the low- and mid- MELD regions, respectively. Another subgroup analysis showed that national sharing significantly increased in those with a score of 15-28 (7.6% to 22.1%, P<0.001) and 29+ (5.0% to 39.6%, P<0.001), but not in those with score of 6-14 (15.7% to 22.7%, P=0.11). Patients with a MELD score 15-28 received DCD-LT more frequently in post-AC era, but not in those with a score of 29+. (Table). Conclusions: Despite the COVID-19 pandemic, AC-based allocation improved waitlist outcomes in mid-MELD regions. While other regions had comparable out comes, aggressive utilization of DCD might offset possible negative effects of the AC-based model and/or pandemic in low-MELD regions. Organ acceptance practice may be significantly changed in certain regions/patient populations such as DCD acceptance for patients with mid MELD score in lower MELD regions. It is crucial to carefully monitor possible effects of those changes on post-transplant outcomes. (Table Presented).