ABSTRACT
Purpose: Viral infections (VI) commonly occur in the post-transplant period and higher cumulative doses of rATG have been correlated with higher rates of infection. However, basiliximab (BAS) has decreased risk of infection but increased risk of rejection due to a lower immunosuppressive profile. There is a shortage of literature evaluating choice and dosing of induction agent and the incidence of VI in kidney transplant recipients (KTR) receiving tacrolimus, mycophenolate and early steroid withdrawal. This study evaluated the incidence of VI in KTR receiving BAS, rATG low (< 3mg/kg), or high dose (> 3mg/kg) within 180 days post-transplant. Method(s): This single-center, retrospective study included adult KTR from July 2020-March 2021. KTR were excluded if they received a multi-organ transplant, no induction, or maintenance immunosuppression other than tacrolimus and mycophenolate. Induction was given based on patients' immunologic risk factors for rejection which included: age, race, cPRA, retransplantation, and DR HLA mismatch. The primary objective compared the incidence of VI with BAS, rATG low and high dose. Secondary outcomes included incidence of CMV, BKV, EBV, HSV, COVID-19, DGF, BPAR, de novo DSA, eGFR, tacrolimus levels, graft loss, and mortality within 180 days post-transplant. Result(s): There were 44 KTR who received BAS, 43 who received low rATG dose, and 129 who received high rATG dose. Statistically significant differences in baseline demographics included age, race, mean peak cPRA, and mean KDPI (due to institutional induction guidelines) [Table 1]. A larger proportion of high rATG patients experienced VI, followed by low rATG patients, p<0.01 [Table 2]. Increased incidence of CMV, BKV, and COVID-19 occurred in patients receiving rATG [Table 2]. Infections generally occurred earlier in the rATG groups [Table 2]. DSA was highest in the high dose rATG (14%) which was attributed to high risk factors for rejection, p=0.0146 [Table 3]. No differences in BPAR, DGF, graft failure, or mortality were seen between all groups within 180 days. Conclusion(s): KTR that received induction with any rATG dose had a higher incidence of viral infections compared to basiliximab. Induction with rATG may lead to an earlier onset of viral infections compared to basiliximab. Further review of data at one year post-transplant is planned to strengthen the results of this study.
ABSTRACT
Purpose: In the USA, there was a 51.1% reduction in kidney transplant (KTx) since March 2020 due to concerns for contraction of COVID-19 in transplant recipients. In our center, cumulative doses of ATG induction were reduced from 4-6mg/kg to 2-4 mg/kg in immunological high risk [HR] [age < 55 years, AA, cPRA > 20%, 2 DR mismatch, KP, retransplant], from ATG 2-4 mg/kg to 1-2 mg/kg in moderate-risk [MR] [age > 55 years, non-AA, CPRA <20% and <2 DR mismatch) and from ATG 0-2mg/kg to basiliximab for low risk [LR] patients [LDKT, age >65 years, cPRA < 20%, with 0 to 1 DR mismatch]. We used Tacrolimus and Myfortic as a maintenance agent and continued with a five-day rapid steroid withdrawal. This study assessed the effect of these changes on our transplant outcomes. Methods: We conducted a retrospective chart review of all adults with KTx or KP from 3/1/2020 to 8/31/2020 with a follow-up of at least two months. Primary outcomes included the incidence of biopsy-proven rejection (BPAR), de-novo DSA, delayed graft function (DGF), infection rate, graft loss, and all causes of mortality. Results: 180 KTx and 5 KP were reviewed with a median follow-up of 161 days [66, 250]. 13% were LDKT, and 11% retransplant. Median recipient age was 55 years [21, 78], and 28% were > 65 years old. 64% were white, and 63% were male. 46% of organs were PHS high-risk, median KDPI was 49 [2, 96], CIT 12 hours (2, 47). Median donor creatinine was 1.3mg/dL (0.2, 7.15). 62% HR received ATG of 3-4mg/ kg, 8% MR received 1-2mg/kg, and 30% LR received basiliximab. Creatinine nadir was 1.35mg/dL (0.52, 3.57). DGF was similar to the national average at 23%. 5% developed new DSA [MFI>2000]. Three patients had Banff 1a rejection. Patient 1 received basiliximab (LR) but likely rejected due to IS reduction during his COVID illness. Patients 2 and 3 both received ATG [HR] and were treated with increased IS and steroids. All three responded well to treatment. Three patients were diagnosed with COVID-19 and responded well to remdesivir, dexamethasone, and convalescent plasma. The median time of diagnosis from transplant was 90 days [12, 210], and the recent creatinine was 1.5mg/dL [1.2, 2.42]. 19% of CMV PCR (+) required dose reductions of IS, while 30% required CMV treatment. BK PCR of >10,000 was noted in 5.4% patients. Two graft losses occurred within a week of transplant secondary to the renal vein thrombosis. No mortality was noted. Conclusions: With careful monitoring and reduction in induction immunosuppression, KT and KP transplants could be performed safely during the COVID pandemic.