ABSTRACT
Purpose: Kidney transplant recipients (KT) and wait-listed individuals exhibit an impaired response to vaccinations. There is currently no data on the impact of induction immunosuppression followed by standard immunosuppression on the antibody (Ab) dynamics of wait-listed individuals undergoing KT. Here, we assess the SARS-CoV-2 antibody dynamics prior and one month following transplantation Methods: Previously immunized wait-listed patients (2 mRNA vaccine doses: mRNA-1273 or BNT162b2 at least 14 days prior to KT) who subsequently underwent KT were included. Serum was collected within 24 hours prior to transplantation and 3-4 weeks following transplantation. ELISAs measuring anti-S and anti-RBD titers on pre- and post-transplant samples were performed. Serial dilutions of patient samples were prepared and AUC were calculated for paired samples from each participant. Paired samples were run simultaneously to reduce the effect of interplate variability. Wilcoxon and Mann-Whitney test were used to compare paired and unpaired samples, respectively Results: 35 patients were included (12 LKT/23 DDKT). 34 patients received induction with ATG, 1 with Basiliximab. Standard immunosuppression consisted of prednisone (2-week taper), mycophenolate and tacrolimus. 61% received mRNA- 1273 and 39% BNT162b2. We found no difference in Abs between vaccines. Anti- RBD Ab and anti-S Ab had a significant decline following KT at the one-month endpoint (anti-RBD Pre-KT: 1581 vs Post-KT: 473 p<0.0001 anti-S Ab Pre-KT: 4058 vs 1739 p<0.0001). 29 wait-listed patients were on dialysis and had lower pre-transplant Abs (anti-RBD dialysis: 1508 vs no dialysis: 3790 p=0.5. Anti-S Ab dialysis: 3841 vs no dialysis: 10058 p=0.17). The differences remained post-KT. 3 patients developed COVID-19 following transplantation (median: 123 days). They had lower pre- and post-transplant Ab (post-transplant anti-RBD COVID-19: 181 vs no COVID-19: 486 p=0.3, anti-S COVID-19: 1672 vs no COVID-19: 613 vs no COVID-19: 1801 p=0.4) Conclusion(s): Induction immunosuppression followed by standard immunosuppression led to a significant decrease of both anti-S and anti-RBD ab in KT recipients. Waitlisted individuals on dialysis had lower Abs both pre-and post-transplant. Patients who developed post KT COVID-19 had lower Ab levels. Our data suggests that immediate post-transplant KTs may require additional vaccinations against COVID-19.
ABSTRACT
Purpose: Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine has the potential to facilitate care delivery/ coordination for donors. We aimed to understand center practices and provider attitudes and perceived barriers of telemedicine services for living kidney donation. Method(s): We conducted a national survey of multidisciplinary providers from 194 U.S. active adult living donor kidney transplant centers in 2020. The survey was distributed with an online link from 2/18/2021 to 5/13/2021, and up to two reminders were provided. The target population included nephrologists, surgeons, nurse coordinators, social workers or independent living donor advocates, and psychiatrists or psychologists. We used descriptive statistics and analysis of variance. Result(s): Two hundred ninety-three providers from 128 unique centers responded to the survey, a center representation rate of 66.0%, reflecting 82.9% of U.S. practice by donor volume and 91.5% of U.S. states/territories. Most centers (70.3%) will continue using telemedicine beyond the COVID-19 pandemic. Video only was mostly used for donor evaluation by nephrologists, surgeons, psychiatrists or psychologists. Telephone and video were mostly used by social workers, while no mutual modality was used by coordinators. Vital signs and weight were obtained largely using self-reported measures or a local provider/primary care physician, and a physical exam was mostly completed at a subsequent in-person visit to the transplant center. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation for potential donors. These attitudes were consistent across provider roles (p>0.05). Providers were favorably disposed to use telemedicine beyond the pandemic for donor evaluation and followup care. Out-of-state licensing and reimbursements were key regulatory barriers. Conclusion(s): These findings help inform clinical practice and policy expanding telemedicine services to enhance access to living donation and may be extended to other medical specialties.
ABSTRACT
Purpose: Treatment options for patients with COVID 19 have limited efficacy in reducing severity and duration of viral symptoms as well as progression to severe disease. Bamlanivimab(LY-CoV555) received Emergency Use authorization (EUA) by the FDA on November 9,2020 for non-hospitalized COVID 19 patients with mild to moderate illness who are considered high risk for progression to severe COVID 19 or to require hospitalization such as those on chronic immunosuppression therapy post-transplant. In this study we review its use among patients with kidney transplant. Methods: 24 patients who tested positive for COVID 19 with nasopharyngeal PCR between November 9, 2020 and February 7, 2021 were retrospectively reviewed and analyzed. Labs, clinical course and communication with transplant team was reviewed. FDA approved standardized infusion dose was used. Results: Average age of recipients was 57.5 +/- 11.8 years. Hypertension was most common co-morbidity in 17/24 patients followed by Diabetes Mellitus in 10/24. 3 patients had combined Pancreas Transplant, 1 combined-heart and 1combined- Liver. 3/24(12.5%) patients required hospitalization, and supplemental oxygen, while 1 patient required mechanical ventilation and died. Dialysis therapy for acute kidney injury was required in 1 patient. Majority of patients 14/24 were on Tacrolimus and Mycophenolic acid. 13/24 had no change to their immunosuppression after COVID diagnosis while 7/24 had mycophenolic acid decreased to half or lower and in 4 cases it was held temporarily. 1 patient each reported headache, elevated blood pressure after infusion. Among the 3 patients who were hospitalized 1 patient each was diagnosed with Aspergillosis and Histoplasmosis. Results summarized in Table 1.Table 1. Characteristics and outcomes among patients receiving Bamlanivimab, n=24 Living Donor Kidney Transplant, DDKT Deceased Donor Kidney Transplant, MPA mycophenolic acid, IS Immunosuppression, Tac. Tacrolimus, Cyc. Cyclosporin, RRT Renal Replacement Therapy, mab. monoclonal antibody Conclusions: To our knowledge this is the first report describing the use of Bamlanivimab in patients with Kidney Transplants. It showed a beneficial effect in immunosuppressed patients with mild to moderate COVID 19 symptoms with majority avoiding hospitalization. It appears to be well tolerated with no significant major adverse effects or allergic reactions in our cohort. Further large scale studies are needed to evaluate its impact on symptom duration and decrease in severity of COVID 19 among patients on immunosuppression for kidney transplant. (Table Presented).
ABSTRACT
Purpose: A critical question facing transplant programs is if, when and how to safely accept living kidney donors (LKD) who have a history and recovered from COVID-19 Infection. The purpose of the study is to understand current practices related to accepting living donors for donation who have recovered from COVID-19. Methods: We surveyed US transplant programs from September 3, 2020 through November 3, 2020 by e-mail and postings to professional society list-serves. Center level as well individual opinion based responses were analyzed. Results: A total of 174 US respondents from 115 unique centers responded, representing 59% of US Living Donor Programs and 72.4% of 2019 and 71.9% of 2020 LKD volume (as of October 31, 2020). Respondent Roles included Nephrologist (53.4%);Surgeon (19.5%);Infectious Disease (11.5%);Coordinator (9.8%). Overall during the survey period, 48.6% of responding centers had received inquiries from such LKDs, while 44.3% were currently evaluating such donors. A total of 98 donors were reported to be in the evaluation phase, while 27.8% centers had approved a total of 42 such donors to proceed with donation. Conclusions: Selection practices and criteria for LKD who have recovered from COVID-19 are variable. Ongoing research and consensus building are needed to guide optimal practices to ensure the safety of accepting such donors.
ABSTRACT
Rhodococcus equi has emerged as a serious pathogen in solid organ transplant recipients. Primary pulmonary involvement is the most common presentation. However, this opportunistic pathogen is often verlooked in the differential of pneumonia in transplant recipients. Approximately less than 30 cases in renal transplants and only 2 in pancreas transplants have been reported with 20-25% mortality. 57-year-old white male who had received his 3rd renal transplant 2 years and 1st pancreas transplant 12 years earlier. At the time of presentation, he was on tacrolimus, mycophenolate mofetil, prednisone and basiliximab for immunosuppression. He presented with a 2-month history of a cough and weight loss. He was prescribed azithromycin, doxycycline, and ciprofloxacin by his local providers with no improvement. Chest x-ray showed necortic 5cm cavitary right middle lobe lung lesion. On evaluation he was positive for influenza virus, corona virus and aspergillus. Bronchoscopy with BAL and lymph node biopsy cultures showed Rhodococcus Equi. He was started on IV vancomycin, meropenem for 6 weeks and his symptoms improved. He was switched to oral azithromycin and linezolid for another 6 months which was later held for cytopenias. He was then given minocycline after 6 months, while the azithromycin prophylaxis was continued. He recieved voriconazole for his aspergilllus for 12 months. Repeat imaging with near total improvement in the cavitary lesion and his symptoms resolved over the next 6-9 months. Although surgery was considered an option, due the pericardial location of the lesion it was not pursued. His immunosuppressants were reduced and basiliximab was stopped. His creatinine remained stable around 2.4. Over the following year his pancreas function experienced elevation of lipase which was successfully reversed with steroids and resuming his mycophenolate. R.equi is a unique Acid fast positive cocci and a intracellular pathogen.We report a very rare case of Rhodococcus infection in a kidney pancreas transplant recipient which was successfully treated without surgical intervention. Choice of antibiotics was challenging while maintaining dual organ transplant function and avoiding acute rejection. Copyright © 2020