ABSTRACT
Purpose: COVID pandemic has posed a significant challenge among kidney transplant recipients (KTR) due to their immunocompromised state. There is uncertainty on immunosuppression (IS) management among those who have COVID infection. We sought to better understand the clinical course, management, and outcomes of our KTR who developed COVID infection during the period when COVID vaccine was more readily available. We also investigated the impact of vaccination status on COVID infection. Method(s): Single-center experience of COVID infected KTR. Baseline demographics, clinical data, COVID vaccination status, management, and outcomes were obtained by manual chart ion of the EMR. Result(s): 83 KTR had COVID infection. Mean age was 54 years;57% were males and 53% were African American. 47% of the patients were >3 years post-transplant. Interestingly, the proportion of COVID-infected patients who were unvaccinated and vaccinated with 2 doses were similar (42% vs 39%;p=NS) and the proportion of asymptomatic patients who were unvaccinated and vaccinated were also similar (47% vs. 53%;p=NS). Respiratory symptom was the most common manifestation (69%);49 patients (59%) required hospitalization. Mean length of stay was 15 days;19 (23%) required ICU admission and 14 (17%) required mechanical ventilation;26 developed AKI with about half requiring RRT;only 2 (18%) patients requiring RRT had renal recovery. The majority of admitted patients received dexamethasone and antibiotics. For IS management, 53% had MMF held or reduced while only 11% had CNI dose reduced;17 patients (20%) died. In multivariable modeling, only age (OR 1.1, 1.02-1.19;p=0.020) and AA race (OR 5.4, 0.73-40.2;p=0.097) were associated with risk of death. Induction, sex, BMI, and vaccination status were not significant predictors. There were no subsequent acute rejections or graft losses in those who recovered. Conclusion(s): KTR represent a vulnerable patient population for COVID infection. Due to their immunocompromised state and often more severe clinical presentation, with majority requiring hospitalization, ICU admission, and mechanical ventilation. In this single center study, COVID vaccination did not seem to have an appreciable impact on the incidence of COVID infection and presentation. It is unclear what impact immunosuppression dose reductions had on the COVID clinical course, but these reductions did not appear to increase risk of rejection or graft loss.
ABSTRACT
Purpose: The COVID pandemic has posed a significant challenge among kidney transplant recipients (KTR) due to their immunocompromised states. The effects of COVID vaccination on KTRs are uncertain. We sought to better understand the clinical course, management, and outcomes of KTRs who developed COVID infection during the pre-and post-COVID vaccine rollout periods. We also compared whether there was a difference in patient outcomes or management of COVID infection between the two groups. Method(s): This was a single-center study of KTRs who were infected with COVID. Baseline demographics, clinical parameters, COVID vaccination status, management, and outcomes were obtained by manual chart ion of the electronic medical records. Result(s): We studied a total of 134 KTRs in the pre-vaccination era and 83 KTRs after vaccination rollout who had COVID infections. The mean age of the patients was 54 years in both groups, and there was a greater proportion of African American KTRs in the pre-vaccination rollout era (70% vs. 53%, P=.02). No statistically significant differences were found among sex, BMI, or induction agents. In the pre-vaccination era, KTRs were more likely to present with fever (71% vs. 51%, P<.001). No statistically significant differences were observed in the onset of COVID infection after transplant, ICU admission, the requirement of mechanical ventilation therapy, incidence of AKI (acute kidney injury), requirement of renal replacement therapy (RRT), or incidence of acute rejection. For COVID infection management, KTRs in the post-vaccination rollout era were more likely to be treated with dexamethasone (47% vs. 32%, P=.035) . No statistically significant difference was found in the proportion of patients who required reduction or discontinuation of immunosuppressive agents. In the pre-vaccination era, KTRs were more likely to recover from acute kidney injury (57% vs, 25%, P=.01). No statistically significant difference was found in mortality between groups, but the risk of death was almost twice a high in the post-vaccination rollout era (21% vs. 12%). Conclusion(s): In this single-center case-control study, COVID vaccination rollout did not seem to have an appreciable impact on the incidence of hospitalization, ICU admission, AKI, RRT requirement, or mortality. Mortality risk among KTRs in the post-vaccination rollout era was almost twice as high as it was in the pre-vaccination rollout era, although there was no statistically significant difference, which might be due to low statistical power. The lack of improved outcomes of KTRs in the postvaccination rollout remains unclear. A combination of suboptimal immunogenic response to vaccination and the Delta variant surge could be a possibility.
ABSTRACT
Purpose: In organ transplant, med errors, adverse drug events, and nonadherence lead to increased healthcare utilization and graft loss. Veterans with transplants are a high-risk population. Method(s): A med safety dashboard was created to identify potential issues that included missing pertinent labs, concerning trends in labs, drug-drug interactions, immunosuppressant non-adherence (refill gaps, expired meds), and transitions in care. This system was tested through a 24-month, prospective, cluster-randomized controlled multicenter study. Pharmacists at 5 intervention sites used the dashboard to identify and address potential med safety issues, which was compared with usual care provided at 5 control sites. Interim findings regarding dashboard functionality and interventions are reported here. Result(s): The study opened Mar 2019 and closed Jun 2021, with a COVID-19 induced hiatus (Apr to Jun 2020). As of the last interim analysis (18m follow-up), there were 1,928 patients enrolled across the 10 sites (1,181 intervention vs 815 control). Mean age was 65 years, 95% male, and 27% Black. Mortality was 9.3%, with no difference between arms (intervention 9.5% vs control 9.0%). ED visits (intervention 38.4% vs control 45.6%) and hospitalizations (intervention 25.6% vs control 37.6%) were higher in the control arm. The dashboard produced a total of 18,132 alerts from the 5 intervention sites;a rate of 1-2 per pt-month. Lab-based issues were most common (Figure 1), followed by non-adherence and transitions in care;70% of alerts were addressed (Figure 2 blue bars) in about 40 days (Figure 2 orange line). Actions taken by pharmacists are displayed in Figure 3, which were often already addressed or not clinically relevant. Adjustments made to med regimens based on dashboard alerts were uncommon. Multivariable modeling demonstrated location site, type of alert, and transplant type were predictors of alerts being addressed (Table 1). Conclusion(s): This multicenter cluster-randomized controlled trial demonstrates that a med safety dashboard is feasibly deployable across the VA healthcare system, creating valid alerts;although most alerts were already addressed by other providers or deemed not to be clinically actionable. Future dashboard refinements should focus on reducing non-actionable alerts and addressing workload barriers to timely review. (Figure Presented).
ABSTRACT
Purpose: COVID pandemic has posed a significant challenge among kidney transplant recipients (KTR) due to their immunocompromised state. There is uncertainty on immunosuppression management among those who have COVID infection. We sought to better understand the clinical course, management, and outcomes of our KTR who developed COVID infection. Methods: Single-center experience of COVID infected KTR. Baseline demographics, clinical data, management, and outcomes were obtained by manual chart abstraction of the EMR. Results: 50 KTR had COVID infection. Mean age was 53;50% males;74% African-Americans. Fever was the most common symptom (71%);36 patients (71%) required hospitalization;11 (22%) required ICU admission and 8 (16%) required mechanical ventilation. 23 developed AKI with one-third requiring RRT;50% of patients requiring RRT eventually had renal recovery. Majority of admitted patients received dexamethasone, remdesivir, and convalescent plasma. In terms of immunosuppression, 28 of 49 (57%) had their MMF held while 8% had MMF dose reductions;one had everolimus held and one had AZA held;7 (14%) had CNI dose reductions with none held. Six patients (12%) died. Those who died were significantly more likely to receive dexamethasone (42% vs 2%;p=0.002), remdesivir (33% vs 7%;p=0.027), and convalescent plasma (40% vs 0%;p=0.001). Mortality rates were similar across those who had immunosuppressive agents dose reduced vs held vs not adjusted (11% vs 17% vs 12%, respectively;p=0.919). CNI dose reductions tended to be more common in those who died (43% vs 7%;p=0.122). There were no subsequent acute rejections or graft losses in those who recovered. Conclusions: KTR represent a vulnerable patient population during COVID. Due to their immunocompromised state and often more severe clinical presentation, the majority require hospitalization, with a significant number needing ICU admission and mechanical ventilation. Severe illness led to higher use of dexamethasone, remdesivir and covalescent plasma in those who ultimately died of COVID. It is unclear what impact immunosuppression dose reductions had on the COVID clinical course, but these reductions did not appear to increase risk of rejection or graft loss.