A Single Centre Experience of Post Renal Transplant Infections in a Tertiary Care Centre in Eastern India

Introduction: In developing countries, Post renal-transplant infections is the leading cause of mortality, morbidity and decreased allograft survival. Our aims and objectives was to determine the incidence and prevalence patterns of clinically or microbiologically confirmed infection in the post renal transplant patients of our population and profiling of infections in relation to time period from the Transplant and the induction agent, also to develop strategies to counter risk of post transplant infection. Method(s): This was a retrospective observational study. Time period: January 2020- April 2022. Post renal transplant recipients presenting with infections (with informed consent) was enrolled in this study. Recurrent episodes of infection by different organisms in a same patient treated as a separate event. Data was tabulated using MS excel and all results projected in bar graphs, pie charts, histograms. Differences of quantitative parameters between groups were assessed using the t test(for data that were normally distributed) or nonparametric test (for data that were not normally distributed). Differences of qualitative results were compared using chi2 test. Kaplan-meier was used for survival analysis. P < 0.05 was considered significant. Result(s): 213 incidents of post renal transplant infections were documented in 148 patients between the study period. Of the 85 patients who underwent renal transplant(57 living donor and 28 cadaveric) in this time period 33(38.8%) patients presented with 42 incidents of infections. Majority (74.3%) : Males. Mean age: 36.3+/-5.6 years. Most common cause of native kidney disease was chronic glomerulonephritis(30%). 121 (81.7%) had living donor transplant and 27(8.3%) patients had cadaveric transplant. Induction agent was basiliximab in 97 patients (65.5%) had 133 infections (62.4%) and ATG was used in 51 patients (34.5%) had 80(37.6%) infections. In recent transplant (last 2 yrs) cases-In Basiliximab group: infection rate 4.1 in 100 patient months and in ATG group infection rate was 5.7 in 100 patient months. (p=0.28). 37.5%cases had infections with graft dysfunction most commonly AKI. Immediate post transplant infections (<1 month) were 34 (15.9%), most commonly UTI (44.11%) followed by pneumonia (15.9%). 48(%) infections occurred between 1-6 months, most commonly pneumonia(27.08%) followed by UTI(22.9%) and superficial fungal infection. Pulmonary tuberculosis was in 14 (6.6%) cases. 3 cases had disseminated TB. Infectious diarrhea was in 18(8.4%) cases, most common organism isolated was EAEC and EPEC. CMV colitis found in 3 cases. 27 (18.2%) patients had NODAT/PTDM. ParvoB19 was in 11(5.16%), CMV in 5 and BKVN in 3 cases. 41(19.2%) cases had severe sepsis requiring intensive care support. New baseline s.cr was achieved in 29.1% cases. Infection related death was 24(16.2%). COVID 19 infection was in 41 cases, 31.7% developed graft dysfunction and 18 (43.9%) required hospital admission due to moderate or severe disease. 2 patients had mucormycosis, one of them died after admission. [Formula presented] Conclusion(s): Profiling of infection in our centre is essential to formulate future strategies for infection control especially as the DDKT & ABOi KT is on the rise. Proper survillence, screening protocol, vaccination and patient education are essential to reduce the burden of post transplant infection and for better graft and patient survival. No conflict of interestCopyright © 2023

A CASE OF LONG-TERM TOLERANCE AFTER KIDNEY TRANSPLANTATION.

We present a case of long-term organ functioning (ca.10 years) after allografting of a cadaveric kidney without usage of immunosuppressing drugs. In 2005, a patient suffering from a hypertensive form of chronic glomerulonephritis, have received an allogeneic graft of cadaveric kidney compatible for AB0 system, HLA antigens (A19, B07, DR04), and negative results of cross-match test. The graft function was immediately restored, with normalization of creatinine levels achieved 4-5 days after surgery. Immunosuppression with cyclosporine, solumedrol, cellcept, metypred and simulect was performed in the hospital. Pulse therapy with solumedrol was performed on the day +20 due to the development of initial rejection signs. The postoperative period proceeded without infectious complications. The patient was discharged being recommended to take cyclosporine, Cell-Sept and Metypred. Within a year after transplantation, the patient claimed for pain in the hip joint, and, therefore, metypred was completely canceled. Subsequently, the Cellcept was replaced with a Mayfortic. In 2007, the signs of coxarthrosis were revealed at computed tomography, followed by aseptic necrosis of the the right femur head. Deforming osteoarthritis of the right hip joint was detected, and the hip replacement surgery was suggested. In 2010, due to risk of side effects from ongoing immunosuppressive therapy, e.g., joint damage, the Mayfortic was canceled. In 2012, being in fear of original Sandimmun Neoral replacement by a generic drug, the patient completely refused cyclosporine therapy. In 2021, the endoprosthetics of the right hip joint was performed, and the surgical wound healed initially. Since 2012, the patient has not completely taken immunosuppressive therapy. Over this time period, the patient has never been admitted to the hospital for impaired functioning of the organ graft. Meanwhile, he monitored his graft function on regular basis undergoing biochemical analyses, clinical examination, ultrasound studies of the graft and made regular visits to the outpatient department. In 2021, a week after hip replacement, there was a slight increase in serum creatinine, followed by further increase to 230 mmol/L in 2021, and to 310 mmol/L in March 2022. In February 2022, the patient suffered mild respiratory infection (confirmed COVID-19). In March 2022, the first clinical signs of increasing nephropathy appeared, i.e., swelling of both lower extremities, with leukocytes in urine upon routine analysis, increased blood flow resistance in the main artery of the transplant shown by ultrasound study. Due to worsening of the patient's condition, he resumed taking the prescribed immunosuppressants. Copyright © 2022, SPb RAACI.

Unmasking of Immunoglobulin A Deposits Posttransplant due to COVID-19 AKI-Incidental or Causal - A Nephrologists' Dilemma A Case Report

COVID-19 is a global pandemic with the chronically immunosuppressed transplant recipients being the most vulnerable both to infection as well as complications of COVID-19. Here, we report a case of live-related renal allograft recipient who presented with complaints of loose stools and new-onset graft dysfunction 2 years posttransplant. He tested positive for COVID-19 infection. On allograft biopsy, there were significant immunoglobulin A (IgA) deposits with no evidence of rejection or ATN or crescents or significant chronicity. The initial pretransplant biopsy of the recipient had revealed chronic glomerulonephritis with nil deposits. The donor had no evidence of hematuria or hypertension and had a preserved GFR. We, therefore, considered the possibility of the unmasking of IgA deposits posttransplantation diagnosed in a recipient with COVID-19 infection. Copyright © 2022 Indian Journal of Transplantation.

Renal Manifestations of Viral Infections

Infections may directly invade kidney or cause immune mediated injury, antigens of microorganisms' form circulating immune-complexes what is seen in post infectious glomerulonephritis. Renal injury may occur in multi-organ failure as is the case in systemic infammatory response syndrome (SIRS) or altered cytokine expression, hemodynamic instabilities, hemolysis, rhabdomyolysis, and cardio or hepatorenal syndrome. Nearly all viral infections can induce kidney injury by various mechanisms including direct cytopathic effects to immune complex mediated GN and vasculitis as well. Hepatitis B, hepatitis C, human immunodefciency virus, hantavirus and coronavirus disease 2019 (COVID-19) infections can induce glomerulopathy. Many of the viral infections such as parvovirus, Epstein-Barr virus and cytomegalovirus have been associated with very severe injury in the form of collapsing focal segmental glomerulosclerosis. Clinicopathological manifestations of viral infections include;Acute kidney injury (AKI) which is the most common presentation and can be de novo or acute on chronic kidney disease, acute and chronic glomerulonephritis syndrome, nephrotic syndrome, nephritic-nephrotic syndrome, acute or chronic tubulointerstitial nephritis, and rapidly progressive glomerulonephritis. Up to forty percent of patients who recover AKI may develop chronic kidney disease (CKD). Renal involvement is common in patients with COVID-19 infections;patients can present with proteinuria and hematuria even in moderately involved patients and at hospital admission, but AKI frequently develops in critically ill patients and is a marker of multiple organ dysfunction and ominous outcome. Fluid resuscitation at emergency department and lung-protective measures lowers the risk of AKI by obviating ventilator-induced hemodynamic disturbances and cytokine storm effects on the kidneys.

Adverse Renal Events After BNT162b2 Pfizer/BioNTech COVID-19 Vaccine in Kidney Transplant Recipients

Purpose: Adverse events of a novel mRNA vaccine are not well described in Kidney Transplant Recipients(KTR), especially the risk of immune activation or recurrent glomerulonephritis(GN), which has been described in native GN after COVID-19 vaccines. Method(s): In this single-center prospective study, 147 KTR were enrolled after informed consent and administered 2 doses of Pfizer/BioNTech vaccine 21 days apart. Follow-up was 3 weeks after Dose2. Result(s): Mean age of KTR was 51 years;55.1% male;65.3% Chinese, 19% Malay, 11.6% Indian;69.5% Living donor, 29.9% Deceased donor, 0.7% Pancreas-kidney transplants;71.5% had biopsy-proven or presumptive chronic GN(CGN), 12.9% diabetic nephropathy, 15.6% other causes. 11(7.5%) KTR had delayed Dose2 administered at median 29 days(range 24-93) after Dose1. 7(4.8%)were delayed due to renal events: rise in creatinine(n=3), or proteinuria(n=2), or both creatinine and proteinuria with allograft biopsy showing acute T-cell and antibody-mediated rejection(n=1), new BK viraemia(n=1). Other reasons were possible anaphylaxis(n=1), intercurrent infection(n=2), and inability to attend due to quarantine(n=1). 27 KTR had new microhaematuria(MH) after Dose1;9 persisted after Dose2. Additional 18 had new MH after Dose2. Of 45 KTR with new MH, 7 had underlying IgAN, 5 had other biopsy-proven-CGN and 22 had presumed CGN, suggesting 34/45 with possible immune activation. 12 KTR had new onset proteinuria (rise in urine protein:creatinine ratio (UPCR) <=30 to >30mg/mmol);5/7 who developed a rise after Dose1 remained elevated;additional 5 had a rise after Dose2. 7 KTR had rise in proteinuria from UPCR <=100 to >100mg/mmol. Conclusion(s): Subclinical changes in allograft monitoring parameters are frequent after COVID-19 mRNA vaccines with up to 40.1% of KTRs showing rises in creatinine, proteinuria or new MH. Although overt recurrent GN and acute rejection are infrequent, high vigilance and monitoring for these occurrences should be undertaken in KTRs receiving mRNA vaccines.

COVID-19 SEQUELS IN NEPHROLOGY CKD PATIENTS MORE PRONE TO FATALITY

BACKGROUND AND AIMS: This strange, prolonged, very exhausting and costly pandemic still is remaining in our world showing us that we are so weak, so unprotected, so fragile. It initiated and continued mostly like a respiratory syndrome but soon after it was seen that it has a systemic impact and consequences in our body. There were patients presented with hematuria, proteinuria and deteriorating of kidney function after the infection. Direct kidney involvement, cytokine storm, coagulopathy, rhabdomyolysis, antibiotic use, sepsis and haemodynamic instability then acute tubular necrosis, all of these factors contribute in this picture of kidney failure. Very difficult to treat and to rehabilitate a part of these patients are going through kidney replacement therapy and a part are dying. METHODS: We studied a population of 77 patients that had passed the COVID-19 infection, confirmed by RT PCR. Males 58% and females 42%. Mean age was 67.1 years old, the BMI 29.6. Comorbidities were present in our cohort in 59.7% only one comorbidity and in 31.1% of patients two comorbidities. Mean time from COVID-19 infection was 56 days. There were CKD 70% patients and 30% non-CKD. Diagnoses of CKD patients were: hypertensive nephrosclerosis 49%, diabetic nephropathy 32%, chronic glomerulonephritis 9%, ADPKD 8% and transplanted patients with CAN 1%. RESULTS: It resulted that our patients had higher D dimer (mean 3660 mcg/dL = 7-fold higher), PCR (mean 35 mg/dL, 7-fold higher) and ferritin (mean 634 ng/dL). Levels of lymphocytes remained lower (mean 13.9%). Proteinuria was found in 92% and hematuria was found in 88% of our patients. There were a significant correlation between need for KRT and diabetic nephropathy was p = 0.037 and also between need for KRT and proteinuria presence was P = 0.048. It was seen that higher the BUN levels lower the lymphocytes counts (P = 0.028) and lower the time post COVID lower the albumin levels (P = 0.007). It was seen that patients with CKD were more prone to need for haemodialysis treatment during the hospitalization and the mortality rate was higher in this group of patients. CONCLUSION: COVID-19 infection and its short term sequels play an important role on morbidity and mortality of CKD patients. It was a decisive factor for KRT in these patients. CKD patients with their immunosuppression, several drugs used, anemia, hypertension, diabetes are more prone for post COVID-19 complications, hospitalizations, dialysis and then death. Being aware of this dangerous infection and being vaccinated are the mainstay and crucial things for being healthy and being alive.

Current status of COVID-19 among hemodialysis patients in the East Azerbaijan Province of Iran.

INTRODUCTION: Management of vulnerable patients during the COVID-19 pandemic requires careful precautions. Hemodialysis patients constitute a large group of at-risk patients that not only suffer from a compromised immune system but also are at a higher risk due to frequent admission to healthcare units. Therefore, a better understanding on the pathogenesis and possible risk factors of COVID-19 in hemodialysis patients is of high importance. METHODS: A total of 670 maintained hemodialysis patients from all dialysis units of the East Azerbaijan Province of Iran, including 44 COVID-19 patients were included in the present study. Possible associations between the backgrounds of patients and the incidence of COVID-19 were assessed. Also, hemodialysis patients with COVID-19 were compared to 211 nonhemodialysis COVID-19 patients. FINDINGS: Chronic glomerulonephritis patients and those with blood group A demonstrated a higher incidence of COVID-19. On the other hand, patients with blood group AB+ and those with hypertension etiology of kidney failure demonstrated a lower incidence of COVID-19. Hemodialysis patients with COVID-19 had higher counts of polymorphonuclears (PMNs) in their peripheral blood compared to other COVID-19 patients. DISCUSSION: A better comprehension on the risk factors associated with COVID-19 in hemodialysis patients can improve our understanding on the pathogenesis of COVID-19 in different situations and help the enhancement of current therapeutics for COVID-19 in hemodialysis patients.