A Comprehensive Review of 275 Kidney Transplants Performed over 3 1/2 Years;a Single Center Experience

Introduction: Access to kidney transplantation has always been a problem in the African countries with many patients having to travel to other medically advanced countries in Asia, Europe and America. This involves unnecessary excessive expenditure and the travails of journey and stay in an unknown foreign land. To ease this situation and to provide affordable Renal transplant services in their home land, we have made an effort to start the transplant services at our medical facility and have successfully carried out about 275 transplants over a period starting from Nov 2018 till September 2022. Method(s): All the Kidney transplants done between the period Nov 2018- September 2022 (275 cases) were included in the analysis. All the transplants were performed at a single center and the data were collected progressively during their Pre transplant evaluation, perioperative course and post op follow up. All the laboratory and radiological tests were done locally at the center except the HLA cross matches and tissue typing, which were outsourced to Transplant immunology labs outside the country. All the patients with positive DSA titres [about 70%], underwent Plasmapheresis and received IVIg before the transplantation. immunological assessment was done by NGS high resolution, for A B C DP DQ DR loci and X match was done by SAB analysis for class 1 and Class II antigens. All the patients underwent laparoscopic donor nephrectomy. All Patients received vaccinations for Hepatitis B, Pneumonia, Infuenza & Covid. Result(s): A series of 275 kidney transplants were performed over a period of 42 months [ Nov 2018- September 2022] at a private hospital successfully. All the cases were live donor kidney transplants with majority of the donors being 1st or 2nd degree relatives or spousal donors. About 70% of the patients had some degree of sensitization in the form of weakly positive B cell X match, or positive for DSAs at CL I, CLII with MFIs > 1000. All high-risk patients received induction with rabbit Thymoglobulin, and IV methyl prednisolone. Around 50 patients received Basiliximab. Of all patients, 4were HBsAg positive, and 6 were HIV positive,& HCV 1 patient. 8 patients required pretransplant Parathyroidectomy for refractory hyperparathyroidism, 3 patients required simultaneous native kidney nephrectomy at the time of transplant. 25 patients had multiple renal vessels which were double barreled and anastamosed.4 patients had lower urinary tract abnormalities requiring simultaneous/subsequent repair. Overall, 4 patients underwent 2nd transplant. All the donors underwent laparoscopic nephrectomy. Most of the patients had good immediate graft function except in 40 patients, who had delayed graft function;most of them improving over 2 - 6 weeks. 6 Patients had hyperacute rejection and the graft was lost,.4patients had main renal artery thrombosis, Renal allograft biopsy was done in 20 patients. Overall, the Patient survival was 95 %.at 1 year and graft survival 90%. Conclusion(s): Our experience shows that kidney transplantation is a viable and practical option for End stage kidney disease and can be performed even in resource constrained centers in third world countries and the survival rates of patients and the grafts are comparable to other centers across the world. No conflict of interestCopyright © 2023

Renal transplantation

Individuals with kidney failure face a future requiring long-term treatment with either dialysis or renal transplantation. Renal transplantation is the preferred form of renal replacement therapy, and is associated with a better quality of life, and usually increased longevity. Unfortunately, owing to excessive co-morbidities, only 30% of patients who develop end-stage renal failure are fit enough for transplantation. Over 90% of kidney transplants still function after 1 year, and most function for >15 years. Improvements in transplant outcomes are attributable to advances in histocompatibility testing, organ procurement, organ preservation, surgical techniques and perioperative care. Long-term outcomes have shown only minor improvements over the last two decades, although this should be considered in the context of deteriorating organ quality as older deceased donors with increasing co-morbidity are used more often to satisfy the need for donor organs. An overall increase in deceased donor numbers has boosted transplant activity in the UK, and it is hoped this will continue with the adoption of the 'opt-out' consent system. Living donor activity remains stable, but the use of non-directed altruistic donation and the living donor exchange scheme have reduced the need for higher immunological risk incompatible transplantation. The COVID-19 pandemic has reduced transplant rates globally, although national transplant systems are now recovering.Copyright © 2022

A renal transplant patient with COVID-19 presented with acute cellular rejection

A 27-year-old man underwent a deceased kidney transplant. Three days after transplantation, COVID-19 was diagnosed for our patient. Immunosuppressants were reduced and a renal biopsy was conducted, which showed acute T cell-mediated rejection. We intened to share a case to help clinicians to understand the risks that kidney transplant recipients face.Copyright © 2023 The Author(s);Published by Society of Diabetic Nephropathy Prevention.

Robotic-Assisted Kidney Transplantation from Living Donors: Single Center Experience

Introduction: Robotic-assisted kidney transplantation (RAKT) is being adopted for renal transplantation in obese patients with ESRD. Method(s): Consecutive RAKT procured via robotic live donor nephrectomy at our center between June 2018 and August 2021 were retrospectively analyzed. Our first 20 cases (Group I) were compared (student's t-test and Fisher's exact test, p < 0.05 significant) to the later 20 cases (Group II). Result(s): There was no difference in donor age (39.6+/-10.51 vs 38.4+/-12.14 years) or BMI (27.46+/-4.64 vs 29.48+/-4.06) between the two groups. 75% of recipients in both groups received a left kidney. A majority (>60%) of recipients in both groups were African Americans. Recipients in Group II were significantly older than in Group I. There was no significant difference in patient or graft survival or serum creatinine (1.67+/-0.99 mg/dL vs 1.93+/-0.55 mg/dL) at 1-year post-RAKT. One patient in group I died from respiratory failure due to COVID-19. The anastomosis times (35.16+/-7.75 vs 32.00+/-7.32 mins) were not significantly different, though the re-warming time was a significantly longer in our early experience (47.75+/-9.59 vs 42.00+/-6.55 mins, p = 0.016). The incidence of post-op washout (10%), ileus (10%), incisional hernia (5%) and delayed graft function (20%) were similar in both groups. Conclusion(s): Our early and more recent experience demonstrates that RAKT from living donors can be safely performed with excellent outcomes in obese, predominantly African American patients with ESRD. Practice paradigms are evolving to offer RAKT to patients with BMI >40 who may otherwise be considered ineligible for kidney transplantation.

Dynamic Parameters of Hypothermic Machine Perfusion-An Image of Initial Graft Function in Adult Kidney Transplantation?

Kidney allografts are subjected to ischemia reperfusion injury during the process of transplantation. Hypothermic machine perfusion (HMP) of deceased donor kidneys from organ procurement until transplantation is associated with a superior outcome when compared to static cold storage (SCS). Nevertheless, cold ischemia time (CIT) remains an independent risk factor for delayed graft function (DGF) in HMP-preserved kidney allografts as well. We performed a retrospective single-center study including all adult recipients who underwent deceased donor kidney-only transplantation at our center between January 2019 and December 2020. Beside the clinicopathological donor and recipient data, flow and resistance data during HMP were assessed. Short- and long-term kidney allograft outcome after end-ischemic HMP and SCS were analyzed and compared. Organ preservation consisted of either SCS (n = 88) or HMP (n = 45). There were no differences in recipient demographics and donor details between groups. CIT was significantly longer in the HMP group (16.5 [8.5-28.5] vs. 11.3 [5.4-24.1], p < 0.0001). The incidence of DGF as well as serum creatinine at discharge and at 1 year post transplant were comparable between groups. Duration of SCS prior to HMP was comparable among grafts with and without DGF. Flow rate and organ resistance at the start of HMP were significantly worse in DGF-kidney grafts (arterial flow 22.50 [18.00-48.00] vs. 51.83 [25.50-92.67] ml/min, p = 0.0256; organ resistance 123.33 [57.67-165.50] vs. 51.33 [28.17-111.50] mmHg/mL/min, p = 0.0050). Recipients with DGF had significantly worse creatinine levels at discharge (2.54 [1.08-7.64] vs. 1.67 [0.90-6.56], p < 0.0001) and at 1 year post transplant (1.80 [1.09-7.95] vs. 1.59 [0.87-7.40], p = 0.0105). In conclusion, baseline HMP parameters could be applied as a predictive tool for initial graft function, which in turn determines long-term outcome.

Efficacy and Safety of a Delayed Graft Function Protocol in Kidney Transplant Recipients

Purpose: To evaluate the efficacy and safety of a protocol increasing the net state of immunosuppression for adult kidney transplant recipients (KTR) with delayed graft function (DGF). Method(s): Single-center retrospective cohort of adult KTR with DGF transplanted from January 2017 to March 2021. Pre- vs post-DGF protocol implementation outcomes were evaluated. Protocol included cumulative 6 mg/kg rabbit antithymocyte globulin (rATG) induction, non-weight-based mycophenolate mofetil dosing (1000 mg bid), and higher goal tacrolimus trough (9-12 ng/mL). Pre-protocol patients received cumulative 4.5 mg/kg rATG. Efficacy outcomes were biopsy proven acute rejection (BPAR) and graft loss at 6 months. Safety outcomes were incidence of cytopenia, infection, and all-cause readmission at 6 months. Result(s): Eighty-nine DGF patients met inclusion criteria. Baseline characteristics were similar between groups, with median age (57+/-19) years and majority Hispanic (42.7%) males (61.8%) with a negative crossmatch (100%). Most post-protocol patients received 6 mg/kg cumulative rATG induction (71.4%) and mycophenolate mofetil 1,000 mg bid (80.3%) with therapeutic tacrolimus troughs by discharge (64.3%). Significantly less BPAR was observed post-protocol (7/56, 12.5% vs 10/33, 30.3%;p = 0.04). Of those with BPAR, significantly less post-protocol patients experienced T-cell mediated rejection (TCMR) than pre-protocol (2/7, 28.6% vs 9/10, 90.0%;p = 0.03). However, antibody-mediated (4/7, 57.1% vs 1/10, 10%) and mixed (1/7, 14.3% vs 0%) rejection were more frequent post-protocol (p = 0.10 and 0.41, respectively). Graft loss was similar post- vs pre-protocol (5/56, 8.9% vs 0;p = 0.16). All post-protocol graft losses were due to death (4 from COVID-19 and 1 unknown). Safety outcomes were similar between groups (Table 1). Conclusion(s): An increased net state of immunosuppression in DGF KTR significantly lowered the 6-month incidence of BPAR without significantly affecting safety. TCMR incidence was significantly decreased, but displaced by antibody-mediated and mixed rejection, implying need to conduct further prospective studies of larger sample sizes. Given majority of graft losses were due to COVID-19 pneumonia, studies are needed to evaluate the risk of COVID-19 infections in DGF KTR, especially with the availability of vaccines. (Table Presented).

Impact of ATG Dose Reduction on Kidney Transplant Outcomes During the Covid-19 Pandemic

Purpose: During the COVID-19 pandemic, many transplant centers modified induction immunosuppression regimens. Beginning December 2020, our center reduced anti-thymocyte globulin (ATG) protocol dosing by up to 33% compared to the pre-pandemic doses (7.5, 4.5, and 3mg/kg, per immunologic risk) for all recipients, with no change in maintenance immunosuppression. We examined the impact of reduced ATG dose on kidney allograft and transplant recipient outcomes. Method(s): We retrospectively reviewed adult recipients who received a kidney transplant between December 2020 and March 2021 (pandemic) with a minimum of 6 months follow up post-transplant, and recipients who received a transplant between January 2019 and December 2019 (pre-pandemic). We chose 2019 as a comparable pre-pandemic cohort as they were treated without influence from the COVID-19 pandemic. We ed patient demographic and laboratory data from electronic health records. We excluded multi-organ transplant recipients. Result(s): 78 adult kidney transplants were performed during the pandemic era and 211 were performed during the pre-pandemic era. The characteristics of the two cohorts are illustrated in Table 1. The primary outcomes are illustrated in Figure 1. The rate of biopsy proven rejection (including surveillance and for-cause biopsies) did not increase during the pandemic as compared to pre-pandemic era (6.3% vs 8.0%, respectively, p=0.8). The rate of BK viremia (>1000 copies/mL) at 3 months was lower in the pandemic era, but not statistically significant (6.4% vs 8.7%, respectively, p=0.6). The rate of delayed graft function (DGF) was significantly higher in the pandemic era compared to pre-pandemic (42.3% vs 22.9%, respectively, p=0.002). No recipients tested positive for COVID-19 within 1-month of transplant. Conclusion(s): Despite the reduction in ATG dose, we found no significant change in the rate of rejection or infection. We did however find a significant increase in the rate of DGF during the pandemic era. Further studies are needed to assess the long-term effects of reduced induction immunosuppression regimen on kidney transplant recipients. (Figure Presented).

The Successful Use of De Novo Belatacept with Reduced Dose Tacrolimus to Mitigate the Risks of Delayed Graft Function in Kidney Transplantation

Purpose: The new kidney allocation system has caused increased organ travel times and therefore increased cold ischemia time. Furthermore, the change in the priority to larger transplant centers has caused deprioritized centers to accept higher risk extended criteria donors. These factors lead to increased risk of delayed graft function (DGF). Method(s): To mitigate these risk factors of delayed graft function we have adopted an immunosuppression regimen of de novo belatacept with reduced dose tacrolimus with trough goal level of 5. We hypothesize that the use of belatacept will allow protection against rejection while allowing the renal allogaft to recover from ischemia reperfusion injury without concomitant calcineurin toxicity or vasoconstriction. The delayed addition of low dose tacrolimus can then aid in rejection prevention in addition to belatacept. Result(s): In a cohort of 83 patients we observed one graft loss, two episodes of rejection and three deaths. Of the 130 standard dose tacrolimus with no belatacept we observed no graft losses, seven rejections and one death. Two patients were converted from tacrolimus alone therapy to belatacept plus tacrolimus therapy after the diagnosis of rejection with concomitant tacrolimus toxicity. The belatacept group had a lower rate of rejection, but a higher rate of patient death with a P value <0.001 as calculated with the Z score test. The death in the tacrolimus group was due to covid. Two of the deaths in the belatacept group were cardiovascular, one was a cerebrovascular accident possible related to skull based osteomyelitis. The graft loss in the belatacept group was related to non-compliance. Conclusion(s): Despite initial reports of increased rates of rejection;we report decreased rejection with our belatacept for DGF regimen. We believe this regimen can be a useful tool to utilize more extended criteria donor kidneys in the new kidney allocation system.

Early Outcomes of Kidney Transplant Recipients from Donors with Severe SARS-CoV-2 Pneumonia

Purpose: Transplantation of kidneys from donors with active SARS-CoV-2 infection is uncommon due to concerns about the risk of viral transmission and kidney quality. To date, there is no conclusive data that viral transmission from extra-pulmonary solid organ transplant is a possibility. Given the prevalence of SARS-CoV-2 infections in potential donors, the shortage of kidneys available for transplantation and the low risk of viral transmission, we developed a clinical protocol for accepting kidneys from donors with active SARS-CoV-2 infection and preserved kidney function. Method(s): Retrospective chart review of 5 kidney transplant recipients from 4 deceased donors with severe SARS-CoV-2 infection. Donor and recipient characteristics are reported using descriptive characteristics. Result(s): Donor creatinine ranged from 0.51 to 0.60 mg/dL and KDPI ranged from 14% to 52%. Three of the 5 kidneys came from donation after circulatory death donors. All recipients were fully vaccinated, and 4/5 received post-exposure prophylactic monoclonal antibody treatment. 3 recipients had delayed graft function but were off of dialysis by postoperative day 6 or 8. 3 recipients were readmitted, one for fluid overload and mild rejection on two different occasions, one for hypotension from dehydration and one for sepsis secondary to an aspiration pneumonia. The latter recipient subsequently died with a functioning graft secondary to a severe bacterial infection. This recipient was also found to have a femoral DVT during readmission on the contralateral side to the kidney graft. At 30 days post-transplant, no recipients displayed signs or symptoms of SARS-CoV-2 infection and the three who were readmitted tested negative for SARS-CoV-2 via nasopharyngeal swab. All had a creatinine less than 2 at the most recent follow up. Conclusion(s): Our findings suggest that kidney grafts from donors with severe SARSCoV- 2 infection but preserved kidney function can be safely used and have good early outcomes. However, more research is needed to determine the safety and long term outcomes of kidney transplantation from donors with severe COVID-19 pneumonia.

Bacterial Infections After Kidney Transplant Before and After the COVID-19 Pandemic

Purpose: Infectious complications are a major cause of mortality and morbidity after kidney transplantation. During the COVID-19 pandemia there were several changes in the management and behavior of patients after transplant. These included measures such as universal masking, social distancing and reinforcing hand hygiene. Our objective was to evaluate if these differences affected the incidence of infections after kidney transplant. Method(s): This is a retrospective cohort study of all kidney transplants performed in our institution from March 2017 to November 2020. We examined the incidence of wound infection, urinary tract infection (UTI), pneumonia, and gastrointestinal (GI) infections. Pediatric and multi-organ transplants were excluded. We used the Fisher test, Chi-squared test of independence and logistic regression models in the analysis. All tests were based on a level of significance of alpha=0.05. Result(s): A total of 185 deceased donor kidney transplant patients were reviewed, 153 before and 54 after the beginning of the COVID-19 pandemic in the United States. The incidence of wound infection, pneumonia and GI infection were similar before and after COVID (Table 1). There was a significant increase in UTI after the COVID pandemic, the main organisms isolated were Klebsiella pneumonia (50%) and E. coli (25%). Overall the presence of UTI and wound infection were significantly related (OR 4.2, p = 0.06). Other clinical variables such as age, BMI, KDPI, EPTS, and the occurrence of delayed graft function were not associated with UTI. COVID infection was present with similar incidence: 12% in patients transplanted before and 14.8% in patients transplanted after the onset of the pandemic. Induction with Thymoglobulin or Basiliximab was not significantly different before and after COVID, and the choice of induction was not associated with the rate of UTI. Conclusion(s): While multiple changes in the management of patients and patient behavior are different before and after the onset of the COVID-19 pandemic, this analysis did not find significant change in the incidence of infections except for UTI in comparative cohorts of kidney transplant recipients. This study did not identify specific factors associated with the increase of UTI in our population. However, in response certain measures were implemented, such as reducing the time to ureteral stent removal and giving 24 hrs of prophylactic antibiotics at the time of stent removal.

Impact of Kidney Allocation Change on Low Volume Kidney Transplant Centers

Purpose: Effective March 15, 2021, the OPTN launched a new policy for matching kidney and pancreas transplant candidates with organs from deceased donors. The new policy was projected to increase equity in transplant access for candidates nationwide by using a scoring system based on a reference of 250 nautical mile radius from donor hospital. Various factors can influence the transplant rates including wait list size, organ acceptance practices as well as access to transplant centers in rural and socio-economically disadvantaged parts of the country. Small volume centers have short waitlist and candidates lower on the national list. With the current change in allocation, they may be forced to accept high risk kidneys. The new allocation may impact outcomes for such centers to stay active and maintain volumes. We propose to evaluate the impact of the allocation change on the kidney transplant practices at our center situated in rural setting. Method(s): A cohort study was designed comparing transplant characteristics of all patients undergoing kidney transplant at our center. The study population was all patients who had a kidney transplant after March 15, 2021. The cohort group was all patients who underwent a kidney transplant at our center from Jan 1, 2019 to Dec 31, 2019. The year 2020 was not considered because of COVID-19 pandemic. Data collected included donor demographics, recipient demographics, donor quality indices and recipient allograft function, transplant related complications. Result(s): There were 66 patients in the pre and the 49 in post allocation group. The most common cause of renal failure was diabetes in both. There were no statistically significant differences in recipient demographics. There was a dramatic increase in the number of DCD donors (48% pre vs 80% post, p 0.007). The cold ischemia time was significantly increased (20hr 5m pre vs 23hr 45m post, p 0.002). The serum creatinine trend showed higher serum creatinine at 1, 3 and 6 months post transplant in the post allocation group. Delayed graft function was seen in 3% in pre vs 10% in post group. There was an increase in hospital stay (6 days vs 8 days). Conclusion(s): The new allocation system may increase utilization DCD kidneys. It also prolongs cold ischemia time. This can result in prolonged hospital stay and DGF rates and result in higher serum creatinine levels. The impact of this on low volume centers and rural hospital systems may decrease organ transplant rates in such areas and lead to disparity in transplant access.

Successful Kidney Transplantation from a Deceased Donor with Severe COVID-19: Undetectable SARS-CoV-2 in Donor Kidney and Aorta by Sensitive Molecular Testing

Purpose: Kidney transplantation (KT) from coronavirus disease 2019 (COVID-19) positive donors has been avoided due to concerns for donor-derived transmission and possibility of the kidney being a viral reservoir. There is no long-term safety data, and sensitive molecular testing for SARS-CoV-2 in donor kidney is not routinely performed. We report a case of successful KT from a deceased donor who died from severe COVID-19 respiratory illness whose donor kidney and aorta were probed for virus using in situ hybridization (ISH) and quantitative reverse transcriptionpolymerase chain reaction (qRT-PCR). Method(s): A 30-year-old female was admitted to the hospital with severe COVID-19 pneumonia with a positive RT-PCR test for SARS-CoV-2 on nasopharyngeal swab. With clinical worsening, she was placed on extracorporeal membrane oxygenation, but developed hypoxic brain injury and progressed to brain death. Renal function was stable during her hospital course with serum creatinine concentration of 0.7 mg/dL. SARS-CoV-2 RT-PCR on bronchoalveolar lavage and nasopharyngeal samples tested again three days prior to donation was negative. A 55-year-old male recipient with an end-stage renal disease secondary to hypertension was transplanted with the left kidney from the above donor. The donor kidney was studied using pre-implantation surgical biopsy tissues to investigate the presence of SARS-CoV-2 RNA. Aorta tissue with the kidney was also studied given high expression of angiotensin-converting enzyme 2 receptors in vasculature. Result(s): ISH analyses did not show any positive signal for SARS-CoV-2 RNA in the donor kidney sample compared to a SARS-CoV-2 positive lung control. All samples tested by qRT-PCR were also negative for SARS-CoV-2. We found no evidence of SARS-CoV-2 mRNA in the donor kidney and aorta. The recipient has been free of COVID-19 related signs or symptoms and tested negative for SARSCoV- 2 by nasopharyngeal swab RT-PCR on days 20, 30, and 90 following KT. After an initial period of delayed graft function requiring hemodialysis, the recipient now has excellent renal recovery over 6 months following the transplant, and the most recent creatinine is 1.3 mg/dL. Conclusion(s): Taken together with recent observations of successful KT outcomes from mild or asymptomatic COVID-19 donors, we believe that the transmission risk of SARS-CoV-2 through KT is likely to be very low. Use of deceased donors who died after severe COVID-19 can be considered for KT. Larger scale studies are needed to confirm our findings.

Reduction of Rabbit Anti-Thymocyte Globulin Dosing for Induction of Kidney Transplant During the COVID-19 Pandemic

Purpose: Rabbit anti-thymocyte globulin (rATG) is a polyclonal antibody utilized for induction immunosuppression in high immunologic risk kidney transplant recipients. However, the optimal total dose of rATG has not been identified. Higher cumulative doses of rATG may be associated with an increased risk of adverse infectious and hematologic outcomes, while lower cumulative doses may not provide adequate immunosuppression to prevent acute rejection. In March 2020, the total rATG dose in our institution's induction protocol for kidney transplant recipients was reduced from 6 mg/kg to 4.5 mg/kg to avoid potential infectious complications from COVID- 19. The objective of this study is to compare the efficacy and safety between two different doses of rATG. Method(s): This was a single center, retrospective chart review of adult kidney transplant recipients who received rATG for induction between September 1, 2019 and August 31, 2020. Patients who received a total dose of 6 mg/kg rATG were compared to patients who received a total dose of 4.5 mg/kg. The primary outcome was biopsy proven acute rejection (BPAR) within 90 days of transplant. Secondary outcomes assessed incidence of infection, leukopenia, neutropenia, thrombocytopenia, and delayed graft function within 90 days of transplant. Result(s): Eighty-one adult kidney transplant recipients were included in this study;37 received 6 mg/kg of rATG and 44 received 4.5 mg/kg of rATG. Incidence of BPAR was significantly lower in the 6 mg/kg rATG group compared to the 4.5 mg/ kg group (2.7% vs 20.5%, p=0.02). The majority of rejection episodes were classified as borderline. Patients who had BPAR were treated with corticosteroids. The number of patients who had an infection was significantly lower in the 6 mg/kg group compared to 4.5 mg/kg group (21.6% vs 47.7%, p=0.02). There was a numerically lower incidence of delayed graft function in the 6 mg/kg group compared to the 4.5 mg/kg group (25.0% vs 43.2%, p=0.18). Incidence of leukopenia, neutropenia, and thrombocytopenia were similar between groups. Conclusion(s): In conclusion, a lower cumulative dose of rATG was associated with an increased risk of borderline rejection and a numerically higher incidence of delayed graft function.

Effect of Covid-19 Diagnosis on Organ Donation and Transplantation

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has challenged many aspects of healthcare, including organ donation and transplantation. The purpose of this study is to demonstrate that utilization of COVID-positive organs can be carried out safely. Method(s): De-identified data from 569 organ donors processed through an organ procurement organization (OPO) from March 24, 2020, through September 30, 2021, was collected from the OPO's database and retrospectively analyzed. Demographics, clinical measures, transplant numbers, and outcomes were recorded. Result(s): 25 COVID-positive (study) and 544 COVID-negative (control) organ donors were analyzed. There was no significant difference between the mean ages of the study group (43.12+/-11.08, p = 0.665) and the control group (44.15+/-17.94, p = 0.665). The COVID-positive group achieved donor management goals at a significantly lower rate than the COVID-negative group (4.0% vs 48.7%, p = 0.000012). The COVID-positive group required significantly more continuous renal replacement therapy (16.0% vs 1.8%, p < 0.00001), and extracorporeal membrane oxygenation (24.0% vs 0.7%, p < 0.00001). Significantly fewer organs were transplanted from the COVID-positive donors (1.12+/-1.013, p < 0.00001) than from the COVIDnegative donors (2.56+/-1.671, p < 0.00001). The mean observed to expected ratio for the study group (0.5372+/-0.47434, p < 0.00001) was significantly lower than that of the control group (0.9489+/-0.55041, p < 0.00001). The study group donors were significantly more likely to be categorized as donation after circulatory death (DCD) donors (96.0% vs 27.8%, p < 0.00001). There was no significant difference between the groups regarding delayed graft function in the recipient (18.2% vs 26.8%, p = 0.522561) nor regarding the need for dialysis post-transplant (9.1% vs 11.6%, p = 0.795292). Conclusion(s): Fewer organs from COVID-positive donors were utilized for transplantation than organs from COVID-negative donors over the study period. COVID-positive organs have been of no detriment to recipients, as there is no evidence of increased delayed graft function nor the need for dialysis. Though no short-term COVID-19 transmission has been identified, we will continue to monitor for this and to track non-renal transplant outcomes. A larger multi-center study is warranted to further delineate the safety and efficacy of implementing protocols to utilize these organs.

Kidney Transplantation Utilizing SARS-CoV-2 Rt-PCR Positive Donor Kidneys with Immediate Post Exposure Casirivimab / Imdevimab Followed by Thymoglobulin Induction

Purpose: At the beginning of the pandemic, kidneys from SARS-CoV-2 (COVID) RT-PCR positive donors were not utilized for transplantation, due to the risk of viral transmission. With the advent of the COVID vaccines, and improved monoclonal antibody therapy we transplanted organs from COVID positive donors irrespective of disease severity. Method(s): We performed six kidney transplants from COVID RT-PCR positive donors. Potential donors were screened for the date of the first positive COVID RTPCR. Only donors whose test had been positive at least 10 days prior to donation on a nasopharyngeal swab or bronchoalveolar lavage were accepted. A cycle threshold (ct)of >= 35 cycles was used as a cut off for accepting kidneys, when results were available prior to donation. Disease severity was not considered in donor evaluation. Recipient selection was performed based on willingness to give informed consent for the use of such kidneys, prior vaccination with at least 2 doses of the COVID vaccine and negative RT-PCRs in the month prior to transplantation. Result(s): We successfully transplanted 6 recipients from 5 donors. While one of the kidneys was recovered locally, the remainder were imported as non mandatory nationally shared organs. Four donors suffered from ARDS secondary to COVID pneumonia. Two donors were on ECMO at the time of donation. Two of the 5 donors were DCD recoveries with warm ischemic times times of 22 and 28 minutes. Co-infections in the donors included Candida glabrata, Enterococcus faecalis, and Burkholderia Cepacia for which appropriate prophylaxis was used in the recipients. All donors had positive nasopharyngeal RT-PCRs. Three had positive bronchioloalveolar lavage RT-PCRs. One donor was RT-PCR negative at the time of donation. Three recipients were sensitized with a PRA of 48%, 96%and 100%. The mean cold ischemic time was 25 hours. The mean KDPI was 51%. The delayed graft function rate was 33%. There was no primary nonfunction, rejection, death or graft loss after median follow-up of 87 (30-250days). The mean recipient GFR was 43ml/min. Dual kidney transplants were performed in two recipients. None of the recipients developed a COVID infection. 5/6 recipients received monoclonal antibodies (casirivimab and imdevimab) immediately after reperfusion. One patient did not receive casirivimab and imdevimab as it was not yet available in our region. All 6 patients received Thymoglobulin induction. Conclusion(s): With careful selection of immunized recipients, clinical assessment of transmission risk, and the preemptive use of monoclonal antibodies post exposure , SARS-Cov-2 positive donor kidneys can be safely utilized for single or dual kidney transplantation, without an increased risk of viral transmission, rejection or graft loss.

Comparative Outcomes at a Single Center for 71 Deceased Donor Kidney Transplants from Donors with Sars-CoV-2 RNA Detection

Purpose: Extra-pulmonary organs from donors with SARS-CoV-2 detection during donor evaluation are not accepted by many centers due to theoretical concerns for productive infection and organ injury from COVID-related sequelae. We aimed to compare outcomes for kidney transplantation (KT) from donors with and without SAR-CoV-2 RNA detection, CoVD+ and CoVDneg, respectively. Method(s): We retrospectively reviewed donor data, recipient data and key outcomes for all adult CoVD+ KTs performed at our center between 2/1/2021 and 10/31/2021 and compared such data to all consecutive adult CoVDneg KTs during the same period. Organ selection was by protocol and excluded donors within the 1st 14 days of diagnosed symptomatic infection. No COVID-directed therapies were provided to CoVD+ KT recipients (KTRs). Vaccination was not required in early 2021. Result(s): There were 159 KTs, including 71 (44%) from 41 CoVD+'s with mean follow up 151d (range 35-291d). Of the 41 CoV+ donors, 16 (40%) died of COVID complications, mostly hypoxic respiratory failure, with 4 on VV ECMO. For those dying of COVID, the median time from first SARS-CoV2 RNA detection to donation was 28d (range 16-65). Compared to CoVneg donors, CoV+D's had lower KDPI (mean 31 v 43, mean difference -10.8, 95% CI -18.41 to -3.17, p=0.006), and were more likely DCD (OR 2.41, 95% CI 1.28-0.463, p=0.007). Having a CoV+ donor was not associated with delayed graft function (DGF). On multivariable analysis, CoVD+ was not associated with a higher serum creatinine (Cr) at 1, 3 or 6 months, but DCD was. There was 1 death (from pre-existing interstitial lung disease without SARS-CoV-2 detection from the lower airway) at 4 mo and 1 graft loss at 6 wk post-KT, both in the CoVD+ group. Neither of these KTR's donors had died of a COVID-related cause. Rejection occurred in 3 CoVD+ and 4 CoVneg KTRs. Six (3.7%) KTRs were diagnosed with COVID, all >3 mo post-KT, with 5/6 occurring >6 mo post-KT during peak periods of circulating virus. Conclusion(s): In a large series, kidney transplant outcomes from CoVD+s were similar to CoVDnegs up to 6 months post-transplant. CoVD+ KT recipients likely benefited from lower KDPI organs. We demonstrate safe and successful transplantation of CoVD+ kidneys outside of the peak period of symptomatic SARS-CoV-2 infection. (Figure Presented).

Evaluation of Hepatitis C Positive Donor to Hepatitis C Negative Recipient Kidney Transplant in a Highly Sensitized Patient Population

Purpose: This study assessed outcomes of hepatitis C virus (HCV) donor positive to recipient negative (D+/R-) kidney transplants (KT) in high immunologic risk patients. Literature reports positive short-term outcomes in low immunologic risk patients, but limited data exists to support HCV D+/R- KT in high immunologic risk patients. Method(s): This retrospective cohort study included HCV antibody negative (-) recipients of a nucleic acid test (NAT) positive (+) KT who received HCV treatment with direct-acting antiviral therapy from 12/1/20 and 11/30/21. NAT+ KT recipients were matched 1:1 with NAT - KT recipients based on age, body mass index, and gender. All serologies were confirmed prior to study inclusion. The primary outcome was a composite of patient and graft survival 3 months post-KT. Secondary outcomes included percent of patients with sustained virologic response (SVR), time to HCV treatment initiation, incidence of cytomegalovirus (CMV) and BK viremia, presence of de novo donor specific antibody (DSA), rejection and HCV treatment related adverse drug reactions (ADRs). Descriptive statistics were used for baseline characteristics and a Log-Rank test was used for the primary outcome. Result(s): Eighteen HCV NAT+ KT recipients were matched with 18 HCV NAT- KT recipients. Study population was similar between groups and had end stage renal disease due to diabetes and/or hypertension, mean class I PRA >14%, pre-transplant DSA in 16% of patients in each cohort, and all received induction with rabbit anti-thymocyte globulin (Table 1). There was no difference in patient (p=0.32) and graft survival (p=0.99) between groups at 3 months post-KT. One death due to COVID-19 occurred in the NAT- group. There was no difference in estimated glomerular filtration rate (eGFR) at 1 (p=0.39) and 3 months (p=0.28), incidence of delayed graft function (DGF) (p= 0.67) or CMV (p=0.1) and BK viremia (p=1) between groups. (Table 2). HCV transmission occurred in all NAT+ KT recipients, and all who completed therapy achieved SVR. Treatment was initiated on average 8.5 weeks post-KT (Table 3). Notably, 33% of patients required financial assistance to obtain HCV treatment. Conclusion(s): Use of HCV D+/R- KT resulted in no difference in patient and graft survival at 3 months in this matched cohort. HCV NAT + KT patients should be connected with financial assistance programs early to promote timely treatment initiation. (Table Presented).

IS IT SAFE TO RECEIVE KIDNEYS FROM DECEASED KIDNEY DONORS WHO TESTED POSITIVE FOR COVID-19 INFECTION?

BACKGROUND AND AIMS: Our modern world is facing extraordinary circumstances while passing through a serious pandemic caused by the novel coronavirus (COVID-19) which may lead to multi-organ system failure and death. COVID-19 deaths may provide a potential source for kidneys available for transplantation. In our study, we are discussing the safety of receiving kidneys from donors who tested positive for the novel coronavirus. METHOD: All renal transplant recipients registered in UNOS database who had their transplants between 1 March 2020 and 1 June 2021 were retrospectively reviewed. Patients who received kidney transplants from a deceased donor with positive PCR of COVID-19 test were included in our study. Patients were followed up till 1 July 2021. Data about recipient factors (age, sex, ethnicity, diabetes and date of renal transplant), transplant factors (type of induction therapy, maintenance immunosuppressive therapy, delayed graft functions, early post-operative rejection episodes, HLA mismatch, PRA level and cold ischemia time) and donor factors (age, sex, ethnicity, diabetes, hypertension, date of COVID-19 test and type of COVID-19 test) were collected. Outcome measured were post-transplant hospitalisation, acute rejection, delayed graft function, patient, and graft survival till the end of the follow-up. RESULTS: Eighty-six transplant patients received kidneys from deceased donors who tested positive for COVID-19 infection using PCR test. Sixty patients received kidneys from deceased patients who tested positive for COVID-19 within 30 days pre-transplant. Twenty-six patients received kidneys from deceased patients who tested positive for COVID-19 between 30 and 90 days pre-transplant. Number of post-transplant hospitalisation and acute rejection episodes were nil. 19.76% of the patients had delayed graft functions. Graft loss occurred in one patient due to graft vein thrombosis. Patient survival was 100%. CONCLUSION: Receiving kidneys from deceased donors who tested positive for COVID-19 infection seems safe and does not affect hospitalisation, acute rejection rates, graft or patient survival. Longer follow-up is needed to confirm our results.

KIDNEY TRANSPLANTATION WITH COVID-19 POSITIVE DONORS: A SERIES OF 55 CASES

INTRODUCTION AND OBJECTIVE: Organs from deceaseddonors who tested positive for COVID-19 were thought to be ineligible for transplantation. Despite lack of evidence showing that COVID-19 can be transmitted through urine or blood. We began to transplant kidneys from COVID-positive deceased-donors in February 2021 and this report comprises our early outcomes in this patient cohort. METHODS: From Feb 2021 to Oct 2021, 55 patients underwent kidney transplantation from 34 COVID-19 positive donors. Prior to initiating this clinical practice, formalized selection criteria for organs from COVID-19 positive deceased-donors were adopted by transplant surgeons, transplant nephrologists, and infectious disease physicians. If a deceased-donor suited these pre-determined criteria, individual kidney selection followed our usual programmatic criteria. RESULTS: The mean donor age was 34±13.7 years with a mean kidney donor profile index (KDPI) of 36.9±22.7%. All donors had at least 1 positive COVID-19 test from the nasopharyngeal ribonucleic acid swab test within a median of 4 (0-76) days prior to declaration as a deceased-donor. Extracorporeal membrane oxygenation (ECMO) was used in 6 donors. The initial and terminal mean creatinine was 1.1±1.1 mg/dl and 1.0±0.4 mg/dL. This patient cohort includes 36 male recipients and 19 female recipients. Mean age among all recipients was 51.2±13.5 years. Thirty-seven recipients (66.7%) were dialysis dependent. A similar proportion (67.3%) had received both COVID-19 vaccine doses. Delayed graft function occurred in 19.6% of the recipients. No patient tested positive for COVID-19 after surgery. At a mean follow up duration of 3.5 months, all kidney allografts are functioning, with a mean serum creatinine of 1.6±0.7 mg/dl. One patient underwent allograft nephrectomy at 1.5 months post-transplant due to Pseudomonas aeruginosa vascular infection. CONCLUSIONS: Transplantation of kidneys from COVID-19 positive donors is safe. Outcomes are comparable to kidneys from regular donors.

Liver transplantation from discarded liver grafts. A useful policy for expanding the liver donor pool in Mexico

Introduction: Extended criteria donors (ECD) in liver transplantation (LT) is gaining worldwide acceptance due to the shortage of optimal donors. Most of liver transplant groups agree that ager over 60, prolonged cold ischemia time (CIT), steatosis, inotropic support, non-heart beating donors (NHBD), sustained hypernatremia, split livers among other factors are related to primary non-function (PNF) with high morbimortality. Before COVID-19 pandemia discarded liver grafts that nobody wants accounts for the double of LT done each year in Mexico and it seems that there is an increasing rate of marginal or ECD. To define discarded liver grafts, these must be refused by 3 of the main liver transplant centers in the country and have ≥ 3 risk factors for PNF and delayed graft function (DGF). Method: A period from january 2015 to january 2021 was observed. Donor characteristics such sustained severe hypernatremia (>165 mEq/l), moderate steatosis (>40%), body mass index (BMI) >30 k/m2, alcohol abuse, CIT >12 h and norepinephrine support were considered risk factors for PNF and DGF. DGF, PNF, morbidity and mortality were evaluated. Result: 159 LT were done. Marginal donors 61 (38.3%), discarded livers 40 (65.5%). Severe hypernatremia (165-188 mEq/l) 20 (50%), obesity (BMI 30-45k/m2) 30 (75%), moderate to severe steatosis (40-76%) 22 (55%), alcohol abuse in 3 (7.5%), age >60 (35%) and norepinephrine support 27 (67%). No CIT > 12 h was recorded. PNF between marginal and discarded liver grafts were the same (5%) and between optimal grafts and discarded or marginal the rate of PNF were 2.1 to 5%. DGF was present in 7.5%, 5% and 3.1% of discarded, marginal and optimal grafts respectively. No differences in mortality rate between groups. Conclusion: Discarded livers are an acceptable choice to expand liver donor pool in Mexico. None hypernatremia, obesity, steatosis or age are independent poor risk factors for developing PNF.