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Objective: Is to find out which revascularization methods have less of risk factors and complications after the surgery and long-term period. Method(s): From January 2018 to December 2019 were operated 134 patients with LAD CTO. 48 of them underwent MIDCAB: 36 (75%) males and 12 (25%) females;aged 58.7 +/-8.7;7 (14.6%) with previous diabetes;10 (20.8%) with previous PCI of LAD with drug-eluting stent. In the PCI group there were 86 patients: 52 (60.5%) males and 34 (39.5%) females;aged 64.8 +/-8.3;23 (26.7%) with previous diabetes. Result(s): Hospital mortality was 0 (0%) in MIDCAB unlike 1 (1.2%) in PCI. Myocardial infarction was 0 (0%) in both the groups. In MIDCAB the number of conversions to onpump and sternotomy was 0 (0%), there were 6 (12.5%) pleuritis with pleural puncture and 3 (6.2%) with long wound-aches. The hospitalization period was 10.7+/-2.9 days for MIDCAB and 9.9 +/-3.9 days for PCI. In the PCI group 2.0 +/-1.0 drug-eluting stents were used. In-hospital costs were higher for PCI 3809 unlike 3258 for MIDCAB. After one year in MIDCAB group died 2 (4.2%) patients, from noncardiac causes. In PCI group died 3 (3.5%) patients, all from cardiac causes. Because of pandemic COVID-19 were checked only 48 patients by angiography and general clinical examination: 25 after MIDCAB and 23 after PCI. 5 patients have a graft failure, caused by surgical mistakes. 4 patients have stents restenosis and 1 has LAD's reocclusion. Conclusion(s): Both methods of revascularization for LAD CTO are demonstrated similar results. EuroSCORE II (P = 0.008) and glomerular filtrating rate (P = 0.004) are significant potential risk factors for mortality in both groups, age is potential risk factor for graft failure (P = 0.05). Dyslipidemia is significant risk factor for LAD restenosis in PCI group (P = 0.02). MIDCAB is associated with lower incidence of revascularization repeat and in-hospital mortality in the literature data and it costs lower than PCI for LAD CTO as our study has shown.
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BACKGROUND: Early in the coronavirus disease 2019 (COVID-19) pandemic, there was a significant impact on routine medical care in the United States, including in fields of transplantation and oncology. AIM: To analyze the impact and outcomes of early COVID-19 pandemic on liver transplantation (LT) for hepatocellular carcinoma (HCC) in the United States. METHODS: WHO declared COVID-19 as a pandemic on March 11, 2020. We retrospectively analyzed data from the United Network for Organ Sharing (UNOS) database regarding adult LT with confirmed HCC on explant in 2019 and 2020. We defined pre-COVID period from March 11 to September 11, 2019, and early-COVID period as from March 11 to September 11, 2020. RESULTS: Overall, 23.5% fewer LT for HCC were performed during the COVID period (518 vs 675, P < 0.05). This decrease was most pronounced in the months of March-April 2020 with a rebound in numbers seen from May-July 2020. Among LT recipients for HCC, concurrent diagnosis of non-alcoholic steatohepatitis significantly increased (23 vs 16%) and alcoholic liver disease (ALD) significantly decreased (18 vs 22%) during the COVID period. Recipient age, gender, BMI, and MELD score were statistically similar between two groups, while waiting list time decreased during the COVID period (279 days vs 300 days, P = 0.041). Among pathological characteristics of HCC, vascular invasion was more prominent during COVID period (P < 0.01), while other features were the same. While the donor age and other characteristics remained same, the distance between donor and recipient hospitals was significantly increased (P < 0.01) and donor risk index was significantly higher (1.68 vs 1.59, P < 0.01) during COVID period. Among outcomes, 90-day overall and graft survival were the same, but 180-day overall and graft were significantly inferior during COVID period (94.7 vs 97.0%, P = 0.048). On multivariable Cox-hazard regression analysis, COVID period emerged as a significant risk factor of post-transplant mortality (Hazard ratio 1.85; 95%CI: 1.28-2.68, P = 0.001). CONCLUSION: During COVID period, there was a significant decrease in LTs performed for HCC. While early postoperative outcomes of LT for HCC were same, the overall and graft survival of LTs for HCC after 180 days were significantly inferior.
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Introduction: Acromegaly is an uncommon pituitary disorder with an incidence of six per million persons. While hypertension is often encountered in these patients, heart failure rarely is seen with an incidence rate under 10%. We describe a case of an individual who was diagnosed with acromegaly after an acute exacerbation of heart failure with subsequent management requiring an LVAD to perform Transsphenoidal Surgery (TSS). Case Description: 37-year-old male otherwise healthy initially presented to an emergency room and was found to be in acute heart failure exacerbation. Concerning acromegaly features included macrognathia, enlarged hands and feet, swollen phalanges, widened spacing of teeth, and frontal bossing. IGF-1 level was found 455 ng/mL. MRI showed a 10mm macroadenoma. A right heart catheterization showed elevated filling pressures. Cardiac MRI showed no defects or enhancement. Endomyocardial biopsy showed no inflammatory infiltrates or evidence of infiltrative diseases. Patient had an ejection fraction of 15% corroborated by cardiac MRI along with the presence of aortic root dilatation and mitral regurgitation. The patient started on 0.5mg of Cabergoline twice weekly and 120mg weekly Lanreotide injections. Patient stabilized with plans for further close monitoring and outpatient neurosurgical evaluation. The COVID-19 pandemic and insurance gaps led the patient to spend two years off his medicines and he was unable to be seen by his medical team. Patient was seen by our system after recurrent hospitalizations for heart failure at our sister hospital, AICD was unable to be placed due to the patient's anatomy, he was placed on wearable cardiac defibrillator and required milrinone infusion for progression to end-stage heart failure with cardiac cachexia. At our institution, the patient was evaluated for Orthotopic Heart Transplant (OHT) but due to active GH secreting macroadenoma there was concern for OHT failure without TSS. Decision was made to utilize LVAD as Bridge-to-Transplant for OHT so the patient could be stabilized and safely undergo TSS. The patient tolerated surgeries well and is currently on the active transplant list. Discussion(s): Heart failure is an uncommon presentation of severe acromegaly requiring multidisciplinary management. We describe a case of a patient who initially presented with heart failure too unstable for surgery. Due to the COVID-19 pandemic the patient's disease progressed resulting in end-stage heart failure requiring LVAD placement for further treatment. We would like to draw attention to the use of LVAD placement in acromegalic patients who develop severe cardiovascular disease who are not candidates for OHT.Copyright © 2023
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The Hermanos Ameijeiras Hospital (HAH) in Havana is the only center performing allogeneic hematopoietic stem cell transplantation (HSCT) in adult patients in Cuba. Because transplants from unrelated donors are not possible due to political restrictions and economic embargo, in 2016 HAH and University of Illinois at Chicago (UIC) started a collaboration to support the training of a physician, annual educational programs and exchange of guidelines and protocols to perform haploidentical transplants. The first haploidentical transplant was performed at HAH in 2016. Because of limited resources, disease risk stratification is based on morphologic assessment, as cytogenetic is tested on an irregular basis. Peripheral blood stem cells (PBSC) were infused based on total nucleated cell count (TNC) due to lack of reagents for flow cytometry. Posttransplant chimerism and CMV monitoring cannot be performed. Transplant activity was stopped in 2020 due to high expenses allocated for COVID19 pandemic in Cuba. From 2016 to 2020, 16 haploidentical HSCT in 15 patients (9 males/ 6 females) were completed at HAH. The median age of patients was 34 years (range:21-54). Diagnoses included: acute leukemia, n=12, myelodysplastic syndrome, n=1, Hodgkin disease, n=1, and severe aplastic anemia, n=1. At the time of transplant, 11 patients were in morphologic remission and 5 had active disease. Conditioning regimens utilized were myeloablative (Flu/Bu) in 10 cases and at reduced intensity (Flu/Cy/ TBI200 +/- ATG) in 6 cases, and GVHD prophylaxis was standard PTCy on D3 and 4, CsA and mycophenolate. The donors were mother (n=10), father (n=1), child (1), or sibling (n=3) and the median age was 48 years (range: 26-68). All patients received fresh stem cells from PBSC(n=13) or bone marrow (n=3). Median cell dose infused was 5.5x108 TNC/kg (range: 2.2-8). All patients but 1 engrafted and median time to neutrophil and platelet engraftment was 17 days (range:12-28) and 16 days (range:11-30), respectively. Acute graft-versus-host disease (GVHD) grade 2-3 occurred in 50% of patients and chronic GVHD in 2 out of 8 that were evaluable. Day 100 and 2-year overall survival rates were 73% and 40%, respectively. With a medium follow-up of 18.8 months (range: 0.3-64), 5 of 15 patients (30%) are alive and complete remission. Causes of death in the remaining 10 patients included relapse of original disease, n= 4;bacterial infection, n=2;brain hemorrhage, n=1;VOD, n=1;graft failure, n=1;and multi-organ failure, n=1. Despite significant difficulties, HAH implemented a haploidentical transplant program for adult patients in Cuba. Among future steps, improving access to molecular testing and using younger donors will be pursued to improve on the results. The partnership between HAH and UIC has been instrumental in building clinical and research capacity and continues to support HAH in its mission to provide care to patients in Cuba.(Figure Presented)Copyright © 2023 American Society for Transplantation and Cellular Therapy
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Background: Allogeneic hematopoietic cell transplantation (HCT) with ex vivo T cell receptor (TCR) alphabeta+ T cell and CD19+ B cell depletion is an effective approach for children with primary immune deficiency disorders (PIDD) as it combines advantages of high CD34+ cell dose facilitating rapid engraftment with low risk of Graft Versus Host Disease (GVHD). The ideal pre-conditioning regimen that facilitates robust donor engraftment without increasing risk of transplant related mortality has not been well defined with this approach. Method(s): We report the outcomes of 4 pediatric subjects: Chronic Granulomatous Disease (CGD) (2), Wiskott Aldrich Syndrome (WAS) (1), and RAC2 deficient Severe Combined Immunodeficiency (1) who underwent haploidentical HCT with TCRalphabeta+ T cell/CD19+ depletion at Johns Hopkins All Children's Hospital/Moffitt Cancer Center from 2020-2022 (NCT04414046). Pre-conditioning regimen consisted of distal thymoglobulin (7.5 mg/kg), fludarabine (175 mg/m2), thiotepa (10 mg/kg) and pharmacokinetic guided busulfan targeting a cumulative area under curve (cAUC) (65-75 mgxhr/L). Rituximab (200 mg/m2) was administered on day +1. Result(s): The median age at HCT was 51 months (range 10-163 months). All patients received mobilized peripheral blood stem cells from HLA- haploidentical donors (paternal=1, maternal=1 sibling=2). Median busulfan cAUC for all patients was 69 mgxhr/L (range 65-76). Median CD34 and TCR alphabeta T cell dose was 9.13x106 cells/kg (range 7.0-18.9x106) and 0.7x105 cells/kg (range 0.09-1.0x105). Median times to neutrophil and platelet engraftment were 11 days (9-12) and 11 days (range 8-15), respectively. All 4 patients are alive with median follow-up of 19.5 months (range 7-24). One patient developed late VOD without organ dysfunction that resolved with defibrotide. At last follow up, peripheral T and myeloid chimerisms exceeded 90% in all 4 patients. Average time to CD4 recovery (> 200x106/L) was 142 days. Pre-existing inflammatory bowel disease in CGD (n=1) and WAS (n=1) patients resolved immediately following transplant. There was no graft failure, and none developed Grade III-IV acute or extensive chronic GVHD. Patient with WAS developed recurrent autoimmune cytopenias requiring corticosteroids, rituximab, sirolimus and daratumumab, and ultimately resolved. Viral reactivations included EBV (n= 1), adeno (n= 1), HHV6 (n= 2), BK (n=1), norovirus (n=1), and late HSV (n=1), all responded to antivirals without disease. All patients acquired SARS-Cov-2 after transplant and recovered without sequelae. Conclusion(s): TCR alphabeta+ and CD19+ depleted haploidentical transplantation using a reduced toxicity conditioning regimen with pharmacokinetic guided busulfan, fludarabine, thiotepa and thymoglobulin is well-tolerated in young children with PIDD that results in rapid, durable engraftment with low likelihood of GVHD and graft rejection.Copyright © 2023 American Society for Transplantation and Cellular Therapy
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The World Health Organization (WHO) declared COVID-19 a pandemic in March 2020. Since then, logistical challenges arose regarding the procurement of allogeneic (allo) hematopoietic stem cell (HSC) donor grafts. Little data was available on transplant outcomes using cryo haploidentical (haplo) HSC grafts with post-transplant cyclophosphamide (PTCy) for GVHD prophylaxis. We retrospectively analyzed patients who received a first PTCy-based haplo hematopoietic stem cell transplant (Haplo HCT) at a single outpatient transplant center between January 2015 and December 2021. We identified 294 patients, 179 received a fresh graft and 115 received a cryo graft (Table 1). Both cohorts were similar in terms of median age, diagnoses, HCT-CI score and DRI. Out of 179 fresh haplo grafts, 160 (89.4%) were from peripheral blood stem cells (PBSC) and 19 (10.6%) were bone marrow grafts (BM). There were no cryo BM grafts used. Conditioning intensity were similar amongst both cohorts, with 43% myeloablative, 41.9% non-myeloablative and 15.1% RIC regimens used for fresh Haplo HCT and 39.1% myeloablative, 42.6% non-myeloablative and 18.3% RIC cryo Haplo HCT. Median time to engraftment was 16 days for fresh Haplo HCT and 17 days for cryo HCT (p=0.18). Median time to platelet engraftment was 27 days for fresh Haplo HCT and 27.5 days for cryo HCT (p=0.96). Since March 2020, only 8 transplants performed at our institution were from fresh haplo HSC grafts. Cryo grafts performed after March 2020 accounted for 73 (63.5%) of 115 total cryo Haplo HCT performed in the period reviewed. Using a Cox model to evaluate the effect of graft type and adjusting for significant variables, we found no difference in overall survival (OS), disease free survival (DFS), non-relapse mortality (NRM) and relapse rates between fresh and cryo Haplo HCT performed (Figure 1). While we found no difference in grades III-IV aGVHD (Table Presented) (Figure Presented) between fresh vs cryo Haplo HCT, we found a statistically significant higher incidence of grades II-IV aGVHD (p=0.033). There was no difference in all-grade cGVHD (p=0.53) or moderate- severe cGVHD (p=0.86) (Figure 2).(Figure Presented) The National Marrow Donor Program (NMDP) released a statement requiring cryopreservation of unrelated donor grafts at the start of the COVID-19 pandemic. The cryopreservation of all types of allo HSC grafts has been adopted by many transplant programs including ours. Our results mimic a CIBMTR analysis published at the start of the pandemic, where survival outcomes using fresh vs cryo haplo HSC grafts with PTCy as GVHD prophylaxis were similar. Contrary to other reports, we did not see differences in graft failure or rates of cGVHD between fresh and cryo Haplo HCT. The use of cryopreserved HSC grafts for Haplo HCT with PTCy results in favorable outcomes in an outpatient transplant setting. Further studies are needed to determine the cost-effectiveness of this practice in the post-pandemic era.Copyright © 2023 American Society for Transplantation and Cellular Therapy
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The coronavirus disease 2019 (COVID-19) pandemic created an unprecedented challenge for healthcare, and the world continues to struggle in recovering from its aftermath. COVID-19 has been clearly linked to hypercoagulable states and can lead to end-organ ischemia, morbidity, and mortality. Immunosuppressed solid organ transplant recipients represent a highly vulnerable population for the increased risk of complications and mortality. Early venous or arterial thrombosis with acute graft loss after whole pancreas transplantation is well-described, but late thrombosis is rare. We herein report a case of acute, late pancreas graft thrombosis at 13 years post pancreas-after-kidney (PAK) transplantation coinciding with an acute COVID-19 infection in a previously double-vaccinated recipient.
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Background:: Since its declaration as a global pandemic on March11th 2020, COVID-19 has had a significant effect on solid-organ transplantation. The aim of this study was to analyze the impact of COVID-19 on Liver transplantation (LT) in United States. Method(s):: We retrospectively analyzed the United Network for Organ Sharing database regarding characteristics of donors, adult-LT recipients, and transplant outcomes during early-COVID period (March 11- September 11, 2020) and compared them to pre-COVID period (March 11 - September 11, 2019). Result(s):: Overall, 4% fewer LTs were performed during early-COVID period (4107 vs 4277). Compared to pre-COVID period, transplants performed in early-COVID period were associated with: increase in alcoholic liver disease as most common primary diagnosis (1315 vs 1187, P< 0.01), higher MELD score in the recipients (25 vs 23, P<0.01), lower time on wait-list (52 vs 84 days, P<0.01), higher need for hemodialysis at transplant (9.4 vs 11.1%, P=0.012), longer distance from recipient hospital (131 vs 64 miles, P<0.01) and higher donor risk index (1.65 vs 1.55, P<0.01). Early-COVID period saw increase in rejection episodes before discharge (4.6 vs 3.4%, P=0.023) and lower 90-day graft/patient survival (90.2 vs 95.1 %, P<0.01;92.2 vs 96.5 %, P<0.01). In multivariable cox-regression analysis, early-COVID period was the independent risk factor for graft failure at 90-days post-transplant (Hazard Ratio 1.77, P<0.01). Conclusion(s):: During early-COVID period in United States, overall LT decreased, alcoholic liver disease was primary diagnosis for LT, rate of rejection episodes before discharge was higher and 90-days post-transplant graft survival was lower.Copyright © 2022 The Author(s)
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Kidney transplantation is a definite treatment for end-stage renal disease (ESRD). However, management of allograft dysfunction has remained a major challenge and some patients return to dialysis after renal transplantation. Studies showed that peritoneal dialysis (PD) results in a higher chance of survival and a lower risk of delayed allograft dysfunction compared to hemodialysis (HD). For this reason, this study explored the initiation of PD in six patients with renal allograft dysfunction in Tabriz Imam Reza hospital (referral PD center). This case reported the results of PD and incremental PD among these patients with failed kidney transplantation. Creatinine and hemoglobin levels, duration of starting PD, PD exchange, PD modality, immunosuppressive drugs mortality rate and urine volume were evaluated during the study. In conclusion, although re-transplantation is a gold standard therapy in failed kidney transplant patients, PD or incremental PD could be a suitable and home-based modality for preserving renal function and urine output in these patients.Copyright © 2022 The Author(s);Published by Society of Diabetic Nephropathy Prevention.
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Introduction: Kidney transplantation is the best treatment option for patients with end-stage kidney diseases. Quality and longevity of life are better with kidney transplant than chronic dialysis. Kidney paired donation and ABO incompatible kidney transplant (ABOiKT) are among the strategies to expand the living donor pool to overcome shortage of organs. Although first ABOiKT done in 1951 by Hume et al. was an unsuccessful attempt;Alexander et al. in 1987, proposed desensitization protocol with successful ABOiKT. Advancements in desensitization protocols have resulted in increasing success with ABOiKT. In developing countries like India, numbers of ABOiKT are steadily increasing. Aim of this study was to assess short term outcome of ABOiKT and their comparison with ABO compatible kidney transplant (ABOcKT). Method(s): This was a single center prospective observational study done over a period of 2 years. All the living donor kidney transplants including both ABOcKT and ABOiKT done between September 2020 to August 2021 at Jaslok Hospital and Research Center, Mumbai were included in this study. All ABOiKT recipients underwent pre-transplantation desensitization with injection rituximab and plasmapheresis. Pretransplant isoagglutinin titer of <= 1 : 8 was considered acceptable. Inj. Antithymocyte globulin (ATG) (1mg/kg), Inj. Anti-T lymphocyte globulin (ATLG) (3 to 5 mg/kg) or Inj. Basiliximab (20mg 2 doses 4 days apart) was used as induction agent. Triple immunosuppression regimen of prednisolone, tacrolimus and mycofenolate mofetil was started 7 days prior to transplant in ABOiKT and 2 days prior to transplant in ABOcKT and continued in post-transplant period. Valganciclovir was given to all patients for Cytomegalovirus (CMV) infection prophylaxis for 6 months. All the transplant recipients were followed up at 0, 3, 6, 9 and 12 months after transplant and in between when clinically indicated. Data collected was analyzed at the end of 1 year for outcomes of rejection episodes, graft dysfunction, graft loss, infections and death. Result(s): Total 95 patients were included in study, 29 (30.5%) out of them were ABOiKT recipients. Mean (SD) age of study population was 37.8 (+/- 10.5) years. Blood group B to B was the most common ABOcKT and B to O was the most common ABOiKT. Highest baseline isoagglutinin titer was 1:1024.There was no significant difference for rejection episodes, graft dysfunction, graft loss and death in ABOiKT and ABOcKT groups. Urinary tract infection was the most common infection in post-transplant period. COVID-19 was most common viral infection followed by CMV infection. Bacterial infections and overall infections were significantly higher in ABOiKT recipients (p value 0.001 and 0.006 respectively) but severe infections requiring hospitalizations and ICU care were not significantly higher. Two deaths occurred during our study, one in each group. One death was related to COVID-19 infection and second was because of pulmonary mucormycosis. Conclusion(s): Contrary to belief, ABOiKT has non inferior short term outcomes when compared with ABOcKT. Though in our study, bacterial infections were significantly higher in ABOiKT recipients, severe infections requiring hospitalization and ICU care were not increased. ABO incompatible kidney transplantation is an effective modality to increase donor pool and can be applied more widely. No conflict of interestCopyright © 2023
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Introduction: The COVID-19 infection amongst the renal transplant recipients (RTR) has a varied presentation and severity of illness. The overall mortality amongst RTR was found to be 11.6%- 27% compared to the mortality rate of 2-3% amongst the COVID-19 infected general population. The incidence of acute kidney injury(AKI) in RTR was also found to be higher compared to general population with Covid 19 (27.5% versus 13.3%). We assessed the clinical outcomes of COVID 19 infection among RTR and its impact on the graft function along with predictors of poor clinical outcomes. Method(s): Ours is a single centre observational cohort study of 83 RTR with Covid 19 infection with a follow up period of 6 months. The data pertaining to demographics, renal transplantation, maintenance immunosuppression, baseline allograft function prior to Covid 19 infection and comorbidities was recorded in both hospitalised and outpatient RTR. Lab investigations including renal function tests and inflammatory markers were noted. Renal allograft function was assessed by estimated glomerular filtration rate(eGFR) using CKD-EPI equation prior to admission, hospital stay and 6 months follow up. The need for oxygenation, invasive ventilation;presence of hypotension, acute kidney injury(AKI),acute respiratory distress syndrome(ARDS) and need for renal replacement therapy(RRT) was noted. Modification of immunosuppressant medications with respect to dose reductions and withdrawal was recorded. The primary endpoint was mortality and presence of acute kidney injury during Covid 19 infection. Result(s): The mean age was 47.67+/-13.7 years and 75.91 % were males. Around 81.9%(68/83) RTR were hospitalised & 18.9%(15/83)were managed as outpatients. Out of 83 patients,43 (51.8%), 23(27.7%),17(20.5%) had mild, moderate and severe COVID 19 illness respectively. The mortality rate amongst COVID 19 infected RTR was 19.3%(16/83). Out of 83 RTR,17 required inotropic support owing to hypotension. The baseline eGFR(ml/min) prior to Covid 19 infection was 66.3 +/- 30.66. The eGFR(ml/min) during Covid 19 was 44.27 +/- 31.53.Acute kidney injury(AKI) was seen in 72.3%(60/83) of RTR.19.28%(16/83) required RRT.The percentage change in eGFR from baseline during COVID-19 was found to be statistically significant(p=0.003)and correlated with mortality(p=0.003).At 6 months of follow up,55/83 RTR had stable allograft function with mean eGFR(ml/min) of 51.74 +/- 29.92 and 8/83 patients(9.6%) patients were on maintenance haemodialysis. In contrast to the survivors, the non survivors had a higher mean age(67+/-13 vs 57+/-12 years), number of years of hypertension(15+/-9 vs 8.5 +/-7 years),body mass index(27.05+/-4.7 vs 23.11+/- 7.8), percentage change in eGFR from baseline(114.1 +/-81.7% vs 58.8 +/-61.4%), serum Interleukin levels (120.7 vs 10 pg/ml) and D dimer(145 vs 21.3 mcg/ml) levels (p<0.05).Other risk factors which correlated significantly with outcome of mortality and reduced renal recovery include presence of hypoxia at presentation and ARDS(87.5 Vs 28.1%),presence of hypotension requiring inotropes(81.3% vs 6%) and AKI and the need for RRT(56.7% vs 10.4%). [Formula presented] [Formula presented] Conclusion(s): The mortality rate amongst the RTR with COVID 19 infection was found to be 19.3%.AKI was found in 72% of patients during the illness and about 9.6% developed graft loss by 6 months. RTR needs a close supervision and follow up as they are prone to acute kidney injury and may develop allograft failure. No conflict of interestCopyright © 2023
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Elective operations were significantly reduced in order to eliminate, as much as possible, the risks of SARS -CoV-2 virus infection for both patients and medical personnel and to leave the clinical facilities and intensive care available for access to COVID patients. We looked at the total number of patients treated for skin cancer surgery at both hospitals from the March 23, 2020 till the May 28, 2020, the demographic characteristics, the medical comorbidities, the pathologies operated on in day surgery regimens of care and the surgical outcomes. With regards to the site, more than one third of the patients were treated at a private hospital setting. Among the surgery complications identified there was one graft failure following excision of scalp lesion which histology confirmed regressed keratoacanthoma. Moreover, three infections associated with the lesions excised occurred and were treated with antibiotics. With regards to morbidity there was only one covid-19 infection among the patients that attended for skin cancer surgery and two deaths. The utilization of Covid-free locations, other than NHS hospitals, for elective surgery improved the efficiency of the service and together with the practical steps in theatre management and minimizing footfall, allowed the successful continuation of care during the pandemic.Copyright © 2021
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BACKGROUND: The long-term outcomes of renal transplant recipients (RTR) affected by SARS-COV2 infection are an unexplored area particularly given the heightened immunosuppression and post-COVID-19 sequelae and increased fungal infections. We aimed to analyze the patient and graft outcomes, infectious and non-infectious sequelae in RTR with COVID-19 over a long-term follow-up of 24 months. AIM OF THE STUDY: To analyze the patient and graft outcomes, infectious and non-infectious sequelae in RTR with COVID-19 over a long-term follow-up of 24 months. METHOD(S): This retrospective study included the RTR admitted during the two pandemic waves between March 25, 2020, and July 31, 2021. The survivors were followed for a maximum period of 24 months (till September 2022) and were studied for readmission rates, serious infection requiring hospitalization (SIRH), graft dysfunctions and biopsy-proven acute rejections (BPAR), patient and graft survival. RESULT(S): Of 251 RTRs with SARS-COV2 infection, 104 were treated during the first wave and 147 during the second wave. After an index mortality noted in 38 patients (15.1% - 11.5% in first wave vs 17.5% in second wave, P = 0.23), follow-up data of 213 patients were analyzed. 45 patients were lost to follow-up, and a complete follow-up data was available for 168 patients. A total of 70 patients (41.7%) required readmission with SIRH being the most common indication for readmission (19.6%) followed by rejection (8.9%). Patients who received high dose steroids during the COVID-19 illness had higher SIRH (32.4% vs 16%, p = 0.027). However, graft dysfunctions (13.5% vs 16%, p = 0.70) and the BPAR (8.1%vs9.2%, p = 0.84) were similar in both the groups. Overall mortality (5.4% vs 6.9%, p = 0.75) and graft loss (10.8% vs 5.3%, p = 0.23) were also similar at 24-month follow-up. CONCLUSION(S): The high-dose corticosteroid dosing in the RTRs during COVID-19 appears to be associated with increased infectious complications over long-term although the overall patient and graft survival was similar.
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Background. The long-term complications of COVID-19 infection in the general population include mortality, re-infection, secondary infection, persistent organ dysfunction, and symptoms of long-COVID. The prevalence of these outcomes and impact on graft function in solid organ transplant (SOT) remain uncertain. We aim to describe these complications in a large series of SOT with COVID-19 with 2 years of long-term follow up. Methods. We retrospectively studied all adult (age >18) SOT from a single center hospitalized with SARS-CoV-2 diagnosed by nasopharyngeal swab between 3/ 10-5/30/2020. Patients with early mortality within 28 days were excluded. Outcomes including mortality, allograft rejection, allograft failure, secondary infections, COVID-19 re-infections, post-COVID complications (oxygen requirement, chronic renal or cardiac dysfunction), and symptoms of long-COVID were analyzed. Re-infections were characterized by severity and likely variant based on local variant predominance. Results. 117 SOT recipients were hospitalized with COVID-19 in the study period. 94 survived the first 28 days and were followed for a median of 751 (742-760) days post-infection. 9 (9.57%) died within 1 year of infection and 14 (14.9%) within 2 years. 21 (22.3%) had >=1 episode of allograft rejection and 21 (22.3%) had allograft failure. 11 (9.4%) were re-infected with COVID-19 at a median of 603 (389-642) days following initial infection, of whom 2 (18.2%) were hospitalized and 0 died. 43 (45.7%) had secondary infections and 18 (19.1%) with multi-drug resistant organisms. 32 (34.0%) developed new chronic kidney disease or end-stage renal disease, 25 (26.6%) had new cardiovascular disease, and 8 (8.51%) had a prolonged oxygen requirement following infection. Of reported long-COVID symptoms, fatigue (26, 27.7%), dyspnea (18, 19.1%), and cough (11, 11.7%) predominated with 25 (26.6%) having >1 symptom. Conclusion. In this large cohort of SOT recipients hospitalized during the first wave of the COVID-19 pandemic, long-term 2-year follow-up showed high rates of mortality, allograft rejection, allograft failure, secondary infection, organ dysfunction, and symptoms consistent with long-COVID. Ongoing study of the impact of these complications will be crucial to improving outcomes in SOT recipients. (Figure Presented).
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Background. COVID-19 disease became a global health care crisis and was declared pandemic by WHO in March 2020. Little is known how the immunosuppressive medications impact the mortality rate in Solid Organ Transplant (SOT) recipients. There is also minimal data regarding the incidence of transplanted graft failure or rejection that could be attributed to the COVID-19 infection itself or its complications and management. Our study aims to investigate the management of COVID-19 infection, outcome of the infection, transplant failure and rejection rates in SOT recipients. Methods. We conducted a retrospective cohort study of all consecutive SOT recipients who were admitted to our transplant center from March 2020 to April 2021 with COVID-19 infection. Data was collected from the electronic medical records after receiving Institutional Review Board approval. Results. A total of 135 patients met the inclusion criteria. After the diagnosis of COVID -19 infection, 31% recipients had decrease in the dose of immunosuppressive medications (change group) and 69% had no changes in the dose (no change group). Out of the 73 Kidney Transplant recipients 33% were in the change group compared to 14% of liver, 25% of heart and 27% of lung transplant recipients. Of the total 42 recipients in the change group, 28.6% required Intensive Care Unit (ICU) level care significantly higher compared to 7.5% in the no change group (p-value < 0.005). Mechanical ventilation was required in 14.3% of the patients in the change group and 6.5% in the no change group (p-value < 0.5). Out of the total, 85.7% patients in the change group survived compared to 94.6% in the no change group (p-value < 0.1). Overall, the transplant rejection rate was higher in the change group compared to the no change group (p-value < 0.5). Conclusion. Our study showed a significantly higher ICU admission rate and mortality in SOT recipients who had their immune suppression reduced at the time of COVID-19 diagnosis. The same group also had a higher risk of rejection of transplanted graft. More studies with larger sample size needs to be done to further understand the management of immunosuppressive drugs in the SOT recipients with COIVD-19 infection.
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Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection has extremely impacted the transplant population. Remdesivir (RemD) has shown some promising results in coronavirus disease (COVID-19) pandemic though with low certitude. Literature in kidney transplant recipients (KTR) were still lacking at the time of ongoing pandemic situation. Method(s): This was a retrospective cohort of 52 moderate to severe COVID-19 positive KTR in a single center who received RemD as a part of COVID-19 management. No dose adjustments were done. The outcomes were measured as acute kidney injury (AKI) recovery;liver function tests abnormalities, other side effects;graft loss and allcause mortality. Result(s): The median (inter-quartile range) age of presentation was 47 (25-56) years. The duration from onset of symptoms to RemD initiation was 5 (4-9) days. Thirty seven (71.2%) cases received RemD on the day of admission. Thirty-nine (75%) cases were on oxygen support upon initiation of RemD. Thirty-two (61.5%) cases had acute kidney injury on admission. The median baseline, admission, and 28-day follow-up serum creatinine of the cohort were 1.5 (1.1-2.0), 2.4 (1.4-3.2), and 1.6 (1.04-2.2) mg/dl, respectively. A total of 12(23%) cases died in the study with 1 (1.9%) graft loss. All those cases that died were on oxygen therapy at the time of initiation of RemD. No significant liver dysfunction or any other major adverse events with the drug were observed. Conclusion(s): RemD therapy is safe and clinically feasible in renal allograft recipients as seen in our cohort. Larger randomized clinical trials should be conducted to further explore the efficacy in renal allograft recipients.
ABSTRACT
Background: The Organ Procurement and Transplantation Network requires documentation of SARS-CoV-2 (COVID) testing status for each potential donor and lower respiratory specimen testing with nucleic acid tests for all donor lungs. In the absence of guidelines for the use of COVID-positive donor kidneys, we sought to examine the clinical characteristics of COVID-positive donors and trends in the utilization of COVID-positive donor kidneys. Method(s): This study used Scientific Registry of Transplant Recipients data and included all deceased donors (n=24,940) and recipients (n= 29,478) from June 1, 2020, through April 2, 2022. Variation in donor and recipient characteristics were considered significant at P<.05. Result(s): 1,310 (5.35%) of donors during the observation period had a positive test for COVID-19 with 1,731 (67.70%) kidneys transplanted, 108 (4.22%) not recovered, and 714 (27.92%) recovered but not transplanted. COVID-positive donors differed from COVID-negative or untested donors in terms of race, ethnicity, cause of death, and donation after circulatory death status (all P < .05). 813 recipients (2.76%) received COVID-positive deceased donor kidneys. Recipients of COVID-positive donor kidneys were more likely to be White, not have received a previous transplant, and had greater cold ischemic times (all P < .05). The number of transplants with COVID-positive donors peaked in early 2022 (Figure 1). Adjusted hazard ratios for all-cause graft failure with COVID-positive donors and death were 0.89 (95% CI, 0.62-1.28) and 0.87 (95% CI, 0.52-1.46), respectively. Conclusion(s): Transplant with COVID-positive donor kidneys increased during the study period and is not associated with increased risks for recipients. However, high discard rates for COVID-positive donors and greater cold ischemic times may suggest that such donor kidneys remain difficult to place. Patient- and transplant program-level interventions targeting decision support and risk aversion may be necessary to reduce discard rates for COVID-positive donor kidneys. (Figure Presented).
ABSTRACT
Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, on KTR remains unknown. We aimed to determine the impact of COVID-19 illness on kidney graft function including graft loss and characterize Long COVID (LC) symptoms in KTR. Method(s): Clinical data were extracted from an established registry of KTR diagnosed with COVID-19 between February 2020 to April 2022. A LC symptom questionnaire was developed and distributed. KTR that self-reported COVID-19 associated symptoms >=2 months were considered to have Long COVID (LC). Result(s): Of the 121 post COVID-19 KTR, 15 (12%) developed graft dysfunction defined as an increase in serum creatinine >0.3 mg/dL. Characteristics of KTR stratified as with and without graft dysfunction are shown in Table 1. Urine albumin/creatinine ratio was higher in the group with dysfunction and 2 (1.6%) KTR lost their allografts as well. Four (18%) reported LC symptoms and the frequency of LC symptoms among the first 22 questionnaire respondents are shown in Figure 1. Conclusion(s): Both allograft injury and LC symptoms are frequent among KTR. Identification of risk factors for long-term complications post COVID-19 and development of mechanism-based interventions may mitigate post COVID-19 sequalae in KTR.
ABSTRACT
Background: We recently reported that in United States, 388 organs from SARSCoV- 2 nucleic acid test (NAT) positive 150 donors were procured between Aug 2020 to Sep 2021. Nearly 1 million deaths have been attributed to SARS-CoV-2 pandemic however only selected group of donor organs were assessed for transplantation. Even after procurement, 28% (of 388) organs were discarded. For kidney transplants (KT), commonest reason for relatively high-quality organ discards (35%) was 'exhaustion of wait list', indicating reluctance to accept these organs. Method(s): We investigated potential risk of donor transmission of SARS-CoV-2 by a prospective study including 23 KT recipients with prior SARS-CoV-2 vaccination. Donor serum and pre-implantation kidney biopsy tissue were assessed for detection of SARSCoV- 2 via a validated commercially available real-time reverse transcription polymerase chain reaction (RT-PCR) (threshold 73 copies/mL). All recipients had SARS-CoV-2 RTPCR on plasma and nasopharyngeal swab at Day-7 post-KT. Result(s): A total of 23 KT were performed from 22 SARS-CoV-2 NAT positive donors between Nov 2021 and Feb 2022. All 22-donor serum samples and 23 procurement biopsies were negative for SARS-CoV-2, including those from 8 donors with symptomatic disease. Six (of 22 donors;27%) had death attributable to SARS-CoV-2 complications. Three recipients with asymptomatic donors were diagnosed with clinical SARS-CoV-2 disease at 10, 14, and 23 days post-KT during 4th pandemic surge. Both graft and patient survival rate was 100% at a median 3 month followup. Collation with national 'Organ Procurement and Transplant Network' registry showed that majority of other organs from these donors were not procured [zero pancreata, zero lungs, 11 (50%) livers, 19 (86%) hearts]. Among 42 KT [55% (23/42) performed at our center], 10 transplanted livers, and 3 hearts;no graft loss or death was reported. Conclusion(s): In this single-center study we report an absence of detectable SARSCoV- 2 virus in donor kidney tissue and plasma from SARS-CoV-2 positive donors.and absence of recipient viremia and nasopharyngeal detectable virus immediately after KT indicating a lack of donor transmission. Our results of excellent graft and patient survival favor utilization of SARS-CoV-2 infected donors.
ABSTRACT
Background: Monoclonal antibodies have been the mainstay of treatment of COVID-19 in patients at high-risk of mortality from COVID-19. We aimed to study our experience with monoclonal antibodies (mAb) in kidney transplant recipients with COVID-19 at our center. Method(s): We reviewed 93 of our kidney transplant recipients who were infected with COVID-19 and received mAb treatment. The mAb infusion received was the one active against the variant that was circulating during that period (39 received either bamlanivimab or casirivimab/imdevimab, 41 received sotrovimab and 13 received bebtelovimab). All patients were on standard immunosuppression with tacrolimus and prednisone, and 88% were on mycophenolate prior to COVID-19 diagnosis, which was subsequently reduced or held for at least 2 weeks. Result(s): Of the 93 patients, median age was 54 (IQR 44-64), 44% were male, 42% were Hispanic, 36% were African American. 76% have received deceased donor kidney transplant, 94% had history of hypertension, 47% diabetes mellitus, 18% coronary artery disease. All the patients had mild symptoms without initial hypoxia requiring supplemental O2 and only 5 patients (5.4%) were admitted to the hospital. While 33 patients (35%) were unvaccinated at the time of COVID-19 diagnosis, 60 patients (65%) have received at least 2 doses of COVID vaccination at time of diagnosis and of those 27 patients (29%) have received a third dose. There was only one death (1%) in a patient that was re-hospitalized with severe COVID-19. There was no allograft loss. The rate of re-infection after mAb treatment was 6.5%. There was no serious adverse event related to the mAb infusion. Conclusion(s): Our experience suggests that monoclonal antibodies are a safe therapeutic to reduce the need for COVID-19 related hospitalization in this high-risk kidney transplant population, while one third of those were unvaccinated at the time of COVID-19 diagnosis.