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1.
J Am Soc Nephrol ; 32(3): 677-685, 2021 03.
Article in English | MEDLINE | ID: covidwho-1496676

ABSTRACT

BACKGROUND: Patients may accrue wait time for kidney transplantation when their eGFR is ≤20 ml/min. However, Black patients have faster progression of their kidney disease compared with White patients, which may lead to disparities in accruable time on the kidney transplant waitlist before dialysis initiation. METHODS: We compared differences in accruable wait time and transplant preparation by CKD-EPI estimating equations in Chronic Renal Insufficiency Cohort participants, on the basis of estimates of kidney function by creatinine (eGFRcr), cystatin C (eGFRcys), or both (eGFRcr-cys). We used Weibull accelerated failure time models to determine the association between race (non-Hispanic Black or non-Hispanic White) and time to ESKD from an eGFR of ≤20 ml/min per 1.73 m2. We then estimated how much higher the eGFR threshold for waitlisting would be required to achieve equity in accruable preemptive wait time for the two groups. RESULTS: By eGFRcr, 444 CRIC participants were eligible for waitlist registration, but the potential time between eGFR ≤20 ml/min per 1.73 m2 and ESKD was 32% shorter for Blacks versus Whites. By eGFRcys, 435 participants were eligible, and Blacks had 35% shorter potential wait time compared with Whites. By the eGFRcr-cys equation, 461 participants were eligible, and Blacks had a 31% shorter potential wait time than Whites. We estimated that registering Blacks on the waitlist as early as an eGFR of 24-25 ml/min per 1.73 m2 might improve racial equity in accruable wait time before ESKD onset. CONCLUSIONS: Policies allowing for waitlist registration at higher GFR levels for Black patients compared with White patients could theoretically attenuate disparities in accruable wait time and improve racial equity in transplant access.


Subject(s)
Glomerular Filtration Rate , Healthcare Disparities , Kidney Transplantation , Racism , Renal Insufficiency, Chronic/physiopathology , Renal Insufficiency, Chronic/surgery , Waiting Lists , African Americans , Aged , Cohort Studies , Disease Progression , Female , Health Policy , Healthcare Disparities/statistics & numerical data , Humans , Kidney Failure, Chronic/physiopathology , Kidney Failure, Chronic/surgery , Male , Middle Aged , Models, Statistical , Racism/statistics & numerical data , Time Factors , United States
2.
Curr Opin Organ Transplant ; 26(5): 531-535, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1349829

ABSTRACT

PURPOSE OF REVIEW: Health disparity in minority populations has been increasingly recognized over the last decade. The COVID-19 pandemic sheds a bright light on this very issue impressing upon the need for more research regarding healthcare in disparate populations. Although kidney transplantation remains the treatment of choice for end-stage renal disease management and longevity of life, access to transplantation remains a critical barrier in minority populations. The literature on disparity in access abounds but remains limited with regards to posttransplantation outcomes. The purpose of this review is to draw attention to existing research and literature in posttransplant outcomes and highlight the overall knowledge gap that persists in postkidney transplant care among disparate populations. RECENT FINDINGS: The current review focuses on important paradigm shifts in the determinants of outcomes in posttransplantation care in minority populations. It emphasizes a departure from immune mediated causes to more salient health inequities and socioeconomic factors contributing to patient and graft survival which require further investigation. SUMMARY: Despite increased awareness of health disparity in minority populations, outcomes data postkidney transplantation remains sparse. Critical to the future of kidney transplantation and improved healthcare coordination in minority populations will be a deeper understanding of contributing socio-economic variables in disparate outcomes.


Subject(s)
Kidney Failure, Chronic , Kidney Transplantation , Minority Groups , COVID-19 , Humans , Kidney Failure, Chronic/surgery , Kidney Transplantation/adverse effects , Pandemics , SARS-CoV-2
4.
BMC Nephrol ; 22(1): 251, 2021 07 06.
Article in English | MEDLINE | ID: covidwho-1298049

ABSTRACT

BACKGROUND: The ongoing coronavirus pandemic has major impacts on both patients and healthcare systems worldwide, thus creating new realities. Patients on maintenance dialysis listed for renal transplantation are a vulnerable subgroup with many comorbidities and recurring contacts with the healthcare system. Due to the COVID-19 pandemic transplant numbers have dropped considerably, further increasing waiting times in this high-risk population. On the other hand, knowledge of the severity of SARS-CoV-2 infection in immunocompromised patients, development and persistence of neutralising antibodies in such patients is just emerging. It is unclear how best to address the dilemma of postponing the life-saving transplantation. CASE PRESENTATION: We present a case report of a successful kidney transplantation only 65 days after the recipient was hospitalized for treatment of COVID-19 pneumonia. In a follow up of 9 months, we observed no signs of recurrent disease and transplant function is excellent. Monitoring SARS-CoV-2 antibody response demonstrates stable IgG levels. CONCLUSION: This reassuring case provides guidance to transplant centers how to proceed with kidney transplantation safely during the pandemic. Careful consideration of risks and benefits of the organ offer, full recovery from COVID-19 symptoms and the presence of a positive SARS-CoV-2 IgG antibody test, qualifies for kidney transplantation.


Subject(s)
Antibodies, Viral/immunology , COVID-19/immunology , Kidney Failure, Chronic/surgery , Kidney Transplantation , Aged , COVID-19/complications , COVID-19 Serological Testing , Female , Graft Rejection/prevention & control , Humans , Immunoglobulin G/immunology , Immunoglobulin M/immunology , Immunosuppressive Agents/therapeutic use , Kidney Failure, Chronic/complications , Renal Dialysis , SARS-CoV-2
5.
Ann Transplant ; 26: e931832, 2021 Jun 04.
Article in English | MEDLINE | ID: covidwho-1262684

ABSTRACT

BACKGROUND Kidney transplant services all over the world were severely impacted by the coronavirus disease 2019 pandemic. The optimum management of kidney transplant recipients with coronavirus disease 2019 remains uncertain. MATERIAL AND METHODS We conducted a multicenter cohort study of kidney transplant recipients with coronavirus disease 2019 infection in Saudi Arabia. Multivariable Cox regression analysis was used to study predictors of graft and patient outcomes at 28 days after coronavirus disease 2019 diagnosis. RESULTS We included 130 kidney transplant recipients, with a mean age of 48.7(±14.4) years. Fifty-nine patients were managed at home with daily follow-up utilizing a dedicated clinic, while 71 (54.6%) required hospital admission. Acute kidney injury occurred in 35 (26.9%) patients. Secondary infections occurred in 38 (29.2%) patients. SARS-CoV-2 antibodies testing was carried out in 84 patients, of whom 70 tested positive for IgG and/or IgM. Fourteen patients died (10.8%). A multivariable Cox regression analysis showed that age, creatinine at presentation, acute kidney injury, and use of azithromycin were significantly associated with worse patient survival. Graft loss was associated with requiring renal replacement therapy and development of secondary infections. CONCLUSIONS Despite kidney transplant recipients with coronavirus disease 2019 infection having higher rate of hospital admission and mortality compared to the general population, a significant number of them can be managed using a telemedicine clinic. Most kidney transplant patients seem to mount an antibody response following coronavirus disease 2019 infection, and it remains to be seen if they will have a similar response to the incoming vaccines.


Subject(s)
COVID-19/complications , COVID-19/therapy , Kidney Failure, Chronic/surgery , Kidney Transplantation , Adult , COVID-19/diagnosis , Cohort Studies , Female , Hospitalization , Humans , Kidney Failure, Chronic/virology , Male , Middle Aged , Renal Replacement Therapy , Saudi Arabia , Telemedicine , Virus Shedding
6.
Clin Transplant ; 35(8): e14292, 2021 08.
Article in English | MEDLINE | ID: covidwho-1249408

ABSTRACT

To predict whether the COVID-19 pandemic and transplant center responses could have resulted in preventable deaths, we analyzed registry information of the US end-stage renal disease (ESRD) patient population awaiting kidney transplantation. Data were from the Organ Procurement and Transplantation Network (OPTN), the US Centers for Disease Control and Prevention, and the United States Renal Data System. Based on 2019 OPTN reports, annualized reduction in kidney transplantation of 25%-100% could result in excess deaths of wait-listed (deceased donor) transplant candidates from 84 to 337 and living donor candidate excess deaths from 35 to 141 (total 119-478 potentially preventable deaths of transplant candidates). Changes in transplant activity due to COVID-19 varied with some centers shutting down while others simply heeded known or suspected pandemic risks. Understanding potential excess mortality for ESRD transplant candidates when circumstances compel curtailment of transplant activity may inform policy and procedural aspects of organ transplant systems allowing ways to best inform patients and families as to potential risks in shuttering organ transplant activity. Considering that more than 700 000 Americans have ESRD with 100 000 awaiting a kidney transplant, our highest annual estimate of 478 excess total deaths from postponing kidney transplantation seems modest.


Subject(s)
COVID-19 , Kidney Failure, Chronic , Tissue and Organ Procurement , Humans , Kidney Failure, Chronic/epidemiology , Kidney Failure, Chronic/surgery , Living Donors , Pandemics , SARS-CoV-2 , United States/epidemiology , Waiting Lists
8.
Transpl Immunol ; 67: 101395, 2021 08.
Article in English | MEDLINE | ID: covidwho-1199110

ABSTRACT

Since its emergence in December 2019 many end-stage renal disease (ESRD) patients have been infected with coronavirus disease 2019 (COVID-19). Herein, we describe the case of an ESRD patient who received a kidney transplant after recovering from COVID-19. We described the clinical course of COVID-19 and kidney transplant management, including the patient's symptoms, laboratory results, computed tomography, and antibody profiles. He recovered well, without complications. Chest computed tomography, PCR, and IgG results indicated no recurrence of COVID-19 during the subsequent two weeks. Therefore, kidney transplantation is feasible in an ESRD patient who has recovered from COVID-19, under a normal immunosuppressive regimen.


Subject(s)
COVID-19/therapy , Immunocompromised Host , Kidney Failure, Chronic/surgery , Kidney Transplantation , Transplant Recipients , Adult , Antiviral Agents/therapeutic use , Glomerulonephritis/surgery , Humans , Immunosuppressive Agents/adverse effects , Immunosuppressive Agents/therapeutic use , Male , SARS-CoV-2
9.
Transplantation ; 105(7): 1423-1432, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1135935

ABSTRACT

BACKGROUND: There is limited current knowledge on feasibility and safety of kidney transplantation in coronavirus disease-19 (COVID-19) survivors. METHODS: We present a retrospective cohort study of 75 kidney transplants in patients who recovered from polymerase chain reaction (PCR)-confirmed COVID-19 performed across 22 transplant centers in India from July 3, 2020, to January 31, 2021. We detail demographics, clinical manifestations, immunosuppression regimen, laboratory findings, treatment, and outcomes. Patients with a previous diagnosis of COVID-19 were accepted after documenting 2 negative severe acute respiratory syndrome coronavirus 2 PCR tests, normal chest imaging with complete resolution of symptom for at least 28 d and significant social distancing for 14 d before surgery. RESULTS: Clinical severity in patients ranged from asymptomatic (n = 17, 22.7%), mild (n = 36.48%), moderate (n = 15.20%), and severe (n = 7.9.3%) disease. Median duration between PCR positive to transplant was 60 d (overall) and increased significantly from asymptomatic, mild, moderate, and severe disease (49, 57, 83, 94 d, P 0.019), respectively. All recipients and donors were asymptomatic with normal creatinine after surgery at a median (interquartile range) follow-up of 81 (56-117) d without any complications relating to surgery or COVID-19. Patient and graft survival was 100%, and acute rejection was reported in 6.6%. CONCLUSIONS: Prospective kidney transplant recipients post-COVID-19 can be considered for transplantation after comprehensive donor and recipient screening before surgery using a combination of clinical, radiologic, and laboratory criteria, careful pretransplant evaluation, and individualized risk-benefit analysis. Further large-scale prospective studies with longer follow-up will better clarify our initial findings. To date, this remains the first and the largest study of kidney transplantation in COVID-19 survivors.


Subject(s)
COVID-19/complications , Kidney Failure, Chronic/surgery , Kidney Transplantation , Adult , Aged , COVID-19/diagnosis , Donor Selection/methods , Female , Follow-Up Studies , Humans , India , Kidney Failure, Chronic/complications , Male , Middle Aged , Patient Selection , Retrospective Studies , Survivors , Treatment Outcome
11.
Transpl Int ; 34(4): 612-621, 2021 04.
Article in English | MEDLINE | ID: covidwho-1066771

ABSTRACT

The COVID-19 pandemic has significantly changed the landscape of kidney transplantation in the United States and worldwide. In addition to adversely impacting allograft and patient survival in postkidney transplant recipients, the current pandemic has affected all aspects of transplant care, including transplant referrals and listing, organ donation rates, organ procurement and shipping, and waitlist mortality. Critical decisions were made during this period by transplant centers and individual transplant physicians taking into consideration patient safety and resource utilization. As countries have begun administering the COVID vaccines, new and important considerations pertinent to our transplant population have arisen. This comprehensive review focuses on the impact of COVID-19 on kidney transplantation rates, mortality, policy decisions, and the clinical management of transplanted patients infected with COVID-19.


Subject(s)
COVID-19 , Health Policy , Kidney Failure, Chronic/surgery , Kidney Transplantation/trends , Perioperative Care/trends , Tissue and Organ Procurement/trends , Waiting Lists/mortality , COVID-19/complications , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19 Vaccines , Europe/epidemiology , Health Care Rationing , Health Services Accessibility/trends , Humans , Kidney Failure, Chronic/complications , Kidney Failure, Chronic/mortality , Kidney Transplantation/methods , Kidney Transplantation/mortality , Pandemics , Perioperative Care/methods , Tissue and Organ Procurement/methods , Tissue and Organ Procurement/organization & administration , United States/epidemiology
12.
Adv Chronic Kidney Dis ; 27(5): 383-389, 2020 09.
Article in English | MEDLINE | ID: covidwho-1019900

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2, has led to the death of hundreds of thousands of people worldwide. If infected, older individuals and those with diabetes, hypertension, cardiovascular disease, and compromised immune systems are at higher risk for unfavorable outcomes. These comorbidities are prevalent in patients with kidney disease, hence the significant burden of COVID-19 on kidney transplant programs. Multiple case series of kidney transplant recipients with COVID-19 have shown increased mortality compared to nontransplant patients. To date, we do not have high-level evidence to inform immunosuppression minimization strategies in infected transplant recipients. Most centers however have adopted early antimetabolite withdrawal in addition to other interventions. This review summarizes the published COVID-19 literature as it relates to outcomes and immunosuppression management in kidney transplant recipients. It also discusses challenges pertaining to pretransplant evaluation and wait-listed patients.


Subject(s)
COVID-19/therapy , Graft Rejection/prevention & control , Immunosuppressive Agents/therapeutic use , Kidney Failure, Chronic/surgery , Kidney Transplantation , Telemedicine , COVID-19/mortality , COVID-19/prevention & control , Cross Infection/prevention & control , Delivery of Health Care/methods , Deprescriptions , Humans , Personal Protective Equipment , Physical Distancing , Preoperative Care , SARS-CoV-2 , Waiting Lists
13.
Am J Kidney Dis ; 77(5): 777-785, 2021 05.
Article in English | MEDLINE | ID: covidwho-1003349

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic required transplant nephrologists, surgeons, and care teams to make decisions about the full spectrum of transplant program operations and clinical practices in the absence of experience or data. Initially, across the country, there was a reduction in kidney transplant procedures and a striking pause in the conduct of living donation and living-donor transplant surgeries. Aspects of candidate evaluation and follow-up rapidly converted to telehealth. Months into the pandemic, much has been learned from experiences worldwide, yet many questions remain. In this Perspective, we reflect on some of the practice decisions made by the transplant community in the initial response to the pandemic and consider lessons learned, including those related to the risks, benefits, and logistical considerations of proceeding with versus delaying deceased-donor transplantation, living donation, and living-donor transplantation during the pandemic. We review the evolution of therapeutic strategies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their use in transplant recipients, current consensus related to immunosuppression management in infected transplant recipients, and emerging information on vaccination against SARS-CoV-2. We share our thoughts on research priorities, discuss the areas in which we are still practicing with uncertainty, and look ahead to the next phase of the pandemic response.


Subject(s)
COVID-19 , Critical Pathways , Kidney Failure, Chronic , Kidney Transplantation/methods , COVID-19/epidemiology , COVID-19/prevention & control , Clinical Decision-Making , Critical Pathways/organization & administration , Critical Pathways/trends , Humans , Infection Control/methods , Kidney Failure, Chronic/epidemiology , Kidney Failure, Chronic/surgery , SARS-CoV-2 , Telemedicine/methods , Time-to-Treatment , Tissue Donors/statistics & numerical data , Transplant Recipients
17.
Transplantation ; 105(1): 115-120, 2021 01 01.
Article in English | MEDLINE | ID: covidwho-990985

ABSTRACT

BACKGROUND: Patients with chronic kidney disease stage 5 and those on immunosuppression are particularly vulnerable and are shielded as per public health strategy. We present our experience of coronavirus disease 2019 (COVID-19) transplant patients in one of the most affected parts of the UK with direct comparison to waitlisted patients. METHODS: A single-center prospective study of symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive waitlisted and transplant patients was undertaken to compare these groups and assess clinical outcomes. RESULTS: A total of 60 consecutive symptomatic SARS-CoV-2 positive patients were identified with 32 active waitlisted patients and 28 functioning renal transplants. Demographics were similar. The incidence of symptomatic COVID-19 in the waitlisted group was 9.9% compared to 1.9% in renal transplant patients (P < 0.001). Immunosuppression did not influence initial symptomology. Fifteen percent of patients in the waitlisted and 32% in the transplant groups died (P = 0.726). Mortality as proportion of total waitlisted (321 patients) and transplant population (1434 patients) of our centre was 1.5% and 0.6% (P < 0.001), respectively. C-reactive protein (CRP) at 48 h and peak CRP were associated with mortality in both groups while quick sequential organ failure assessment score at 48 h (P = 0.036) was associated with mortality for transplant patients. CONCLUSIONS: Incidence of COVID-19 is higher in the waitlisted population but transplant patients have more severe disease, reflected by higher mortality. CRP at 48 h can be used as a predictive tool. In the absence of effective treatments, the current strategy of shielding is arguably the most important factor in protecting patients while resuming transplantation.


Subject(s)
COVID-19/epidemiology , Immunosuppressive Agents/therapeutic use , Kidney Failure, Chronic/surgery , Kidney Transplantation/methods , SARS-CoV-2/genetics , Waiting Lists , Adult , Aged , Comorbidity , Female , Follow-Up Studies , Humans , Immunocompromised Host , Kidney Failure, Chronic/epidemiology , Male , Middle Aged , Pandemics , Prospective Studies , RNA, Viral/analysis , Transplant Recipients
20.
Clin Transplant ; 34(12): e14118, 2020 12.
Article in English | MEDLINE | ID: covidwho-852259

ABSTRACT

Hydroxychloroquine (HCQ) is an antimalarial drug with immunomodulatory effects used to treat systemic lupus erythematosus (SLE) and scleroderma. The antiviral effects of HCQ have raised attention in the context of the COVID-19 pandemic, although safety is controversial. We examined linkages of national transplant registry data with pharmaceutical claims and Medicare billing claims to study HCQ use among Medicare-insured kidney transplant recipients with SLE or scleroderma (2008-2017; N = 1820). We compared three groups based on immunosuppression regimen 7 months-to-1 year post transplant: (a) tacrolimus (Tac) + mycophenolic acid (MPA) + prednisone (Pred) (referent group, 77.7%); (b) Tac + MPA + Pred + HCQ (16.5%); or (c) other immunosuppression + HCQ (5.7%). Compared to the referent group, recipients treated with other immunosuppression + HCQ had a 2-fold increased risk of abnormal ECG or QT prolongation (18.9% vs. 10.7%; aHR,1.12 1.963.42 , p = .02) and ventricular arrhythmias (15.2% vs. 11.4%; aHR,1.00 1.813.29 , p = .05) in the >1-to-3 years post-transplant. Tac + MPA + Pred + HCQ was associated with increased risk of ventricular arrhythmias (13.5% vs. 11.4%; aHR,1.02 1.542.31 , p = .04) and pancytopenia (35.9% vs. 31.4%; aHR,1.03 1.311.68 , p = .03) compared to triple immunosuppression without HCQ. However, HCQ-containing regimens were not associated with an increased risk of death or graft failure. HCQ may be used safely in selected kidney transplant recipients in addition to their maintenance immunosuppression, although attention to arrhythmias is warranted.


Subject(s)
Hydroxychloroquine/therapeutic use , Immunosuppressive Agents/therapeutic use , Kidney Failure, Chronic/surgery , Kidney Transplantation , Lupus Erythematosus, Systemic/drug therapy , Maintenance Chemotherapy/methods , Scleroderma, Systemic/drug therapy , Adolescent , Adult , Aged , Aged, 80 and over , Drug Therapy, Combination , Female , Graft Rejection/prevention & control , Graft Survival , Humans , Information Storage and Retrieval , Insurance, Health , Kidney Failure, Chronic/etiology , Kidney Failure, Chronic/mortality , Lupus Erythematosus, Systemic/complications , Lupus Erythematosus, Systemic/mortality , Male , Middle Aged , Registries , Retrospective Studies , Scleroderma, Systemic/complications , Scleroderma, Systemic/mortality , Treatment Outcome , United States , Young Adult
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