NON-KIDNEY INFECTIONS ARE CRITICAL FACTORS IN 5-YEAR KIDNEY GRAFT LOSS IN A TRANSPLANT POPULATION AT LOW RISK FOR CARDIOVASCULAR DISEASE

ABSTRACT

Introduction: Kidney transplantation is the World's most common renal replacement therapy (RRT). In under-resourced countries, few transplant patients are elderly or diabetic, and the risk of cardiovascular events is low. Nevertheless, graft survival closely resembles that of living donor transplants in developed countries, where cardiovascular disease (CVD) death is a major cause of graft loss. Methods: This study evaluates kidney transplants performed in the Sulaimania Governate of Iraq from 2015 through 2019 and followed-up through 2021. There were 656 patients. The average age was 39.2 ± 14.0 years, 75% were under 50 years old, 3.5% were ≥ 65 years old, 19.7% were diabetic, and 11.7% had a BMI ≥ 30. All donors were living, and 96% of recipients were first-time transplants. Outcomes consisted of return to HD (RHD) and death with a functional graft (DWFG), and all graft loss (RHD+DWFG). Identified infections were pyelonephritis, PCR+ BK viremia (BKV), biopsy+ BK nephropathy (BKN), PCR+ COVID-19, and non-kidney-deep infections (NK-deep infections), the latter consisting of non-COVID pneumonia, septicemia, gastrointestinal infections, and hepatitis. Logistic regression tested the relationships between clinical characteristics, infections, and graft loss. Results: Graft failure consisted of 53 patients with RHD and 50 with DWFG. Sixty-eight patients died, 41 of infection, 14 of CVD, and 13 of other or undetermined causes. NK-deep infections consisted mainly of bacterial pneumonia and septicemia. Septicemia followed implantation wound infections in 4 patients and intensified immunotherapy for recurrent disease in 3 patients (Table). Pyelonephritis affected 79 patients, and 37 patients had BKV with BKN in five. One pyelonephritis and 3 BKN progressed to dialysis. Two BKN resolved, but both patients DWFG, one of fungal sepsis, and one of CVD. COVID infected 211 patients, with 11 deaths (5.2%), 2 DOD and 9 DWFG. DWFG was attributed to infections in 26 patients (17 NK-deep infections and 9 COVID), CVD in 11 patients, and other causes in 13 patients. NK-deep infections were all fatal and were the most significant variable affecting all graft loss (NK-deep infection, OR=233.1, 30.4-1786.6, p<0.001;age, p=0.85;BMI, p=0.24;diabetes, p=0.16;pyelonephritis, p=0.21;BKV, p=0.38;COVID, p=0.28). [Formula presented] Conclusions: BKN was associated with graft loss in part indirectly by DWFG. COVID was responsible for 18% of DWFG, but it was NK-deep infections causing pneumonia and septicemia that had the most significant influence on graft loss. COVID and NK-deep infections caused 52% of DWFG and exceeded CVD by 2.41. The 5-year rate of graft loss was 18.6%. Currently, this rate does not seem excessive and is probably an unavoidable complication of immunosuppression. The transplantation of older patients with more CVD risk factors will assuredly increase rates of DWFG. No conflict of interest