Impact of ABO Compatibility/Incompatibility on the Perioperative Anti-SARS-CoV-2 Immunoglobulin G Levels in 2 Preoperatively Vaccinated Patients Undergoing Kidney Transplant: A Case Report.

Herein, we monitored the perioperative anti-SARS-CoV-2 spike immunoglobulin G titers in patients who were preoperatively vaccinated with 2 doses of a COVID-19 messenger RNA vaccine. Additionally, we compared the clinical settings between ABO-incompatible and ABO-compatible pre-emptive kidney transplant (KTx). Case 1 was of a 45-year-old man who was an ABO-incompatible KTx recipient. Before transplant, his serum antibody titers decreased from 278 U/mL at baseline to 41.9 U/mL after desensitization therapy (84.9% lower) and 54.7 U/mL (80.3% lower) at day 8; it is now maintained at 4.1 U/mL at 6 months posttransplant (98.5% lower). Case 2 was of a 50-year-old man who was an ABO-compatible KTx recipient. His serum antibody titer level decreased from 786 U/mL at baseline to 386 U/mL on day 8 (50.8% lower) and is now maintained at 156 U/mL at 6 months posttransplant (80.1% lower). We suggest that anti-SARS-CoV-2 spike immunoglobulin G titers should be monitored during the perioperative period to determine the optimal timing of COVID-19 vaccine booster doses for the maintenance of protective immunity, particularly in ABO-incompatible KTx recipients who require desensitization therapy.

Evaluation of the Correlation Between Responders and Non-Responders to the Second Coronavirus Disease Vaccination In Kidney Transplant Recipients: A Retrospective Single-Center Cohort Study.

BACKGROUND: The immune response to COVID-19 vaccination in kidney transplant (KTx) recipients is significantly lower than that in healthy controls. We evaluated immune responses after the COVID-19 vaccine and their possible relationship with other cofactors in KTx recipients. METHODS: This retrospective single-center cohort study included 29 KTx recipients 2-8 weeks after receiving 2 doses of the Pfizer-BioNTech SARS-CoV-2 messenger RNA vaccine. Anti-SARS-CoV-2 spike (S) immunoglobulin (Ig)-G levels were evaluated to define cofactors influencing the immune response between the responder (anti-SARS-CoV-2 IgG level ≥0.8 U/mL) (n = 16) and nonresponder groups (anti-SARS-CoV-2 IgG level <0.8 U/mL) (n = 13). The kinetics of antibodies between 2 and 6 months after the second vaccination was also compared between the groups. RESULTS: KTx recipients with IgG levels ≥0.8 U/mL were younger (54 [interquartile range {IQR}, 46.5-61] years vs 65 [IQR, 55-71.5] years; P = .01), had been transplanted for a longer median time (1588 [IQR, 1382-4751] days vs 1034 [IQR, 548.5-1833] days; P = .02), and were more often treated with a lower mycophenolate mofetil dosage (765.6 ± 119.6 vs 1077 ± 76.9 mg; P = .04) than KTx recipients with IgG levels <0.8 U/mL. There was no significant difference in antibody titers between time periods after the second dose in the responder group. At the 6-month follow-up, a serologic response against the SARS-CoV-2 S was observed in 44.4% of KTx recipients in the nonresponder group. CONCLUSIONS: More than 50% of KTx recipients developed a higher antibody response after the second dose of COVID-19 vaccination.

Comparison of antibody response following the second dose of SARS-CoV-2 mRNA vaccine in elderly patients with late-stage chronic kidney disease.

Background: Currently, it is unclear whether the progression of chronic kidney disease (CKD) could be an independent predictor of antibody response after administration of a COVID-19 vaccine. This study aimed to investigate the immune response to COVID-19 vaccination in patients with CKD stage G4 to G5 without renal replacement therapy and G5D using the recommended dose and schedule. Methods: This retrospective single-center cohort study evaluated immunogenicity regarding antibody response after COVID-19 vaccination in our hospital for late-stage CKD patients aged ≥ 60 years. We evaluated antibody responses in 48 patients with CKD G4, 35 patients with CKD G5, and 70 patients undergoing hemodialysis (HD; CKD G5D). Results: After the second vaccination, anti-SARS-CoV-2-S (Spike) IgG levels were found to be positive (> 0.8 U/mL) in all CKD G4 and G5 patients (100%), and 69 of 70 HD patients (98.5%). The median (interquartile range [IQR] S-IgG level (Ab titers) was 358 [130.2-639.2], 218 [117-377], and 185.5 [95.1-323.5] U/mL in the CKD G4, G5, and HD groups, respectively. The median S-IgG levels were significantly lower in the HD group than in the CKD G4 group (p < 0.01). However, there was no significant difference in the antibody titers between the CKD G4 and G5 groups. To further analyze the decline in S-IgG levels after 6 months, we additionally assessed and compared antibody titers at 1 month and 6 months after the second vaccination in the HD group. Compared with the median S-IgG levels of 185.5 [95.1-323.5] U/mL 1 month after the second dose, the median S-IgG level 6 months thereafter was significantly decreased at 97.4 [62.5-205.5] U/mL (p < 0.05). Conclusions: We highlight two major factors of variability in the vaccine response. First, in elderly patients with late-stage CKD, antibody titers tended to be lower in the G5D group than in the G4 and G5 groups despite the shorter time since vaccination; therefore, CKD stage progression might cause a decline in antibody titers. Second, waning immune responses were observed 6 months after second dose administration in HD patients advocating a potential need for a third booster dose vaccine after 6 months.

Early Steroid Withdrawal Protocol With Basiliximab and Rituximab in ABO-Incompatible Kidney Transplant Recipients.

OBJECTIVES: Corticosteroids remain an important component of immunosuppressive regimens in high-risk kidney transplants. In this study, we investigated the efficacy of early steroid withdrawal with basiliximab and rituximab in ABO-blood type incompatible (ABO-i) recipients of kidney transplants. METHODS: Between 2008 and 2019, 15 patients underwent ABO-i kidney transplantation. Seven of the 15 patients were treated with a steroid maintenance protocol and the remaining 8 with an early steroid withdrawal protocol. The immunosuppressive protocol consisted of tacrolimus, mycophenolate mofetil, and methylprednisolone (MP), with basiliximab administered as induction therapy. Rituximab was administered as a single 200-mg dose 1 to 4 weeks before kidney transplantation. Two to 4 sessions of either double-filtration plasmapheresis or regular plasmapheresis or both were performed to remove anti-AB antibodies before transplantation. During surgery, MP was administered at a dose of 500 mg; thereafter, the dosage was tapered rapidly, and the drug was discontinued on day 14 post transplant. RESULTS: In the steroid maintenance group, 2 patients experienced acute antibody-mediated rejection (AMR). One patient with severe AMR had graft loss on postoperative day 4. Patient and graft survival rates in the steroid maintenance group were 100% and 86%, respectively. MP was successfully withdrawn in the steroid withdrawal group. In this group, there was no biopsy-proven rejection. Patient and graft survival rates were 100%, and when last measured, serum creatinine level ± SD was 1.6 ± 0.8 mg/dL. CONCLUSIONS: Our protocol successfully enabled the early withdrawal of steroids in recipients of ABO-i grafts; however, further follow-up is necessary to confirm our results.

Successful cadaveric kidney transplantation in an extended-hours hemodialysis patient with long-term hemodialysis vintage for 297 months.

The patient was a 41-year-old male who had been maintained on extended-hours hemodialysis for 297 months. Despite of long-term hemodialysis vintage, he had no vascular calcification and ectopic calcification. His kidney graft did not experience rejection or other complications 18 months after the cadaveric kidney transplant. Previous reports indicated that graft survival of extended-hours hemodialysis patients did not differ from conventional hemodialysis. However, the dialysis periods in these reports were much shorter than our case. Therefore, extended-hours hemodialysis in long-term dialysis patients may improve renal transplant outcomes in the countries where the waiting time for kidney transplant is long.

High low-density lipoprotein cholesterol level is the independent risk factor of primary patency rate of arteriovenous fistula.

OBJECTIVES: An arteriovenous fistula is the first choice of vascular access in dialysis patients. However, the correlations between patient factors and the arteriovenous fistula patency rate remain unclear. Therefore, we examined the effect of dialysis patient factors on arteriovenous fistula patency rate. METHODS: This study included 101 patients who received maintenance dialysis and used arteriovenous fistula for vascular access at Atami Hospital, International University of Health and Welfare in July 2018. A retrospective review was performed from the time of arteriovenous fistula creation to July 2018, and the primary and secondary arteriovenous fistula patency rates were investigated. The patency rate was calculated using the Kaplan-Meier method, and risk factor analysis was performed using Cox proportional hazards regression analysis. RESULTS: The primary patency rate of arteriovenous fistula was 71.2% at one year and 43.0% at five years, and the secondary patency rate was 92.7% at one year and 79.8% at five years. In the multivariate analysis, high low-density lipoprotein cholesterol (LDL-C) level and a history of diabetes were considered significant risk factors (HR 1.023, p value <0.01 and HR 2.550, p value <0.01, respectively). A log rank test was conducted on the groups of patients with LDL <90 mg/dl and LDL ≥90 mg/dl, and the <90 mg/dl group resulted in a good primary patency rate (p value 0.0327). CONCLUSIONS: High LDL-C level was considered the independent risk factors of arteriovenous fistula primary patency rate.

Low-dose In Situ Perfusion With Euro-Collins Solution Is Effective for the Procurement of Marginal Kidney Grafts From Donation After Circulatory Death Donors.

We have adopted a modified method to resuscitate kidneys from donation after circulatory death (DCD) donors with the use of Euro-Collins (EC) solution instead of University of Wisconsin solution. This study aimed to evaluate kidney transplantation (KTx) outcomes of DCD procured with low-dose in situ perfusion using EC solution. PATIENTS AND METHODS: KTx was performed in 8 adults. Kidney grafts were procured following in situ perfusion with approximately 1 L of EC solution and preserved in the solution. The kidney donor profile index value was 88% ± 21%. The terminal creatinine level of the donors was 5.5 ± 3.4 mg/dL. Of the 8 donors, 6 experienced oligoanuria prior to graft procurement. RESULTS: The mean age of the recipients and the hemodialysis vintage were 50 ± 10 years and 161 ± 25 months, respectively. The warm and cold ischemic times were 8.3 ± 7.9 minutes and 8.7 ± 4.3 hours, respectively. All grafts functioned after a delayed graft function of 10.6 ± 6.9 days (2-25 days). There was neither immediate graft function nor primary nonfunction. The patient and graft survivals were both 100% with a terminal creatinine level of 1.3 ± .5 mg/dL. CONCLUSIONS: Kidney grafts procured from DCD donors with a high kidney donor profile index value demonstrated good renal function with an excellent midterm outcome. Low-dose in situ perfusion with EC solution is effective for the procurement of marginal kidney grafts from DCD donors under optimal conditions such as a relatively shorter preservation time.

Thrombotic microangiopathy caused by oral contraceptives in a kidney transplant recipient.

Thrombotic microangiopathy (TMA) after kidney transplantation has various aetiologies, including acute antibody-mediated rejection, bacterial or viral infection and immunosuppressive drugs, particularly calcineurin inhibitors. We present the case of a 28-year-old woman who developed TMA 30 months after the transplantation of an ABO-incompatible kidney from a living unrelated donor. The patient developed a sudden onset of allograft renal dysfunction and became uremic. She was transferred to our institution from a community hospital with strongly suspected acute allograft rejection. Intensive treatments for both T- and B-cell mediated acute rejection, including steroid pulse therapy, double-filtration plasmapheresis, antithymocyte globulin (1.5 mg/kg × 14 days) and rituximab (100 mg), were initiated during haemodialysis. However, her renal allograft function did not improve. Histopathological analysis 8 days after the treatment indicated TMA, despite the absence of apparent acute T-cell- or acute antibody-mediated rejection. There were no symptoms of infectious diseases, such as intestinal haemorrhagic colitis or viral infection. We concluded that the use of oral contraceptives, which had been initiated 3 weeks before TMA onset for the treatment of irregular vaginal bleeding, was the aetiologic agent.