Cystinosis in Pediatric Renal Transplant Recipients: A Case-Control Study From Kuwait.

OBJECTIVES: Cystinosis is the most frequent cause of the inherited renal Fanconi syndrome and is also potentially treatable. In this study, we have reported our single-center experience of the longterm outcomes of kidney transplant in patients with cystinosis. MATERIALS AND METHODS: Pediatric patients with cystinosis (n = 17) were compared with a matched control group without cystinosis (n = 126). The 2 groups were compared with regard to demographic data, posttransplant complications, and graft and patient outcomes. RESULTS: Most patients with cystinosis were male teenagers (52.9%) with comparable mean age (12.4 ± 4.1 vs 14 ± 3.1 years) versus the group without cystinosis. The 2 study groups were comparable with regard to type of dialysis, type of donor, blood group, and pretransplant comorbidities (P > .05). Patients with cystinosis received significantly more potent induction therapy (P < 0.05), but both groups were maintained on comparable immunosuppressive regimens (mostly tacrolimus based) (P > .05). Most grafts in both groups displayed immediate graft function. The percentage of patients with cystinosis with primary graft function was significantly higher than the percentage of those patients without cystinosis who had primary graft function (P = .024); this was associated with a relatively lower baseline creatinine level, although this was not significant (P > .05). Posttransplant complications, especially posttransplant diabetes, cytomegalovirus viremia, or BK nephropathy, were comparable (P > .05). Moreover, patient and graft survival rates were similar in the 2 groups (P > .05). CONCLUSIONS: Under standard immunosuppression, renal transplant and cysteamine therapy were safe with good long-term outcomes in patients with cystinosis. Studies that can include more patients and that have longer follow-up are needed to better understand the nature of this genetic disease and to discover the best treatment options.

Better outcome of COVID-19 positive kidney transplant recipients during the unremitting stage with optimized anticoagulation and immunosuppression.

INTRODUCTION: COVID-19 is an ongoing pandemic with high morbidity and mortality and with a reported high risk of severe disease in kidney transplant recipients (KTR). AIM: We aimed to report the largest number of COVID-19-positive cases in KTR in a single center and to discuss their demographics, management, and evolution. METHODS: We enrolled all the two thousand KTR followed up in our center in Kuwait and collected the data of all COVID-19-positive KTR (104) from the start of the outbreak till the end of July 2020 and have reported the clinical features, management details, and both patient and graft outcomes. RESULTS: Out of the one hundred and four cases reported, most of them were males aged 49.3 ± 14.7 years. Eighty-two of them needed hospitalization, of which thirty-one were managed in the intensive care unit (ICU). Main comorbidities among these patients were hypertension in 64.4%, diabetes in 51%, and ischemic heart disease in 20.2%. Management strategies included anticoagulation in 56.7%, withdrawal of antimetabolites in 54.8%, calcineurin inhibitor (CNI) withdrawal in 33.7%, the addition of antibiotics in 57.7%, Tocilizumab in 8.7%, and antivirals in 16.3%. During a follow-up of 30 days, the reported number of acute kidney injury (AKI) was 28.7%, respiratory failure requiring oxygen therapy 46.2%, and overall mortality rate was 10.6% with hospital mortality of 13.4% including an ICU mortality rate of 35.5%. CONCLUSION: Better outcome of COVID-19-positive KTR in our cohort during this unremitting stage could be due to the younger age of patients and early optimized management of anticoagulation, modification of immunosuppression, and prompt treatment of secondary bacterial infections. Mild cases can successfully be managed at home without any change in immunosuppression.

Screening for BK Viremia/Viruria and the Impact of Management of BK Virus Nephropathy in Renal Transplant Recipients.

OBJECTIVES: The prevalence of BK-induced nephritis in renal transplant recipients is estimated to be 1% to 10%; the rate of graft loss within 1 year is 30% to 65%. We conducted this study to evaluate screening of BK virus in blood and/or urine among renal transplant recipients and to assess the effects of different therapeutic modalities in renal transplant recipients with BK nephropathy. MATERIALS AND METHODS: Kidney transplant recipients were screened at the time of transplant and then at 1, 2, 3, 6, 9, 12, 18, and 24 months posttransplant. Fiftynine patients were diagnosed with BK virus viremia. Patients were divided into 2 groups according to treatment: group 1 (n = 29) received an active treatment and group 2 (n = 30) received minimized immunosuppression. RESULTS: Most patients required graft biopsies to confirm diagnosis (86.2% in group 1 vs 50% in group 2; P = .03). Both groups were comparable regarding demographic data. Initial posttransplant graft function was significantly better in group 1 (P = .017); ultimately, there was no significant difference between both groups regarding graft survival (P= .51). Fifty percent of patients had biopsy-proven acute T-cell-mediated rejection before BK virus-associated nephropathy diagnosis (significantly higher in group 1). Serum creatinine levels were significantly better in group 2 at 3, 4, and 5 years after BK nephropathy (P = .001, .017, and .003, respectively). CONCLUSIONS: The prevalence of BK nephropathy in our renal transplant recipients was 5.9% with a rate of graft loss ranging from 43% to 51%. Regular screening, less intensive immunosuppressive therapy, and early intervention by reduction of immunosuppressive medications are advisable to obtain early diagnosis and to have better outcomes of BK virus-associated nephropathy with antiviral agents.

Pregnancy After Renal Transplant: Single Center Experience From the Middle East in Patients Using Different Calcineurin Inhibitors.

OBJECTIVES: Pregnancy after kidney transplant has a high risk for maternal and fetal complications; however, it can be successful if patients are properly selected. Here, we studied outcomes and complications of pregnancies in kidney transplant recipients who received calcineurin inhibitor-based immunosuppression. MATERIALS AND METHODS: In this case control study, we reviewed patients who became pregnant between 2004 and 2017. For this analysis, each pregnancy was considered an event. We divided pregnancies into 2 groups according to calcineurin inhibitor-based maintenance immunosuppression: group 1 (49 pregnancies) received cyclosporine, and group 2 (33 pregnancies) received tacrolimus. Patients also received steroids and azathioprine. Patients had regular antenatal follow-up at the Hamed Alessa Organ Transplant Center (Kuwait) and in the maternity hospital (monthly until month 7 and then weekly until delivery). RESULTS: Of 750 female kidney transplant recipients within childbearing potential, there were 82 pregnancies (10.9%) in 49 recipients (6.5%). Seventy-eight pregnancies were planned, and 4 pregnancies occurred while women were using contraception. There was 1 triple pregnancy, 5 double, and 76 single pregnancies. Two women had preeclampsia as maternal complication, 2 had uncontrolled hypertension, and 7 developed graft dysfunction. Forty-seven women (57.3%) had caesarean section, and the remaining had vaginal deliveries. Of 89 babies, 86 were viable (1 intrauterine fetal death and 2 abortions). Eight babies were delivered prematurely with low birth weight, and 2 needed incubators. Mean serum creatinine levels were 97.9 ± 24, 109 ± 38, 100 ± 39, 120 ± 46, and 115 ± 57 µmol/L at baseline, first, second, and third trimesters, and postpartum, respectively. Twelve patients showed high panel reactive antibodies but without donor-specific antibodies. CONCLUSIONS: Posttransplant pregnancy can be successful in most renal allograft recipients, but the increased risk of fetal and maternal complications, including low birth weight, spontaneous abortus, and preeclampsia, should be considered.