Complications of total joint arthroplasty in solid organ transplant patients versus a large control group

BackgroundSolid organ transplant patients are theoretically at increased risk for complications after total joint replacement due to immunosuppressive medication regimens and multiple medical co-morbidities. There are a number of studies that report on outcomes of total joint arthroplasty (TJA) following solid organ transplant, however, the results are heterogeneous. This study evaluated the outcomes of TJA in solid organ transplant patients as compared to non-organ transplant controls at one academic medical center.MethodsThis study was a single institution retrospective review of a consecutive series of patients who underwent joint replacement following solid organ transplant as compared to a control cohort over a 10-year period. Univariable and multivariable generalized linear mixed effects models were used to compare the odds of readmission, infection, mortality, and being discharged home between transplanted (cases) and non-transplanted (control) patients.ResultsTransplant and non-transplant cohorts had similar BMI, although transplant patients were younger (61 versus 65 years) and had a higher incidence of Diabetes (55% vs. 16%). On multivariable analysis, there was no difference in the odds of re-admission or rate of infection, but there was an increased risk of death and admission to a rehab facility in the transplant cohort.ConclusionOverall, this study demonstrates that solid organ transplant alone does not increase the risk of peri-operative complications in patients who underwent hip and knee replacement. However, it should be expected that these patients have a higher mortality rate and that many of them will need to be discharged to a post-acute care facility.     

The antibody response to pandemic H1N1 2009 influenza vaccine in adult organ transplant patients

Limited data are available regarding antibody response and the safety of the monovalent influenza A H1N1/09 vaccine for immunocompromised patients. In this study, the humoral response to this vaccine in solid organ transplant (SOT) recipients and healthy individuals was evaluated. Eighty‐two SOT recipients and 28 healthy individuals received two doses of the influenza A H1N1/09 AS03 adjuvanted vaccine containing 3.75 mg of haemagglutinin at a 3‐ to 4‐week interval. Serum samples were drawn at baseline and 3–4 weeks after the first and second vaccine doses. Seroprotective titres were measured with a haemagglutination inhibition. After the first dose seroprotective titres were observed in 69% of the SOT patients and in 96% of the healthy controls (P = 0.006), and increased after the second dose to 80% and 100%, respectively (P = 0.003). All controls and 77% of the SOT recipients achieved a ≥4‐fold titre rise after the first immunisation (P = 0.005). The vaccine was well tolerated and no acute rejection was observed. Influenza A H1N1/09 vaccine elicited a protective antibody response in the majority of SOT recipients, but the response was lower when compared with controls. A second dose significantly improved vaccine immunogenicity in SOT recipients. (ClinicalTrials.gov number: NCT01254955)     

Patterns of emergency department utilization between transplant and non-transplant centers and impact on clinical outcomes in kidney recipients

There is a high rate of Emergency Department (ED) utilization in kidney recipients post-transplant; ED visits are associated with readmission rates and lower survival rates. However, utilization within and outside transplant centers may lead to different outcomes. The objective was to analyze ED utilization patterns at transplant and non-transplant centers as well as common etiologies of ED visits and correlation with hospitalization, graft, and patient outcomes. This was a longitudinal, retrospective, single-center cohort study in kidney transplant recipients evaluating ED utilization. Comparator groups were determined by ED location, time from transplant, and disposition/readmission from ED visit. 1,106 kidney recipients were included in the study. ED utilization dropped at the transplant center after the 1st year (P < .001), while remaining at a similar rate at non-transplant centers (0.22 vs 1.06 VPPY). Infection and allograft complications were the most common causes of ED visits. In multivariable Cox modeling, an ED visit due to allograft complication at a non-transplant center >1 year post-transplant was associated with higher risk for graft loss and death (aHR 2.93 and aHR 1.75, P < .0001). The results of this study demonstrate an increased risk of graft loss among patients who utilize non-transplant center emergency departments. Improved communication and coordination between transplant centers and non-transplant centers may contribute to better long-term outcomes.     

Postexposure Prophylaxis of H1N1 With Oseltamivir in a Newly Transplanted Kidney Recipient Receiving Intense Immunosuppressive Therapy

Solid organ transplant recipients undergoing immunosuppressive therapy are considered to be at high risk for serious infectious complications. Recently in the United States, a pandemic of H1N1 flu infection has been reported with serious complications. We describe H1N1 infection in a living kidney donor and the 42-year-old kidney transplant recipient exposed to this kidney donor and undergoing intense immunosuppressive therapy. Postexposure prophylaxis with oseltamivir was effective to prevent H1N1 influenza A virus in a donor and a recipient.     

The Impact of Solid Organ Transplant History on Inpatient Complications,Mortality, Length of Stay,and Cost for Primary Total Hip Arthroplasty Admissions in the United States

Background

As the prevalence of and life expectancy after solid organ transplantation increases, some of these patients will require total hip arthroplasty (THA). Immunosuppressive therapy, metabolic disorders, and post-transplant medications may place transplant patients at higher risk of adverse events following surgery. The objective of this study was to compare inpatient complications, mortality, length of stay (LOS), and costs for THA patients with and without solid organ transplant history.

Use of sodium-glucose co-transporter 2 inhibitors in solid organ transplant recipients with pre-existing type 2 or post-transplantation diabetes mellitus: A systematic review

IntroductionSodium-Glucose Co-Transporter 2 (SGLT2) inhibitors have demonstrated kidney, cardiovascular and mortality benefits in the general population; however, the evidence is limited in solid organ transplant recipients. The aim of this systematic review was to evaluate the current efficacy and safety data of SGLT2 inhibitors in adult kidney, heart, lung, and liver transplant recipients with pre-existing type 2 or post-transplantation diabetes mellitus.MethodWe searched MEDLINE, MEDLINE Epub, CENTRAL, CDSR, EMBASE, CINAHL, and sources of unpublished literature. All primary interventional and observational studies on SGLT2 inhibitors in transplant recipients were included. Clinical outcomes included mortality, cardiovascular and kidney events, and adverse events such as graft rejection. Surrogate markers including hemoglobin A1c (HbA1c) and weight reduction were also evaluated.ResultsOf the 17 studies that were included in this systematic review, there were 15 studies on kidney transplant recipients (n = 2417 patients) and two studies on heart transplant recipients (n = 122 patients). There was only one randomized controlled trial which evaluated 49 kidney transplant patients over 24 weeks. Overall, studies were heterogeneous in study design, sample size, duration of diabetes, time to SGLT2 inhibitor initiation post-transplantation (ranging from 0.88 to 11 years post kidney transplant; five to 5.7 years post heart transplant) and follow-up (ranging from 0.4 to 5.25 years in kidney transplant patients; 0.75 to one year in heart transplant patients). Only one retrospective study evaluated mortality as a part of a composite outcome in kidney transplant patients; however, study limitations restrict generalizability of results. Overall, studies could not confirm clinical cardiovascular and kidney benefits in the transplant population. Findings suggested that SGLT2 inhibitors may improve glycemic control; however, they are associated with urinary tract infection. Diabetic ketoacidosis and acute kidney injury also occurred in these studies, with precipitating factors such as infection and acute heart failure exacerbation.ConclusionsWhile SGLT2 inhibitors are promising agents with expanding indications in the non-transplant population, these agents may not be suitable for all solid organ transplant recipients, and close monitoring (e.g. for urinary tract infections) and patient education (e.g. sick day management) are essential if these agents are initiated. Evidence is based on short-term findings and suggests an association with hemoglobin A1c reduction and increased adverse events. Further long-term randomized controlled trials are needed to evaluate the effect of SGLT2 inhibitors on clinically important outcomes, including mortality reduction, in solid organ transplant recipients.     

De Novo Anti‐HLA Antibody After Pandemic H1N1 and Seasonal Influenza Immunization in Kidney Transplant Recipients

In solid organ transplanted patients, annual influenza immunization is strongly recommended because of morbidity and mortality of influenza infections. In 2009, the rapid spread of a novel H1N1 influenza A virus led to the accelerated development of novel pandemic influenza vaccines. In Switzerland, the recipients received one dose of seasonal influenza and two doses of AS03‐adjuvanted H1N1 vaccines. This situation provided a unique opportunity to analyze the influence of novel adjuvanted influenza vaccines on the production of de novo anti‐HLA antibodies. We prospectively followed two independent cohorts including 92 and 59 kidney‐transplanted patients, assessing their anti‐HLA antibodies before, 6 weeks and 6 months after vaccination. Sixteen of 92 (17.3%) and 7 of 59 (11.9%) patients developed anti‐HLA antibodies. These antibodies, detected using the single antigen beads technology, were mostly at low levels and included both donor‐specific and non‐donor‐specific antibodies. In 2 of the 20 patients who were followed at 6 months, clinical events possibly related to de novo anti‐HLA antibodies were observed. In conclusion, multiple doses of influenza vaccine may lead to the production of anti‐HLA antibodies in a significant proportion of kidney transplant recipients. The long‐term clinical significance of these results remains to be addressed.     

H1N1 vaccination in pediatric renal transplant patients

Background

Solid organ transplant recipients undergoing immunosuppressive therapy are considered to be at high risk of serious infectious complications. In 2009, a new influenza pandemic caused serious infections and deaths, especially among children and immunocompromised patients. Herein we have reported the safety and efficacy of a single-shot monovalent whole-virus vaccine against H1N1 infection in the pediatric renal transplant population.

Methods

In November and December 2009, we vaccinated 37 renal transplant children and adolescents and measured their antibody responses. Seroprotection, seroconversion, and seroconversion factors were analyzed at 21 days after vaccination.

Results

None of the vaccinated patients experienced vaccine-related side effects. None of the patients had an H1N1 influenza infection after vaccination. All of the patients showed elevations in antibody titer at 21 days after vaccination. In contrast, only 29.72% of the patients achieved a safe seroprotection level and only 18.75% a safe seroconversion rate. More intense immunosuppressive treatment displayed negative effect on seroprotection and seroconversion, and antibody production significantly increased with age. No other factor was observed to influence seroprotection.

Conclusions

We recommend vaccination of children and adolescent renal transplant recipients against H1N1 virus. However, a single shot of vaccine may not be sufficient; to achieve seroprotection, a booster vaccination and measurement of the antibody response are needed to assure protection of our patients.     

Hospital‐Onset Clostridium difficile Infection Among Solid Organ Transplant Recipients

Clostridium difficile infection (CDI) is a considerable health issue in the United States and represents the most common healthcare‐associated infection. Solid organ transplant recipients are at increased risk of CDI, which can affect both graft and patient survival. However, little is known about the impact of CDI on health services utilization posttransplantation. We examined hospital‐onset CDI from 2012 to 2014 among transplant recipients in the University HealthSystem Consortium, which includes academic medical center–affiliated hospitals in the United States. Infection was five times more common among transplant recipients than among general medicine inpatients (209 vs 40 per 10 000 discharges), and factors associated with CDI among transplant recipients included transplant type, risk of mortality, comorbidities, and inpatient complications. Institutional risk‐standardized CDI varied more than 3‐fold across high‐volume hospitals (infection ratio 0.54–1.82, median 1.04, interquartile range 0.78–1.28). CDI was associated with increased 30‐day readmission, transplant organ complications, cytomegalovirus infection, inpatient costs, and lengths of stay. Total observed inpatient days and direct costs for those with CDI were substantially higher than risk‐standardized expected values (40 094 vs 22 843 days, costs $198 728 368 vs $154 020 528). Further efforts to detect, prevent, and manage CDI among solid organ transplant recipients are warranted.     

Acute appendicitis after solid organ transplantation

Appendicitis has rarely been reported following solid organ transplantation and never following liver transplantation. We reviewed records of all patients who received solid organ transplants at UCLA between 1989 and 2002 and subsequently underwent appendectomy for presumed acute appendicitis. Of nearly 8000 transplant patients, 17 (nine male, eight female) subsequently underwent appendectomy for presumed acute appendicitis. Average age at appendectomy was 37 yrs (range 6-73 yrs). Organ transplants included liver (seven patients), heart (four), kidney (three), kidney-pancreas (two), and heart-kidney (one). The mean interval from transplant to appendectomy was 1064 d (16-2977). Presenting symptoms and signs included abdominal pain in 16 patients (94%); nausea and or vomiting in 15 (88%); right lower quadrant tenderness in 16; and leukocytosis (WBC > 10 000) in 13 (76%). Mean interval from presentation to appendectomy was 0.94 d (range 0-4). Computed tomography (CT) was performed in 16 patients and showed signs of acute appendicitis in 15. Open technique was used in all patients, preceded by laparoscopy in one. Pathology showed appendicitis in 15 patients (one with perforation), serositis in one, and a normal appendix in one. Mean duration of hospitalization was 7 d (range 1-20). Complications occurred in four patients (24%) and included intra-abdominal abscess requiring percutaneous drainage, ventral hernia, small bowel obstruction, and hematuria in one patient each. There were no deaths and no cases of acute rejection during hospitalization. Average length of follow-up was 712 d (range 3-2492). We conclude that appendicitis is relatively rare following solid organ transplantation. CT facilitates prompt diagnosis. The clinical presentation is similar to that of non-transplant patients, but complications are more frequent, and hospitalization is longer.     

Complications of Systemic Retinoid Therapy in Organ Transplant Recipients With Squamous Cell Carcinoma

Background. Organ transplant recipients receiving immunosuppressive medications are at increased risk of cutaneous malignancies.
Objective. We sought to determine the complications associated with systemic retinoid therapy in severely affected organ transplant recipients receiving treatment before or during the course of metastatic squamous cell carcinoma.
Methods. This was a collaborative retrospective study of solid organ transplant recipients treated with systemic retinoids for severe squamous cell carcinoma, with subjective analysis of complications associated with treatment.
Results. Complications and intolerance of systemic retinoid therapy were common, necessitating discontinuation of therapy in six of eight cases.
Conclusion. This subset of transplant patients, severely affected by skin cancer, appeared to be less able to tolerate systemic retinoid therapy than patients in formal clinical trials. Intolerance of adverse effects in this context suggests the need for novel approaches with these challenging patients.     

The Impact of Pandemic Influenza A H1N1 2009 on Australian Lung Transplant Recipients

Influenza A H1N1 2009 led to 189 deaths during the Australian pandemic. Community‐acquired respiratory viruses not only can cause prolonged allograft dysfunction in lung transplant recipients but have also been linked to bronchiolitis obliterans syndrome (BOS). We report the impact of the 2009 H1N1 pandemic on Australian lung transplant recipients. An observational study of confirmed H1N1 cases was conducted across five Australian lung transplant programs during the pandemic. An electronic database collected patient demographics, clinical presentation, management and outcomes up to a year follow‐up. Twenty‐four H1N1 cases (mean age 43 ± 14 years, eight females) were identified, incidence of 3%. Illness severity varied from upper respiratory tract symptoms only in 29% to lung allograft dysfunction (≥10% decline FEV1) in 75% to death in 5 (21%) cases (pre‐existing BOS grade 3, n = 4). Treatment with oseltamivir occurred in all but one case confirmed after death, reduced immunosuppression, n = 1, augmented corticosteroid therapy, n = 16, and mechanical/noninvasive ventilation, n = 4. There was BOS grade decline within a year in six cases (32%). In conclusion, Australian lung transplant recipients were variably affected by the H1N1 pandemic mirroring the broader community with significant morbidity and mortality. After initial recovery, a considerable proportion of survivors have demonstrated BOS progression.     

Antibody persistence 1 year after pandemic H1N1 2009 influenza vaccination and immunogenicity of subsequent seasonal influenza vaccine among adult organ transplant patients

We investigated the antibody persistence in solid organ transplant (SOT) recipients 1 year after immunization with two doses of monovalent AS03‐adjuvanted influenza A(H1N1)pdm09 vaccine. We also assessed the boosting effect of the seasonal trivalent inactivated vaccine 2010 (TIV/10) that contained the influenza A(H1N1)pdm09 strain. A total of 49 SOT recipients and 11 healthy controls were included. After a blood sample was obtained to assess the persistent immunity, one dose of TIV/10 was administered and another blood sample was collected 1 month after vaccination. A(H1N1)pdm09 antibodies were measured using a haemagglutination inhibition assay. The percentage of SOT recipients with protective titres decreased between 1 month and 10–14 months after the monovalent influenza A(H1N1)pdm09 vaccination, from 79% (n = 38) to 47% (n = 23) (P = 0.02). The corresponding numbers for the control group were 100% and 63%, respectively (P = 0.008). After the TIV/10 boosting dose, the number of SOT recipients with protective titres increased from 47% (n = 23) to 71% (n = 35) (P = 0.2). All the controls reached a protective titre level. The median titre rise was significantly higher among controls when compared to SOT recipients (P = 0.0036). No rejection or adverse events were seen. The results show an obvious need for vaccine boosting doses in the SOT patients. (ClinicalTrials.gov number: NCT01256931).     

Case Report: Cystic Fibrosis, Lung Transplantation, and the Novel H1N1 Flu

The H1N1 pandemic flu is a significant risk factor for both patients with chronic disease who need organ transplantation and transplant recipients. This population needs special care regarding comorbidities and related complications. MB, a 38-year-old Italian cystic fibrosis male patient with lung and pancreatic involvement, was referred to our division in July 2009 for fever-associated arthromyalgia, headache, and rhinitis. Lung transplantation had been performed in September 2005, and he was subsequently treated with immunosuppressive therapy: tacrolimus, everolimus, and prednisolone. In the past, chronic respiratory colonization with Pseudomonas aeruginosa and intermittent infection with Aspergillus flavus, chronic renal failure, hypertension, and diabetes mellitus complicated his clinical history. He started antiviral treatment with oseltamivir despite no travel history and no respiratory symptoms. H1N1 swab was positive. Three days later, the patient was admitted to the hospital for the persistence of fever and the onset of cough. Chest x-ray showed a left lower pneumonia, which was confirmed by computerized tomography. Broad-spectrum antibiotic therapy led to an improvement of the clinical condition. The patient was discharged 8 days later; a control swab was negative. This case report suggests some general considerations regarding solid organ recipients: 1) Flu-related complications require early treatment (both antiviral and antibiotic); 2) active microbiologic surveillance is important to prevent lethal infections (ie, invasive aspergillosis); 3) evaluation of immunosuppressant blood levels is necessary for drug-drug interactions. Active prevention is the best option for decreasing morbidity and mortality in the transplanted patient.     

The burden of new-onset diabetes mellitus after transplantation

The clinical impact of new-onset diabetes mellitus (NODM) is frequently underestimated by clinicians. NODM occurs in approximately 15-20% of renal transplant patients and 15% of liver transplant recipients. Diabetes after transplantation is a leading risk factor for cardiovascular events, with a higher prognostic value than in the non-transplant population. NODM also appears to have a negative influence on graft function, and graft survival rates after renal transplantation are significantly lower in patients who develop diabetes than in controls. Patient mortality following renal transplantation is generally found to be higher in patients with NODM, due to increased cardiovascular and peripheral vascular disease, accelerated graft deterioration and diabetes-related complications, notably infection. A renal registry analysis has reported an increase of 87% in risk of death following onset of NODM. There is also limited evidence that NODM is associated with increased risk of death in liver transplant patients. The relative incidence and severity of diabetic complications in transplant recipients have not been assessed rigorously in a clinical trial but registry data indicate that 20% of renal transplant patients with NODM experience at least one clinically significant diabetic complication within three years. Financially, the additional healthcare costs incurred over the first two years following onset of NODM amount to 21,500 dollars. Routine pre-transplant assessment of diabetic risk, with requisite modification of lifestyle, glycaemic monitoring and immunosuppressive regimens, and coupled with standardized, aggressive hypoglycaemic management as necessary, offers an important opportunity to alleviate the burden of NODM for transplant patients.     

Impact of solid organ transplantation and immunosuppression on fever, leukocytosis, and physiologic response during bacterial and fungal infections

Immunosuppressed solid organ transplant patients may exhibit a blunted response to infection compared to non-transplant patients. To test this hypothesis, we prospectively identified all episodes of bacterial and fungal infection on the in-patient abdominal organ transplant service in our hospital, in 1997, and compared them to infected general surgery and trauma admissions treated simultaneously on the same wards. Eighty-two infections occurred in transplant patients versus 463 in non-transplant patients. Transplant patients demonstrated an overall greater physiologic response [Acute Physiology and Chronic Health Evaluation (APACHE II) and Acute Physiology Scores (APS) at the time of infection of 17.0+/-0.7 and 10.3+/-0.6, respectively, vs. 12.2+/-0.4 and 8.0+/-0.3 for non-transplant patients, p < 0.003], with a similar maximum temperature (38.0+/-0.1 vs. 38.2+/-0.1 degrees C, p = 0.2) and white blood cell (WBC) count (12.1+/-1.0 vs. 13.9+/-0.4 k/mL, p = 0.08). Upon further analysis of subgroups, patients receiving mycophenolate or azathioprine had significantly lower maximum temperatures (37.9+/-0.2 degrees C) and WBC counts (11.0+/-0.9 k/mL) when compared to non-transplant patients, while steroids appeared to have little effect on the systemic inflammatory response. Overall mortality was similar between groups. In general, solid organ transplant recipients exhibit a physiologic response to bacterial or fungal infection (as measured by the APS) at least as great as that seen in non-transplant surgical patients, although mycophenolate and azathioprine appear to slightly depress the ability to respond with fever and leukocytosis. None of these differences appeared to affect overall mortality.     

Etiology of increased cancer incidence after solid organ transplantation

Over the past decades, there has been an encouraging increase in survival after solid organ transplantation. However, with longer life spans, more transplant recipients are at risk of dying with functioning grafts from illnesses such as cancer and cardiovascular conditions. Malignancy has emerged as an important cause of death in transplant recipients and is expected to become the leading cause of death in transplanted patients within the next decade. While it is known that solid organ transplant recipients have a three to five-fold increased risk of developing cancer compared with the general population, the mechanisms that lead to the observed excess risk in transplant recipients are less clear. This review explores the etiology of the increased cancer incidence in solid organ transplant including the effect of immunosuppressants on immunosurveillance and activation of oncogenic viruses, and carcinogenic effects of these medications; the role of chronic stimulation of the immune system on the development of cancer; and the impact of pre-existing cancer risk factors and factors related to end-stage organ disease on the cancer excess incidence in solid organ transplant recipients.     

Cardiovascular disease risk in patients receiving organ transplantation: a national cohort study

Although organ transplantation is the definitive treatment for end‐stage organ failure, the post‐transplant outcomes can be substantially influenced by cardiovascular complications. A national cohort study was performed to estimate risks of cardiovascular diseases in those with heart, lung, kidney, and liver transplantation. This cohort study consisted of 5978 solid organ transplantations identified using the Taiwan National Health Insurance Database. Cardiovascular and mortality risks in transplant recipients were evaluated using standardized incidence ratios, excess absolute risks, and standardized mortality ratios as compared to those in the general population. In heart, kidney, and liver recipients, the standardized incidence ratios of overall cardiovascular diseases were 9.41 (7.75–11.44), 3.32 (2.29–3.77), and 1.4 (1.15–1.7) and the overall standardized mortality ratios were 5.23 (4.54–6.03), 1.48 (1.34–1.63), and 3.95 (3.64–4.28), respectively. Except for heart organ recipients who were at highest risk for coronary artery disease with a standardized incidence ratio of 13.12 (10.57–16.29), kidney and liver organ recipients had a ninefold increased risk in developing deep vein thrombosis post‐transplant. In conclusion, solid organ transplant patients are at risk of cardiovascular disease, in particular, deep vein thrombosis, which may warrant early identification of high‐risk patients in addition to prompt and adequate thromboprophylaxis perioperatively.     

Pulmonary infections following lung transplantation

Infectious complications are a major cause of morbidity and mortality in solid organ transplant recipients. Infections with viruses, bacteria, and fungi have all been associated with the development of bronchiolitis obliterans syndrome (chronic allograft rejection) in lung transplant recipients. Lung transplant recipients have a higher risk of infectious complications than recipients of other solid organs because of the intensity of immunosuppression, blunted cough mechanism, and constant exposure to the environment. This review provides a broad overview of the infectious complications encountered in caring for patients who have undergone lung transplantation.     

Mycophenolate and lower graft function reduce the seroresponse of kidney transplant recipients to pandemic H1N1 vaccination

In late 2009 transplant organizations recommended that kidney recipients be vaccinated for pandemic H1N1 influenza (pH1N1); however, the vaccine efficacy was unknown. We had offered a monovalent non-adjuvanted pH1N1 vaccine to transplant recipients. Here we compared the pre- and post-vaccination seroresponses of 151 transplant recipients to that of 71 hemodialysis patients and 30 healthy controls. Baseline seroprotection was similar between groups but was significantly different at 1 month (44, 56, and 87%, respectively). Seroconversion was significantly less common for transplant recipients (32%) than dialysis patients (45%) and healthy controls (77%). After adjusting for age and gender, dialysis patients were significantly more likely (2.7-fold) to achieve new seroprotection than transplant recipients. The likelihood of seroprotection in transplant recipients was significantly reduced by mycophenolate use (adjusted odds ratio 0.24), in a dose-dependent manner, and by reduced eGFR (adjusted odds ratio 0.16 for worst to best). Seroprotection and geometric mean antibody titers increased substantially in 49 transplant recipients who subsequently received the 2010 seasonal influenza vaccine. Thus, patients requiring renal replacement therapy had reduced seroresponses to vaccination with the monovalent vaccine compared with healthy controls. Transplant recipient responses were further reduced if they were receiving mycophenolate or had significantly lower graft function.