Outcomes in Obese Kidney Transplant Recipients

BackgroundKidney transplantation (KT) in obese patients is controversial. The present study aimed to evaluate patient and graft survival and post-transplantation complications between obese and nonobese recipients.MethodsPatients (n = 3,054) receiving a KT from 1998 to 2008 were divided according to body mass index (BMI) into 3 groups for analysis: group I: BMI <30 kg/m² (nonobese); group II: ≥30–34.9 kg/m² (class I obese); and group III: ≥35 kg/m² (class II and III obese).ResultsMean BMIs were: group I (n = 2,822): 22.6 ± 3.3 kg/m²; group II (n = 185): 31.9 ± 1.3 kg/m²; and group III (n = 47): 36.8 ± 1.7 kg/m². There were no differences among the 3 groups in patient demographic variables regarding race, sex, or organ source. One-year (I, 98%; II, 98%; III, 95%) and 5-year (I, 90%; II, 92%; III, 89%) patient survival rates were similar among groups. Graft survival rates at 1 year were 96% for groups I and II and 91.5% for group III. Five-year graft survivals were: I, 81%; II, 96%; and III, 79%. The most common cause of graft loss was death, and the main cause of death was infection in all groups. Obese patients were more likely to experience wound dehiscence (I, 1.9%; II, 7.6%; III, 19.1%; P < .001), develop new-onset diabetes after transplantation (NODAT; I, 16.2%; II, 27%; III, 36%; P < .001), and have a prolonged length of hospital stay (I, 11.3 ± 11.4 d; II, 14.5 ± 14.3 d; III, 15.9 ± 16.7 d; P < .001).ConclusionsObese recipients demonstrated outcomes similar to nonobese patients regarding patient and graft survival. However, they had higher rates of prolonged length of hospital stay, wound dehiscence, and NODAT.     

Humoral Response to the Third Dose of Sars-Cov-2 Vaccine in Kidney Transplant Recipients

BackgroundMost solid organ transplant recipients did not develop an appreciable serologic response after 2 doses of the mRNA SARS-CoV-2 vaccine.MethodsWe analyzed the humoral response after a third dose of the BNT162b2 vaccine in 130 kidney transplant recipients, compared to 48 health care workers, and associated factors, including prevaccine cellular immune response, by evaluating intracellular cytokine production after stimulation of donor's peripheral blood mononuclear cells.ResultsAfter 2 doses, most of the controls (47 out of 48, 98%) and only 40% of kidney recipients (52 of 130) kidney recipients were seropositive (P < .001). Most seronegative recipients developed a serologic response after the booster (47 out 78, 60%), thus bringing the total number of seropositive recipients to 99 out of 130 (76%). After the third dose, there was a significant increase in antibodies titers in both groups. Decreased humoral response was significantly associated with an older age, lower lymphocyte count, and a lower level of antibodies before booster administration. CD4⁺TNFα⁺ and CD4⁺INFγ⁺ were correlated with mean increase in antibody titers.ConclusionsA third dose of the BNT162b2 mRNA vaccine in kidney recipients is safe and effectively results in increased IgG anti-S levels, including in individuals who were seronegative after 2 doses. Long-term studies of the length of the immune response and protection are required.     

Pregnancy Outcomes for Kidney Transplant Recipients

Pregnancy outcomes in a transplant population have not been well documented. Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and the National Perinatal Epidemiology and Statistics Unit (NPESU) were analyzed. We described pregnancy outcomes within the transplant population and compared these to outcomes for the general population. Six hundred ninety‐two pregnancies in 447 transplant recipients were reported between 1971 and 2010 (ANZDATA); a corresponding 5 269 645 pregnancies were reported nationally in Australia between 1991 and 2010 (NPESU). At pregnancy transplant mothers had a median age of 31 years (interquartile range [IQR]: 27, 34), a median creatinine of 106 µmol/L (IQR: 88, 1103 µmol/L) and a functioning transplant for a median of 5 years (IQR: 3, 9). The mean gestational age at birth was 35 ± 5 weeks in transplant recipients, significantly shorter than the national average of 39 weeks (p < 0.0001). Mean live birth weight for transplant recipients was 873 g lower than the national average (2485 ± 783 g vs. 3358 ± 2 g); a significant difference remained after controlling for gestational age. There was lower perinatal survival rate in babies born to transplant recipients, 94% compared with 99% nationally (p < 0.001). Although transplant pregnancies are generally successful, outcomes differ from the general population, indicating these remain high‐risk pregnancies despite good allograft function.     

Outcomes Following Colorectal Resection in Kidney Transplant Recipients

Background

Kidney transplant recipients (KTR) are at increased risk of requiring colorectal resection compared to the general population. Given the need for lifelong immunosuppression and the physiologic impact of years of renal replacement, we hypothesized that colorectal resection may be riskier for this unique population.

Methods

We investigated the differences in mortality, morbidity, length of stay (LOS), and cost between 2410 KTR and 1,433,437 non-KTR undergoing colorectal resection at both transplant and non-transplant centers using the National Inpatient Sample between 2000 and 2013, adjusting for patient and hospital level factors.

Results

In hospital, mortality was higher for KTR in comparison to non-KTR (11.1 vs 4.3%, p?<?0.001; adjusted odds ratio [aOR] _2.683.59_4.81) as were overall complications (38.5 vs 31.5%, p?=?0.001; aOR _1.081.30_1.56). LOS was significantly longer (10 vs 7 days, p?<?0.001; ratio _1.421.53_1.65) and cost was significantly greater ($23,056 vs $14,139, p?<?0.001; ratio _1.421.54_1.63) for KTR compared to non-KTR. While LOS was longer for KTR undergoing resection at transplant centers compared to non-transplant centers (aOR 1.68 vs 1.53, p?=?0.03), there were no statistically significant differences in mortality, overall morbidity, or cost by center type.

Conclusions

KTR have higher mortality, higher incidence of overall complications, longer LOS, and higher cost than non-KTR following colorectal resection, regardless of center type. Physicians should consider these elevated risks when planning for surgery in the KTR population and counsel patients accordingly.

     

Pregnancy and Maternal Outcomes Among Kidney Transplant Recipients

Fertility rates, pregnancy, and maternal outcomes are not well described among women with a functioning kidney transplant. Using data from the Australian and New Zealand Dialysis and Transplant Registry, we analyzed 40 yr of pregnancy-related outcomes for transplant recipients. This analysis included 444 live births reported from 577 pregnancies; the absolute but not relative fertility rate fell during these four decades. Of pregnancies achieved, 97% were beyond the first year after transplantation. The mean age at the time of pregnancy was 29 ± 5 yr. Compared with previous decades, the mean age during the last decade increased significantly to 32 yr (P < 0.001). The proportion of live births doubled during the last decade, whereas surgical terminations declined (P < 0.001). The fertility rate (or live-birth rate) for this cohort of women was 0.19 (95% confidence interval 0.17 to 0.21) relative to the Australian background population. We also matched 120 parous with 120 nulliparous women by year of transplantation, duration of transplant, age at transplantation ±5 yr, and predelivery creatinine for parous women or serum creatinine for nulliparous women; a first live birth was not associated with a poorer 20-yr graft or patient survival. Maternal complications included preeclampsia in 27% and gestational diabetes in 1%. Taken together, these data confirm that a live birth in women with a functioning graft does not have an adverse impact on graft and patient survival.One of the many perceived benefits of kidney transplantation has been restoration of pituitary-ovarian function and fertility in women of reproductive age. Prenatal advice for women with a functioning kidney transplant has been primarily based on data derived from observational research,^1–13 and the reported live-birth rates achieved in such women range from 43.2¹⁴ to 82%.¹⁵Although an increased pregnancy event number has been reported for women with a functioning kidney transplant,¹⁶ little is actually known about “pregnancy rate changes” during the past 40 yr. More importantly, long-term graft and maternal survival analyses, referred to when advising women who have undergone transplantation and are considering a pregnancy, have been mostly performed without adequate matching,¹² or, alternatively, matching has been used but outcomes followed up for only brief intervals^14,17,18 and in small cohorts.^19–22 Published graft matching studies to date suggest no adverse impact 10 yr after a live birth.¹⁴In most instances, pregnancies in women with a kidney graft have been encouraged. Historically, renal function,^8,15,17,18 baseline proteinuria,²³ intercurrent hypertension,^1,24 and time from transplantation^{1,3,5,8,14,15,18,24,25} have been used to predict adverse event risks to the mother, kidney, and offspring. To this are added the often unquantifiable inherent risks for genetically transmitted diseases or the problems associated with prematurity.^26,27 More recently, epidemiologic evidence suggests low birth weight may be associated with the development of hypertension,²⁸ cardiovascular disease,²⁹ insulin resistance,³⁰ and end-stage renal failure.³¹ Moreover, low birth weight is associated with an increased risk for hypertension, independent of genetic and shared environmental factors.³²Series published to date have not captured all pregnancy events or their outcomes. Limitations of some of the published studies include short duration of follow-up and studies with no adequate or long-term matching for decade and renal function.We examined fertility rates, pregnancy rates, and pregnancy outcomes over 40 yr in an at-risk population, defined as women who were aged between 15 and 49 and had a functioning kidney transplant, using ANZDATA registry data. In addition, maternal and graft outcomes were analyzed, and, uniquely, a matched cohort analysis of 120 nulliparous and 120 parous women who had undergone transplantation enabled analysis of outcomes at 20 yr.     

Belatacept Conversion Protocols and Outcomes in Kidney Transplant Recipients

BackgroundConversion from calcineurin inhibitor (CNI)-based to belatacept-based immunosuppression has become common; however, numerous protocols have emerged in lieu of a standardized protocol. The purpose of this study was to characterize belatacept conversion protocols from multiple centers and observe outcomes.MethodsThis was a retrospective study that included Kaiser Permanente Southern California members. The primary outcome was rejection 6 months after conversion and secondary outcomes included change in serum creatinine and graft loss.ResultsSeventy-eight patients were included. Thirteen distinct protocols were identified from 8 different transplant centers. Protocols varied by initial dose, induction schedule, and CNI taper. The observed rate of rejection was 6%. There was a trend toward an association of rejection with lower tacrolimus exposure at the time of conversion and lower mycophenolic acid dosing postconversion. Graft survival was 88% and patient survival was 94%. There was a significant improvement in creatinine after conversion. Those with early conversions and creatinine >2.0 mg/dL at the time of conversion had the best response.ConclusionsA large variety of belatacept conversion protocols were identified. Protocols were defined by the initial dose, induction regimen, and CNI taper. Rejection rates were low and may be influenced by exposure to maintenance immunosuppression during and after conversion. Most patients showed stabilization and improvement in creatinine postconversion, with the largest effect in those with an early conversion and serum creatinine >2.0 mg/dL.     

Impact of Pre-existing Comorbidities on Long-term Outcomes in Kidney Transplant Recipients

Background

Outcomes of patients with end-stage renal disease are mainly affected by their comorbidities. Detailed data evaluating the impact of pre-transplant comorbidities on long-term outcome after kidney transplantation are largely missing.

Effect of Immigration Status on Outcomes in Pediatric Kidney Transplant Recipients

Kidney transplantation is the optimal treatment for children with end‐stage renal disease. For children with undocumented immigration status, access to kidney transplantation is limited, and data on transplant outcomes in this population are scarce. The goal of the present retrospective single‐center study was to compare outcomes after kidney transplantation in undocumented children with those of US citizen children. Undocumented residency status was identified in 48 (17%) of 289 children who received a kidney transplant between 1998 and 2010. In undocumented recipients, graft survival at 1 and 5 years posttransplantation was similar, and mean estimated glomerular filtration rate at 1 year was higher than that in recipients who were citizens. The risk of allograft failure was lower in undocumented recipients relative to that in citizens at 5 years posttransplantation, after adjustment for patient age, donor age, donor type, and HLA mismatch (p < 0.04). In contrast, nearly one in five undocumented recipients who reached 21 years of age lost their graft, primarily because they were unable to pay for immunosuppressive medications once their state‐funded insurance had ended. These findings support the ongoing need for immigration policies for the undocumented that facilitate access to work‐permits and employment‐related insurance for this disadvantaged group.     

H-Y Incompatibility Predicts Short-Term Outcomes for Kidney Transplant Recipients

A recent report suggested that female recipients of male deceased-donor kidneys are at increased risk for graft failure because of H-Y antigen mismatch. In an attempt to confirm and extend these results, we studied all adult recipients of deceased-donor kidney transplants from 1990 through 2004 in the US Renal Data System. Compared with all other gender combinations, female recipients of male donor kidneys had a 12% increased risk for graft failure at 1 yr (hazard ratio 1.12; 95% confidence interval 1.05 to 1.19) but no excess risk at 10 yr (hazard ratio 1.03; 95% confidence interval 0.98 to 1.07). We observed a similar pattern of short- and long-term risk for both death-censored graft failure and mortality. The main results were consistent across several prespecified patient subgroups and were robust to sensitivity analyses. In conclusion, compared with other recipient-donor gender combinations, female recipients of male donor kidney transplants in the United States have an increased short-term risk but not long-term risk for adverse outcomes.Allorecognition of human major histocompatibility antigens (i.e., HLA) and the associated immune response has important short- and long-term implications for successful kidney transplantation. Although much effort has been placed on trying to understand and control the immune response to these major histocompatibility antigens, relatively little is known about the role of minor histocompatibility antigens as determinants of outcome. H-Y antigens, derived from the Y chromosome, are a group of minor histocompatibility antigens that are widely expressed in human tissues¹ and have been found to be prognostically important for the survival of recipient–donor gender-mismatched hematopoietic stem cell transplants.^2–9Several studies of heart, lung, liver, and corneal transplantation have suggested that female recipients of male donor organs/tissues are at increased risk for adverse graft outcomes^10–13; however, other studies have failed to show this effect.^14–18 Recently, a report by Gratwohl et al.,¹⁹ using data from the Collaborative Transplant Study (CTS), suggested that, after adjustment for the independent effects of recipient and donor gender, female recipients of male deceased-donor kidney transplants (versus all other recipient–donor gender combinations) were significantly associated with a 6 to 8% increase in the risk for graft failure and a 10 to 11% increase in the risk for death-censored graft failure during 10-yr of follow-up. They termed this phenomenon the “H-Y effect”; however, only 18.6% of the patients in the study by Gratwohl et al. were from North America, and a previous report failed to show an H-Y effect in zero-mismatched, US living-donor kidney transplants.²⁰ In addition, the impact of adjusting for a more extensive set of covariates (including recipient and donor weight) was not assessed.Given their greater susceptibility to unmeasured or residual confounding (as compared with randomized, controlled trials), it is important to reproduce the results of observational studies in different patient populations from different data sources.²¹ In an attempt to confirm the results of Gratwohl et al. and to determine the relevance of the H-Y effect in deceased-donor kidney transplants performed in the United States, we undertook a retrospective cohort study using data from the US Renal Data System (USRDS). We used a modeling strategy similar to that of Gratwohl et al. and then extended it to include additional covariate data, an evaluation of prespecified subgroups, and various sensitivity analyses.     

Panel Reactive Antibody Responses Against Influenza Vaccination in Kidney Transplant Recipients

IntroductionSeasonal influenza is an important cause of morbidity and mortality in the post-transplant period; therefore, the influenza vaccination has been recommended for all kidney transplant recipients before the influenza season. However, at least theoretically, the introduction of antigens via vaccines may trigger rejection attacks by causing an antibody response. In this study, we examined the development of de novo panel reactive antibody (PRA) development against the influenza vaccine in kidney transplant recipients.Materials and MethodsOverall, 41 kidney transplant recipients who received the influenza vaccination and 50 kidney transplant recipients (study group) who refused to receive the influenza vaccination (control group) were enrolled in the study. Following basal biochemistry examination, the inactivated trivalent influenza vaccine was administered intramuscularly. Panel reactive antibodies were screened in all patients before and after vaccination on days 30 and 180. The primary outcome variable was development of de novo panel reactive antibodies.ResultsOne patient in the study group developed de novo class I and II PRA at 6 months after vaccination (P > .05), while no antibody development was noted in the control group. Graft dysfunction or biopsy-confirmed rejection was not observed during the follow-up period in both groups.ConclusionThe influenza vaccination is generally effective and safe in solid organ transplant recipients. The vaccination procedure has the potential to trigger antibody development and occurrence of rejection. Therefore, vaccinated kidney transplant recipients should be monitored more carefully with regard to PRA; if the graft deteriorates, a rapid transplant biopsy should be performed.     

Humoral and Cellular Immune Responses after Influenza Vaccination in Kidney Transplant Recipients

It has been speculated that influenza vaccination of renal allograft recipients could be associated with de novo production and/or increased titers of anti-HLA antibodies (HLA-Ab). To directly address this issue, we recruited 66 stable renal transplant recipients and 19 healthy volunteers during the 2005–2006 vaccination campaign. At day 0 and day 30 following vaccination, HLA-Ab were screened and in parallel influenza-specific antibody and T-cell responses were assessed. Humoral postvaccinal responses to A/H1N1 and A/H3N2 strains, but not B strain, were less frequent in transplanted patients than in control subjects. Significant expansion of influenza-specific IFN-γ-producing T cells was observed at similar frequencies in patients and controls. There was no correlation between cellular and humoral postvaccinal responses. No impact of sex, age or immunosuppressive regimen could be evidenced. Vaccination was not associated with any significant change in preexisting or de novo anti-HLA sensitization. No episode of allograft rejection was recorded in any of the patients. Our results suggest that flu vaccination is safe in stable renal transplanted patients. Larger studies are needed for definitive statistical proof of the safety and effectiveness, with regard to the quality of the immune response, of yearly influenza vaccination in immunosuppressed patients.     

A National Study of Outcomes among HIV-Infected Kidney Transplant Recipients

Kidney transplantation is a viable treatment for select patients with HIV and ESRD, but data are lacking regarding long-term outcomes and comparisons with appropriately matched HIV-negative patients. We analyzed data from the Scientific Registry of Transplant Recipients (SRTR; 2002–2011): 510 adult kidney transplant recipients with HIV (median follow-up, 3.8 years) matched 1:10 to HIV-negative controls. Compared with HIV-negative controls, HIV-infected recipients had significantly lower 5-year (75.3% versus 69.2%) and 10-year (54.4% versus 49.8%) post-transplant graft survival (GS) (hazard ratio [HR], 1.37; 95% confidence interval [95% CI], 1.15 to 1.64; P<0.001) that persisted when censoring for death (HR, 1.43; 95% CI, 1.12 to 1.84; P=0.005). However, compared with HIV-negative/hepatitis C virus (HCV)–negative controls, HIV monoinfected recipients had similar 5-year and 10-year GS, whereas HIV/HCV coinfected recipients had worse GS (5-year: 64.0% versus 52.0%, P=0.02; 10-year: 36.2% versus 27.0%, P=0.004 [HR, 1.38; 95% CI, 1.08 to 1.77; P=0.01]). Patient survival (PS) among HIV-infected recipients was 83.5% at 5 years and 51.6% at 10 years and was significantly lower than PS among HIV-negative controls (HR, 1.34; 95% CI, 1.08 to 1.68; P<0.01). However, PS was similar for HIV monoinfected recipients and HIV-negative/HCV-negative controls at both times. HIV/HCV coinfected recipients had worse PS compared with HIV-negative/HCV-infected controls (5-year: 67.0% versus 78.6%, P=0.007; 10-year: 29.3% versus 56.23%, P=0.002 [HR, 1.57; 95% CI, 1.11 to 2.22; P=0.01]). In conclusion, HIV-negative and HIV monoinfected kidney transplant recipients had similar GS and PS, whereas HIV/HCV coinfected recipients had worse outcomes. Although encouraging, these results suggest caution in transplanting coinfected patients.     

Humoral Response After SARS-CoV-2 Vaccination in Kidney Transplant Recipients: Role of Immunosuppression Therapy

BackgroundMessenger RNA vaccination against COVID-19 has been shown to produce an immune response with sufficient efficacy to prevent natural infection in immunocompetent recipients. However, the response in kidney transplant recipients is low. We aimed to evaluate the specific humoral response to SARS-CoV-2 after vaccination in a population of kidney transplant recipients and assess the main factors associated with a lack of response.MethodsWe undertook a prospective study of 105 kidney transplant recipients and 11 recipients of a combined kidney-pancreas transplant. We analyzed immunoglobulin G and immunoglobulin M antibodies after the patients received their second and third doses of the messenger RNA 1273 (Moderna) or BNT162b1 (BionTECH-Pfizer) vaccinations between February and November 2021.ResultsMean (SD) age of the 116 patients was 50 (16) years, and 65% were men. They had their transplants for 40 months (IQR, 15-123 months), with 14% undergoing retransplant and 11% sensitized. The maintenance immunosuppression regimen was steroids + tacrolimus + mycophenolate (MMF) in 68% of the patients and any combination with mammalian target of rapamycin inhibitor (mTORi) in 28%. A humoral response developed in 40% of the patients 6 weeks (IQR, 4-10 weeks) after receiving the second dose of the vaccine. Of the 67 patients with no response to the second dose, 51 had an analysis of the humoral response after the third dose, which was positive in 16 (31%). A total of 80% received the Moderna vaccine and 20% the BionTECH-Pfizer. No patient experienced major adverse effects after the vaccination.Factors associated with a lack of humoral response to the vaccine were recipient age (odds ratio [OR], 1.02; 95% CI, 1.001-1.05; P = .04), diabetes (OR, 2.8; 95% CI, 1.2-6.9; P = .02), and treatment with MMF (OR, 2.6; 95% CI, 1.08-6.8; P = .03). Treatment with mTORi was associated with a better response to vaccination (OR, 0.3; 95% CI, 0.1-0.9; P = .04).ConclusionsThe humoral response to the COVID-19 vaccine in kidney transplant recipients is poor. Factors related with this lack of immunity are recipient age and diabetes, plus MMF therapy, whereas mTORi therapy was associated with a better response to vaccination.     

A Case of Acute Kidney Injury Caused by Myoglobin Cast Nephropathy With Sars-Cov-2 Infection in a Living-Donor Kidney Transplant Recipient

When COVID-19 affects patients with risk factors such as chronic kidney disease or on immunosuppressive drugs, they often rapidly become seriously ill. We describe a 50-year-old man who was affected with SARS-CoV-2 and had undergone an ABO-compatible living-donor kidney transplantation from his father 14 years ago because of end-stage renal failure due to hypertensive nephrosclerosis. He had continued on immunosuppressive drugs and completed vaccination twice (9 months ago and 6 months ago) with messenger RNA (mRNA) vaccines against SARS-CoV-2. However, he was temporarily on a mechanical ventilator due to respiratory failure and hemodialysis due to acute kidney injury (AKI). He was finally weaned from the ventilator and hemodialysis by taking steroid and antiviral drugs. Echo-guided renal biopsy revealed myoglobin cast nephropathy. We experienced 14 outpatients after living-donor kidney transplantation infected with SARS-CoV-2, but only this case developed AKI.     

Effects of Rituximab on Atherosclerotic Biomarkers in Kidney Transplant Recipients

IntroductionCardiovascular disease is the leading cause of mortality in kidney transplant recipients. Rituximab is widely used in kidney transplantation for a variety of situations, and rituximab may inhibit some cytokines and antibodies that may play an active role in the atherosclerotic process. The aim of the study was to evaluate the efficacy of rituximab on atherosclerosis biomarkers in kidney transplant recipients.MethodsAll patients, 18 years of age and older, who underwent kidney transplantation and received at least 1 dose of 375 mg/m² rituximab were considered for participation in this study. The primary study endpoint was the development of cardiovascular diseases after rituximab therapy. The secondary endpoint was the onset of cytomegalovirus (CMV) disease or biopsy-confirmed BK virus nephropathy. In addition, comparison of atherosclerosis biomarkers was performed between study and control groups.ResultsThere were no cardiovascular events observed during follow up. Only 8 patients in the study group suffered from CMV disease during follow up. Serum interleukin 10 levels were significantly higher in the rituximab group compared with the control group, although anti–oxidized low-density lipoprotein levels were lower in the rituximab group compared with the control group, though this did not achieve statistical significance.DiscussionRituximab treatment may increase the risk of CMV reactivation and decrease lymphocyte counts and interleukin 10 levels; however, significant decreases in all atherosclerotic-related biomarkers have not been shown in our study.     

Pregnancy Outcomes Related to Mycophenolate Exposure in Female Kidney Transplant Recipients

In 2012, the U.S. Food and Drug Administration issued guidelines advising kidney transplant recipients (KTRs) to discontinue mycophenolate (MPA) in preparation for pregnancy. Little is known about how this guidance has affected pregnancy and graft outcomes. The purpose of this retrospective cohort study was to investigate any association between the discontinuation of MPA and KTR pregnancy and graft outcomes. Data from the National Transplantation Pregnancy Registry included 382 cases in which KTRs managed on MPA became pregnant. Overall, 22 variables, including the time in which a KTR discontinued MPA, were assessed across four end points: miscarriages, birth defects, and 2‐ and 5‐year postpartum graft loss. Birth defects and miscarriages were similar among KTRs who discontinued MPA >6 and <6 weeks prior to pregnancy and during the first trimester. In contrast, discontinuing MPA during the second trimester or later significantly increased the risk of miscarriages (odds ratio [OR] 9.35, 95% confidence interval [CI] 4.31–20.00, p < 0.001) and birth defects (OR 6.06, 95% CI 1.96–18.87, p = 0.002). Discontinuing MPA <6 weeks prior to pregnancy was associated with an increased risk of 5‐year graft loss. For the fetus, there is value to discontinuing MPA anytime prior to the second trimester. Adhering to current guidelines does not negatively affect graft survival.     

Risk of Severe Coronavirus Disease 2019 Infection in Kidney Transplant Recipients

BackgroundDespite all efforts, the incidence of severe coronavirus disease 2019 (COVID-19) infection has been high in renal transplant recipients, as in other groups (eg, older adults, patients with comorbidities or immunosuppression). The detection of any possible predictor of gravity could improve the early approach in these patients.Patients and methodsWe registered data from renal transplant recipients with severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection in our area for a year (March 2020 to March 2021). We collected demographics, comorbidity, body mass index, lymphocyte count, and vitamin D levels before the diagnosis. We performed statistical analysis using SPSS Statistics version 20 (IBM Corp, Armonk, NY, United States).ResultsOf 63 patients, 57.1% required hospital admission and 14.3% required intensive care. The incidence of acute renal failure was 28.6%; 34.9% developed hyperinflammatory syndrome; 67% had lymphopenia, which was severe in 13.1%; and 11 patients died. There was significant correlation between lymphocyte count before and during the infection. For hospitalization, we found differences in age, pulmonary disease, and renal function. Related factors for admission to an intensive care unit were obesity, severe lymphopenia, altered renal function, and low level of vitamin D. Predictors for mortality were age, renal function, and minimum lymphocyte count.ConclusionIn kidney transplant recipients with COVID-19 infection, renal function determines hospitalization, and body mass index determines admission to an intensive care unit. Previous vitamin D levels are also significantly lower in patients requiring intensive care. The analysis of lymphocyte count previous to infection is correlated with the minimum level during the disease, which is a predictor of mortality, and could be a prognosis factor.