Does Monocyte Chemoattractant Protein-1 Levels Determine the Prognosis of Covid-19 Disease in Kidney Transplant Recipients?

BackgroundIn the normal population, a high monocyte chemoattractant protein (MCP-1) level is an important biomarker for the progression of COVID-19. This study investigated whether MCP-1 level can determine the disease prognosis in kidney transplant (KT) patients with COVID-19.MethodsA total of 89 patients, including 49 KT patients (group 1) diagnosed with COVID-19 who required hospitalization, and 40 KT patients who did not have COVID-19 disease (group 2), were included. Demographic characteristics and laboratory results of the patients were recorded. The serum reserved for MCP-1 was stored at –80°C and studied blindly by a single microbiologist at the end of the study.ResultsWhile the mean age of the patients was 51.0 years (40.0-59.50) in group 1, it was 48.0 years (40.75-54.75) in group 2 (P > .05). In terms of the female sex, it was 36 (73.5%) and 27 (67.5%) in group 1 and group 2, respectively (P > .05). Similarly, there was no significant difference between the 2 groups regarding primary disease and basal graft function (P > .05). There was a statistically significant difference in inflammation indicators in group 1 compared with group 2 (P < .05). A correlation was found between inflammation indicators and COVID-19 (P < .05). However, no significant correlation was detected between COVID-19 disease and MCP-1 levels in both groups (P > .05). Also, according to basal MCP-1 levels, we did not find a significant difference between survival and nonsurvival patients (164.0 pg/mL [146.0-202.0] vs 156.0 pg/mL [143.0-173.0], respectively (P > .05).ConclusionMonocyte chemoattractant protein, an indicator of inflammation, was not found to predict the prognosis of COVID-19 disease in kidney recipients.     

Treatment of Anemia With Erythropoietin-Stimulating Agents in Kidney Transplant Recipients and Chronic Kidney Disease—Another Drawback of Immunosuppression?

Anemia is more prevalent in allograft recipients compared with glomerular filtration rate (GFR) matched patients with chronic kidney diseases. There is a paucity of data concerning the correction of anemia in the posttransplant period with erythropoietin-stimulating agents (ESA). The aim of this study was to compare the iron status, kidney function, inflammatory state, use of drugs affecting erythropoiesis (immunosuppressants ACEi/ARB) and correction of anemia using ESA in a chronic kidney disease (CKD) population versus kidney transplant recipients. We included 67 patients treated with ESA including 17 after kidney transplantation. CKD Patients with native kidneys were significantly older than allograft recipients (mean age 69 versus 51 years; P < .001, and despite similar serum creatinine and iron parameters showed an estimated lower GFR (19 mL/min versus 23 mL/min; P < .05). Median time of ESA therapy was similar among patients with native kidney CKD versus kidney recipients, but they achieved a significantly higher hemoglobin (11.04 versus 10.36 g/dL; P < .05). There was no difference between patients administered or not a mammalian target of rapamycin antagonist. None of the patients with native kidney CKD received immunosuppressive therapy, but they were prescribed ACEi more often than kidney recipients. The higher degree of anemia in kidney allograft recipient is the most probably attributed to the use of immunosuppressive drugs, despite their better kidney function and comparable iron status. This study suggested that higher doses of ESA should be employed to anemia in kidney transplant recipients.     

Is Early COVID-19 in Kidney Transplant Recipients Concerning Enough to Halt Transplantation? A Multicenter Comparative Analysis from India

BackgroundLimited data exist on the incidence and outcome of early coronavirus disease 2019 (COVID-19) in kidney transplantation recipients (KTR).MethodsA retrospective multicenter research study was conducted across 12 centers in India. We explored the symptomatology, demographic, laboratory findings, and outcome of COVID-19 within 30 days of transplantation. The outcome was compared with the overall KTR and waitlisted patients acquiring COVID-19.ResultsThe incidence of early COVID-19 was 2.6% (n = 22) for the cumulative 838 renal transplants performed since nationwide lockdown in March 2020 until May 2021. Overall, 1049 KTR were diagnosed with COVID-19 and 2% of those had early COVID-19. The median age of the early COVID-19 cohort was 43 (31-46) years. COVID-19 severity ranged from asymptomatic (18.2%), mild (59.1%), moderate (9.1%), and severe (13.6%). Among clinical symptoms, dyspnea and anosmia were frequent, and in laboratory parameters, neutrophil lymphocyte ratio, high-sensitivity C-reactive protein, and D-dimer were higher in patients requiring oxygen. The mortality in early COVID-19 was not higher than overall KTR (4.5% vs 8.5%; P = 1). COVID-19 severity (23.9% vs 15.7%; P = .0001) and mortality (15.5% vs 8.5%; P = .001) among waitlisted patients (n = 1703) were higher compared with overall KTR.ConclusionsWe report higher burden of COVID-19 in waitlisted patients compared with KTR and a favorable outcome in early COVID-19 in KTR. Our report will help the transplant physicians in dealing with the ongoing dilemma of halting or resuming transplantation in the COVID-19 era.     

Nonverbal Communication and Psychopathology in Kidney Transplant Recipients

Transplant recipients have difficulty expressing, identifying, and describing their emotional experiences. The Machover human figure test allows us to bring out the deepest contents of a patient's personality, which are normally hidden and not explained to structured quantitative tests. The study analyzed possible situations of distress and possible symptoms of psychopathology in kidney transplant recipients, emerged from the projective test of the human figure and not easily verbalized to the common standardized tests.The sample included 80 kidney transplant patients (51 men and 29 women; mean age, 47.74 [SD, 12.39] years) during follow-up visits at 12 months after transplant. The Machover test was used to evaluate body image, affective aspects, and personality variables by projective method; the Symptom Checklist-90-R was used for the evaluation of possible psychopathology, and the 36-Item Short Form Health Survey was used for the assessment of perceived quality of life.Resultsshowed that the more anxiety there is in the human figure test, the less somatization dimensions (ANX/SOM R = ?331, P < .05), depression (ANX/DEP R = ?326, P < .05), and the global index of psychic symptomatology (ANX/GSI R = ?367, P < .05) of the Symptom Checklist-90-R are present.This research has confirmed the hypothesis that the spontaneous graphic production of the recipients, through the projective methods, allows them to identify and deepen their psychological contents and to activate and maintain a good psychophysical balance post transplant.     

Adverse Outcomes of Tacrolimus Withdrawal in Immune–Quiescent Kidney Transplant Recipients

Concerns about adverse effects of calcineurin inhibitors (CNIs) have prompted development of protocols that minimize their use. Whereas previous CNI withdrawal trials in heterogeneous cohorts showed unacceptable rates of acute rejection (AR), we hypothesized that we could identify individuals capable of tolerating CNI withdrawal by targeting immunologically quiescent kidney transplant recipients. The Clinical Trials in Organ Transplantation-09 Trial was a randomized, prospective study of nonsensitized primary recipients of living donor kidney transplants. Subjects received rabbit antithymocyte globulin, tacrolimus, mycophenolate mofetil, and prednisone. Six months post-transplantation, subjects without de novo donor-specific antibodies (DSAs), AR, or inflammation at protocol biopsy were randomized to wean off or remain on tacrolimus. The intended primary end point was the change in interstitial fibrosis/tubular atrophy score between implantation and 24-month protocol biopsies. Serially collected urine CXCL9 ELISA results were correlated with outcomes. The study was terminated prematurely because of unacceptable rates of AR (4 of 14) and/or de novo DSAs (5 of 14) in the tacrolimus withdrawal arm. Positive urinary CXCL9 predated clinical detection of AR by a median of 15 days. Analyses showed that >16 HLA-DQ epitope mismatches and pretransplant, peripheral blood, donor–reactive IFN-γ ELISPOT assay results correlated with development of DSAs and/or AR on tacrolimus withdrawal. Although data indicate that urinary CXCL9 monitoring, epitope mismatches, and ELISPOT assays are potentially informative, complete CNI withdrawal must be strongly discouraged in kidney transplant recipients who are receiving standard-of-care immunosuppression, including those who are deemed to be immunologically quiescent on the basis of current clinical and laboratory criteria.     

Is Vitamin D Deficiency Associated With Metabolic Syndrome in Renal Transplant Recipients?

Renal transplantation is the gold standard method for the treatment of end-stage renal failure. The main causes of graft loss are chronic allograft dysfunction and death with functioning graft due to cardiovascular diseases. Metabolic syndrome (MetS) is common in renal transplant recipients (RTRs).Vitamin D deficiency or insufficiency is common in RTRs. Studies suggest that vitamin D deficiency or insufficiency may lead to the development of MetS apart from impairment in calcium and bone metabolism. We aimed to investigate the relationship between vitamin D deficiency and MetS in patients with renal transplantation.One hundred forty-one RTRs were included in the study. MetS prevalence was 63.8%. Mean vitamin D level was 17.2 ± 10. 2 ng/mL. Patients were divided into 2 groups according to vitamin D level. Patients with vitamin D levels below 25 ng/mL were in group 1; those above were group 2. There were no differences regarding the presence of metabolic syndrome; presence of diabetes mellitus; hypertension; systolic and diastolic blood pressure; waist circumference; glucose; creatinine; triglyceride; or HDL level between groups (P > .05). The area under curves (confidence interval [CI] 95%) of vitamin D level to predict MetS were 0.58 (0.48-0.68) (P > .05).We did not find any relationship between vitamin D level and MetS. This result may be related to the small sample size of our study. Investigation of this relationship with large study groups are needed to clearly determine this relationship.     

Spot Urine Protein Measurements: Are these Accurate in Kidney Transplant Recipients?

BACKGROUND: Proteinuria and albuminuria are important markers of allograft pathology and are associated with graft loss and cardiovascular disease. Traditionally, these have been quantified using a 24-hr urine collection, but spot urine measurements (albumin-creatinine and protein-creatinine ratios) have become popular because of convenience. Aside from tests of correlation, there has been little evaluation of these measurements in kidney transplantation. METHODS: To further assess the value of albumin-creatinine and protein-creatinine ratios, we measured protein-creatinine ratio and 24-hr urine protein excretion (n=192) and albumin-creatinine ratio and 24-hr urine albumin excretion (n=189) in stable renal transplant patients. Bias (measured minus estimated value), precision, and accuracy was calculated. RESULTS: For the protein-creatinine ratio, percent bias ranged from 12% to 21%, and the accuracy (within 30% of 24-hr collection) was only 47% to 56% depending on the degree of proteinuria. For the albumin-creatinine ratio, percent bias ranged from 9% to 21%, and the accuracy (within 30%) ranged from 38% to 80% depending on the degree of albuminuria. There was no statistical difference between accuracy of protein-creatinine and albumin-creatinine ratios. CONCLUSIONS: The ability of the albumin-creatinine and protein-creatinine ratios to accurately predict 24-hr albumin and protein excretion is modest. Given the similar accuracy of both measurements, either protein-creatinine ratio or albumin-creatinine ratio can be used for monitoring protein excretion. However, given the limitations of both the albumin-creatinine ratio and protein-creatinine ratio in this population, a 24-hr urine collection should be considered before making major clinical decisions (e.g., biopsy) based on the presence of proteinuria.     

Conversion to Everolimus in Kidney Transplant Recipients: To Believe or Not Believe?

IntroductionImmunosuppression with calcineurin inhibitors (CNI) in renal transplantation is associated with chronic graft dysfunction, increased cardiovascular risk, and malignancies. Everolimus (EVR) appears to permit a CNI-sparing regimen among stable kidney recipients.AimThe aim of this study was to analyze the efficacy and safety of conversion from CNI to EVR.Material and MethodsThis was a retrospective registry-based study of all kidney transplant recipients converted from CNI to EVR between 2006 and 2010. One hundred fifty-one patients, including 69.5% males and with an overall mean age of 50.2 ± 12.7 years, underwent conversion to EVR at 37.0 ± 49.8 (16) months after transplantation with 33.7% during the first 6 months. Reasons for conversion included: CNI nephrotoxicity prevention (54.3%), chronic graft dysfunction (25.8%), malignant tumors (10.6%), CNI-adverse reactions (6.6%), and biopsy-proven CNI nephrotoxicity (2.6%). During a follow-up of 17.9 ± 9.9 months (range, 6–58.5), 18 patients (11.9%) were reconverted to CNI, 2 died with functioning grafts, and 2 lost kidney function.ResultsWe observed a significant (P < .001) increase in estimated glomerular filtration rate–Modification of Diet in Renal Disease (eGFR-MDRD) by 11.3% within 6 months: 56.7 ± 22.1 to 64.1 ± 23.4 mL/min/1.73 m². At final evaluation it was 13.7%, namely, to 65.5 ± 23.0 mL/min/1.73 m². At the end of follow-up the proportion of patients with >300 mg/d proteinuria increased from 7.9% to 23.3% (P = .001). Dyslipidemia prevalence increased from 69.5% to 77.5% (P = not significant [NS]) and arterial hypertension increased from 49% to 65.9% (P < .001) at the end of follow-up. Other reported side effects included oral ulcers (2.6%), edema (5.3%), interstitial pneumonitis (1.3%), and toxic hepatitis (1.3%), some of them leading to EVR discontinuation.ConclusionIn our population, renal function improved significantly after conversion from CNI to EVR. Although side effects were common, most were mild, withdrawal of EVR was necessary in a low percentage of cases. EVR appears to be an effective, safe alternative to CNI for maintenance therapy in selected kidney transplant recipients.     

Is Serum Magnesium Level Associated With Serum Lipid Levels in Kidney Transplant Recipients?

BackgroundMagnesium (Mg) is key in diabetes mellitus, hyperlipidemia, and cardiovascular disease.MethodsThis is a retrospective cross-sectional study including 103 kidney transplant recipients. Patients aged under 18 years, patients treated with Mg supplementation, antihyperlipidemic agents, or diuretics, and patients with active infection or malignancy were not enrolled. Patients were divided into 2 groups according to median serum Mg level. The atherogenic index of plasma was calculated by a logarithmic transformation of the number acquired by dividing the molar concentrations of serum triglyceride by high-density lipoprotein value.ResultsThe mean serum Mg level was 1.91 ± 0.28 mg/dL. Six patients (5.8%) had hypomagnesemia (Mg <1.5 mg/dL), and 2 (1.9%) had hypermagnesemia (Mg >2.6 mg/dL). Serum Mg level was negatively correlated with body mass index, estimated glomerular filtration rate (eGFR), and tacrolimus trough level and positively correlated with levels of phosphorus, total cholesterol, and low-density lipoprotein (LDL-C). There was no correlation between serum Mg and triglyceride, high-density lipoprotein, atherogenic index of plasma, and cyclosporin A trough level. Patients with Mg >1.87 mg/dL had lower eGFR, tacrolimus, and cyclosporin A trough level and higher total cholesterol and LDL-C compared to those with Mg ≤1.87 mg/dL. In adjusted ordinal analysis, eGFR (hazard ratio (HR): 0.981, 95% CI 0.964-0.999, P = .036) and total cholesterol (HR: 1.015, 95% CI 1.004-1.027, P = .008) were independently associated with serum Mg. In multivariate linear regression analysis, serum Mg level was independently associated with LDL-C (β = .296, t = 3.079, P = .003) and total cholesterol (β = .295, t = 3.075, P = .003).ConclusionSerum Mg level may have an important impact on dyslipidemia in kidney transplant recipients.     

Kidney Transplantation in the Obese Transplant Candidates: To Transplant or Not To Transplant?

The prevalence of obesity (body mass index ≥30 kg/m²) at the time of transplantation among kidney transplant recipients in the United States has doubled between 1987 and 2001 and continues to increase inexorably. Single‐center and large registry studies in kidney transplant recipients demonstrated that high body mass index (BMI) at transplant is associated with increased risk of wound and surgical site infections, delayed graft function (DGF), acute rejection episodes, and graft loss, among others. Hence, in many centers, obese transplant candidates are denied a transplant based on their body mass index (BMI) alone. The impact of obesity on short‐ and long‐term graft and patient outcomes after kidney transplantation are herein revisited, followed by the authors' proposed approach to evaluate and select obese transplant candidates for a kidney transplant. Suggested interventions to optimize the health of such candidates are also discussed.     

Cystatin C–Based Equation for Predicting the Glomerular Filtration Rate in Kidney Transplant Recipients

Background

Precise monitoring of the glomerular filtration rate (GFR) is needed to estimate the allograft function in kidney transplant recipients (KTRs). The GFR is widely estimated with the use of formulas based on serum cystatin C (SCys) and serum creatinine (SCr) levels. We compared the efficacy of SCys-based equations with that of SCr-based equations to predict the allograft function.

Early Rehospitalization Post–Kidney Transplant Due to Infectious Complications: Can We Predict the Patients at Risk?

Introduction

Rehospitalization early post–kidney transplant is common and has a negative impact in morbidity, graft survival, and health costs. Infection is one the most common causes, and identifying the risk factors for early readmission due to infectious complications may guide a preventive program and improve outcome. The aim of this study was to evaluate the incidence, characterize the population, and identify the risk factors associated with early readmission for infectious complications post–kidney transplantation.