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Noncirrhotic hyperammonemia (NCH) is a rare but often fatal complication of solid organ transplantation. We present a case wherein an infectious cause of NCH was suspected following kidney transplantation (KT) and the patient was promptly started on empirical antibiotic treatment which proved to be lifesaving. A 56‐year‐old Chinese woman with a past medical history of end‐stage renal disease secondary to ischemic nephropathy and cerebrovascular accident received a kidney from a 52‐year‐old brain‐dead donor with a Kidney Donor Profile Index score of 70%. She experienced immediate graft function and was discharged on post‐operative day (POD) 4. On POD 10, she presented with a fever, acute onset of confusion, and abdominal pain. Her mental status deteriorated and required emergent intubation. Empiric broad‐spectrum antibiotics were initiated. On hospital day 3, a serum ammonia was 889 μmol/L (normal <53 μmol/L). A urine sample was sent for Ureaplasma polymerase chain reaction (PCR) testing, and moxifloxacin and doxycycline were empirically started. Her ammonia rapidly normalized, and her mental status improved 48 hours after antibiotic initiation. She was extubated 5 days into treatment and was discharged after an 11‐day hospitalization. Following discharge, her urine test resulted positive for Ureaplasma parvum or Ureaplasma urealyticum DNA detection with the 16S rRNA gene amplification probe. Mental status changes and hyperammonemia in the first 30 days post‐KT should raise suspicion for NCH, and prompt empiric treatment with antimicrobials covering Ureaplasma and Mycoplasma should be considered. [ABSTRACT FROM AUTHOR]

Summary: BK polyomavirus (BKPyV) reactivation is regularly monitored after kidney transplant to prevent progression to BK associated nephropathy (BKAN). The New England BK Consortium, made up of 12 transplant centres in the northeastern United States, conducted a quality improvement project to examine adherence to an agreed upon protocol for BKPyV screening for kidney transplants performed in calendar years 2016–2017. In a total of 1047 kidney transplant recipients (KTR) from 11 transplant centres, 204 (19%) had BKPyV infection, defined as detection of BKPyV in plasma, with 41 (4%) KTR progressing to BKAN, defined by either evidence on biopsy tissues or as determined by treating nephrologists. BKPyV infection was treated with reduction of immune suppressants (RIS) in >70% of the patients in all but two centres. There was no graft loss because of BKAN during the two‐year follow‐up. There were nine cases of post‐RIS acute rejection detected during this same period. Adherence to the protocol was low with 54% at 12 months and 38% at 24 months, reflecting challenges of managing transplant patients at all centres. The adherence rate was positively correlated to increased detection of BKPyV infection and was unexpectedly positively correlated to an increase in diagnosis of BKAN. [ABSTRACT FROM AUTHOR]

Utilization of Hepatitis B virus (HBV)‐infected kidney allografts represents an opportunity to bridge the gap between organ supply and demand. Highly efficacious vaccines and antiviral therapies allow these allografts to be transplanted with negligible risk to the recipient. The purpose of this study was to describe the prophylactic strategies and related clinical outcomes of kidney transplant recipients who received a kidney from an HBV viremic donor. Eight patients received an allograft from an HBV viremic deceased kidney donor between January 1, 2017 and December 4, 2020. All recipients were immune to hepatitis B with a surface antibody titer greater than or equal to 10 mIU/ml (range: 12 ‐ > 1000 mIU/ml). After transplant, 62.5% demonstrated HBV core antibody seroconversion at an average of 47.4 ± 28.5 days post‐transplant. Anti‐viral prophylaxis was initiated in 87.5% of patients; 62.5% preemptively during the transplant admission (range 1–3 days post‐transplant) and 25% following HBcAb seroconversion (range 45–304 days post‐transplant). Of the four patients who were started on entecavir preemptively, two subsequently core converted. These two patients had an HBV surface antibody less than 100 mIU/ml at the time of transplant. None of the recipients converted to HBV surface antigen positivity. The average estimated glomerular filtration rate was 41 ± 19 ml/min/1.73m2, and there were no significant elevations in liver enzymes through one year post‐transplant. The use of HBV viremic kidney allografts may represent an additional source of transplant organs; however, more studies are needed to better elucidate the optimal protective strategies for these recipients. [ABSTRACT FROM AUTHOR]

Cytomegalovirus (CMV) is a significant cause of morbidity in kidney transplant recipients (KTR). Historically at our institution, KTR with low and intermediate CMV risk received 6 months of valganciclovir if they received lymphocyte depleting induction therapy. This study evaluates choice and duration of CMV prophylaxis based on donor (D) and recipient (R) CMV serostatus and the incidence of post‐transplant CMV viremia in low (D‐/R‐) and intermediate (R+) risk KTR receiving lymphocyte‐depleting induction therapy. A protocol utilizing valacyclovir for 3 months for D‐/R‐ and valganciclovir for 3 months for R+ was evaluated. Adult D‐/R‐ and R+ KTR receiving anti‐thymocyte globulin, rabbit or alemtuzumab induction from 8/20/2016 to 9/30/2018 were evaluated through 1 year post‐transplant. Patients were excluded if their CMV serostatus was D+/R‐, received a multi‐organ transplant, or received basiliximab. Seventy‐seven subjects met the inclusion criteria: 25 D‐/R‐ (4 historic group, 21 experimental group) and 52 R+ (31 historic, 21 experimental). No D‐/R‐ patients experienced CMV viremia. Among the R+ historic and experimental groups, there was no significant difference in viremia incidence (35.5% vs 52.4%; P =.573). Of these cases, the peak viral load was similar between the groups (median [IQR], 67 [<200‐444] vs <50 [<50‐217]; P =.711), and there was no difference in the incidence of CMV syndrome (16.1% vs 14.3%; P = 1.000) or CMV related hospitalization (12.9% vs 14.3%; P = 1.000). No patient experienced tissue invasive disease. These results suggest limiting valganciclovir exposure may be possible in low and intermediate risk KTR receiving lymphocyte‐depleting induction therapy with no apparent impact on CMV‐related outcomes. [ABSTRACT FROM AUTHOR]