Search

Background The effect of low‐level pretransplant donor‐specific antibody (DSA) on kidney transplant outcomes is not well described. The goal of this study was to compare outcomes among patients of varying immunologic risk, based on the level of pretransplant DSA. Methods We retrospectively reviewed all adult kidney transplant recipients who had undergone a transplant at our center between January 2013 and May 2017. Patients were grouped as negative DSA (mean fluorescence intensity, [MFISUM 1000). Rejection, infection, graft, and patient survival were outcomes measured. Results Of 952 patients, 82.1% had negative DSA, 10.7% had low‐level DSA, and 7.1% had positive DSA. The positive DSA group had the highest rate of antibody‐mediated rejection (10.3%), followed by low‐level DSA (7.8%) and the negative DSA group (4.5%) (p = .034). The rate of BK viremia was highest in the positive DSA group (39.7%), followed by the low‐level group (30.4%) and the negative DSA group (25.6%), (p = .025). None of the other outcomes, including graft or patient survival, were different between the groups. Conclusion While low‐level DSA should not prevent proceeding with kidney transplantation, it should not be ignored. Future studies are needed to investigate the long‐term effects of varying levels of pre‐transplant DSA on outcomes., The presence of pretransplant donor‐specific antibody (DSA) represents a significant barrier to kidney transplantation for highly sensitized patients as they are less likely to undergo transplants compared with their nonsensitized counterparts. The goal of this study was to compare outcomes among patients of varying immunologic risk, based on the level of pre‐transplant DSA. The positive DSA group had the highest rate of antibody‐mediated rejection (10.3%), followed by low‐level DSA (7.8%) and the negative DSA group (4.5%) (p = .034). Also, the rate of BK viremia was highest in the positive DSA group (39.7%), followed by the low‐level group (30.4%) and the negative DSA group (25.6%), (p = .025).

BK polyomavirus (BKV) is a common infection among kidney transplant recipients (KTR). Risk factors and outcomes based on donor characteristics remain largely unknown.In this study, we aimed to analyze the impact of donor factors through a paired kidney analysis. We included 289 pairs of adult deceased donor transplants (578 KTRs total); each pair had received kidneys from the same donor. Recipient pairs were divided into three groups: "no BK group" if neither KTR developed BK viremia (n = 336), "discordant" if the only one did (n = 176), and "concordant" if both did (n = 66). Acute rejection (AR), graft failure, and BK nephropathy (BKN) were outcomes of interest.Donors in the concordant group were younger, had lower kidney donor profile index (KDPI), and were less likely to be donor after circulatory death (DCD). In multivariate analyses, KTRs who had a donor with a higher body mass index (BMI) (hazard ratio (HR): 0.97; 95% confidence interval (CI): 0.95-0.99; p = .009) were less likely to develop BKV. Concordance was not associated with AR (HR: 0.83; 95% CI: 0.51-1.34; p = .45), graft failure (HR: 1.77; 95% CI: 0.42-7.50; p = .43), or BKN (HR: 1.02; 95% CI: 0.51-2.03; p = .96).Our study suggests lower donor BMI is associated with BKV infection, and concordance or discordance between paired kidney recipients is not associated with poor outcomes.

BACKGROUND: Despite the institution of a new Kidney Allocation System in 2014, A2/A2B to B transplantation has not increased as expected. The current Organ Procurement and Transplantation Network policy requires subtyping on two separate occasions, and in the setting of discrepant results, defaulting to the A1 subtype. However, there is significant inherent variability in the serologic assays used for blood group subtyping and genotyping is rarely done. METHODS: The National Kidney Registry, a kidney paired donation (KPD) program, performs serological typing on all A/AB donors, and in cases of non-A1/non-A1B donors, confirmatory genotyping is performed. RESULTS: Between 2/18/2018 and 9/15/2020, 13.0% (145) of 1,111 type A donors registered with the NKR were ultimately subtyped as A2 via genotyping. Notably, 49.6% (72) of these were subtyped as A1 at their donor center, and in accordance with OPTN policy, ineligible for allocation as A2. CONCLUSION: Inaccurate A2 subtyping represents a significant lost opportunity in transplantation, especially in KPD where A2 donors can not only facilitate living donor transplantation for O and highly sensitized candidates, but can also facilitate additional living donor transplants. This study highlights the need for improved accuracy of subtyping technique, and the need for policy changes encouraging optimal utilization of A2 donor kidneys.

COVID‐19‐associated vasculitis has been reported as a defining feature of systemic disease including acute kidney injury. However, the understanding of COVID‐19 kidney transplant‐related injuries is still evolving. We report a case of AKI with isolated vasculitis (v2 lesion) in a new kidney transplant recipient with COVID‐19 pneumonia.

Effective management of BK viremia (BKPyV-DNAemia) in kidney transplant recipients (KTRs) involves regular monitoring and adjustment of immunosuppression. With this strategy, the majority of patients will clear BK or have ongoing, but non-significant, low-level BKPyV-DNAemia. However, despite adjustments, some will develop more severe sequelae of BK including BKPyV-DNAemia5 logThis was a single-center study of KTRs transplanted at the University of Wisconsin-Madison between 01/01/2015 and 12/31/2017. In this study, we sought to elucidate characteristics associated with the progression of BKPyV-DNAemia to unfavorable outcomes after decreasing immunosuppressive medications for the management of BK viremia as described in consensus guidelines.A total of 224 KTRs fulfilled our selection criteria; 118 (53%) resolved or had persistent low DNAemia, 64 (28%) had severe BK/nephropathy, and 42 (19%) developed dnDSA or AR. In multivariable analysis, female gender (HR: 2.05; 95% CI: 1.08-3.90; P = .02); previous rejection (HR: 2.90; 95% CI: 1.04-8.12; P = .04), and early infection (HR: 0.81; 95% CI: 0.72-0.90; P .001) were associated with the development of severe BK/nephropathy. Conversely, non-depleting induction at transplant (HR: 2.06; 95% CI: 1.03-4.11; P = .03), HLA mismatches3 (HR: 2.27; HR: 1.01-5.06; P = .04), and delayed graft function (HR: 4.14; 95% CI: 1.12-15.28; P = .03) were associated with development of dnDSA and/or rejection.Our study suggests that almost half of KTRs with BKPyV-DNAemia managed by our immunosuppressant adjustment protocol progress unfavorably. Identification of these risk factors could assist the frontline clinician in creating an individualized immunosuppressive modification plan potentially mitigating negative outcomes.

The incidence, risk factors, and outcomes of kidney transplant recipients (KTRs) with post-transplant erythrocytosis (PTE) in the modern era of strong, protocolized immunosuppressive management are unknown. In this study, we aim to identify the incidence and risk factors of PTE and outcomes associated with PTE. This study examined adult KTRs transplanted at our hospital between 01/2001 and 12/2016. Controls were KTRs without PTE and selected in a 1:5 ratio using incident density sampling. Patient survival, graft survival, and vascular thromboembolism (VTE) incidence were outcomes of interest. Of 4,317 kidney transplants during the study period, 214 (5%) had PTE and were compared with controls. In the multivariate analysis, recipients with older age (HR: 0.97, 95% CI 0.96-0.99, p = .001) were less likely to develop PTE, while male gender (HR: 3.2; 95% CI: 1.92-5.3, p

Due to high prevalence of primary aldosteronism (PA) in the general hypertensive population, and its association with worse cardiovascular and renal outcomes, the 2016 Endocrine Society Guidelines explicitly recognize PA as a major public health issue requiring urgent attention. Its prevalence in hypertensive kidney transplant recipients (KTRs) is unknown. In this cross-sectional study, we screened KTRs with hypertension who were on ≥4 antihypertensive medications, on 3 antihypertensive medications with BP ≥ 140/90, and on potassium supplements, or were hypokalemic. 172 of 280 eligible patients successfully completed the testing. A positive screen for PA defined by an aldosterone-to-renin ratio of ≥20 and a plasma aldosterone concentration of >15 ng/dL yielded a prevalence of 15.7%. Potassium supplement requirement (52% vs 27%, P = .01) and hypokalemia (25.9% vs 4.8%, P < .01) were more common in patients who screened positive compared with those who screened negative. 67% of patients who screened positive were on potassium supplements and/or were hypokalemic. Our study is the first to systematically explore the prevalence of PA among the hypertensive KTR population, which has inherently high cardiovascular risk. Further studies are needed to determine the cardiovascular and renal risk attributable to PA, and define optimal therapy for KTRs with PA.

The risk of cytomegalovirus infection (CMV) after rejection treatment is poorly understood. To investigate this, we conducted a case/control (1:2) analysis of adult renal transplant recipients between January 1, 2005 and December 31, 2015, via incidence density sampling and survival analysis. Our objective was to evaluate the association of prior acute rejection with subsequent CMV, including epidemiology and outcomes. There were 2481 eligible renal transplants within the study period and 251 distinct CMV infections. Despite the use of antiviral prophylaxis rejection was a significant risk factor for CMV on unadjusted (HR 1.73 [1.34, 2.24] P < 0.05) and adjusted analysis (HR 1.46 [1.06, 2.04] P < 0.05). When matching cases to controls patients with CMV had significantly more rejection prior to CMV diagnosis (26.7% vs 14.2%, P < 0.01). CMV was associated with a twofold increased risk of prior rejection on unadjusted (OR 1.94, 95%CI: 1.28-2.96, P < 0.01) and adjusted analysis (OR 2.16, 95% CI: 1.31-3.58, P < 0.01). Patients with rejection preceding CMV had significantly increased graft loss (HR 2.89, 95% CI: 1.65-5.09, P < 0.01) and mortality (HR 1.82, 95% CI: 1.12-4.24, P = 0.03) as compared to those CMV cases without rejection. In conclusion, rejection is a risk factor for CMV infection that appears to persist for 1 year. Preceding rejection events increased risk of graft loss and mortality in CMV patients. Given this, prolonged surveillance monitoring for CMV after rejection may be warranted. Studies are needed investigating optimal monitoring strategies.

Aim: End-stage renal disease is a prevalent and growing health problem worldwide. With increasing Internet use, video-sharing websites could potentially serve as a powerful platform for dissemination of information on dialysis. We conducted a cross-sectional study to assess the accuracy, content and viewership of YouTube videos on dialysis. Methods: YouTube videos identified using the search term 'dialysis' were classified independently by two physicians as 'useful,' 'misleading' and 'patient's personal experiences'. Five-point ordinal scales were used to grade reliability and quality. Information regarding source of upload, content in seven pre-defined domains and various viewer interaction metrics was collected. Results: Of the 115 videos with cumulative duration of 16.2 h and viewership of approximately 2.7 million, 67 (58.3%) were useful, 19 (16.5%) were misleading and 29 (25.2%) represented patient's personal experiences; kappa statistic for inter-observer agreement was 0.985. Useful videos were the most comprehensive and had the highest reliability and quality scores. However, viewership per day was the lowest for useful videos at a median of 3 (interquartile range (IQR) 1-17), as compared with 11 (IQR 4-43) for misleading videos and 14 (IQR 5-30) for patient experiences (P = 0.013). All misleading videos were uploaded by individual users with unknown credentials. Of these, 68.4% promoted alternative therapies such as herbs and osmotherapy; 47.4% included advertisements for related services. Conclusions: Viewers favoured misleading videos and patient narratives over scientifically accurate information. Authoritative sources should use popular social media websites to provide relevant and easy-to-understand information on dialysis; including patient stories can make this material more engaging.

BACKGROUND Cytomegalovirus (CMV) infection in kidney transplant recipients has been anecdotally observed with concomitant or subsequent opportunistic infections (OI), but this association has yet to be defined or quantified. METHODS Patients who received a renal transplant between 1/1/2005 and 6/30/2014 and developed CMV infection were matched to controls in a ratio of 1:2 and the rates of opportunistic co-infection were calculated within pre-specified time frames (-30 days to +90 days and -30 days to +180 days). The primary outcome was composite OI rate, and secondary outcomes included time to OI and patient and graft outcomes. CMV-OI association rates were estimated via conditional logistic regression. RESULTS There were 2405 patients who received a renal transplant during the study period; 394 cases of CMV infection were identified. These cases were matched to 783 controls for a total of 805 participants. OI occurred in 14 patients in the CMV case group (CMV+) and in 5 patients in the control group (CMV-) in the -30 to +90 day time period (3.55% vs 0.64%, OR = 5.60, 95% CI: 2.02-12.55). When considering 180-day follow-up, OI occurred in 17 CMV+ patients and 8 CMV- patients (4.3% vs 1%, OR = 4.25, 95% CI: 1.83-9.85). Mean time from CMV diagnosis to OI was 33 ± 64 days (median 7 days). Mortality was 3 times more likely in the group with concomitant OI (CMV+/OI+) as compared to a matched cohort of patients with CMV infection without OI (CMV+/OI-) (unadjusted HR 3.02, 1.64-5.55, Tables 6 and 7). Cumulative survival for CMV+/OI+ patients was significantly worse than CMV+/OI- patients (P

Dyslipidemias are highly prevalent in chronic kidney disease, end-stage renal disease, and kidney transplant patients. These dyslipidemias are associated with high cardiovascular risk and mortality. Many clinical trials have shown that statin therapy can significantly reduce adverse cardiovascular events in chronic kidney disease patients and kidney transplant recipients. However, three major trials did not show a benefit of statin therapy in end-stage renal disease patients on dialysis. Major guidelines either recommend against the use of statins in patients on dialysis or provide no recommendations about statin use for this complex patient population. As a result, we suspect many patients on dialysis are not on statins, even if they have known atherosclerotic cardiovascular disease. When these patients receive kidney transplants, the risk of adverse cardiovascular events increases in the peri-operative period. Although there are no randomized clinical trials looking at statin use in these patients, we suggest that statin use be considered in patients with a history of atherosclerotic cardiovascular disease, to potentially minimize peri-operative cardiovascular complications. We also recommend further research to determine whether statin therapy in dialysis patients awaiting kidney transplant is associated with better survival.

Little data exist comparing outcomes following BK nephropathy (BKN) vs acute rejection. We reviewed outcomes among recipients who had a primary diagnosis of biopsy-proven BKN or rejection between 1 and 18 months post-transplant. There were 96 cases of BKN and 256 cases of rejections. We compared outcomes of BKN with all rejection combined and also with cellular rejection. Seven of 256 (2.7%) patients developed BKN after treatment of rejection. Conversely, 8 of 96 (8.3%) developed rejection after BKN. The eGFR at time of diagnosis in the BKN group (33.7 ± 12.6) was lower than the rejection group (44.8 ± 23.3, P < .001). The eGFR at 6 months after diagnosis of BKN was 32.7 ± 14.9 and for rejection was 48.8 ± 20.7 (P ≤ .001). The mean eGFR at 3 years postdiagnosis was 41.6 ± 18.5 in BKN and 53 ± 21.3 for rejection (P = .001). The graft failure incidence rates were similar between 2 groups. A similar pattern was observed comparing BKN with cellular rejection. While the difference in rate of graft loss between BKN and rejection did not reach statistical significance, kidney function up to 3 years after diagnosis was worse for BKN than for rejection, suggesting that BKN is at least as damaging to kidneys as rejection.