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Introduction: Kidney transplant recipients and patients on the waiting list for kidney transplant who acquire SARS-CoV-2 infection are at serious risk of developing severe COVID-19, with an increased risk of mortality for the their immunosuppressive state; other risk factors for mortality have been identified in some comorbidities such as obesity, diabetes, asthma and chronic lung disease. Materials and methods: The COVID-19 pandemic has led to a sharp reduction in kidney transplants in most countries, mainly due to the concern of patients on the waiting list for their potential increased susceptibility to acquire SARS-CoV-2 infection in healthcare facilities and for the difficulties of transplant centers to ensure full activity as hospitals have had to focus most of their attention on COVID-19 patients. Indeed, while the infection curve continued its exponential rise, there was a vertical decline in kidney donation/transplant activity. Conclusion: This review article focuses on the damage induced by SARS-CoV-2 infection on kidney and on the adverse effect of this pandemic on the entire kidney transplant sector.

Education for pre-transplant, solid-organ recipient candidates aims to improve knowledge and understanding about the transplant process, outcomes and potential complications to support informed, shared decision-making to reduce fears and anxieties about transplant, inform expectations, and facilitate adjustment to post-transplant life. In this review, we summarize novel pre-transplant initiatives and approaches to educate solid-organ transplant recipient candidates. First, we review approaches that may be common to all solid-organ transplants, then we summarize interventions specific to kidney, liver, lung, and heart transplant. We describe evidence that emphasizes the need for multi-disciplinary approaches to transplant education. We also summarize initiatives that consider online (eHealth) and mobile (mHealth) solutions. Lastly, we highlight education initiatives that support racialized or otherwise marginalized communities to improve equitable access to solid-organ transplant. A considerable amount of work has been done in solid-organ transplant since the early 2000s with promising results. However, many studies on education for pre-transplant recipient candidates involve relatively small samples and non-randomized designs and focus on short-term surrogate outcomes. Overall, many of these studies have a high risk of bias. Frequently, interventions assessed are not well characterized or they are combined with administrative and data-driven initiatives into multifaceted interventions, which makes it difficult to assess the impact of the education component on outcomes. In the future, well-designed studies rigorously assessing well-defined surrogate and clinical outcomes will be needed to evaluate the impact of many promising initiatives.

Nontuberculous mycobacteria are pathogens with diverse manifestations in immunocompromised hosts. The lesser-known Mycobacterium haemophilum usually causes cutaneous infection. Diagnosis is challenging but is aided by molecular testing and multidisciplinary communication. We present an immunocompromised patient with disseminated cutaneous mycobacterial infection with digital tenosynovitis.

Purpose: Improved graft reinnervation and functional recovery would greatly enhance the utility of vascularized composite allotransplantation (VCA). Pre-implantation of nerve grafts in a limb transplant recipient prior to transplantation to increase the length of the severed nerves in the amputation stump offers a novel, readily translatable approach to this problem. At the time of transplantation a pre-implanted nerve graft (PING) would be elevated from its wound bed in the amputated stump and unfurled distally into the transplanted limb, allowing for a more distal nerve coaptation. Methods: We used a reversed sciatic-tibial nerve isograft coapted end-to-end to a median nerve in a rat to: (1) determine viability of distal axons after elevating PINGs; and (2) assess for ischemic injury to axons in the distal PING following elevation from the wound bed. For axonal viability, grafts of varying lengths (2cm,3cm,4cm, n≥5/group) were left to regenerate for 8 weeks. The distal ends were then biopsied prior to elevation, and again one week after elevation. For ischemia assessment, blood flow along 4cm long PINGs was measured with laser doppler at multiple timepoints: baseline (at time of grafting), 8 weeks after grafting (before elevation), immediately after elevation, and 3 and 7 days post-elevation (n=8/timepoint). Means were compared with t-tests and ANOVA. A pig forelimb model was used to assess the functional impact of PINGs. A 6cm long reversed ulnar-PING was coapted to the proximally transected ulnar nerve. After 12 weeks of regeneration, the distal PING was transferred end-to-end to the median nerve just proximal to the elbow. A control group underwent ulnar-to-median nerve transfer 6cm proximal to the elbow (n=4 limbs/group). Hoof flexion force was measured every three weeks. Results Axonal viability: after 8 weeks, axons had regenerated into the distal grafts in all lengths: mean myelinated axon counts (±SD): 7043 (±790), 6066 (±1838), 6491 (±983) in 2cm,3cm,4cm grafts, with no differences between graft lengths (p=0.48). One week after elevation and unfurling, the number of myelinated axons was significantly decreased in all groups (p

In this report, the case of a 24-year-old Caucasian female with type 2 membranoproliferative glomerulonephritis status-post living donor kidney transplant managed on triple regimen immunosuppressive therapy who developed shingles is discussed. With its onset, she promptly reached out to her nephrologist who deferred her to primary care. Prior to seeing her primary provider, she developed disseminated herpes zoster. She consulted emergency services where she was given inadequate care and again deferred to primary care. One day later, the dissemination included her entire torso, face, oral cavity, and all extremities. Fortunately, the patient had the insight to again reach out to her nephrologist who arranged for her to be admitted for appropriate care 6 days after her initial inquiry that carried 6 days of zoster progression. This case demonstrates how it is pertinent that specialists recognize potentially lethal complications associated with the conditions they follow. Although convenient to defer to primary care, if specialists were to take on the responsibility of providing a broader scope of care for their unique subsets of patients, it would likely result in a reduction in the 80% of serious medical errors that occur as a result of miscommunication, or lack thereof, between care providers.

The new kidney allocation system in the United States has introduced longevity matching, which gives priority to allocating the best quality organs to wait-listed candidates with the longest predicted survival for the efficient utilization of organs that are of limited availability. The estimated post-transplant survival (EPTS) score was developed in the United States to risk-stratify all wait-listed patients. However, prognostic indices used in Western countries were derived from data that may be different for Korea and do not necessarily reflect prognostic values for Korean deceased donor kidney transplantation. Prognostic indices for Korean wait-listed candidates therefore need to be developed from Korean data.We analyzed 6,731 adult solitary kidney transplant patients for candidate risk prediction using the national data from the Korean Network for Organ Sharing (KONOS) and National Health Insurance Data Sharing Service (NHISS). Cox regression analysis was used to model the risk of patient death.The Korean EPTS (K-EPTS) score was developed based on four recipient parameters (age, diabetes mellitus, hepatitis C virus, and duration of dialysis) that showed a significant association with post-transplant survival. K-EPTS scores showed good discrimination (C-statistics 0.690; 95% confidence interval, 0.666-0.715). Moreover, the ability of the K-EPTS score to discriminate patient survival was better than that of the EPTS according to the criteria of the United Network for Organ Sharing (US-EPTS) score (P0.001).The K-EPTS score, which was developed based on Korean national data, is expected to contribute to the assessment of recipient prognosis and efficient utilization of deceased donor kidneys.

BACKGROUND Allocation for pediatric deceased-donor kidney transplantation (pDDKT) in the United States now de-emphasizes HLA matching to improve equality in access to transplantation, but other national systems still consider HLA matching due to concerns about graft survival. We hypothesized that the impact of HLA mismatching has decreased over time due to advances including improved immunosuppression. METHODS Using Scientific Registry of Transplant Recipient data, we analyzed whether the association between the number of HLA mismatches and outcomes of first-time pDDKTs changed between 2 eras: 1995 to 2004 (N = 2854) and 2005 to 2014 (N = 4643). RESULTS Between eras, the median number of mismatches increased from 4 to 5 (P < 0.001). Overall graft failure risk was higher among HLA-mismatched versus HLA-matched transplants (adjusted hazard ratio 1.211.431.69 for 3-6 versus 0-2 mismatches; P < 0.001), and this association was similar pre-2005 and post-2005 (Pinteraction = 0.5). Median panel-reactive antibody change at relisting increased from 79 to 85 (P = 0.01), but the association between number of HLA mismatches and panel-reactive antibody change was similar between eras (Pinteraction = 0.6). CONCLUSIONS Our finding that increased HLA mismatching continues to impact graft survival, with 43% higher risk of graft failure, highlights the tradeoff between transplant access equity and outcomes and calls into question the deemphasis on HLA matching in pDDKT allocation in the United States.

Cytomegalovirus (CMV) may no longer be the menace that plagues stem cell transplant outcomes, owing to marked improvements in transplantation techniques and methods of prophylaxis. However, it still remains a common and morbid problem for recipients of stem cell transplant and patients with certain hematologic malignancies. This article discusses the epidemiology and risk factors of CMV infection and disease, associated morbidity and mortality, diagnosis, and clinical features of clinical syndromes associated with CMV and the principles of management of CMV, with special attention to resistant CMV as it pertains to infectious disease specialists.

Introduction Trichosporon asahii is an emerging cause of systemic fungal infection in an immunocompromised host. Several life threatening disseminated T. asahii infection in single solid organ (liver or kidney) transplant recipients, in neutropenic and hematological malignancy patients have been reported. Case presentation (Methods and Results) A 49‐year old gentleman who underwent simultaneous living‐donor liver transplantation (donor sister) and kidney transplant (donor wife) developed fever and subsegmental patchy consolidation with right sided pleural effusion on fourth postoperative day. Central line blood stream infection was suspected. Blood culture grew creamy white colonies of T. asahii on blood agar with characteristic dirty‐green colonies on CHROMagar. Laboratory analysis of pleural fluid also revealed budding yeast cells identified as T. asahii. Microscopy of the isolates showed hyphae, arthroconidia, and blastospores. The isolates were identified as T. asahii by VITEK MS which uses matrix‐assisted laser desorption/ionization time‐of‐flight (MALDI‐TOF) technology. Initially liposomal amphotericin B and micafungin was initiated, but due to lack of clinical and microbiological response, patient was switched to voriconazole. Simultaneously, tacrolimus doses were reduced to one‐third in view of interaction with voriconazole. Subsequently, patient improved with resolution of fever and microbiological cure. Conclusion This is the first case report of disseminated T. asahii infection in a combined liver‐kidney transplant recipient successfully treated with voriconazole. Azole antifungal are the promising drug of choice for systemic T. asahii infection. Drug interactions should be considered while using these antifungal agents.

Lung donor utilization rates remain low, with many organs refused for donor quality. However, some centers have successfully transplanted these organs despite multiple refusals for donor quality (RDQs) by other centers. We hypothesized that the number of refusals due to donor quality does not impact post-transplant outcomes.Lung transplants (LTxs) from 2006 to 2015, identified using the United Network for Organ Sharing (UNOS) database, were matched against the potential transplant recipient (PTR) data set by donor identification. Transplants were categorized into 2 groups: low RDQ (0 to 3 RDQs) and high RDQ (3 RDQs). Post-transplant survival and predictors for high RDQ were observed using Kaplan‒Meier and logistic regression analyses, respectively.Of 10,126 adult (18 years) LTxs, 77% had at least 1 RDQ, with a median of 4 RDQs. Post-transplant 1-year survival was similar for both the low and high RDQ groups (p = 0.49). Furthermore, groups of recipients who received donors with an increasing number of RDQs (3,6, or10) also had similar post-transplant 1-year survival (p = 0.77). Treatment for rejection within 1 year and intubation at 72 hours post-transplant were higher in the high RDQ group (p0.01). An inverse relationship was identified between the number of RDQs and likelihood of utilization. After 10 RDQs, the likelihood of utilization varied significantly by donor characteristics.Lung transplant survival is not associated with number of refusals due to donor quality. When determining whether an organ is suitable for transplant, the number of refusals due to donor quality should not influence one's decision, especially in this era of limited donor supply.

Intraoperative extracorporeal membrane oxygenation (ECMO) support, both venoarterial and venovenous (VV), have been used sparingly and with limited success in the setting of liver transplantation. Here, we report the successful use of VV-ECMO in the resuscitation and pulmonary bridging support after severe systemic inflammatory response in a combined liver and kidney transplant recipient who suffered primary nonfunction of both allografts. Where conventional ventilator maneuvers may prove ineffective, the implementation of VV-ECMO should be considered as a therapeutic option in limited, short-lived acute pulmonary injury.

Background Bezlotoxumab significantly reduces the incidence of recurrent Clostridioides difficile infection (CDI); however, limited data are available in solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients. Methods We conducted a single-center retrospective analysis comparing recurrent CDI in SOT and HCT recipients receiving standard of care alone (oral vancomycin, fidaxomicin, or metronidazole) or bezlotoxumab plus standard of care. The primary outcome was 90-day incidence of recurrent CDI, and secondary outcomes included 90-day hospital readmission, mortality, and incidence of heart failure exacerbation. Results Overall, 94 patients received bezlotoxumab plus standard of care (n = 38) or standard of care alone (n = 56). The mean age was 53 years; patients had a median of 3 prior Clostridioides difficile episodes and 4 risk factors for recurrent infection. Most patients were SOT recipients (76%), with median time to index CDI occurring 2.7 years after transplantation. Ninety-day recurrent CDI occurred in 16% (6/38) in the bezlotoxumab cohort compared to 29% (16/56) in the standard of care cohort (P = .13). Multivariable regression revealed that bezlotoxumab was associated with significantly lower odds of 90-day recurrent CDI (odds ratio, 0.28 [95% confidence interval, .08–.91]). There were no differences in secondary outcomes, and no heart failure exacerbations were observed. Conclusions In a cohort of primarily SOT recipients, bezlotoxumab was well tolerated and associated with lower odds of recurrent CDI at 90 days. Larger, prospective trials are needed to confirm these findings among SOT and HCT populations.

BackgroundImmune-checkpoint inhibition has improved outcomes in metastatic melanoma. However, limited data describes the safety and efficacy of this treatment in the setting of cardiac allograft. Emerging translational and clinical evidence suggests that the majority of the benefit from these therapies is driven by the initial dose(s), and that attenuated dosing schedules may be as effective as continuous treatment.Case presentationWe present a case vignette of a cardiac transplant recipient with metastatic melanoma who experienced six months of clinical benefit after one dose of pembrolizumab and did not suffer allograft rejection.ConclusionThis case adds to the current available literature on the administration of checkpoint inhibitors in patients with cardiac allografts. Further, it explores potential markers of immunotherapy response and supports the potential of shorter or individualized immune-checkpoint blockade dosing strategies.

More than 109,000 people in the United States were awaiting organ transplants in November 2020, and approximately 17 die each day before receiving one (1). Seeking to expand the pool of organs available to these patients, clinicians are beginning to look to sources once considered off-limits: organs from deceased donors with infections such as HIV and hepatitis C. Making more organs viable for transplant requires not only an effective treatment and reliable tests to detect infections, but also building the confidence of patients and doctors. Image credit: Shutterstock/David Tadevosian. At first, the notion of knowingly giving an organ from an infected donor to an immunosuppressed transplant recipient seems unthinkable. But a better understanding of the diseases caused by certain pathogens, as well as the availability of new drugs to treat or even prevent infections, mean that donor organs once discarded can now be used successfully. In recent years, this principle has been demonstrated dramatically via a series of hepatitis clinical trials: Organ recipients treated prophylactically with new, highly effective hepatitis C (HCV) medications were protected from infection after receiving organs from HCV-infected donors. This proof of concept was made possible in 2013, with advances in a curative new class of HCV drugs known as direct-acting antivirals. And it comes at a time when the opioid epidemic has, for tragic reasons, increased the potential supply of deceased organ donors—many of them infected with HCV. But researchers are also exploring ways to safely use organs from donors infected with other viruses, including HIV, as well as other pathogens. In all cases, making more organs viable requires not only an effective treatment and reliable tests to detect infections but also building the confidence of patients and doctors. Organ recipients and their physicians have always had to carefully weigh the benefits and risks of …

Human papillomavirus (HPV), a DNA virus, infects basal keratinocytes and causes common warts and as well as malignancies of skin and mucous membranes. Although many treatment options are available, persistent HPV infections are common among transplant recipients. Herein, we present a patient with a 15‐year history of treatment‐resistant warts that regressed during COVID‐19 (Coronavirus disease 2019) treatment.

Kidney transplant patients are prone to a variety of complications, even for the most experienced surgical teams. Our busy transplant center recently performed its 5,000th solid organ transplant. We present the case of an 18-year-old male with end-stage renal disease who underwent a deceased donor kidney transplant. He developed a urine leak from the necrotic lower pole of his graft kidney and subsequently developed urosepsis and was admitted. Clinicians must have a high suspicion for complications in the immediate post-operative period in kidney transplant patients. In this report, we will highlight our diagnostic and treatment steps to preserve the patient's graft while addressing his rare complications.

We recently read with interest the article entitled "Clearance of longstanding treatment-resistant warts during COVID-19 in a transplant recipient" by Erkayman et al.1 The authors report on a 49-year-old man, known to have had renal transplantation and maintained on immunosuppressive therapy, who had a longstanding resistant warts regressing during the course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The authors speculated on possible mechanism leading to wart regression including the immunological response against SARS-CoV-2.

Objectives To investigate:(1) the risk of severe COVID-19 in those eligible for shielding, and (2) the relation of severe COVID-19 to transmission-related factors in those in shielding and the general population. Design Matched case-control study (REACT-SCOT). Setting Population of Scotland from 1 March 2020 to 28 January 2021. Participants All 160307 diagnosed cases of COVID-19 and 1564782 controls matched for age, sex and primary care practice, linked with all 204913 individuals identified as eligible for shielding by Public Health Scotland. Main outcome measure Severe COVID-19, defined as cases that entered critical care or were fatal. Results With those without risk conditions as reference category, the univariate rate ratio for severe COVID-19 was 5.3 (95% CI 5.0 to 5.7, p=4 × 10−527) in those with moderate risk conditions and 7.6 (95% CI 7.1 to 8.3, p=1 × 10−527) in those eligible for shielding. The highest rate was in solid organ transplant recipients: rate ratio 13.6 (95% CI 9.6 to 19.2, p=8 × 10−50). In both the shielded and the general population, the risk of severe COVID-19 increased with the number of adults but decreased with the number of school-age children in the household. Severe COVID-19 was strongly associated with recent exposure to hospital (defined as 5 to 14 days before presentation date): rate ratio 12.6 (95% CI 11.7 to 13.6, p=2 × 10−989) overall. In a case-crossover analysis with less recent exposure only (15 to 24 days before first testing positive) as reference category, the rate ratio associated with recent exposure only was 6.3 (95% CI 3.6 to 11.1, p=2 × 10−10). Among those eligible for shielding, the population attributable risk fraction (PARF) of severe cases for recent exposure to hospital was 36%. In the general population the PARF for recent exposure to hospital peaked at 46% in May 2020 and again at 64% in December 2020. Conclusions The effectiveness of shielding vulnerable individuals was limited by the inability to control transmission in hospital and from other adults in the household. For solid organ transplant recipients, in whom the efficacy of vaccines is uncertain, these results support a policy of offering vaccination to household contacts. Mitigating the impact of the epidemic requires control of nosocomial transmission. Summary What is already known on this topic? Individuals designated as “clinically extremely vulnerable” – about 3% of the population – have been advised to shield themselves during the COVID-19 epidemic The effectiveness of this shielding programme has not been evaluated. What this study adds Hospital-acquired infection has made a substantial contribution to the burden of COVID-19 in the population, accounting for more than half of severe cases in early December 2020. For vulnerable individuals to be shielded, the risk of hospital-acquired infection must be reduced and support must be provided for other adults in the household to co-isolate with the vulnerable individual. Solid organ transplant recipients are at the highest risk; vaccination of household contacts should be considered for this group.

Preoperative sensitization of the cardiac transplant recipient, defined as the presence of anti-Human Leukocyte Antigen (HLA) antibodies before transplant, represents a significant management challenge for physicians. Sensitization prolongs the pre-transplant wait time and is associated with postoperative transplant complications and death. It is critical that sensitized heart transplant candidates be identified and optimized before surgery. In this review, we describe the risk for sensitization, discuss the means through which sensitization may be diagnosed, and highlight some of the new therapeutic options for managing the sensitized cardiac transplant patients.

Background HHV-8/Kaposi Sarcoma herpesvirus has been associated with a broad spectrum of diseases in solid organ transplant (SOT) recipients. Primary donor-derived infection can be associated with severe and rapidly fatal non-neoplastic disease, and diagnosis is made with high HHV-8 DNAemia. Methods We carried out an international survey to investigate the current approach to HHV-8 screening, and management in SOT since a protocol has not been established by international guidelines. Results A total of 51 transplant centers from 15 countries filled out the survey. HHV-8-associated diseases in SOT have been diagnosed during the previous 5 years in 67% of centers. Pretransplant serological screening is performed in 17 centers (33%), and posttransplant HHV-8 nucleic acid testing (NAT) monitoring is performed in 21 centers (41%). Performing HHV-8 NAT monitoring and serological screening were found associated with having diagnosed in the previous 5 years a non-malignant HHV-8-associated disease. Conclusions Serological pretransplant screening of donors and recipients and post-transplant HHV-8 NAT monitoring recommendations should be standardized. Even though serological assays are not optimal, they could contribute to increasing knowledge on epidemiology and management of HHV-8-associated diseases after SOT.

The permanent gap between organ demand and supply has prompted use of organs from extended criteria donors (ECD). These carry a higher risk of disease transmission, with regard to infections and malignancies. We present herein the donor risk stratification algorithm implemented in Italy since 2004 for identification management of donor-to-recipient risk of disease transmission. The principles underlying this algorithm are: (1) the risk of disease transmission must be assessed against the potential benefit for the transplant recipient (i.e., no donor can be excluded from evaluation and their organs might benefit potential candidates); (2) patients awaiting organ transplantation must be informed that the risk of disease transmission is small but finite (standard risk); and (3) risk evaluation is an ongoing process based on information collected longitudinally after transplantation. Regional and national transplant authorities are committed to regular updating of guidelines based on clinical data derived from clinicians and on evaluation of posttransplant graft and patient survival rates.

BK polyomavirus (BKPyV) has been associated with some high-grade and special urothelial cell carcinoma (UCC) subtypes in immunosuppressed patients. Here, we evaluated the relationship of BKPyV-positive urine cytology specimens (UCS) with UCC. A large single-institution database was retrospectively searched for UCS positive for decoy cells, suggesting BKPyV infection. These were tested for the presence of BKPyV by PCR and immunohistochemistry (IHC) in urine sediments and formalin-fixed paraffin-embedded (FFPE) tissue samples of UCC. Decoy cells were reported in 30 patients out of the database with 22.867 UCS. Of these 30 patients, 16 (53.3%) had no history of UCC. Six patients out of these 16 had a history of transplantation, 4 had a history of severe chronic medical conditions, and 6 had no chronic disease. The other fourteen patients were diagnosed with either in situ or invasive UCC of the urinary bladder (14/30, 46.6%) prior to the detection of decoy cells in the urine. Nine of these UCC patients received intravesical treatment (BCG or mitomycin) after the first presentation with UCC. However, the clinical data on the treatment of the other five UCC patients was lacking. IHC identified BKPyV-positivity in the urine samples of non-UCC and UCC patients, while no BKPyV positivity was found in FFPE tissues of primary UCCs and metastases. In addition, BKPyV-PCR results revealed the presence of BKPyV DNA in the urine of the UCC cases, yet none in the UCC tissues itself. These data strongly indicate that BKPyV reactivation is not restricted to immunosuppression. It can be found in UCS of the immunocompetent patients and may be related to the intravesical BCG or mitomycin treatment of the UCC patients.

Cytomegalovirus (CMV) retinitis (CMVR) has been reported rarely in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). In addition, little is known about strategies for ophthalmic surveillance and adequate antiviral treatment of CMVR. A case of CMVR in an allogeneic HSCT recipient is described, including clinical signs and therapy. An adult patient received HSCT from a matched unrelated donor for treatment of a Burkitt lymphoma. Donor and recipients were both CMV positive. Starting on day +40, the patient presented multiple CMV reactivation, treated with valganciclovir, foscarnet and a combination of both. On day +160, the patient started complaining of conjunctival hyperaemia and a decrease in visual acuity. Fundoscopy revealed retinal lesions consistent with CMVR, although whole blood CMV DNAemia was negative. Aqueous humor biopsy showed the presence of CMV infection (CMV DNA 230400 UI/ml). CMVR was treated with foscarnet (180 mg i.v. and 1.2 mg intravitreal injection) combined with anti CMV immunoglobulin at 0.5 ml/kg every 2 weeks. After 4 weeks of systemic therapy, 20 weekly doses of intravitreal foscarnet and six cycles of immunoglobulins, a significant improvement of visual acuity was observed. The treatment was well tolerated with no side effect. In conclusion, our case suggests that systemic and local antiviral treatment combined with CMV-specific-IVIG, may reduce CMV load in the eye of patients with CMVR, leading to a consistent improvement of visual acuity. Systematic ophthalmologic examination should be recommended in HSCT recipients with multiple CMV reactivations and high peak CMV DNA levels.

Kidney-alone transplant (KAT) candidates may be disadvantaged by the allocation priority given to multi-organ transplant (MOT) candidates. This study identified potential KAT candidates not receiving a given kidney offer due to its allocation for MOT. Using the Organ Procurement and Transplant Network (OPTN) database, we identified deceased donors from 2002 to 2017 who had one kidney allocated for MOT and the other kidney allocated for KAT or simultaneous pancreas-kidney transplant (SPK) (n = 7,378). Potential transplant recipient data were used to identify the "next-sequential KAT candidate" who would have received a given kidney offer had it not been allocated to a higher prioritized MOT candidate. In this analysis, next-sequential KAT candidates were younger (p < .001), more likely to be racial/ethnic minorities (p < .001), and more highly sensitized than MOT recipients (p < .001). A total of 2,113 (28.6%) next-sequential KAT candidates subsequently either died or were removed from the waiting list without receiving a transplant. In a multivariable model, despite adjacent position on the kidney match-run, mortality risk was significantly higher for next-sequential KAT candidates compared to KAT/SPK recipients (hazard ratio 1.55, 95% confidence interval 1.44, 1.66). These results highlight implications of MOT allocation prioritization, and potential consequences to KAT candidates prioritized below MOT candidates.

Introduction. COVID-19 presents a special challenge to the kidney transplant population. Methods. A systematic review of articles that examined COVID-19 in kidney transplant recipients was performed. Patients’ demographics, clinical, laboratory and radiological presentations, immunosuppression modification, and COVID-19 specific management were abstracted and analyzed. COVID-19 severity was classified into mild, moderate, and severe. Disease outcome was classified by whether the patient was discharged, still hospitalized, or died. Results. 44 articles reporting individual data and 13 articles reporting aggregated data on 149 and 561 kidney transplant recipients respectively with COVID-19 from Asia, Europe and America fulfilled all inclusion and exclusion criteria. Among studies reporting case specific data, 76% of cases had severe disease. Compared to patients with mild/moderate disease, patients with severe disease had higher CRP, LDH, Ferritin, D-dimer and were more likely to have bilateral lung involvement at presentation and longer time since transplantation (P < 0.05 for all). Recipients’ age, gender and comorbidities did not impact disease severity. Patients with severe disease had a more aggressive CNI reduction and more antiviral medications utilization. Outcome was reported on 145 cases, of those 34 (23%) died all with severe disease. Longer duration from transplant to disease diagnosis, hypoxia and higher LDH were associated with mortality (P < 0.05). Different immunosuppression reduction strategies, high dose parenteral corticosteroids use and various antiviral combinations did not demonstrate survival advantage. Similar finding was observed for studies reporting aggregated data. Conclusion. COVID-19 in kidney transplant patients is associated with high rate of disease severity and fatality. Higher LDH and longer time since transplantation predicted both disease severity and mortality. None of the COVID-19 specific treatment correlated with, or improved disease outcome in kidney transplant recipients.

Key Points A patient with myelodysplastic syndrome was transplanted twice and developed clonally unrelated relapse each time in donor-derived cells. This case supports the concept that a leukemogenic marrow environment may predispose the transplant recipient to malignant transformation.

The novel coronavirus disease 2019 (COVID‐19) is associated with increased risk of thromboembolic events, but the extent and duration of this hypercoagulable state remains unknown. We describe the first case report of renal allograft infarction in a 46‐year‐old kidney‐pancreas transplant recipient with no prior history of thromboembolism, who presented 26 days after diagnosis of COVID‐19. At the time of renal infarct, he was COVID‐19 symptom free and repeat test for SARS‐CoV‐2 was negative. This case report suggests that a hypercoagulable state may persist even after resolution of COVID‐19. Further studies are required to determine thromboprophylaxis indications and duration in solid organ transplant recipients with COVID‐19.

Substance abuse is infrequently addressed during pre- and post-transplant care. However, the significant increase in the use of nicotine- and marijuana-containing products in the general and transplant adolescent population is concerning. In addition, alcohol use/abuse remains prevalent in the US population as it is highly accessible. Pediatric transplant providers should be prepared to screen for the use of any of these substances (eg, alcohol, nicotine, marijuana, cocaine, opiates, amphetamines) and to counsel them about the dangers of substance use and abuse including the unique dangers of the substances as a transplant recipient. Formal screening tools (in children as young as 9 years) should always be used as casual assessment of substance abuse has a high failure rate. This review summarizes the substances most commonly used in adolescent transplant recipients and the approach that transplant providers should take in order to prevent, decrease, or halt use in this patient population.

Vaccine-preventable diseases (VPD) are a significant risk to paediatric solid organ transplant (SOT) recipients on lifelong immunosuppressive therapy. Children progressing to end-stage organ dysfunction are unable to mount a robust immune response. Hence, it is important to plan vaccination early in the course of disease, especially if a child is anticipated to be a SOT candidate. Vaccine recommendations need to be individualised in this population based on vaccine history and serology. Catch-up or accelerated schedules may be used to complete vaccinations before transplant. Post-transplant, immunisation is recommenced in consultation with the transplant team taking into context the time since transplant and the intensity of the immunosuppressive regime. Inactivated vaccines are safe post-transplant but postexposure prophylaxis may still be required in children with inadequate immunity to VPD. Specific vaccines may be advised for SOT recipients travelling abroad (in consultation with a travel clinic) or those entering high-risk professions. Additionally, the vaccination status of all household members and close contacts should be reviewed and optimised, offering additional protection to the transplant recipient.

Iliac atherosclerosis is common in renal transplant recipients. In severe cases, it affects intraoperative renal arterial anastomosis and increases the risk of postanastomosis complications. At present, safe and efficient vascular replacement methods are relatively limited. In the 2 renal transplant cases at our center, described here, the donors' iliac arteries were unavailable. We therefore attempted to replace the recipients' diseased external iliac artery with the donors' inferior vena cava and then performed an end-to-side grafting with the attachment in arterial reconstruction. One patient received a single kidney transplantation, while the other received a dual kidney transplantation. Antiplatelet/anticoagulation drug application was avoided, and both patients were observed for more than 6 months. Stable renal graft function was achieved without any vascular complications. During this study, all procedures were in compliance with the Helsinki Congress and the Declaration of Istanbul. For end-stage renal disease patients with severe iliac atherosclerosis who are waiting for kidney transplantation, a donor's vena cava graft could potentially be a promising replacement option to restore external iliac artery patency and reconstruct renal blood flow, without the necessity of harvesting a recipient's autologous vessels or looking for costly artificial ones.