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Background: Recent studies suggest the transplantation of Hepatitis C (HCV) hearts from viremic donors is associated with comparable 1 year survival to nonviremic donors. Though HCV viremia is a known risk factor for accelerated atherosclerosis, data on cardiac allograft vasculopathy (CAV) outcomes are limited. We compared the incidence of CAV in heart transplant recipients from HCV viremic donors (nucleic acid amplification test positive; NAT+) compared to non‐HCV infected donors (NAT−). Methods: We retrospectively reviewed annual coronary angiograms with intravascular ultrasound from April 2017 to August 2020 at two large cardiac transplant centers. CAV was graded according to ISHLT guidelines. Maximal intimal thickness (MIT) ≥ 0.5 mm was considered significant for subclinical disease. Results: Among 270 heart transplant recipients (mean age 54; 77% male), 62 patients were transplanted from NAT+ donors. CAV ≥ grade 1 was present in 8.8% of the NAT+ versus 16.8% of the NAT‐ group at 1 year, 20% versus 28.8% at 2 years, and 33.3% versus 41.5% at 3 years. After adjusting for donor age, donor smoking history, recipient BMI, recipient, hypertension, and recipient diabetes, NAT+ status did not confer increased risk of CAV (HR.80; 95% CI.45–1.40, p = 0.43) or subclinical IVUS disease (HR.87; 95% CI.58–1.30, p = 0.49). Additionally, there was no difference in the presence of rapidly progressive lesions on IVUS. Conclusion: Our data show that NAT+ donors conferred no increased risk for early CAV or subclinical IVUS disease following transplantation in a cohort of heart transplant patients who were treated for HCV, suggesting the short‐term safety of this strategy to maximize the pool of available donor hearts. [ABSTRACT FROM AUTHOR]

Background: Little is known about the relationship between cytomegalovirus (CMV) infections and donor‐derived cell‐free DNA (dd‐cfDNA) in heart transplant recipients. Methods: In our study, CMV and dd‐cfDNA results were prospectively collected on single‐organ heart transplant recipients. If the CMV study was positive, a CMV study with dd‐cfDNA was repeated 1‐3 months later. The primary aim was to compare dd‐cfDNA between patients with positive and negative CMV results. Results: Of 44 patients enrolled between August 2022 and April 2023, 12 tested positive for CMV infections, 25 were included as controls, and seven patients with a viral infection without CMV were excluded. Baseline characteristics did not differ significantly between CMV‐positive and CMV‐negative patients with the exception of a later median time post‐transplant in the CMV‐positive group (253 days vs. 120 days, p =.03). Dd‐cfDNA levels were significantly higher in patients with CMV infections compared to those without (p <.001) with more patients in the CMV positive group showing dd‐cfDNA results ≥.12% (75% vs. 8%, p <.001) and ≥.20% (58% vs. 8%, p =.002). Each 1 log10 copy/ml reduction in CMV viral load from visit 1 to visit 2 was associated with a.23% reduction in log10 dd‐cfDNA (p =.002). Conclusion: Our findings suggest that active CMV infections may raise dd‐cfDNA levels in patients following heart transplantation. Larger studies are needed to validate these preliminary findings. [ABSTRACT FROM AUTHOR]

Background: National data demonstrate that hepatitis C virus (HCV)—infected organ donors are increasingly being used in the US, including for lung transplantation. We aimed to assess whether there were any differences in the acute or chronic rejection rates at 1 year following lung transplantation from HCV‐viremic versus uninfected donors. Methods: We retrospectively reviewed all lung transplant recipients at our institution from April 1, 2017 to October 1, 2020 and then assessed various outcomes between those who received a transplant from HCV‐viremic donors versus HCV‐negative donors. Primary outcome was to determine if there was a higher incidence of acute and/or chronic allograft rejection when using HCV NAT+ lung donation. We carried out univariate and multivariate analyses. Results: We transplanted 135 patients during the study period, including 18 from HCV‐viremic donors. Standard induction therapy with basiliximab and maintenance triple drug immunosuppression was utilized per UC San Diego protocol. All 17 patients receiving HCV‐viremic organs developed acute HCV infection and were treated in the postoperative period with 12 weeks of direct acting antivirals (DAA). HCV genotypes included 1, 2, and 3. DAA used included glecaprevir/pibrentasvir (12), sofosbuvir/velpatasvir (1), and ledipasvir/sofosbuvir (2) with drug choice determined by patient's medical insurance coverage. Sustained virological response at 12 weeks after end of DAA therapy (SVR12), indicative of a cure, was achieved in all (100%) recipients. No recipient had a serious adverse event related to HCV infection. The lung transplant recipient (LTR) HCV‐viremic donors had lower rates of clinically significant rejection (5.9% vs. 11% LTR HCV‐nonviremic donors), and no chronic lung allograft dysfunction at 1 year (vs. 5.9% LTR HCV‐nonviremic donors). One‐year survival was 100% in the LTR HCV‐viremic donors compared to 95.8% in the LTR HCV‐nonviremic donors. Conclusions: We demonstrate the feasibility and success of using HCV NAT + donors with excellent results and without a higher incidence of rejection. Longer term follow‐up and a larger sample size are needed to allow this to be a more widely accepted practice for lung transplant programs and payors. [ABSTRACT FROM AUTHOR]

Liver transplantation (LT) with hepatitis B core antibody (anti‐HBc) positive grafts to hepatitis B surface‐antigen (HBsAg) negative recipients is safe and has likely contributed to improvements in organ access over the years. The incidence of de novo hepatitis B infection (HBV) in these instances is low with appropriate prophylaxis and is affected by recipient immunologic status. There is debate as to whether hepatitis B surface antibody (anti‐HBs) positivity may safely inform prophylaxis discontinuation post‐LT. In this retrospective study of all hepatitis B surface antigen (HBsAg) negative recipients of anti‐HBc positive organs at three large academic centers between January 2014 and December 2019, nine LT recipients discontinued prophylaxis after developing anti‐HBs antibodies 1 year or later post‐LT. Three of the nine patients (33%) developed de novo HBV, defined by positive HBsAg or hepatitis B virus (HBV) DNA, during the study period. The remaining six patients had no evidence of HBV infection after a mean follow‐up of 37 months. The patients without de novo HBV had higher anti‐HBs titers at the time of prophylaxis discontinuation and were less likely to have negative anti‐HBs at the time of transplant or negative anti‐HBc at any time point. These results suggest that quantitative anti‐HBs titer thresholds rather than qualitative anti‐HBs positivity at 1 year or later after LT should be used to identify patients at decreased risk of de novo infection and help guide prophylaxis duration. [ABSTRACT FROM AUTHOR]

Background: Experience with lung transplantation (LT) in patients with human immunodeficiency virus (HIV) is limited. Many studies have demonstrated the success of kidney and liver transplantation in HIV‐seropositive (HIV+) patients. Our objective was to conduct a national registry analysis comparing LT outcomes in HIV+ to HIV‐seronegative (HIV−) recipients. Methods: The United Network for Organ Sharing database was queried to identify LTs performed in adult HIV+ patients between 2016 and 2023. Patients with unknown HIV status, multiorgan transplants, and redo transplants were excluded. The primary endpoints were mortality and graft rejection. Survival time was analyzed using Kaplan–Meier analysis. Results: The study included 17 487 patients, 67 of whom were HIV+. HIV+ recipients were younger (59 vs. 62 years, p =.02), had higher pulmonary arterial pressure (28 vs. 25 mm Hg, p =.04), and higher lung allocation scores (47 vs. 41, p =.01) relative to HIV− recipients. There were no differences in graft/recipient survival time between groups. HIV+ recipients had higher rates of post‐transplant dialysis (18% vs. 8.4%, p =.01), but otherwise had similar post‐transplant outcomes to HIV‐recipients. Conclusions: This national registry analysis suggests LT outcomes in HIV+ patients are not inferior to outcomes in HIV− patients and that well‐selected HIV+ recipients can achieve comparable patient and graft survival rates relative to HIV− recipients. [ABSTRACT FROM AUTHOR]

Background: While presumably less common with modern molecular diagnostic and imaging techniques, fever of unknown origin (FUO) remains a challenge in kidney transplant recipients (KTRs). Additionally, the impact of FUO on patient and graft survival is poorly described. Methods: A cohort of adult KTRs between January 1, 1995 and December 31, 2018 was followed at the University of Wisconsin Hospital. Patients transplanted from January 1, 1995 to December 31, 2005 were included in the "early era"; patients transplanted from January 1, 2006 to December 31, 2018 were included in the "modern era". The primary objective was to describe the epidemiology and etiology of FUO diagnoses over time. Secondary outcomes included rejection, graft and patient survival. Results: There were 5590 kidney transplants at our center during the study window. FUO was identified in 323 patients with an overall incidence rate of.8/100 person‐years. Considering only the first 3 years after transplant, the incidence of FUO was significantly lower in the modern era than in the early era, with an Incidence Rate Ratio (IRR) per 100 person‐years of.48; 95% CI:.35–.63; p <.001. A total of 102 (31.9%) of 323 patients had an etiology determined within 90 days after FUO diagnosis: 100 were infectious, and two were malignancies. In the modern era, FUO remained significantly associated with rejection (HR = 44.1; 95% CI: 16.6–102; p <.001) but not graft failure (HR = 1.21; 95% CI:.68–2.18; p =.52) total graft loss (HR = 1.17; 95% CI:.85–1.62; p =.34), or death (HR = 1.17; 95% CI:.79–1.76; p =.43. Conclusions: FUO is less common in KTRs during the modern era. Our study suggests infection remains the most common etiology. FUO remains associated with significant increases in risk of rejection, warranting further inquiry into the management of immunosuppressive medications in SOT recipients in the setting of FUO. [ABSTRACT FROM AUTHOR]

Mortality among patients hospitalized for COVID-19 has declined over the course of the pandemic. Mortality trends specifically in solid organ transplant recipients (SOTR) are unknown. Using data from a multicenter registry of SOTR hospitalized for COVID-19, we compared 28-day mortality between early 2020 (March 1, 2020-June 19, 2020) and late 2020 (June 20, 2020-December 31, 2020). Multivariable logistic regression was used to assess comorbidity-adjusted mortality. Time period of diagnosis was available for 1435/1616 (88.8%) SOTR and 971/1435 (67.7%) were hospitalized: 571/753 (75.8%) in early 2020 and 402/682 (58.9%) in late 2020 (p

Lung transplant recipients are at an increased risk for Clostridioides difficile infection (CDI), and those who develop CDI post‐transplant can have worsened outcomes including graft failure and death. We sought to describe the efficacy and safety of primary CDI prophylaxis with oral vancomycin among 86 adult lung transplant recipients. Overall, we observed a 9.3% (8/86) incidence of CDI among patients receiving prophylaxis, with the majority of infections occurring a median of 25 days after completion of prophylaxis. Furthermore, we observed a 4.7% incidence of VRE infection/colonization. Opportunities exist to optimize the duration of CDI prophylaxis to balance the benefits and risks in lung transplant recipients. [ABSTRACT FROM AUTHOR]

Background: Post‐transplant lymphoproliferative disorder (PTLD) is a serious complication of pediatric heart transplant (PHTx). 18F‐FDG PET/CT has been used to differentiate early lympho‐proliferation from more advanced PTLD. We report our experience with PET/CT in the management of PTLD following PHTx. Methods: This was a retrospective study of 100 consecutive PHTx recipients at our institution between 2004 and 2018. Patients who underwent PET/CT or conventional CT scans to evaluate for PTLD or high Epstein‐Barr viral load were included. Results: Males, eight females. Median age at transplant was 3.5 months (IQR = 1.5‐27.5). Median age at PTLD diagnosis was 13.3 years (IQR = 9.2‐16.1). Median time between transplant and PTLD diagnosis was 9.5 (IQR = 4.5‐15) years. Induction agents were used in 12 patients (50%): Thymoglobulin (N = 9), anti‐IL2 (N = 2), and Rituximab (N = 1). Eighteen patients (75%) had PET/CT, of whom 14 had 18FDG‐avid PTLD. Six had conventional CT. Nineteen patients (79.2%) had diagnostic biopsy confirmation of PTLD, and 5 (20.8%) had excisional biopsies. Two patients had Hodgkin's lymphoma; nine had monomorphic PTLD; eight had polymorphic PTLD; five were classified as other. Nine patients had monomorphic PTLD, including seven with diffuse large cell lymphoma (DLBC) and one with T cell lymphoma. The majority (16/24) had multi‐site involvement at PTLD diagnosis, and PET/CT showed that 31.3% (5/16) had easily accessible subcutaneous nodes. Seventeen patients (overall survival 71%) underwent successful treatment without recurrence of PTLD. Of seven deaths (7/24, 29%), five had DLBC lymphoma, one had polymorphic PTLD and one had T‐cell lymphoma. Conclusion: PET‐CT allowed simultaneous anatomical and functional assessment of PTLD lesions, while guiding biopsy. In patients with multiple lesions, PET/CT revealed the most prominent and active lesions, improving diagnostic accuracy. [ABSTRACT FROM AUTHOR]

There are limited data on the impact of COVID-19 in children with a kidney transplant (KT). We conducted a prospective cohort study through the Improving Renal Outcomes Collaborative (IROC) to collect clinical outcome data about COVID-19 in pediatric KT patients. Twenty-two IROC centers that care for 2732 patients submitted testing and outcomes data for 281 patients tested for SARS-CoV-2 by PCR. Testing indications included symptoms and/or potential exposures to COVID-19 (N = 134, 47.7%) and/or testing per hospital policy (N = 154, 54.8%). Overall, 24 (8.5%) patients tested positive, of which 15 (63%) were symptomatic. Of the COVID-19-positive patients, 16 were managed as outpatients, six received non-ICU inpatient care and two were admitted to the ICU. There were no episodes of respiratory failure, allograft loss, or death associated with COVID-19. To estimate incidence, subanalysis was performed for 13 centers that care for 1686 patients that submitted all negative and positive COVID-19 results. Of the 229 tested patients at these 13 centers, 10 (5 asymptomatic) patients tested positive, yielding an overall incidence of 0.6% and an incidence among tested patients of 4.4%. Pediatric KT patients in the United States had a low estimated incidence of COVID-19 disease and excellent short-term outcomes.

Lung transplant recipients (LTR) with coronavirus disease 2019 (COVID-19) may have higher mortality than non-lung solid organ transplant recipients (SOTR), but direct comparisons are limited. Risk factors for mortality specifically in LTR have not been explored. We performed a multicenter cohort study of adult SOTR with COVID-19 to compare mortality by 28 days between hospitalized LTR and non-lung SOTR. Multivariable logistic regression models were used to assess comorbidity-adjusted mortality among LTR vs. non-lung SOTR and to determine risk factors for death in LTR. Of 1,616 SOTR with COVID-19, 1,081 (66%) were hospitalized including 120/159 (75%) LTR and 961/1457 (66%) non-lung SOTR (p = .02). Mortality was higher among LTR compared to non-lung SOTR (24% vs. 16%, respectively, p = .032), and lung transplant was independently associated with death after adjusting for age and comorbidities (aOR 1.7, 95% CI 1.0-2.6, p = .04). Among LTR, chronic lung allograft dysfunction (aOR 3.3, 95% CI 1.0-11.3, p = .05) was the only independent risk factor for mortality and age >65 years, heart failure and obesity were not independently associated with death. Among SOTR hospitalized for COVID-19, LTR had higher mortality than non-lung SOTR. In LTR, chronic allograft dysfunction was independently associated with mortality.

A novel coronavirus has had global impact on individual health and health care delivery. In this C4 article, contributors discuss various aspects of transplantation including donor and recipient screening, management of infected patients, and prevention of coronavirus disease (COVID). Donor screening with SARS-CoV-2 nucleic acid testing (NAT) close to the time of procurement is recommended. Many programs are also screening all potential recipients at the time of admission. The management of COVID has evolved with remdesivir emerging as a new potential option for transplant recipients. Dexamethasone has also shown promise and convalescent plasma is under study. Prevention strategies for transplant candidates and recipients are paramount. Pediatric-specific issues are also discussed. Strategies for the psychological well-being of patients and providers are also imperative, in addition to future research priorities for transplantation.

As the SARS-CoV-2-pandemic continues to unfold, the number of heart transplants completed in the United States has been declining steadily. The current case series examines the immediate short-term outcomes of seven heart transplant recipients transplanted during the SARS-CoV-2 pandemic. We hope to illustrate that with proper preparation, planning, and testing, heart transplantation can be continued during a pandemic. We assessed 7 patients transplanted from March 4, 2020, to April 15, 2020. The following endpoints were noted: in-hospital survival, in-hospital freedom from rejection, in-hospital nonfatal major cardiac adverse events (NF-MACE), severe primary graft dysfunction, hospital length of stay, and ICU length of stay. There were no expirations throughout the hospital admission. In addition, there were no patients with NF-MACE or treated rejection, and 1 patient developed severe primary graft dysfunction. Average length of stay was 17.2 days with a standard deviation of 5.9 days. ICU length of stay was 7.7 days with a standard deviation of 2.3 days. Despite the decreasing trend in completed heart transplants due to SARS-CoV-2, heart transplantation appears to be feasible in the immediate short term. Further follow-up is needed, however, to assess the impact of SARS-CoV-2 on post-heart transplant outcomes months after transplantation.

Our previous Multicenter Trial to Transplant HCV‐infected Kidneys (MYTHIC) observed that 100% of hepatitis C virus (HCV)‐uninfected patients who received a kidney from an HCV‐infected deceased donor were cured of HCV with an 8‐week regimen of glecaprevir and pibrentasvir (G/P) initiated 2–5 days after transplantation. Following acute and chronic infection with HCV, immune system perturbations have been reported to persist even after viral clearance. The aim of this study was to determine whether HCV viremic kidney recipients in the MYTHIC study experience sustained changes in the soluble inflammatory milieu associated with HCV infection. Among nine patients with HCV viremia at day 3 post‐kidney transplant (post‐KT D3), IP‐10, IL‐10, MIP‐1β, and IL‐8 were significantly elevated from baseline. However, over the subsequent visits, there was a rapid, dramatic reduction back to baseline levels. Among seven patients who were not HCV viremic at post‐KT D3, the cytokine levels did not significantly change. HCV‐uninfected patients who received a kidney from an HCV‐viremic deceased donor and were treated with early G/P experienced only transient alterations in the soluble inflammatory milieu. These data provide reassuring evidence that there appear to be no persistent cytokine disturbances with transient HCV viremia accompanying HCV donor positive/recipient negative kidney transplant. [ABSTRACT FROM AUTHOR]

The increased procurement of organs from donors with risk factors for blood‐borne diseases and the expanding syphilis epidemic have resulted in a growing number of organs transplanted from donors with reactive syphilis serology in our center. Based on guidelines, recipients typically receive therapy shortly after the transplant, but data on outcomes are limited. The primary objective of this study was to determine syphilis seroconversion rates at three months post‐transplant in recipients of solid organs procured from donors with reactive syphilis serology. Organ donors and recipients were tested for syphilis antibody; positive results were confirmed with Treponema pallidum Particle Agglutination (TPPA). Eleven donors with reactive syphilis antibody donated organs to 25 syphilis negative recipients. Three recipients seroconverted at post‐transplant month 3. All of them had received therapy shortly after transplant. TPPA was negative in all 3. Despite post‐transplant treatment, 3 of 25 (12%) syphilis negative recipients of organs from syphilis positive donors seroconverted at 3 months. All remained TPPA negative possibly reflecting passive antibody transfer or differing test sensitivity to low level treponemal antibodies. Further studies are needed to assess optimal syphilis transmission prevention strategies and follow up recipient testing in organ transplantation. [ABSTRACT FROM AUTHOR]

Purpose: Studies conducted in the northern United States found cytomegalovirus (CMV) disease after liver transplantation follows a seasonal pattern, with increased incidence in fall and winter. This has not been evaluated in kidney transplant recipients. Improved understanding of CMV seasonality may help guide use of preventative therapies. Methods: We evaluated adult patients receiving a kidney transplant at our center in Wisconsin from January 1, 1995 to December 31, 2018. CMV event was defined as quantifiable viral replication with clinical signs or symptoms suspicious for CMV per current consensus recommendations. Seasons were divided as follows: winter (December–February), spring (March–May), summer (June–August), and fall (September–November). The primary objective was to evaluate the annual distribution of CMV disease and determine whether this differed by season. Results: There were 6151 kidney transplants in the study period. A total of 913 patients had 1492 episodes of CMV. Median time from transplant to first detection was 5.51 months (interquartile range [IQR] 2.87–11.7). The observed overall incidence exceeded the expected incidence in winter (+.7%), spring (+5.5%), and fall (+3.4%) and was less than expected in summer (−9.5%) (p =.18). The incidence of CMV during summer, however, was 21% less than expected (p =.001) in recipients who were CMV positive (R+) at the time of transplantation. No such difference was observed in CMV negative recipients (R−; p =.58). Conclusion: CMV after kidney transplant appears to be less common during the summer season in patients who were R+ at transplant but does not follow seasonal variation in R−. Reasons for this are unclear but are likely related to CMV‐specific cell‐mediated immunity. These findings may have clinical implications, particularly the use of non‐pharmacologic strategies to improve response to antiviral therapy. [ABSTRACT FROM AUTHOR]

Lung transplant immunosuppression regimens generally include the calcineurin inhibitor tacrolimus. We hypothesized that mean residual expression (MRE) of calcineurin-dependent genes assesses rejection and infection risk better than does tacrolimus trough. We prospectively followed 44 lung allograft recipients at 2 to 18 months posttransplant and measured changes in whole blood interleukin-2, interferon-γ, and granulocyte-macrophage colony-stimulating factor gene expression following a tacrolimus dose. Posttransplant duration, immunosuppressive medication levels, and bronchoscopic rejection and infection assessments were compared with MRE by using generalized-estimating equation-adjusted models. Prednisolone effect on MRE was assessed ex vivo in blood samples from nontransplanted controls. Tacrolimus concentration inhibiting 50% of cytokine production (IC50 ) was measured in a pretransplant subset. Results showed that MRE did not change with diagnosis of rejection but that airway infection was associated with a 20% absolute decrease (95% confidence interval 11%-29%). MRE increased with time after transplant but was not associated with tacrolimus trough. Interestingly, MRE correlated inversely with corticosteroid dose in the study cohort and ex vivo. Pretransplant tacrolimus IC50 depended on the cytokine measured and varied between individuals, suggesting a range in baseline responses to tacrolimus. We conclude that MRE identifies infection risk in lung allograft recipients, potentially integrating calcineurin inhibitor and steroid effects on lymphocyte effector function.

Little is known about the effects of hepatitis C viremia on immunologic outcomes in the era of direct‐acting antivirals. We conducted a prospective, single‐arm trial of lung transplantation from hepatitis C‐infected donors into hepatitis C‐naïve recipients (n = 21). Recipients were initiated on glecaprevir‐pibrentasvir immediately post‐transplant and were continued on therapy for a total of 8 weeks. A control group of recipients of hepatitis C‐negative lungs were matched 1:1 on baseline variables (n = 21). The primary outcome was the frequency of acute cellular rejection over 1‐year post‐transplant. Treatment with glecaprevir‐pibrentasvir was well tolerated and resulted in viremia clearance after a median of 16 days of therapy (IQR 10–24 days). At one year, there was no difference in incidence of acute cellular rejection (71.4% vs. 85.7%, P =.17) or rejection requiring treatment (33.3% vs. 57.1%, P =.12). Mean cumulative acute rejection scores were similar between groups (.46 [SD ±.53] vs..52 [SD ±.37], P =.67). Receipt of HCV+ organs was not associated with acute rejection on unadjusted Cox regression analysis (HR.55, 95% CI.28‐1.11, P =.09), or when adjusted for risk factors known to be associated with acute rejection (HR.57, 95% CI.27‐1.21, P =.14). Utilization of hepatitis C infected lungs with immediate treatment leads to equivalent immunologic outcomes at 1 year. [ABSTRACT FROM AUTHOR]

New federal regulations allow HIV-positive individuals to be live kidney donors; however, potential candidacy for donation is poorly understood given the increased risk of end-stage renal disease (ESRD) associated with HIV infection. To better understand this risk, we compared the incidence of ESRD among 41 968 HIV-positive participants of North America AIDS Cohort Collaboration on Research and Design followed for a median of 5 years with the incidence of ESRD among comparable HIV-negative participants of National Health and Nutrition Examination III followed for a median of 14 years. We used risk associations from multivariable Cox proportional hazards regression to derive cumulative incidence estimates for selected HIV-positive scenarios (no history of diabetes, hypertension, AIDS, or hepatitis C virus coinfection) and compared these estimates with those from similarly selected HIV-negative scenarios. For 40-year-old HIV-positive individuals with health characteristics that were similar to those of age-matched kidney donors, viral load

The Immune Development in Pediatric Transplantation (IMPACT) study was conducted to evaluate relationships among alloimmunity, protective immunity, immune development, physical parameters, and clinical outcome in children undergoing kidney transplantation. We prospectively evaluated biopsy-proven acute rejection (BPAR), de novo donor-specific antibody (dnDSA) formation, viremia, viral infection, T cell immunophenotyping, and body mass index (BMI)/weight Z scores in the first year posttransplantation in 106 pediatric kidney transplant recipients. Outcomes were excellent with no deaths and 98% graft survival. Rejection and dnDSAs occurred in 24% and 22%, respectively. Pretransplant cytomegalovirus (CMV) and Epstein-Barr virus (EBV) serologies and subsequent viremia were unrelated to BPAR or dnDSA. Viremia occurred in 73% of children (EBV, 34%; CMV, 23%; BMK viremia, 23%; and JC virus, 21%). Memory lymphocyte phenotype at baseline was not predictive of alloimmune complications. Patients who developed viral infection had lower weight (-2.1) (p = 0.028) and BMI (-1.2) (p = 0.048) Z scores at transplantation. The weight difference persisted to 12 months compared with patients without infection (p = 0.038). These data indicate that there is a high prevalence of viral disease after pediatric kidney transplantation, and underweight status at transplantation appears to be a risk factor for subsequent viral infection. The occurrence of viremia/viral infection is not associated with alloimmune events.

Solid organ transplant patients are vulnerable to suffering neurologic complications from a wide array of viral infections and can be sentinels in the population who are first to get serious complications from emerging infections like the recent waves of arboviruses, including West Nile virus, Chikungunya virus, Zika virus, and Dengue virus. The diverse and rapidly changing landscape of possible causes of viral encephalitis poses great challenges for traditional candidate-based infectious disease diagnostics that already fail to identify a causative pathogen in approximately 50% of encephalitis cases. We present the case of a 14-year-old girl on immunosuppression for a renal transplant who presented with acute meningoencephalitis. Traditional diagnostics failed to identify an etiology. RNA extracted from her cerebrospinal fluid was subjected to unbiased metagenomic deep sequencing, enhanced with the use of a Cas9-based technique for host depletion. This analysis identified West Nile virus (WNV). Convalescent serum serologies subsequently confirmed WNV seroconversion. These results support a clear clinical role for metagenomic deep sequencing in the setting of suspected viral encephalitis, especially in the context of the high-risk transplant patient population.

Introduction: Healthcare provision has been severely affected by COVID‐19, with specific challenges in organ transplantation. Here, we describe the coordinated response to, and outcomes during the first wave, across all UK liver transplant (LT) centers. Methods: Several policy changes affecting the liver transplant processes were agreed upon. These included donor age restrictions and changes to offering. A "high‐urgency" (HU) category was established, prioritizing only those with UKELD > 60, HCC reaching transplant criteria, and others likely to die within 90 days. Outcomes were compared with the same period in 2018 and 2019. Results: The retrieval rate for deceased donor livers (71% vs. 54%; P <.0001) and conversion from offer to completed transplant (63% vs. 48%; P <.0001) was significantly higher. Pediatric LT activity was maintained; there was a significant reduction in adult (42%) and total (36%) LT. Almost all adult LT were super‐urgent (n = 15) or HU (n = 133). We successfully prioritized those with highest illness severity with no reduction in 90‐day patient (P =.89) or graft survival (P =.98). There was a small (5% compared with 3%; P =.0015) increase in deaths or removals from the waitlist, mainly amongst HU cohort. Conclusions: We successfully prioritized LT recipients in highest need, maintaining excellent outcomes, and waitlist mortality was only marginally increased. [ABSTRACT FROM AUTHOR]

Liver transplantation (LT) recipients are susceptible to infections, including measles. Concerns about the safety and efficacy of live-attenuated vaccines, such as the measles-mumps-rubella (MMR) vaccine, have led to hesitancy among providers in administering them to immunocompromised patients. This 9-year interventional study assessed seroprotection against measles following MMR vaccination in pediatric LT recipients. Of 119 participants enrolled, 60 (50%) were seroprotected against measles after transplantation. Among the 59 nonseroprotected participants, 56 fulfilled safety criteria and received MMR vaccination with a seroprotection rate of 90% (95% confidence interval [CI], 73%-98%) after a first dose, 95% (95% CI, 85%-99%) after primary vaccination with 1 to 3 doses, comparable to nonimmunocompromized populations. However, measles antibodies declined over time, suggesting the need for regular monitoring, and booster doses. Half of the vaccinees (26/53, 49%) subsequently lost seroprotection. Among them, 23 received additional doses of MMR, with a high seroconversion rate. At their last follow-up (median, 6.1 years; interquartile range, 3.0-8.1 after inclusion), 63% (95% CI, 49%-75%) of all vaccinees were seroprotected against measles. In conclusion, MMR vaccination in pediatric LT recipients offers seroprotection against measles, but long-term immunity should be monitored closely., Competing Interests: Declaration of competing interest The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Infection with Strongyloides stercoralis is typically asymptomatic in immunocompetent hosts, despite chronic infection. In contrast, immunocompromised hosts such as solid organ transplant recipients are at risk for hyperinfection syndrome and/or disseminated disease, frequently resulting in fatal outcomes. Infection in these recipients may result from reactivation of latent infection or infection through transmission from an infected donor. We describe the Centers for Disease Control and Prevention's experience with seven clusters of donor-derived infection from 2009 to 2013. Six of the seven (86%) donors were born in Latin America; donor screening was not performed prior to organ transplantation in any of these investigations. Eleven of the 20 (55%) organ recipients were symptomatic, two of whom died from complications of strongyloidiasis. We also describe the New York Organ Donor Network (NYODN) experience with targeted donor screening from 2010 to 2013. Of the 233 consented potential donors tested, 10 tested positive for Strongyloides antibody; and 18 organs were transplanted. The majority (86%) of the donors were born in Central or South America. Fourteen recipients received prophylaxis after transplantation; no recipients developed strongyloidiasis. The NYODN experience provides evidence that when targeted donor screening is performed prior to transplantation, donor-derived infection can be averted in recipients.

Staphylococcus aureus is the most commonly isolated gram-positive bacterium after lung transplantation (LT) and has been associated with poor posttransplant outcomes, but its effect on bronchiolitis obliterans syndrome (BOS) and death in the context of the allograft inflammatory environment has not been studied. A three-state Cox semi-Markovian model was used to determine the influence of allograft S. aureus and the ELR+ CXC chemokines on the survival rates and cause-specific hazards for movement from lung transplant (State 1) to BOS (State 2), from transplant (State 1) to death (State 3), and from BOS (State 2) to death (State 3). Acute rejection, pseudomonas pneumonia, bronchoalveolar lavage fluid (BALF) CXCL5 and its interaction with S. aureus all increased the likelihood of transition from transplant to BOS. Transition to death from transplant was facilitated by pseudomonas infection and single lung transplant. Movement from BOS to death was affected by the interaction between aspergillus, pseudomonas and CXCL5, but not S. aureus. S. aureus isolation had state specific effects after LT and only in concert with elevated BALF CXCL5 concentrations did it augment the risk of BOS. Pseudomonas and elevated BALF concentrations of CXCL5 continued as significant risk factors for BOS and death after BOS in lung transplantation.

Problem: Incidence and impact of CMV infection in pancreas‐transplant recipients (PTRs) in the valganciclovir prophylaxis era has not been completely elucidated. Methods: Adult D+/R‐ PTRs were divided into a current era (1/1/2011‐12/31/17; 6‐month PPX) and a historic era (1/1/2003‐12/31/09; 3‐month PPX). Primary objective: effect of prophylaxis extension on the incidence of CMV infection. Secondary objective: impact of extension on valganciclovir‐related toxicity (leukopenia) and transplant outcomes. Results: There were 177 D+/R‐ PTRs in the study period (historic:98, current:79). Prophylaxis extension resulted in significant reduction of CMV infection from 25.4% to 10.9% at 6 months, (57% reduction, p =.021). However, 1‐year rates of CMV infection (historic:31% vs current:36%) and end‐organ disease (historic:7.7% vs current:6.9%) were not different (p =.93). Prophylaxis extension significantly increased leukopenia (white blood cell count<3 K/uL) at 6 months (historic:9.5% vs current:28.6%, p =.018). On multivariable analysis prophylaxis extension was not associated with reduced rates of CMV infection (p =.99) or CMV end‐organ disease (p =.3). Additionally, there was no significant difference in rejection (p =.2), graft survival (p =.08), death‐censored graft survival(p =.07) or patient survival (p =.6). Conclusions: Prophylaxis extension in D+/R‐ PTRs appears to delay time to first CMV but not reduce overall incidence. These findings suggest a hybrid approach, incorporating antiviral withdrawal and protocolized monitoring, may be needed to improve CMV‐related outcomes. [ABSTRACT FROM AUTHOR]

Background: The COVID‐19 pandemic has negatively impacted organ donation and transplantation across the globe. Methods: This study analyzed transplant outcomes during the pre‐pandemic [PPE, 1/2019–2/2020] and pandemic era [PE, 3/2020–8/2020] based on changes in induction immunosuppression. During PPE, high immunological risk patients received 4–6 mg/kg, moderate risk 2–4 mg/kg, and low risk 1–2 mg/kg of ATG. During PE, ATG doses were reduced to 3–4 mg/kg for high risk, 1–2 mg/kg for moderate, and low changed to basiliximab. Primary outcomes are as follows: biopsy‐proven rejection [BPAR], de‐novo donor‐specific antibody [DSA], delayed graft function [DGF], infection rates, graft loss, and all‐cause of mortality. Results: During PPE, 224 kidney transplants [KTx] and 14 kidney/pancreas transplants [KP] were included, while 180 KTx and 5 KP were included for PE. Basiliximab use increased by 30% in the PE. The odds of DGF were statistically significant between PE vs PPE, OR 1.7 [1.05, 2.8, p‐value =.042]. The odds of developing DSAs and BPAR during the PE vs. PPE were 0.34 [0.16, 0.71, p‐value =.004] and OR 0.34 (0.1 to 1.1, p‐value,.104)], respectively. Cytomegalovirus [19% in PE, 37% in PPE] and BK virus [5.4% PE vs. 16% PPE] incidence reduced during PE vs. PPE. COVID‐19, graft loss, and mortality were comparable between groups. Conclusion: KTx and KP transplants were performed safely during the COVID‐19 pandemic with a reduction of induction immunosuppression. [ABSTRACT FROM AUTHOR]

Cytomegalovirus (CMV) infection is one of the most common and significant complications after solid organ transplant (SOT). Severe acute respiratory coronavirus 2 (SARS‐CoV‐2), which causes the novel betacoronavirus 2019 disease (COVID‐19), has become the first global pandemic in 100 years. The world's attention has turned to address this unanticipated development; however, the viral infection that has long plagued outcomes after solid organ transplantation still requires vigilance. With physical distancing as the key intervention to reduce the healthcare burden, and the unease related to healthcare contact within the transplant population given the associated morbidity and mortality of COVID‐19 in transplant recipients, providers have struggled to evaluate and streamline essential in‐person healthcare contact, including laboratory visits. Owing to this, the COVID‐19 pandemic has placed a significant strain on the delivery of CMV prophylaxis and treatment after solid organ transplantation. In this piece, we will describe issues our CMV antiviral stewardship service has encountered in the care of the transplant recipient with CMV during the this unprecedented time and share our expert opinion to approaches to providing optimal, evidenced based care during a pandemic associated with a seemingly unrelated viral infection. [ABSTRACT FROM AUTHOR]

Introduction: COVID‐19 is an ongoing pandemic with high morbidity and mortality and with a reported high risk of severe disease in kidney transplant recipients (KTR). Aim: We aimed to report the largest number of COVID‐19‐positive cases in KTR in a single center and to discuss their demographics, management, and evolution. Methods: We enrolled all the two thousand KTR followed up in our center in Kuwait and collected the data of all COVID‐19‐positive KTR (104) from the start of the outbreak till the end of July 2020 and have reported the clinical features, management details, and both patient and graft outcomes. Results: Out of the one hundred and four cases reported, most of them were males aged 49.3 ± 14.7 years. Eighty‐two of them needed hospitalization, of which thirty‐one were managed in the intensive care unit (ICU). Main comorbidities among these patients were hypertension in 64.4%, diabetes in 51%, and ischemic heart disease in 20.2%. Management strategies included anticoagulation in 56.7%, withdrawal of antimetabolites in 54.8%, calcineurin inhibitor (CNI) withdrawal in 33.7%, the addition of antibiotics in 57.7%, Tocilizumab in 8.7%, and antivirals in 16.3%. During a follow‐up of 30 days, the reported number of acute kidney injury (AKI) was 28.7%, respiratory failure requiring oxygen therapy 46.2%, and overall mortality rate was 10.6% with hospital mortality of 13.4% including an ICU mortality rate of 35.5%. Conclusion: Better outcome of COVID‐19‐positive KTR in our cohort during this unremitting stage could be due to the younger age of patients and early optimized management of anticoagulation, modification of immunosuppression, and prompt treatment of secondary bacterial infections. Mild cases can successfully be managed at home without any change in immunosuppression. [ABSTRACT FROM AUTHOR]

Transplant recipients are vulnerable to infections, including COVID‐19, given their comorbidities and chronic immunosuppression. In this study, all hospitalized renal transplant recipients (RTR) with a positive nasal swab for Severe Acute Respiratory Syndrome‐Coronavirus‐2 (SARS‐CoV2) seen consecutively between 03/01/2020 and 05/01/2020 at the Detroit Medical Center were included. Data on demographics, clinical presentation, laboratory findings, management, and outcomes were collected. Twenty‐five patients were included, all African American (AA) and deceased‐donor transplant recipients. The most common presenting symptom was dyspnea, followed by fever, cough and diarrhea. Multifocal opacities on initial chest x‐ray were seen in 52% patients and 44% of patients had a presenting oxygen saturation of less than or equal to 94%. Four patients (16%) required transfer to the intensive care unit, one required intubation and one expired. COVID‐19‐infected RTR in this cohort had low mortality of 4% (n = 1). Despite multiple comorbidities and chronic immunosuppression, our cohort of African American RTR had favorable outcomes compared to other reports on COVID‐19 in RTR. [ABSTRACT FROM AUTHOR]

Background: Currently, there is limited literature evaluating rATG induction dosing and incidence of opportunistic viral infections when using steroid‐free maintenance immunosuppression. Methods: This single‐center, retrospective, study compared high rATG (>4.5 mg/kg) versus low (<4.5 mg/kg) induction dosing and the overall incidence of early opportunistic viral infection at 180 days in the setting of maintenance immunosuppression consisting of tacrolimus, mycophenolate, rapid steroid withdrawal, and a tiered antiviral prevention strategy based on donor‐recipient Cytomegalovirus (CMV) serostatus. Results: A total of 209 patients were included; 76 patients received low‐dose and 133 patients received high‐dose rATG. Incidence of overall opportunistic viral infection occurred more frequently in patients who received high compared to low dose (29.8% vs 25% p =.030). Incidence of CMV infection was also significantly increased in the high‐dose group (31.6% vs 18.4% p =.039). In a multivariable model, rATG dose, as a continuous variable, remained a significant independent predictor of infection along with CMV risk (OR 1.46, 95% CI 1.02‐2.09) controlling for age and CMV risk. There were no differences in graft‐related outcomes at 180 days. Conclusion: Higher cumulative rATG induction dose was associated with increased incidence of opportunistic viral infections, in the setting of a steroid‐free maintenance immunosuppression in the early post‐transplant period. [ABSTRACT FROM AUTHOR]

COVID‐19 case fatality rate in the United States is currently reported at 4.8% based on the confirmed cases of COVID‐19. However, there are conflicting reports of estimated deaths in the post‐cardiac transplantation patient population associated with COVID‐19. Methods: Observational, retrospective analysis of a large cohort of post Orthotopic Heart Transplantation (OHT) patients in a high volume heart transplantation program in Dallas, Texas underwent outpatient COVID‐19 screening and testing for both SARS‐CoV‐2 nasopharyngeal RT‐PCR and anti‐SARS‐CoV2 IgG serology as a result of a clinic protocol to facilitate re‐opening of face‐to‐face outpatient clinical visits. Results: The full outpatient cohort tested at time of their clinic visit tested negative for COVID‐19 by nasopharyngeal RT‐PCR. Only 2 patients tested seropositive for anti‐SARS‐COV2 IgG. Five positive inpatient cases were also identified and all, but one recovered. Conclusion: A COVID‐19 surveillance protocol can be easily instituted in this high‐risk population and facilitate safe transplant clinic operation. As the cases and prevalence increase across the United States, further strategies will need to be developed to determine the best course of action to help manage this select population while minimizing their exposure to the ongoing pandemic. [ABSTRACT FROM AUTHOR]

Solid organ transplant (SOT) recipients may be at higher risk for poor outcomes with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. Convalescent plasma is an investigational therapy that may benefit immunosuppressed patients by providing passive immunity. Convalescent plasma was administered to hospitalized patients with coronavirus disease‐2019 (COVID‐19) at an academic transplant center in New York City. Eligible patients were hospitalized and required to have positive nasopharyngeal polymerase chain reaction (PCR) diagnosis of SARS‐CoV‐2 infection, be at least 18 years old, and have either dyspnea, blood oxygen saturation ≤ 93% on ambient air, respiratory frequency ≥ 30 breaths/min, partial pressure of arterial oxygen to fraction of inspired oxygen ratio < 300, or lung infiltrates > 50%. Thirteen SOT recipients received convalescent plasma from April 9, 2020, to May 17, 2020. The median time from symptom onset to plasma infusion was 8 days. Eight of 13 patients (62%) had de‐escalating oxygenation support by day 7 post‐convalescent plasma. Nine (69%) patients were discharged, 1 (7%) patients remain hospitalized, and 3 (23%) patients died. This series supports the need for additional studies on convalescent plasma use in SOT recipients with COVID‐19 to better determine efficacy and identify patients who are likely to benefit. [ABSTRACT FROM AUTHOR]

An unprecedented global pandemic caused by a novel coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) has quickly overwhelmed the health care systems worldwide. While there is an absence of consensus among the community in how to manage solid organ transplant recipients and donors, a platform provided by the American Society of Transplantation online community "Outstanding Questions in Transplantation," hosted a collaborative multicenter, multinational discussions to share knowledge in a rapidly evolving global situation. Here, we present a summary of the discussion in addition to the latest published literature. [ABSTRACT FROM AUTHOR]

Background: The use of direct‐acting antivirals (DAA) has expanded transplantation from hepatitis C viremic donors (HCV‐VIR). Our team has conducted an open‐label, prospective trial to assess outcomes transplanting HCV viremic hearts. Glecaprevir/pibrentasvir (GLE/PIB) was our sole DAA. Methods: Serial quantitative hepatitis C virus (HCV) RNA PCR was obtained to assess HCV viral titers. Between January 2018 and June 2019, a total of 50 recipients were transplanted. Of these, 22/50 (44%) were from HCV‐VIR, the remaining 28 from non‐viremic (HCV NON‐VIR) donors. An 8‐week course of GLE/PIB was initiated at 1 week post‐transplant. Results: There was no difference in demographic or clinical parameters between groups. All 22 recipients of HCV‐VIR transplants became viremic. GLE/PIB was effective in decreasing viremia to undetectable levels by 6 weeks post‐transplant in all patients. The median time to first undetectable HCV quantitative PCR was (4.3 weeks, IQR: 4‐5.7 weeks). All patients demonstrated sustained undetectable viral load through 1‐year follow‐up. There was no difference in survival at one year between HCV NON‐VIR 28/28: (100%) vs HCV‐VIR 21/22 (95%) recipients. Conclusions: Our center reports excellent outcomes in transplanting utilizing hearts from HCV‐VIR donors. No effect on survival or co‐morbidity was found. An 8‐week GLE/PIB course was safe and effective when initiated approximately 1 week post‐transplant. [ABSTRACT FROM AUTHOR]

With increasing utilization of hepatitis C (HCV) viremic donor organs, there may be a role for kidney pump perfusion to reduce viral load and prevent HCV transmission. We performed a prospective pilot study of HCV viremic donors; one kidney from each donor pair was pumped with perfusate exchanges and viral load testing at least every 4 hours. Donor, recipient, and transplant characteristics were obtained with clinical outcomes. Linear regression was performed to quantify the association between pump time and perfusate viral load. Six HCV viremic donors for six pairs of aviremic recipients were included. Perfusate of the pumped kidneys showed detectable virus throughout the pump cycles. Although perfusate viral levels decreased with increasing pump times, this was not statistically significant (β = −.48, P =.36). All recipients had detectable HCV RNA postoperatively. The pumped cohort had an insignificantly reduced mean viral load compared to pumped recipients (1352 ± 2006 vs 26 170 ± 61 211, P =.09). Time to initiation of direct‐acting antiviral was 32 ± 12 vs 26 ± 7 days (P =.17) and to undetectable levels was 66 ± 27 vs 55 ± 22 days (P =.82) for the pumped and unpumped cohorts, respectively. Pulsatile perfusion alone does not appear adequate to decrease HCV transmission. Future studies will need to explore additional ex vivo interventions to pumping. [ABSTRACT FROM AUTHOR]

Purpose: Describe use and predictive potential of an intracellular cytokine staining (ICS) cytomegalovirus cell‐mediated immunity (CMV CMI) assay and a risk factor screening tool on CMV reactivation in a real‐world clinical setting and compare this to serologically demonstrated immunity by CMV IGG. Methods: Adult transplant patients at our center with the ICS assay resulted between 10/1/2018 and 9/1/2019 were included. Assays were considered positive per manufacturer specifications. Results: Twenty‐five patients underwent ICS CMV CMI testing at our institution during the study period. The majority were kidney transplant recipients, 76% were D+/R−, and 76% were receiving CMV treatment. The positive predictive value (PPV) of the assay to predict lack of CMV was 87%; 93% when patients with antiviral resistance were excluded and 91% in only those receiving treatment. The presence of ≤2 clinical risk factors on the screening tool had a PPV of 92% in predicting lack of recurrence. In comparison, serologically demonstrated immunity by CMV IGG had a PPV of 62%. Conclusions: In our study representing real‐world clinical use, the ICS CMV CMI assay and the risk factor screening tool had predictive potential that was superior to serologically demonstrated immunity. The reliability of the assay seemed to decrease with higher degrees of clinical risk suggesting a multimodal screening approach is warranted. [ABSTRACT FROM AUTHOR]

Background: Letermovir was approved in 2017 for prevention of cytomegalovirus (CMV) infection in seropositive (R+) allogeneic hematopoietic cell transplantation (HCT) patients. Post‐marketing data with this new agent are scarce. Methods: We compared the incidence of both CMV reactivation (any viremia) and clinically significant CMV infection (CS‐CMVi; CMV DNAemia leading to preemptive treatment or presence of CMV tissue invasive disease) at days +100 and +200 post‐HCT in 25 adult allogeneic HCT patients who received letermovir prophylaxis (until day 100) and a historical control group of 106 CMV R+ allogeneic HCT recipients who underwent CMV preemptive therapy. Results: CMV reactivation within 100 days post‐HCT was lower in the letermovir group vs control group (20% vs 72% respectively, P <.001). The 100‐day cumulative incidence of CS‐CMVi was significantly lower in the letermovir group vs control group (4% vs 59% respectively, P <.001). Significantly reduced incidence of CMV reactivation and CS‐CMVi was also observed at 200 days in the letermovir group. No difference in mortality was observed between the two groups. Conclusion: This study confirms the efficacy of letermovir in preventing CMV reactivation in CMV R+ allogeneic HCT recipients in first 100 days post‐HCT and suggests sustained efficacy after discontinuation of prophylaxis. [ABSTRACT FROM AUTHOR]

The advent of direct‐acting antivirals (DAAs) has provided the impetus to transplant kidneys from hepatitis C virus‐positive donors into uninfected recipients (D+/R−). Thirty D+/R− patients received DAA treatment. Sustained virologic response (SVR12) was defined as an undetectable viral load in 12 weeks after treatment. An age‐matched cohort of uninfected donor and recipient pairs (D−/R−) transplanted during same time period was used for comparison. The median day of viral detection was postoperative day (POD) 2. The detection of viremia in D+/R− patients was 100%. The initial median viral load was 531 copies/μL (range: 10‐1 × 108 copies/μL) with a median peak viral load of 3.4 × 105 copies/μL (range: 804‐1.0 × 108 copies/μL). DAAs were initiated on median POD 9 (range: 5‐41 days). All 30 patients had confirmed SVR12. During a median follow‐up of 10 months, patient and graft survival was 100%, and acute rejection was 6.6% with no major adverse events related to DAA treatment. Delayed graft function was significantly decreased in D+/R− patients as compared to the age‐matched cohort (27% vs 60%; P =.01). D+/R− transplantation offers patients an alternative strategy to increase access. [ABSTRACT FROM AUTHOR]

Abstract: Background: Lung transplant remains an established treatment for end‐stage lung disease, but limited organ availability remains a major barrier and contributor to waitlist mortality.1 Only 20% of available organs are considered suitable for lung transplantation (Am J Transplant, 16, 2016 and 141; Thorac Surg Clin, 25, 2015 and 35). Successful lung transplantation has been reported from donors infected with bacterial or fungal organisms, but there is a paucity of evidence regarding the use of donors with bacterial meningitis (Transplant Proc, 32, 2000 and 75; Transplantation, 64, 1997 and 365; Ann Thorac Surg, 86, 2008 and 1554). Method: The Cleveland Clinic lung transplant database was retrospectively reviewed for patients between January 1998 and December 2014. Post‐transplantation outcomes collected included graft dysfunction, infectious complications, and survival. Results: The recipients were identified as having lungs from donors with bacterial meningitis. All recipients remained free of infectious organisms responsible for bacterial meningitis related in the donor. Severe primary graft dysfunction (PGD) was not seen in these recipients. Conclusion: In our study, lung transplantation from increased risk donors with bacterial meningitis was not associated with an increased risk of early infectious complications in recipients. Donors with bacterial meningitis should be considered for lung donation and may expand the donor pool safely. [ABSTRACT FROM AUTHOR]

Abstract: There are limited data regarding the association of different levels of BK viremia and BK nephropathy (BKN), and graft outcomes. We studied the BK plasma PCR levels of all kidney transplant recipients (KTR) transplanted at our institution between 01/01/2006 and 06/30/2014. Patients were divided into groups based on their highest BK plasma PCR level within the first year following transplantation: undetectable, low (<1000 copies/mL), moderate (1000‐10 000 copies/mL), high (>10 000‐100 000 copies/mL), very high (>100 000 copies/mL), and those that had biopsy‐proven BKN. There were a total of 1146 KTR during the study period: 813 with undetectable BK levels and 333 with any detectable BK level (87 with low, 79 with moderate, 88 with high, 34 with very high level BK, and 45 that had BKN). Compared to KTR with an undetectable BK level, incidence of mortality, graft failure, rejections,and infections were not significantly different for those with low, moderate, high, or very high BK level. Patients with BKN had a higher rate of infection and higher rates of total graft failure or death‐censored graft failure compared to those with undetectable BK levels. BK viremia in the absence of BKN does not significantly increase the risk of rejection, infections, or graft failure compared to an undetectable BK level. [ABSTRACT FROM AUTHOR]

Trichodysplasia spinulosa ( TS) is a rare dermatologic complication associated with the immunosuppressive therapy used in solid organ transplantation. The distinctive clinical manifestation of this condition is spiny follicular papules on the face, ears, extremities, and trunk. Histopathologically, abnormally maturing hair follicles with hyperkeratotic material are noted. The condition is produced by the trichodysplasia spinulosa-associated polyomavirus. Treatment of this condition in the past has entailed a reduction in immunosuppression, topical agents such as cidofovir or retinoids, or oral valganciclovir. Herein, we report a case of generalized TS treated successfully with leflunomide. [ABSTRACT FROM AUTHOR]