Risk stratification of renal transplant recipients using routine parameters: Implication of learning from SARS-CoV-2 into transplant follow-up program

BACKGROUND

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is a global pandemic that is associated with a high risk of morbidity and mortality among recipients of solid organ transplantation. In the course of acute SARS-CoV-2 infection, various laboratory markers have been identified as predictors for high risk of mortality.

AIM

To risk stratify renal transplant recipients (RTxR) using general demographic parameters, comorbidities and routine laboratory markers for the severity of the disease and its outcomes. We believe that learning about these routinely moni tored parameters can help us plan better strategies for the RTxR follow-up program.

METHODS

This present study includes RTxR who acquired SARS-CoV-2 infection from March 2020 to February 2021. We recorded the basic demographics, comorbidities and routine laboratory markers. We investigated the impact of SARS-CoV-2 infection on RTxRs and risk-stratified the progression of disease severity and outcomes in terms of recovery or mortality.

RESULTS

From 505 RTxRs in our renal transplant follow-up program, 29 (7.75%) RTxRs had PCR-positive SARS-CoV-2 infection. We recorded 8 deaths from SARS-CoV-2 infection giving an overall mortality rate of 1.6% but a significant 27.6% mortality in SARS-CoV-2 positive recipients. Age more than 68 years, non-Caucasian ethnicity and male gender were associated with a significant drop in survival probability; P ≤ 0.001. < 0.001 and < 0.0001 respectively. 87.5% of the deceased were diabetic; P ≤ 0.0.0001. Estimated glomerular filtration rate of less than 26 mL/min/1.73 m2, serum albumin less than 20 g/L, Hemoglobin less than 9.6 g/L and serum calcium less than 1.70 mmol/L were all associated with significantly increased risk of mortality; P = 0.0128, < 0.001, < 0.0001 and 0.0061 respectively.

CONCLUSION

This study has identified some routinely used modifiable parameters in predicting a higher risk of mortality and morbidity. This knowledge can be used in RTxR follow-up programs by addressing these parameters early to help reduce the morbidity and mortality in RTxRs.

Safety and Efficacy of Kidney Transplants From Older Adult Living Donors: A Comparative Analysis of Donor and Recipient Outcomes

OBJECTIVES

We investigated the safety of donor nephrectomy from older adult donors (age ≥60 years), as well as long-term donor, recipient, and graft outcomes.

MATERIALS AND METHODS

We retrospectively analyzed data from 307 living donor kidney transplants from 1996 to 2016 and defined 2 cohorts based on donor age. Cohort A comprised donors aged 60 years and older, and cohort B comprised donors from 18 to 59 years old. We recorded donor and recipient perioperative complications, outcomes, and survival rates and used SPSS and MedCalc statistical software programs for data analyses.

RESULTS

The mean follow-up period for donor-recipient pairs in cohort A was 97 months (SD, 25.1 months) with median 108 months (IQR, 92-108 months) and in cohort B was 100.57 months (SD, 25.45 months) with median 120 months (IQR, 84-120 months). Mean donor age in cohort A was 64.13 years (SD, 3.78 years) with median 63 years (IQR, 61-66.5 years) and in cohort B was 41.08 years (SD, 9.15 years) with median 41 years (IQR, 34.5-48 years) (P < .001, cohort A vs B). Mean recipient age in cohort A was 47.65 years (SD, 14.26 years) with median 48.5 years (IQR, 35.5-61 years) and in cohort B was 43.55 years (SD, 13.15 years) with median 40.5 years (IQR, 33.5-54 years) (P < .001, cohort A vs B). Both cohorts showed no significant differences in perioperative donor and recipient complications. Renal function (measured as estimated glomerular filtration rate) in remaining native kidneys of cohort A showed no significant decline during median 8-year follow-up (P = .089 and P < .414, respectively). There were no significant differences in survival rates for donors, recipients, and grafts.

CONCLUSIONS

Living donor kidney transplant from older adult donors is safe and effective with good long-term patient and allograft survival.

SP5.2.1 Renal Transplant Outcomes Through the COVID-19 Pandemic at a London Transplant Centre

Aims

The aim of this audit was to establish the impact of COVID-19 on the outcomes of renal transplant recipients in the post-transplant period at our centre, through the 2020 calendar year.

Methods

Living donor and deceased donor renal transplant recipients in the period of interest were identified and any complications or adverse outcomes were reviewed and compared to outcome data from the previous year.

Results

A total of 88 renal transplants were performed in 2020. Fifty-five cases were performed after reopening the Unit. Five patients tested positive for COVID-19 in the post-transplant period. One patient was admitted to the Intensive Care Unit and subsequently died from related complications. Another patient suffered from internal jugular vein thrombosis shortly after testing positive and could be attributed to the hypercoagulable state post-infection.

A total of 4 deaths and 1 graft loss were recorded within 2020. This compares to 1 death, 2 graft losses and 1 primary non-function in 172 transplants in 2019. Of the 4 deaths, one was directly linked to COVID-19. The other 3 deaths could be indirectly linked to the disruptions that were made in the healthcare system during this period in adapting to the pandemic.

Conclusions

It was anticipated that COVID-19 will directly and indirectly affect patient outcomes from surgery during this period. This was clearly seen at this Unit, with mortality rates having increased almost eight-fold in the post-transplant period compared to the same period in the previous year. However, no significant difference was seen with graft losses.

The impact of coronavirus disease 2019 pandemic on working dynamics of junior and middle grade doctors in the United Kingdom: Learning from their experience requires immediate improvement in health care planning and management-An outcome analysis of a nationwide survey

OBJECTIVES

Severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019) pandemic had an unprecedented impact on health services across the world resulting in increased demand of intensive care capacity, opening Nightingale hospitals, and mass movement of doctors across various specialities. This unplanned redeployment raised concerns among various health care workers. The objective of the current study is to explore working dynamics and experience of junior and middle grade doctors during current pandemic.

METHODS

We organised a nationwide cross-sectional survey of junior and middle grade doctors working in the United Kingdom. The survey was aimed to study their level of participation during coronavirus disease 2019 pandemic and its impact on their clinical practices and well-being.

RESULTS

In total, 1564 completed questionnaires with representations from all regions of the United Kingdom were included. The mean age of respondents was 30.64 years (95% confidence interval +1.025; standard deviation = 9.9057). There were 51.5% females with significantly more participants from Black, Asian, and minority ethnic group (n = 835, p = 0.0073); 963 (61.6%, p ⩽ 0.0001) doctors were redeployed outside their primary speciality. The major redeployments were from other specialities to Intensive Therapy Units (41.8%, p ⩽ 0.001); 63.3% of respondents spend more than 8 weeks in redeployed speciality (p ⩽ 0.0001). There was a significant impact of coronavirus disease 2019 on personal, mental, and physical well-being of doctors. The major areas requiring immediate attention include proper leadership and clinical support (64.1%), pre-redeployment planning and induction (48.5%), redeployment according to the skills and/or in familiar specialities (44.6%), and regular mental and physical well-being checks (37%).

CONCLUSION

The outcome of the survey concluded with four major recommendations, including the need to have a named supervisor for these doctors, structured induction program, regular well-being checks, and involving them in crisis planning. These recommendations will help to shape future health care policies and management particularly when it is related to redeployment of doctors during any crisis or pandemic.

Kidney transplantation and patients who decline SARS-CoV-2 vaccination: an ethical framework

The COVID-19 pandemic has had a major impact on kidney transplantation and on patients with end-stage kidney disease. Transplantation activity has been substantially reduced, and kidney transplant recipients have suffered increased mortality. The introduction of vaccines against SARS-CoV-2 has offered considerable hope that it may be possible to protect patients from the risks associated with SARS-CoV-2 infection, and that more patients may once again have access to kidney transplantation.

Mortality Rates in Transplant Recipients and Transplantation Candidates in a High-prevalence COVID-19 Environment

BACKGROUND

The risk of COVID-19 infection in transplant recipients (TRs) is unknown. Patients on dialysis may be exposed to greater risk of infection due to an inability to isolate. Consideration of these competing risks is important before restarting suspended transplant programs. This study compared outcomes in kidney and kidney/pancreas TRs with those on the waiting list, following admission with COVID-19 in a high-prevalence region.

METHODS

Audit data from all 6 London transplant centers were amalgamated. Demographic and laboratory data were collected and outcomes included mortality, intensive care (ITU) admission, and ventilation. Adult patients who had undergone a kidney or kidney/pancreas transplant, and those active on the transplant waiting list at the start of the pandemic were included.

RESULTS

One hundred twenty-one TRs and 52 waiting list patients (WL) were admitted to hospital with COVID-19. Thirty-six TR died (30%), while 14 WL patients died (27% P = 0.71). There was no difference in rates of admission to ITU or ventilation. Twenty-four percent of TR required renal replacement therapy, and 12% lost their grafts. Lymphocyte nadir and D-dimer peak showed no difference in those who did and did not die. No other comorbidities or demographic factors were associated with mortality, except for age (odds ratio of 4.3 [95% CI 1.8-10.2] for mortality if aged over 60 y) in TR.

CONCLUSIONS

TRs and waiting list patients have similar mortality rates after hospital admission with COVID-19. Mortality was higher in older TRs. These data should inform decisions about transplantation in the COVID era.

Systematic Review and Meta-analysis of COVID-19 and Kidney Transplant Recipients, the South West London Kidney Transplant Network Experience

Introduction

There is paucity of literature comparing outcomes of kidney transplant patients with COVID-19 to that of dialysis and waitlisted patients. This report describes our data, provides comparative analysis, together with a meta-analysis of published studies, and describes our protocols to restart the transplant program.

Methods

Data were analyzed on kidney transplant, dialysis, and waitlisted patients tested positive for SARS-CoV-2 (nasopharyngeal swab polymerase chain reaction [PCR] test) between March 1, 2020, and June 30, 2020, together with a meta-analysis of 16 studies.

Results

Twenty-three of 1494 kidney transplant patients tested positive for SARS-CoV-2 compared with 123 of 1278 hemodialysis patients (1.5% vs. 9.6%, P < 0.001) and 12 of 253 waitlisted patients (1.5% vs. 4.7%, P = 0.002). Nineteen patients required hospital admission, of whom 6 died and 13 developed AKI. The overall case fatality ratio was 26.1% compared with patients on hemodialysis (27.6%, P = 0.99) and waitlisted patients (8.3%, P = 0.38). Within our entire cohort, 0.4% of transplant patients died compared with 0.4% of waitlisted patients and 2.7% of hemodialysis patients. Patients who died were older (alive [median age 71 years] vs. dead [median age 59 years], P = 0.01).

In a meta-analysis of 16 studies, including ours, the pooled case fatality ratio was 24% (95% confidence interval [CI] 19%, 28%); AKI proportion in 10 studies was 50% (95% CI 45%, 56%), with some evidence against no heterogeneity between studies (P = 0.02).

Conclusions

From our cohort of transplant patients, a significantly lower proportion of patients contracted COVID-19 compared with waitlisted and dialysis patients. The case fatality ratio was comparable to that of the dialysis cohort and to a pooled case fatality ratio from a meta-analysis of 16 studies. The pooled AKI ratio in the meta-analysis was similar to our results.

Presentations, etiology and outcome of patients with Chronic Renal Failure admitted at Urology Department, Mayo Hospital Lahore - A retrospective analysis of 1257 patients over a period of 10 years

Chronic kidney failure is a common and serious medical problem. It is characterized by progressive destruction of renal mass with irreversible sclerosis and loss of nephrons. End-stage renal (kidney) disease is the point in this progression when the kidneys no longer function well enough to support life. The objective of this retrospective study is to analyze different patrons of chronic renal failure its etiology and outcome. Over a period of ten years starting from January 1992 a total of 1257 patients presents with the diagnosis of chronic renal failure to the NephroUrology Department of Mayo Hospital Lahore. The minimum age at presentation was 2.5 years and maximum age was 66 years with mean age of 37.8 years. Malaise, loss of energy, nausea, vomiting and symptoms of anemia were the major presentation in all the patients. Uncontrolled Diabetes Mellitus was seemed to be the major cause of chronic renal failure which was diagnosed in 441 patients, followed by uncontrolled hypertension in 253 patients, polycystic kidney disease in 107 patients, Glomerulonephritis in 97 patients, reflux nephropathy in 96 patients, obstructive (stones) nephropathy in 78 patients, drugs/nephrotoxic agents 39 patients, congenital renal obstructions 21 patients and hypoplastic kidney in 03 patients. 339 (27%) patients were primarily put on to conservative treatment. In 568 (45%) patients haemodialysis was started and in 350 (28%) patients peritoneal dialysis was started. 8.51% (n=l08) patients under went renal transplantation.

Aetiological factors of Acute Pancreatitis

Acute pancreatitis is a non-bacterial inflammation of pancrease. It is caused by a variety of aetiological factors. The two most common being gall stones and alcoholism. Tegether they account for 80%0 cases of acute pancreatitis. The other causes are abdominal trauma, hyperlipidaemia, hypercalcaemia and viral infections. This descriptive, non-interventional case report study was conducted at Mayo Hospital, Lahore from March 1998 to February 2000, to study the aetiological factors in our circumstances. It included 45 patients with mean age of 45 years and male to female ratio of 1:1. Gall stones were the commonest factor in 53.33% (n=24), followed by abdominal trauma is 28.88% (n=13). Alcohol in take, ERCP, hyperlipidaemia and idiopathic pancreatitis were 6.66%, 4.44%, 4.44% and 2.22% respectively. The overall mortality was 22.22% (n=10).

Cardiovascular Risk Assessment in Elderly Living Kidney Donors: Risk Comparison Before and After Donation Using QRISK Equation

OBJECTIVES

This study aimed to assess whether donor age would increase the risk of cardiovascular comorbidities during the first few years after donation. Cardiovascular risk was calculated using the QRISK tool (University of Nottingham and EMIS, Nottingham, UK).

MATERIALS AND METHODS

Data were collected from 221 living renal transplant donors at St. George's University Hospital NHS Foundation Trust between 2008 and 2012 before and after donation (at 6, 12, and 24 mo). QRISK scores were calculated for each patient at these time points before stratifying our patients into 2 cohorts: cohort A (age ≤ 59 y) and cohort B (age ≥ 60 y). QRISK scores were then compared using unpaired t tests.

RESULTS

Before donation, mean QRISK scores were 3.4% in cohort A and 12.4% in cohort B (P < .001). At 6, 12, and 24 months after kidney donation, the risks were 3.3% and 12.2% (P < .001), 3.8% and 13.6% (P < .001), and 5% and 15.4% (P < .001) in cohort A versus cohort B.

CONCLUSIONS

When we analyzed risk before donation, both age groups showed a significant increase in cardiovascular risk at 24 months. This subtle increase in cardiovascular risk in the 2 groups may be attributed to changing patient demographics, such as the increasing age of patients, rather than the donation itself. Elderly kidney donors, therefore, are a key source of donation after satisfactory cardiovascular work-up. However, elderly kidney donors will require long-term postoperative follow-up care and specific counseling aimed at reducing modifiable cardiovascular risk factors.

Outpatient parenteral antibiotic therapy in a renal transplant population: A single-center experience

Outpatient parenteral antimicrobial therapy (OPAT) is a well-established method in medical specialties. Its use in renal transplant recipients has not been thoroughly explored. No guidelines within this patient subset exist. This study describes OPAT outcomes within a UK teaching hospital renal transplant population. Renal function, mapped by estimated glomerular filtration rate (eGFR), and clinical response to infection were collected retrospectively. A total of 635 antimicrobial episodes were administered to nine renal transplant patients over 12 discrete OPAT courses during the study period. Eleven of 12 OPAT courses (91.67%) produced a clinical improvement in infection. One course was terminated due to immunosuppressive-related neutropenia. No patient required admission due to failure of OPAT or adverse events. There was no significant change in graft function throughout the OPAT courses compared with baseline renal function (ANOVA, P = 0.06). One minor line infection was reported. This was treated conservatively and did not interrupt the OPAT. OPAT is safe and clinically effective in our renal transplant recipients with no significant deterioration in eGFR. The incidence of adverse events, specifically line complications, was lower in our population than those reported in the literature. Future work should develop OPAT guidelines designed for transplant recipients to outline the degree of monitoring required.

Outcome of kidney transplant with double ureter: a multicenter study

OBJECTIVES

Renal transplant with double ureters is uncommon. However, with increasing numbers of en bloc and dual transplants from marginal donors, we frequently observe 2 ureters for implant. The current study reviewed our experience with 76 double-ureter renal transplants.

MATERIALS AND METHODS

We performed a retrospective analysis of renal transplant performed in 2 institutes from 1996 to 2011. We recorded the outcomes of renal transplants with double ureters including complications. We compared outcomes with renal transplants with single ureters.

RESULTS

Irrespective of the technique used for implant, we recorded no significant risk of complications of double, compared with single, ureter renal transplants. There were no significant differences in patient and graft survival.

CONCLUSIONS

We believe that double-ureter transplant does not require additional risk discussion with the recipient because it is safe. However, when ureteral stents are used, we should ensure that a mechanism is in place for both stents to be removed postoperatively.

Diffused idiopathic skeletal hyperostosis in a fighting Bulldog: a case report

This case report illustrates the presence of diffuse idiopathic skeletal hyperostosis (DISH) in a fighting Bulldog. The dog was referred to the Veterinary Teaching Hospital, University of Agriculture Faisalabad Pakistan, with the presenting complaint of slowly progressing staggering gait, inability to stand on hind limbs and muscle stiffness in lumbo-sacral region. Hematological, sero-biochemical and clinical examination were insignificant except presence of extensive new bone formation in the radiograph on the ventral of last 4 consecutive body lumbar vertebras (L4-L8) in lumbar region, running parallel to nuchal ligament. Diagnosis of DISH was made on the basis of clinical signs and radiographical examination which were suggestive of DISH. This report documents the first case of DISH in fighting Bulldog in Pakistan.

Appendicular Sinus as a Cause of Chronic Psoas Abscess in a Renal Transplant Recipient: A Case Report

A psoas abscess is a condition with vague symptomatology that is associated with potentially life-threatening suppurative myositis of the iliopsoas muscular compartment. Immunocompromised pa-tients run an increased risk of developing suppurative or chronic abscesses from acute foci. The presence of a solid-organ transplant, and the attendant need for immunosuppressant therapies and impaired renal provide additional factors that could contribute to the comorbidities of this condition. Here, we present a 61-year-old white man with a functioning renal transplant who developed a chronic psoas abscess associated with an appendicular sinus that required serial computed tomographic-guided drainages during 8 years. We highlight the difficulties and limitations of managing a psoas abscess. We conclude that a conservative approach toward managing a chronic psoas abscess may be associated with good long-term patient and graft functions, with minimal risk to the patient.

Successful en bloc renal transplant from a 19-month-old nonheart-beating donor into an adult recipient: case report

Worldwide, there is a shortage of organs available for transplant into patients with end-stage renal failure. This has led to donor selection of the most-marginal donors. These strategies, so far, have failed to meet the requirements. Further adaptations are required to maximize the donor pool. One such pool is nonheart-beating pediatric donors less than 2 years of age. This report highlights a successful en bloc renal transplant using a 19-month-old nonheart-beating pediatric donor kidney into an adult recipient. Renal transplant from a nonheart-beating pediatric donor kidney can be a way forward toward increasing the organ donor pool.

Management of transplant renal artery stenosis and its impact on long-term allograft survival: a single-centre experience

BACKGROUND

Transplant renal artery stenosis (TRAS) is a recognized complication resulting in post-transplant hypertension associated with allograft dysfunction. It is a commonly missed but potentially treatable complication that may present from months to years after transplant surgery. In this retrospective study, we compared management strategies and outcomes of TRAS from 1990 to 2005.

METHODS

Case notes of transplant recipients with TRAS demonstrated by angiography were reviewed. Angiography and was carried out when there was a clinical or Doppler ultrasound suspicion of TRAS. The clinical diagnosis of TRAS was based on uncontrolled refractory/new-onset hypertension and/or unexplained graft dysfunction in the absence of another diagnosis, such as rejection, obstruction or infection. The two-tailed Student t-test was used to analyse the differences between mean arterial pressure, serum creatinine, and estimated glomerular filtration rate before and after the intervention.

RESULTS

Sixty-seven patients with angiogram-confirmed TRAS were included. Forty-four, 9 and 14 patients were managed with primary percutaneous transluminal renal angioplasty (PTRA), surgical intervention and conservative treatment, respectively. Uncontrolled hypertension was the most common presentation noted in 74.62%. Post-anastamotic single stenosis was the commonest occurrence (n = 53). Angioplasty had the highest 1- and 5-year graft survival rate of 91% and 86%, respectively. The worst prognosis was noted in patients treated with secondary PTRA after failed surgery or secondary surgery after failed primary PTRA.

CONCLUSIONS

TRAS is a recognized complication resulting in loss of renal allografts. Early Doppler ultrasound is a good primary diagnostic tool. Early intervention is associated with a good long-term graft function.

Acute appendicitis complicating pregnancy; experience with the management of 50 patients

BACKGROUND

The purpose of this study was to highlight the problems related to acute appendicitis complicating pregnancy and to lay down the principle of their management.

MATERIALS AND METHODS

This study was conducted at Department of Surgery, East Surgical unit Mayo Hospital Lahore from January 1999 to June 2001. It included 50 pregnant patients who presented to emergency department with the diagnosis of acute appendicitis.

RESULTS

Of these 50 patients, 16 were primigravida and 34 were multigravida, with the mean age of 26.5 years. Most of these patients were in their second trimester (n = 26), followed by first trimester (n = 19) and third trimester (n = 5). Pain right iliac fossa (72%) was the commonest symptom, followed by vague generalized abdominal pain (18%) and backache (10%). All the patients under went laparotomy; with 86% positive and 14% negative results. There was no maternal mortality in our study, however 14% foetal mortality was noted.

CONCLUSION

Unnecessary delay in diagnosis and management should be avoided as it is directly related to maternal and foetal morbidity and mortality. The general use of this principle may explain the marked improvement in maternal and foetal mortality and morbidity.