Introduction: Prolonged dialysis times (DT) have been associated with inferior outcomes. Nevertheless, rarely suitable candidates with extreme dialysis vintage are transplanted. We aimed to review the characteristics, demographics and outcomes of such patients. Methods: We used United Network for Organ Sharing registry data to assess outcomes for patients who were on dialytic therapy for a minimum of 10 years, who received a kidney alone transplant from Jan 1 2000 – Dec 31 2021. Pediatrics, multi-organ transplants and those without a confirmed dialysis start date were excluded. Results: During the study period, a total of 361,029 kidney alone transplants were performed, of which 70.3% were patients who were on dialysis at the time of transplant. Out of the 253,841 dialysis patients, transplanted, 962 (0.37%) patients met our criteria. The majority of transplants (78.7%) in these 962 cases were performed after Dec, 2014 when the new KAS allocation which credits waitlist time from chronic dialysis initiation was implemented. There was no difference in graft survival for race, gender, but DM and DGF were independant predictors of inferior survival (p<0.05). Conclusions: The present study is the first to look at the granular details of this unique group of patients who receive a transplant after a minimum of 10 years of dialysis. Although outcomes may be somewhat inferior to standard outcomes of patients with shorter dialysis times, carefully selected candidates can still have reasonable successful outcomes. - Recipient Characteristics Mean Age at Time of Transplant (yrs) 49.9+/-10.5 (18-75) Race (AA/Whites/Hispanics) (%) 41.9/ 21.1/ 24.7 Gender (M/F) (%) 53.5/ 38.5 Re-Transplants (%) 38.5 Deceased Donor/ Living Donor Transplants (%) 97.3/ 2.7 Etiology of ESRD (DM/HTN/Other) (%) 24.8/ 20.7/ 54.5 CPRA (0-20, 20-80, 80-97, 98-100) (%) 31.8/ 19.6/ 12.7/ 35.9 Zero Mismatch (%) 5.7 PVD (%) 5.2 MedianDialysis Time (yrs) 12.4 (10-32) Dialysis Time (10-15yrs/ 15-20yrs/ > 20 yrs) (%) 76.7/ 16.4/ 6.8 Donor Characteristics Mean Donor Age (yrs) 36.4 +/-13.9 (1-69) Donor Race (Whites/AA/Hispanics) (%) 52/ 18.6/ 22.6 Donor Gender (M/F) (%) 61.9/ 38.1 DCD (%) 16.4 ECD (%) 6.3 KDPI Median 38 KDPI > 85 (%) 1.8 Donor HTN/ DM (%) 21.5/ 4.3 Median Cold Ischemia Time (hrs) 16 Kidneys Pumped (%) 34.5 Donor PHS Increased Risk (%) 15 Transplant Outcomes DGF (%) 34.7 Acute Rejection within 1 year (%) 9.8 Mean Length of Stay (days) 7.7+/- 9.1 Patient Death within 30 days n (%) 8 (0.8) Graft Failure Within 30 days n (%) 25 (2.5) Graft Survival (%) 1yr/ 3yr/ 5yr/ 10 yr 92/ 80/ 70/ 41 Patient Survival (%) 1yr/ 3yr/ 5yr/ 10yr 96/ 88/ 80/ 50

Patients on the transplant waiting list continue to have a significant wait time as organ supply remains low. Many initiatives have been undertaken in the last few years to attempt to increase the organ allograft supply. As organ procurement organizations have attempted to increase their procurement of organs from deceased donors, emphasis has been placed on avoidance of injury to organs during procurement. To analyze the success of this attention, data were collected from 29 of 57 organ procurement organizations in the United States. Data collection was from November 2017 to January 2020. Total injury rate ranged from 6% (donation after brain death) to 8.4% (donation after circulatory death). Level 3 injuries, those resulting in loss of the allograft, ranged from 1.1% in donation after brain death to 1.6% in donation after circulatory death. The most likely injured organ resulting in loss of viability (level 3 injury) during procurement was the right kidney. We noted that among donors with procurement injuries, a higher number had no previous abdominal surgery and there were more injuries noted from attending surgeons (compared to trainees). Deceased donor procurement organ injuries, though rare, lead to substantial loss of transplantable organs every year. Given that the United Network for Organ Sharing has recorded >10,000 deceased donors yearly for the past few years, such injuries can result in hundreds of transplantable organs lost. In this article we detailed the incidence and degree of injury and some variables that may be associated with these injuries.

Introduction: Nondirected donation (NDD) of the kidneys is a growing practice where donors who do not have any genetic or emotional relationship are selected to donate to a wide variety of recipients with a range of selection criteria and decisions which are left up to individual transplant centers.Methods: We review all adult living kidney donor-recipient (DR) pairs and outcomes from NDDs who were recorded in United Network for Organ Sharing (UNOS) database as code 10 (anonymous) from October 1997 to September 2017 for demographics and outcomes. Results: A total of 2174 DR pairs were identified. The number of NDDs increased from 18 in 2000 to 256 in 2016. Survival analysis showed higher death-censored-graft survival (DC-GS) when recipient was 20 years or more older than donor followed by recipient-donor within 20 years of age and lowest when donor was 20 years or more older than recipient (P 1/4 0.0114).Conclusion: Overall, the number of NDDs has increased significantly in the 20-year review period. Transplants from NDDs have excellent long-term outcomes. Better matching of controllable DR factors, such as age and body mass index (BMI), could further improve GS. Further research is needed to incorporate these DR factors into paired kidney donation programs potentially enhancing the utility and beneficence of this invaluable donation.(c) 2022 Published by Elsevier, Inc., on behalf of the International Society of Nephrology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction:Hypotension after deceased donor kidney transplant (DDKT) is a risk factor for delayed graft function (DGF) and poor graft survival (GS). We hypothesize that vasopressin use in hypotensive DDKT recipients (DDKTRs) to increase blood pressure (BP) reduces DGF rates and is safe without increasing mortality. Methods:Group with vasopressin "study group" (n = 45) was defined as DDKTRs between 2012 and 2017 who required vasopressin for hypotension systolic BP (SBP) <120 mm Hg or diastolic BP (DBP) <60 mm Hg. DDKTRs with no-vasopressin "comparison group" (n = 90) were propensity score-matched DDKTRs between 2012 and 2017 without vasopressin use. Primary outcomes were GS, creatinine and allograft biopsy rate at 1 year, DGF rate, and death during transplant hospitalization. Results:Vasopressin group had lower mean maximum and minimum SBP and DBP in the operating room (OR). Median vasopressin start time post-DDKT was 2 hours (interquartile range [IQR] 1-6), and duration of use was 42 hours (IQR 24-63). DGF, creatinine at 1 year, and allograft biopsy rates were comparable. No deaths occurred during transplant hospitalization. Multivariable analysis did not find an effect of vasopressin use on GS. Conclusion:Treatment of hypotensive DDKTRs with vasopressin is safe and facilitated similar graft function and survival with that of nonhypotensive patients. In the absence of a randomized control trial, our study supports the safety of vasopressin therapy to prevent the adverse effects of hypotension.

Kidney transplant recipients (KTRs) are at an increased risk of hospitalization, complications, and mortality from COVID-19 compared with the general population.1Akalin E. Azzi Y. Bartash R. et al.Covid-19 and kidney transplantation.N Engl J Med. 2020; 382: 2475-2477Crossref PubMed Scopus (594) Google Scholar, 2Hartzell S. Bin S. Benedetti C. et al.Evidence of potent humoral immune activity in COVID-19-infected kidney transplant recipients.Am J Transplant. 2020; 20: 3149-3161Crossref PubMed Scopus (51) Google Scholar, 3Husain S.A. Dube G. Morris H. et al.Early outcomes of outpatient management of kidney transplant recipients with coronavirus disease 2019.Clin J Am Soc Nephrol. 2020; 15: 1174-1178Crossref PubMed Scopus (77) Google Scholar, 4Lubetzky M. Aull M.J. Craig-Schapiro R. et al.Kidney allograft recipients, immunosuppression, and coronavirus disease-2019: a report of consecutive cases from a New York City transplant center.Nephrol Dial Transplant. 2020; 35: 1250-1261Crossref PubMed Scopus (62) Google Scholar, 5Mehta S.A. Leonard J. Labella P. et al.Outpatient management of kidney transplant recipients with suspected COVID-19-Single-center experience during the New York City surge.Transpl Infect Dis. 2020; 22: e13383Crossref PubMed Scopus (22) Google Scholar Among KTRs with COVID-19 in the United States, studies have shown hospitalization rates ranging from 32% to 100%,1Akalin E. Azzi Y. Bartash R. et al.Covid-19 and kidney transplantation.N Engl J Med. 2020; 382: 2475-2477Crossref PubMed Scopus (594) Google Scholar,3Husain S.A. Dube G. Morris H. et al.Early outcomes of outpatient management of kidney transplant recipients with coronavirus disease 2019.Clin J Am Soc Nephrol. 2020; 15: 1174-1178Crossref PubMed Scopus (77) Google Scholar, 4Lubetzky M. Aull M.J. Craig-Schapiro R. et al.Kidney allograft recipients, immunosuppression, and coronavirus disease-2019: a report of consecutive cases from a New York City transplant center.Nephrol Dial Transplant. 2020; 35: 1250-1261Crossref PubMed Scopus (62) Google Scholar, 5Mehta S.A. Leonard J. Labella P. et al.Outpatient management of kidney transplant recipients with suspected COVID-19-Single-center experience during the New York City surge.Transpl Infect Dis. 2020; 22: e13383Crossref PubMed Scopus (22) Google Scholar, 6Cravedi P. Mothi S.S. Azzi Y. et al.COVID-19 and kidney transplantation: results from the TANGO International Transplant Consortium.Am J Transplant. 2020; 20: 3140-3148Crossref PubMed Scopus (276) Google Scholar intensive care unit (ICU) admission rates from 20% to 61%,2Hartzell S. Bin S. Benedetti C. et al.Evidence of potent humoral immune activity in COVID-19-infected kidney transplant recipients.Am J Transplant. 2020; 20: 3149-3161Crossref PubMed Scopus (51) Google Scholar,4Lubetzky M. Aull M.J. Craig-Schapiro R. et al.Kidney allograft recipients, immunosuppression, and coronavirus disease-2019: a report of consecutive cases from a New York City transplant center.Nephrol Dial Transplant. 2020; 35: 1250-1261Crossref PubMed Scopus (62) Google Scholar and overall mortality of 13% to 39%.1Akalin E. Azzi Y. Bartash R. et al.Covid-19 and kidney transplantation.N Engl J Med. 2020; 382: 2475-2477Crossref PubMed Scopus (594) Google Scholar,2Hartzell S. Bin S. Benedetti C. et al.Evidence of potent humoral immune activity in COVID-19-infected kidney transplant recipients.Am J Transplant. 2020; 20: 3149-3161Crossref PubMed Scopus (51) Google Scholar,4Lubetzky M. Aull M.J. Craig-Schapiro R. et al.Kidney allograft recipients, immunosuppression, and coronavirus disease-2019: a report of consecutive cases from a New York City transplant center.Nephrol Dial Transplant. 2020; 35: 1250-1261Crossref PubMed Scopus (62) Google Scholar, 5Mehta S.A. Leonard J. Labella P. et al.Outpatient management of kidney transplant recipients with suspected COVID-19-Single-center experience during the New York City surge.Transpl Infect Dis. 2020; 22: e13383Crossref PubMed Scopus (22) Google Scholar, 6Cravedi P. Mothi S.S. Azzi Y. et al.COVID-19 and kidney transplantation: results from the TANGO International Transplant Consortium.Am J Transplant. 2020; 20: 3140-3148Crossref PubMed Scopus (276) Google Scholar A high incidence of acute kidney injury was noted, ranging from 30% to 89%,2Hartzell S. Bin S. Benedetti C. et al.Evidence of potent humoral immune activity in COVID-19-infected kidney transplant recipients.Am J Transplant. 2020; 20: 3149-3161Crossref PubMed Scopus (51) Google Scholar,4Lubetzky M. Aull M.J. Craig-Schapiro R. et al.Kidney allograft recipients, immunosuppression, and coronavirus disease-2019: a report of consecutive cases from a New York City transplant center.Nephrol Dial Transplant. 2020; 35: 1250-1261Crossref PubMed Scopus (62) Google Scholar, 5Mehta S.A. Leonard J. Labella P. et al.Outpatient management of kidney transplant recipients with suspected COVID-19-Single-center experience during the New York City surge.Transpl Infect Dis. 2020; 22: e13383Crossref PubMed Scopus (22) Google Scholar, 6Cravedi P. Mothi S.S. Azzi Y. et al.COVID-19 and kidney transplantation: results from the TANGO International Transplant Consortium.Am J Transplant. 2020; 20: 3140-3148Crossref PubMed Scopus (276) Google Scholar while renal replacement therapy was required in 13% to 21% of patients.1Akalin E. Azzi Y. Bartash R. et al.Covid-19 and kidney transplantation.N Engl J Med. 2020; 382: 2475-2477Crossref PubMed Scopus (594) Google Scholar,7Columbia University Kidney Transplant ProgramEarly description of coronavirus 2019 disease in kidney transplant recipients in New York.J Am Soc Nephrol. 2020; 31: 1150-1156Crossref PubMed Scopus (186) Google Scholar Given the natural history of COVID-19 pneumonia, most of these complications occurred ≥1 week after the diagnosis of COVID-19. Given the high impact of COVID-19 infection on KTRs, early COVID-19–directed therapies are critical. Bamlanivimab (LY-CoV555) was given Emergency Use Authorization (EUA) by the US Food and Drug Administration on November 9, 2020.8US Food and Drug Administration websiteFact sheet for health care providers emergency use authorization (EUA) of bamlanivimab.https://www.fda.gov/media/143603/downloadGoogle Scholar It is a neutralizing IgG1 monoclonal antibody that binds to the receptor-binding domain of the spike protein of SARS-CoV-2, inhibiting attachment to human angiotensin-converting enzyme 2 receptor. This EUA was given for treatment of mild to moderate COVID-19 in patients ≥12 years of age weighing >40 kg who are positive with a direct viral testing for SARS-CoV-2 and have high risk for progressing to severe COVID-19 and/or hospitalization.8US Food and Drug Administration websiteFact sheet for health care providers emergency use authorization (EUA) of bamlanivimab.https://www.fda.gov/media/143603/downloadGoogle Scholar KTRs with COVID-19 are considered high risk because of immunosuppressive medication use.9Chen P. Nirula A. Heller B. et al.SARS-CoV-2 neutralizing antibody LY-CoV555 in outpatients with Covid-19.N Engl J Med. 2020; 384: 229-237Crossref PubMed Scopus (872) Google Scholar Studies on the use of bamlanivimab among KTRs are limited. To provide more insight on the use of bamlanivimab in KTRs we report our experience with 24 KTRs. Demographic information is shown in Table 1.Table 1Demographics, transplant history timeline of symptoms, testing, resolution, and adverse eventsDemographics, timelines, and adverse eventsValue or %, N = 24Age, yr, median (range)53.1 (36.3–76.6)Gender, n (%) Male15 (62.5) Female9 (37.5)Race, n (%) Caucasian19 (79.2) African American4 (16.6) Hispanic1 (4.2)Kidney transplant, n (%) Living donor10 (41.7) Deceased donor14 (58.3)Combined transplants, n Kidney and pancreas3 Heart and kidney1 Liver and kidney1Comorbidities, n (%) Hypertension19 (79.2) Hyperlipidemia11 (45.8) Diabetes mellitus (types I and II)7 (29.2) Asthma3 (12.5) Hypothyroidism4 (16.7) Coronary artery disease3 (12.5)Median time from transplant to COVID-19, days (range)1610 (19–11,884)Baseline creatinine before COVID-19, mg/dl ± SD1.43 ± 0.46Median ± SD time from symptom onset to COVID-19 testing, days (median [range])2.08 ± 1.2 (2 [0–4])Median ± SD time from SARS CoV-2 PCR test result to infusion,aBamlanivimab infusion days2.67 ± 2.5 (1.5 [0–9])Median ± SD time from onset of symptoms to infusion,aBamlanivimab infusion days4.75 ± 2.3 (4 [2–8])Major symptoms, n (%) Fatigue15 (62.5) Fever12 (50) Cough9 (37.5) Anosmia/dysgeusia4 (16.7) Chills4 (16.7) Headache4 (16.7) Shortness of breath4 (16.7) Sore throat/sinus congestion3 (12.5)Pre–COVID-19 immunosuppressive regimen Tacrolimus/mycophenolic acid13 (54.2) Tacrolimus/mycophenolic acid/prednisone4 (16.7) Tacrolimus/sirolimus3 (12.5) Tacrolimus/sirolimus/mycophenolic acid1 (4.2) Mycophenolic/prednisone1 (4.2) Other2 (8.3)Post–COVID-19 immunosuppressive regimen No change to regimen13 (54.2) Decrease mycophenolic acid by ≥50%7 (29.2) Hold mycophenolic acid4 (16.7)Adverse events from infusion, n (%) Nausea2 (8.3) Headache2 (8.3) Rash on fingers that resolved within 2–3 days1 (4.2)No side effects noted, %87.5Median ± SD time to resolution of symptoms reported (among those who reported improvement), hours (median [range])31.4 ± 15.9 (24 [12–72]), n = 14No improvement, n (%)6 (26.1)Other symptoms improved but fever for 30 days, n (%)1 (4.2)Fatigue for 30 days, n (%)1 (4.2)Fever 14 days, n (%)1 (4.2)Unable to recall, n (%)1 (4.2)PCR, polymerase chain reaction; SD, standard deviation.a Bamlanivimab infusion Open table in a new tab PCR, polymerase chain reaction; SD, standard deviation. The average time from symptom onset to SARS CoV-2 polymerase chain reaction (PCR) results was 2.08 ± 1.2 days. The most common symptoms were fatigue, fever, and cough. Three of 24 patients were tested before a scheduled procedure or because of positive contacts for SARS CoV-2. They were asymptomatic at the time of SARS CoV-2 PCR testing but subsequently developed symptoms. The mean time from diagnosis to bamlanivimab infusion was 2.67 ± 2.5 days. More than half (62.5%) of KTRs received the infusion locally from their primary care or emergency department physician; 37.5% received it at our transplant center's designated COVID-19 infusion center. Most of the patients reported a resolution of symptoms within 31.4 ± 15.9 hours after the infusion. None of the patients reported difficulty in arrangement of bamlanivimab infusion. Three patients reported side effects during or after the infusion, including nausea, headache, worsening of body aches for 1 day, and rash on the fingers. No anaphylactic reactions were reported. This is summarized in Table 1. Fourteen of 24 patients (54.2%) were taking tacrolimus and mycophenolic acid on a prednisone-free regimen before COVID-19 infection. Thirteen of 24 had no change to their immunosuppressive regimen after COVID-19 diagnosis, while 7 of 24 had their dose of mycophenolic acid decreased by ≥50%. Four of 24 (16.7%) patients required hospitalization, all of whom required supplemental oxygen and 2 of whom required ICU care. One patient required mechanical ventilation and dialysis therapy for acute kidney injury and died. Among those who required ICU admission, 1 patient each was diagnosed with COVID-associated pulmonary aspergillosis and disseminated histoplasmosis later in the course and were treated with antifungal therapies. All admitted patients received dexamethasone for 10 days per our COVID-19 infection treatment protocol and 2 of 4 received remdesivir. Patients in the ICU received additional dexamethasone based on the Dexamethasone Treatment for the Acute Respiratory Distress Syndrome trial regimen.S1 These data are shown in Table 2.Table 2Follow-up and outcomesFollow-up or outcomeValue or %, N = 24Mean ± SD follow-up after bamlanivimab, days (median [range])66.7 ± 20.7 (70 [23–113])Hospitalization, n (%)4 (16.7)Need for supplemental oxygenaAt the time of admission to the hospital.4/4 admitted patientsMedian ± SD time from infusionbBamlanivimab infusion. to admission, days (median [range])13.5 ± 9.5 (11 [5–27])Site of infusion,bBamlanivimab infusion. % Transplant infusion center37.5 Local clinic/hospital62.5Intensive care unit admission, n (%)2 (8.3)Additional diagnosis in patients admitted to the intensive care unit, n Aspergillosis1 Histoplasmosis1Additional COVID-19 treatments, n (%) Dexamethasone4 (12.5) Remdesivir2 (8.3)Mechanical ventilation, n (%)1 (4.2)Acute kidney injury, n (%)3 (12.5)Need for dialysis, n (%)1 (4.2)Death, n (%)1 (4.2)a At the time of admission to the hospital.b Bamlanivimab infusion. Open table in a new tab Clinical data on bamlanivimab use in KTRs are currently limited. We hereby report its use, safety, effect on timeline of symptoms, and outcomes in a real-world setting. Most of our patients avoided hospitalization, ICU admission, and did not report any sequalae of COVID-19 in the follow-up period. Dhand et al.S2 reported outcomes in 6 KTRs with none requiring hospitalization. In their report, the average time from onset of symptoms to infusion was 3.3 days.S2 In our study, the mean time from onset of symptoms to infusion was 4.75 days; however, mean SARS CoV-2 PCR testing and return time was 2 days, which accounted for nearly half the time. Distance from the transplant center, availability, and arrangement of bamlanivimab were other factors in this regard. In our series, 4 patients required hospitalization over a mean follow-up time of 66 days, with an average time to hospitalization of 13.5 days after receiving bamlanivimab infusion. Respiratory failure with hypoxemia related to COVID-19 infection was the cause of hospitalization in 3 cases, while it was a contributory cause in the other. Work-up for clinical evidence of other etiologies for hypoxemia, such as heart failure, pulmonary embolism, and acute respiratory distress syndrome, was negative at the time of hospitalization in all 4 patients, and none had underlying lung disease. All hospitalized patients received 10 days of dexamethasone therapy. Among these, 2 required ICU admission and received additional dexamethasone based on the Dexamethasone Treatment for the Acute Respiratory Distress Syndrome trialS1 and 1 of the 2 required mechanical ventilation. Interim analysis from the BLAZE-1 clinical trial showed a day 29 hospitalization rate of 1.6% for those treated with bamlanivimab compared with 6.3% in the placebo group.9Chen P. Nirula A. Heller B. et al.SARS-CoV-2 neutralizing antibody LY-CoV555 in outpatients with Covid-19.N Engl J Med. 2020; 384: 229-237Crossref PubMed Scopus (872) Google Scholar Our rates of hospitalization are higher than the preliminary studies in nontransplant settings; however, it could be related to the longer follow-up time in our study and the smaller number of patients. Final data from the BLAZE-1 trial became available after our study timeframe and reported bamlanivimab alone versus bamlanivimab plus etesevimab (combination therapy) compared with placebo. These dataS3 showed that combination therapy was successful in reducing day 11 viral load compared with bamlanivimab alone. While it failed to show a significant difference in the primary outcome, rates of hospitalization among patients who received a 700-mg dose of bamlanivimab or combination therapy was 1% and 0.9%, respectively, compared with 5.8% in the placebo group, although it was significant only in the combination therapy group. Mean total symptom scores were also comparable between bamlanivimab monotherapy and the combination group.S3 Because of emerging SARS CoV-2 variants with resistance, the EUA for bamlanivimab use alone has been withdrawnS4; however, combination monoclonal antibody therapies including bamlanivimab plus etesevimab and casirivimab plus imdevimabS5 still retain their EUA for use as previously authorized for bamlinivimab alone. Bamlanivimab was well tolerated with no significant major adverse effects or allergic reactions in our cohort, which is similar to previously reported casesS2 and the BLAZE-1 trial.9Chen P. Nirula A. Heller B. et al.SARS-CoV-2 neutralizing antibody LY-CoV555 in outpatients with Covid-19.N Engl J Med. 2020; 384: 229-237Crossref PubMed Scopus (872) Google Scholar,S3 Nausea (3.9%) was most common symptom in the BLAZE-1 trial, followed by diarrhea (3.2%). Infusion reactions occurred in 2.3% of the patients and included rash and pruritis.9Chen P. Nirula A. Heller B. et al.SARS-CoV-2 neutralizing antibody LY-CoV555 in outpatients with Covid-19.N Engl J Med. 2020; 384: 229-237Crossref PubMed Scopus (872) Google Scholar Similar trends were seen in our study, with 4.2% having a rash, 8.3% reporting nausea, and no reports of diarrhea. None of the side effects required discontinuation of the infusion. The mortality rate in our series of KTRs (4.2%) was lower compared with those KTRs who had COVID-19 but did not receive bamlanivimab infusion (9.4%) over the same timeframe. Confounding factors in ICU admission included additional diagnosis of disseminated histoplasmosis in 1 patient and COVID-19–related pulmonary aspergillosis in another who died. Additional factors contributing to patient death included multiorgan dysfunction from sepsis caused by ventilator-associated pneumonia from Klebsiella and Stenotrophomonas, pneumothorax, acute respiratory distress syndrome, and acute stroke late in the course leading to decision a transition to comfort measures by the family. The patient with disseminated histoplasmosis received a kidney transplant 2 years before their COVID-19 infection, while the patient with COVID-19–related pulmonary aspergillosis had a kidney transplant 10 years earlier. There was no history of these diagnoses in each case. In addition to these 2 patients, 1 patient was treated for community-acquired pneumonia at 4 weeks from COVID-19 infection based on radiologic findings. This highlights the fact that among KTRs who require hospitalization, other infectious etiologies such as fungal pneumonia should be worked up and excluded. There are several limitations to our study. We relied on patients to establish a timeline of reported symptoms and their resolution after receiving bamlanivimab, which can lead to recall bias. Second, the total number of patients in our series was small to estimate hospitalization rates. Third, there was no control group, although it may not be ethically justified to withhold this therapy in such high-risk individuals. Fourth, given the study timeframe, testing for variants of SARS CoV-2 and viral loads were not possible. Finally, the effects of other COVID-19 treatments may have confounded our results. Important lessons for transplant programs in a quickly changing COVID-19 pandemic situation include effective communication with and tracking of KTRs with COVID-19 infection. The emergence of resistant variants to bamlanivimab may have reduced its clinical benefit, as seen during the BLAZE-1 trial study period; however, it provides insight into potential use of similar agents alone or in combination in the future and the coordination it requires in a real-world setting. In conclusion, bamlanivimab showed a safe profile among immunosuppressed KTRs with mild to moderate COVID-19 symptoms. A majority of our KTRs avoided hospitalization and did not develop sequelae of COVID-19 in the follow-up period. It is important for transplant centers and KTRs alike to ensure quick symptom reporting and testing turn-around times for SARS CoV-2 PCR, with effective communication between KTRs and transplant programs to determine the window of opportunity. Additional data from larger studies will help clarify the role of bamlanivimab among KTRs with COVID-19. All the authors declared no competing interests. 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Background. Since 1964 when Indiana University performed its first kidney transplant, immunosuppression protocol was steroid-based until 2004 when steroid-free immunosuppression protocol was adopted. We describe clinical outcomes on our patients administered early steroid withdrawal (ESW) protocol (5 days) compared with our historical cohort (HC), who were on chronic steroid-based immunosuppression. Methods. We performed a retrospective study evaluating kidney transplant recipients between 1993 and 2003 (HC, n = 1689) and between 2005 and 2016 (ESW cohort, n = 2097) at the Indiana University program, with a median follow-up of 10.5 years and 6.1 years, respectively. Primary outcomes were patient and death-censored graft survival at 1, 3, and 5 years in both study cohorts. Secondary outcomes were 1-year rates of biopsy-proven acute rejection; graft function at 1, 3, and 5 years; and risk of post-transplant infection (BK virus and cytomegalovirus) in the ESW cohort. Cox proportional model and Kaplan-Meier estimates were used to estimate survival probabilities. Fisher exact tests were used to compare episodes of acute rejection in the ESW cohort. Results. No difference was observed in patient survival between the ESW and HC cohorts (P = .13). Compared with the ESW cohort, death-censored graft survival was significantly worse in the HC (5 year: 86.4% vs 90.6%, log-rank P < .001). One-year acute rejection reported in the ESW cohort alone was 15.7% and significantly worse in Black patients and younger patients (P < .05). Conclusions. In this sizeable single-center cohort study with significant ethnic diversity, ESW is a viable alternative to steroid-based immunosuppression protocol in kidney transplant recipients.

Purpose: Treatment options for patients with COVID 19 have limited efficacy in reducing severity and duration of viral symptoms as well as progression to severe disease. Bamlanivimab(LY-CoV555) received Emergency Use authorization (EUA) by the FDA on November 9,2020 for non-hospitalized COVID 19 patients with mild to moderate illness who are considered high risk for progression to severe COVID 19 or to require hospitalization such as those on chronic immunosuppression therapy post-transplant. In this study we review its use among patients with kidney transplant. Methods: 24 patients who tested positive for COVID 19 with nasopharyngeal PCR between November 9, 2020 and February 7, 2021 were retrospectively reviewed and analyzed. Labs, clinical course and communication with transplant team was reviewed. FDA approved standardized infusion dose was used. Results: Average age of recipients was 57.5 +/- 11.8 years. Hypertension was most common co-morbidity in 17/24 patients followed by Diabetes Mellitus in 10/24. 3 patients had combined Pancreas Transplant, 1 combined-heart and 1combined- Liver. 3/24(12.5%) patients required hospitalization, and supplemental oxygen, while 1 patient required mechanical ventilation and died. Dialysis therapy for acute kidney injury was required in 1 patient. Majority of patients 14/24 were on Tacrolimus and Mycophenolic acid. 13/24 had no change to their immunosuppression after COVID diagnosis while 7/24 had mycophenolic acid decreased to half or lower and in 4 cases it was held temporarily. 1 patient each reported headache, elevated blood pressure after infusion. Among the 3 patients who were hospitalized 1 patient each was diagnosed with Aspergillosis and Histoplasmosis. Results summarized in Table 1.Table 1. Characteristics and outcomes among patients receiving Bamlanivimab, n=24 Living Donor Kidney Transplant, DDKT Deceased Donor Kidney Transplant, MPA mycophenolic acid, IS Immunosuppression, Tac. Tacrolimus, Cyc. Cyclosporin, RRT Renal Replacement Therapy, mab. monoclonal antibody Conclusions: To our knowledge this is the first report describing the use of Bamlanivimab in patients with Kidney Transplants. It showed a beneficial effect in immunosuppressed patients with mild to moderate COVID 19 symptoms with majority avoiding hospitalization. It appears to be well tolerated with no significant major adverse effects or allergic reactions in our cohort. Further large scale studies are needed to evaluate its impact on symptom duration and decrease in severity of COVID 19 among patients on immunosuppression for kidney transplant. (Table Presented).

Objectives. Presence of nephrolithiasis in a living donor has been at least a relative contraindication to living donor nephrectomy. The concern for stone recurrence and outcomes has been one of the reasons for reluctance to consider these medically complex donors. We evaluate long-term outcomes in recipients of kidney grafts from donors with nephrolithiasis, or history of nephrolithiasis, and provide results from our experience at Indiana University. Materials and Methods. We retrospectively reviewed 57 donor-recipient pairs, where the allograft was received from a living donor with symptomatic calculi, or with imaging evidence of kidney stones, between 2003 and 2018. This research study was done in compliance with the ethical standards set forth in the Helsinki Congress. Results. The mean age of recipients was 46?19 years and 58% were male. Kidney recipients were followed for a median of 3.5 years and 59.6% of patients had follow-up imaging studies. None of the recipients had obstructing renal calculi or related infections. None of the recipients required any interventions for recurrent calculi and no stone episode lead to adverse event to the graft. Hyperoxaluria and hypercalciuria were the most common risk factors in 24-hour urine collections obtained from donors. Conclusions. Our findings from a single large center looking at kidney recipient outcomes over a long follow-up period found that gifted lithiasis is a safe procedure. Careful selection of ?medically complex donors? with kidney stones based on appropriate guidelines is a key step. Further studies are needed to help develop consensus guidelines.

Introduction: A critical question facing transplant programs is whether, when, and how to safely accept living kidney donors (LKDs) who have recovered from COVID-19 infection. The purpose of the study is to understand current practices related to accepting these LKDs. Methods: We surveyed US transplant programs from 3 September through 3 November 2020. Center level and participant level responses were analyzed. Results: A total of 174 respondents from 115 unique centers responded, representing 59% of US LKD programs and 72.4% of 2019 and 72.5% of 2020 LKD volume (Organ Procurement and Transplantation Network-OPTN 2021). In all, 48.6% of responding centers had received inquiries from such LKDs, whereas 44.3% were currently evaluating. A total of 98 donors were in the evaluation phase, whereas 27.8% centers had approved 42 such donors to proceed with donation. A total of 50.8% of participants preferred to wait >3 months, and 91% would wait at least 1 month from onset of infection to LD surgery. The most common reason to exclude LDs was evidence of COVID-19-related AKI (59.8%) even if resolved, followed by COVID-19-related pneumonia (28.7%) and hospitalization (21.3%). The most common concern in accepting such donors was kidney health postdonation (59.2%), followed by risk of transmission to the recipient (55.7%), donor perioperative pulmonary risk (41.4%), and donor pulmonary risk in the future (29.9%). Conclusion: Practice patterns for acceptance of COVID-19-recovered LKDs showed considerable variability. Ongoing research and consensus building are needed to guide optimal practices to ensure safety of accepting such donors. Long-term close follow-up of such donors is warranted.

Although the data supporting long-term safety of nephrectomy in hypertensive donors has been reported, there is scarcity of long term data on the recipient outcomes of such donors. Furthermore the use of older (>60 year) hypertensive donors is even further rare and minimal data exists on the transplant recipient outcomes for these donors. Hence the purpose of our study was to study the demographics of older living donors and their recipient outcomes in the United States.

To the Editor: We found no published works reporting COVID-19 infection presenting as neutropenic fever in renal transplant adult patients. We report the first case. On March 18, 2020, a 33-year-old female presented to our hospital with chief complaint of dry cough and dyspnea for 5 days prior to admission that progressively gotten worse. She had fever (temperature of 38.3 C) and malaise. She had End Stage Renal Disease (ESRD) and had Living Unrelated Kidney Transplant in February of 2019. She travelled to Ghana for medical mission trip with layover in Paris on March 6th. Physical exam was remarkable for bilateral crackles in her lungs and labored respiration. Labs showed low white blood cell (absolute neutrophil count of 0.8 k/cumm). A nasopharyngeal/oropharyngeal swab specimen was obtained and sent for detection of COVID-19. Rapid flu A/B test and HIV-1/-2 Ab/HIV Ag QL were negative. CMV IgG EIA QN and EBV VCA IgM EIA were not checked during this admission. Computerized tomography scan of chest showed new patchy peripheral interstitial and airspace opacities with air bronchograms within both lungs. The PCR for COVID-19 came back positive (confirmed by COVID-19 GeneXpert detection) on March 19, 2020. The patient was initiated on Hydroxychloroquine 400 mg po twice a day for 1 day then 200 mg twice a day for total 5 days. Given her immunosuppressed status with COVID-19 associated with neutropenic fever, she was given Cefepime for 5 days and Azithromycin for 3 days. Home medications were continued including Fluticasone and Salmeterol Diskus, Ferrous Gluconate, Malarone (Atovaquone and Proguanil), Montelukast, Tacrolimus, Acetaminophen, Albuterol HFA, Ondansetron and Cetirizine. The patient was not on ACE inhibitor due to the fact she had history of angioedema. She was given IVF in the form of Sodium Chloride 0.9% at 100 mL/hour. Her Mycophenolic acid was stopped when her COVID-19 test came back positive and her Tacrolimus dose was adjusted to achieve a level of 3-5 ng/mL. Her creatinine, WBCs, platelets and hemoglobin dropped during her hospitalization (Figure 1). The patient improved and was discharged home on March 24, 2020. She was placed on self-quarantine till April 17, 2020. The patient's symptoms resolved on April 30, 2020 with both clinical and laboratorial improvement.

Although guidance documents have been published regarding organ donation from individuals with a prior history of COVID-19 infection, no data exist regarding successful recovery and transplantation from deceased donors with a history of or positive testing suggesting a prior SARS-CoV-2 infection. Here, we report a case series of six deceased donors with a history of COVID-19 from whom 13 organs were recovered and transplanted through several of the nation's organ procurement organizations (OPOs). In addition, at least two potential donors were authorized for donation but with no organs were successfully allocated and did not proceed to recovery. No transmission of SARS-CoV-2 was reported from the six donors to recipients, procurement teams, or hospital personnel. Although more studies are needed, organ donation from deceased donors who have recovered from COVID-19 should be considered.