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Immunosuppression and comorbidities might place solid organ transplant (SOT) recipients at higher risk from COVID‐19, as suggested by recent case series. We compared 45 SOT vs. 2427 non‐SOT patients who were admitted with COVID‐19 to our health‐care system (March 1, 2020 ‐ August 21, 2020), evaluating hospital length‐of‐stay and inpatient mortality using competing‐risks regression. We compared trajectories of WHO COVID‐19 severity scale using mixed‐effects ordinal logistic regression, adjusting for severity score at admission. SOT and non‐SOT patients had comparable age, sex, and race, but SOT recipients were more likely to have diabetes (60% vs. 34%, p< .001), hypertension (69% vs. 44%, p= .001), HIV (7% vs. 1.4%, p= .024), and peripheral vascular disorders (19% vs. 8%, p= .018). There were no statistically significant differences between SOT and non‐SOT in maximum illness severity score (p= .13), length‐of‐stay (sHR: 0.91.11.4, p= .5), or mortality (sHR: 0.10.41.6, p= .19), although the severity score on admission was slightly lower for SOT (median [IQR] 3 [3, 4]) than for non‐SOT (median [IQR] 4 [3–4]) (p= .042) Despite a higher risk profile, SOT recipients had a faster decline in disease severity over time (OR = 0.760.810.86, p< .001) compared with non‐SOT patients. These findings have implications for transplant decision‐making during the COVID‐19 pandemic, and insights about the impact of SARS‐CoV‐2 on immunosuppressed patients. This comparison of inpatient transplant and nontransplant recipients with COVID‐19 does not show differences in mortality or measures of illness severity but does show that time to improvement was more rapid in the transplant group.

Immunosuppression and comorbidities might place solid organ transplant (SOT) recipients at higher risk from COVID-19, as suggested by recent case series. We compared 45 SOT vs. 2427 non-SOT patients who were admitted with COVID-19 to our health-care system (March 1, 2020 - August 21, 2020), evaluating hospital length-of-stay and inpatient mortality using competing-risks regression. We compared trajectories of WHO COVID-19 severity scale using mixed-effects ordinal logistic regression, adjusting for severity score at admission. SOT and non-SOT patients had comparable age, sex, and race, but SOT recipients were more likely to have diabetes (60% vs. 34%, p< .001), hypertension (69% vs. 44%, p= .001), HIV (7% vs. 1.4%, p= .024), and peripheral vascular disorders (19% vs. 8%, p= .018). There were no statistically significant differences between SOT and non-SOT in maximum illness severity score (p= .13), length-of-stay (sHR: 0.91.11.4, p= .5), or mortality (sHR: 0.10.41.6, p= .19), although the severity score on admission was slightly lower for SOT (median [IQR] 3 [3, 4]) than for non-SOT (median [IQR] 4 [3–4]) (p= .042) Despite a higher risk profile, SOT recipients had a faster decline in disease severity over time (OR = 0.760.810.86, p< .001) compared with non-SOT patients. These findings have implications for transplant decision-making during the COVID-19 pandemic, and insights about the impact of SARS-CoV-2 on immunosuppressed patients.

Desensitization has enabled incompatible living donor kidney transplantation (ILDKT) across HLA/ABO barriers, but added immunomodulation might put patients at increased risk of infections. We studied 475 recipients from our center from 2010 to 2015, categorized by desensitization intensity: none/compatible (n = 260), low (0‐4 plasmaphereses, n = 47), moderate (5‐9, n = 74), and high (≥10, n = 94). The 1‐year cumulative incidence of infection was 50.1%, 49.8%, 66.0%, and 73.5% for recipients who received none, low, moderate, and high‐intensity desensitization (P< .001). The most common infections were UTI (33.5% of ILDKT vs. 21.5% compatible), opportunistic (21.9% vs. 10.8%), and bloodstream (19.1% vs. 5.4%) (P< .001). In weighted models, a trend toward increased risk was seen in low (wIRR = 0.771.402.56,P= .3) and moderately (wIRR = 0.881.352.06,P= .2) desensitized recipients, with a statistically significant 2.22‐fold (wIRR = 1.332.223.72,P= .002) increased risk in highly desensitized recipients. Recipients with ≥4 infections were at higher risk of prolonged hospitalization (wIRR = 2.623.574.88, P< .001) and death‐censored graft loss (wHR = 1.154.0113.95,P= .03). Post–KT infections are more common in desensitized ILDKT recipients. A subset of highly desensitized patients is at ultra‐high risk for infections. Strategies should be designed to protect patients from the morbidity of recurrent infections, and to extend the survival benefit of ILDKT across the spectrum of recipients. Among living donor kidney transplant recipients, infections are most common in patients who receive high‐intensity desensitization, and patients with more than 4 infections in the first year posttransplant are at increased risk of adverse outcomes.

We aimed to compare the efficacy of ceftazidime-avibactam (CAZ-AVI) versusthe best available therapy (BAT) in solid organ transplant (SOT) recipients with bloodstream infection caused by carbapenemase-producing Klebsiella pneumoniae(CPKP-BSI). A retrospective (2016-2021) observational cohort study was performed in 14 INCREMENT-SOT centers (ClinicalTrials.govidentifier: NCT02852902). Outcomes were 14-day and 30-day clinical success (complete resolution of attributable manifestations, adequate source control and negative follow-up blood cultures) and 30-day all-cause mortality. Multivariable logistic and Cox regression analyses adjusted for the propensity score to receive CAZ-AVI were constructed. Among 210 SOT recipients with CPKP-BSI, 149 received active primary therapy with CAZ-AVI (66/149) or BAT (83/149). Patients treated with CAZ-AVI had higher 14-day (80.7% versus 60.6%, P=0.011) and 30-day (83.1% versus 60.6%, P=0.004) clinical success and lower 30-day mortality (13.25% versus 27.3%, P=0.053) than those receiving BAT. In the adjusted analysis, CAZ-AVI increased the probability of 14-day (adjusted odds ratio [aOR]: 2.65; 95% confidence interval [95%CI]: 1.03-6.84, P=0.044) and 30-day clinical success (aOR: 3.14; 95%CI: 1.17-8.40; P=0.023). In contrast, CAZ-AVI therapy was not independently associated with 30-day mortality. In the CAZ-AVI group, combination therapy was not associated with better outcomes. In conclusion, CAZ-AVI may be considered a first-line treatment in SOT recipients with CPKP-BSI.