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Introduction Methods Results Conclusions BK polyomavirus (BKPyV)‐DNAemia is a common complication in kidney transplant recipients (KTRs). The significance of achieving viral clearance at different time intervals is not well understood.All adult KTRs transplanted between January 1, 2015 and December 31, 2017 who developed BKPyV‐DNAemia were included. Outcomes were analyzed based on persistent clearance of BKPyV‐DNAemia at 3‐month intervals up to 2 years after initial detection, and for recipients with persistent BKPyV‐DNAemia at last follow‐up. Uncensored graft failure, death‐censored graft failure (DCGF), and a composite outcome of DCGF or fall in estimated glomerular filtration rate (eGFR) by ≥50% from the time of initial BKPyV‐DNAemia were outcomes of interest.Of 224 KTRs with BKPyV‐DNAemia, 58 recipients (26%) achieved viral clearance by 3 months after initial detection, 105 (47%) by 6 months, 120 (54%) by 9 months, 141 (63%) by 12 months, 155 (69%) by 15 months, 167 (75%) by 18 months, 180 (80%) by 21 months, and 193 (86%) by 24 months. Nine recipients (4%) had persistent BKPyV‐DNAemia at last follow‐up. Compared to recipients who achieved viral clearance by 3 months, those who achieved clearance by 6 months (adjusted odds ratio [aOR]: 3.15; 95% confidence interval [CI]: 1.22–8.12; p = .02) and 9 months (aOR: 3.69; 95% CI: 1.02–13.43; p = .04) had significantly increased risk for uncensored graft failure. There was no significant association between time to viral clearance and DCGF or composite outcomes.We found a trend of increased risk for uncensored graft failure among those who cleared BKPyV‐DNAemia more slowly. Aiming to clear viremia early, without risking rejection, may be beneficial for allograft function and patient morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Infection remains a relevant complication after kidney transplantation (KT). A well‐established strategy in modern medicine is the application of bundles of evidence‐based practice in clinical settings. The objective of this study is to explore the application of a personalized bundle of measures aimed to reduce the incidence of infection in the first 12 months after KT.A single‐center prospective cohort of 148 patients undergoing KT between February 2018 and September 2019 that received an individualized infection prevention strategy was compared to a preintervention cohort (n = 159). The bundle comprised a review of the patient's immunization history, infection risk by country of origin, screening for latent tuberculosis infection (LTBI), antimicrobial prophylaxis, and immunological assessment. Individualized recommendations were accordingly provided at a scheduled visit at day +30 after transplantation.The intervention cohort showed a higher compliance rate with the recommended vaccine schedule, screening for geographically restricted infections and LTBI, and intravenous immunoglobulin and vitamin D supplementation (p values <.001). The 1‐year incidence rate of infection was lower in the intervention cohort (42.6% vs. 57.9%; p value = .037), as was the rate of infection‐related hospitalization (17.6% vs. 32.1%; p value = .003) and the incidence of severe bacterial infection. There were no differences in graft rejection or mortality rates between groups.A multifaceted intervention, including a bundle of evidence‐based practices, enhanced compliance with recommended preventive measures and was correlated with a reduction in the 12‐month incidence of infection after KT. [ABSTRACT FROM AUTHOR]

Background: Cytomegalovirus (CMV) infections are a common complication after kidney transplantation (KTx) and negatively affecting patient outcome. Valganciclovir (VGC) prophylaxis is often limited by drug‐induced side effects and dose reduction due to decline in kidney function. Method: In the present study, episodes of CMV viremia in the first year after KTx in a cohort of 316 recipients were analyzed retrospectively to identify risk factors linked to persistent infections. Results: In the studied cohort, 18.7% of patients showed a high‐risk (HR) constellation (D+/R–) for CMV infections. CMV viremia affected 22% of our cohort, with HR patients being the most affected cohort (44.1%). Within this group, most viremic events (65.3%) occurred while patients were still on prophylactic therapy, showing significantly higher viral loads and a longer duration compared to seropositive recipients. Conclusion: The analysis at hand revealed that detection of viremia under ongoing antiviral prophylaxis bears an increased risk for sustained viral replication and antiviral drug resistance in HR patients. We identified low estimated glomerular filtration rate (eGFR) and lower dose VGC prophylaxis post‐KTx as a risk factor for breakthrough infections in HR patients in our single center cohort. These patients might benefit from a closer CMV monitoring or novel prophylactic agents as letermovir. [ABSTRACT FROM AUTHOR]

3 Tweet linked to the visual abstract: I Ureaplasma urealyticum i encrusted pyelitis in a kidney graft patient: a case report and narrative review on encrusted pyelitis. Encrusting pyelitis, kidney graft, kidney transplant, Ureaplasma urealyticum Keywords: encrusting pyelitis; kidney graft; kidney transplant; Ureaplasma urealyticum EN encrusting pyelitis kidney graft kidney transplant Ureaplasma urealyticum 1 4 4 02/10/22 20220201 NES 220201 INTRODUCTION Alkaline-encrusted pyelitis is a rare and chronic infectious disease of the urothelium, characterized by renal pelvicaliceal calcific encrustations also known as struvite stones. Ureaplasma urealyticum-encrusted pyelitis in a kidney graft patient: A case report and narrative review on encrusted pyelitis. [Extracted from the article]

Objectives: This study focused on the role that BK polyomavirus (BKPyV) genotypes can play in the development of BKPyV‐associated complications in renal transplant recipients. Methods: A retrospective observational study (January 2015 to April 2018) was conducted by analyzing BKPyV genotypes in 180 blood samples with detectable BKPyV viral load (VL) > 1000 copies/mL, from 63 renal transplant recipients. VL and BKPyV genotypes detections were based on real‐time PCR (rt‐PCR)‐specific assays. Results: Forty‐four patients (44/63 [69.8%]) were men, and the median age was 55.0 (interquartile range 49.0‐66.0 years). Eleven patients had clinical manifestations (11/63 [17.5%]). The most frequently detected genotypes were I (14/63 [22.2%]) and II (13/63 [20.6%]). Half of the patients (33/63 [52.4%]) had a mixed genotype, most with genotypes I and II (25/33 [75.8%]). Patients with infection by mixed genotypes showed VLs that were detected earlier (in the first year after transplantation) than those with a single genotype (25/33 [75.8%] vs 13/30 [43.3%], P =.009) and demonstrated greater risk of developing clinical manifestations associated with BKPyV (odds ratio 12.609, 95% confidence interval 1.503‐105.807). Moreover, patients with first BKPyV VL > 10 000 copies/mL more frequently presented mixed genotypes (12/16 [75.0%] vs 21/47 [44.7%], P =.036). Conclusions: The probability of developing clinical manifestations is higher in infections by mixed genotypes. Therefore, the detection of BKPyV genotypes by rt‐PCR can provide relevant information to stratify patients' risk of BKPyV‐associated complications and guide the clinical management of BKPyV infection in kidney transplant recipients. [ABSTRACT FROM AUTHOR]

Adenovirus is an infrequent but challenging viral complication of transplantation that is rarely reported after autologous stem cell transplant. We present a case of disseminated adenovirus infection in a woman who received an autologous stem cell transplant for treatment of multiple sclerosis. After presenting with post‐transplant episodic diarrhea and viremia, endoscopic biopsies and immunohistochemical staining confirmed the diagnosis of disseminated adenovirus infection. Her symptoms and viremia resolved after treatment with cidofovir. This case demonstrates that a high index of suspicion, a systematic clinical approach, and immunohistochemical tissue staining are necessary to diagnose disseminated adenovirus infection in an unexpected host. [ABSTRACT FROM AUTHOR]

Background Urinary tract infections ( UTIs) are the most common infectious complications among renal transplant recipients ( RTR). UTIs caused by extended-spectrum beta-lactamase ( ESBL)-producing Enterobacteriaceae ( ESBL- PE) have been associated with inferior clinical outcomes and increased financial burden. Methods We performed a systematic review and meta-analysis by searching through the PubMed and EMBASE databases (to May 20, 2016) and identifying studies that reported data on the number of RTR who developed an ESBL- PE UTI. Results Our analysis included seven studies, out of 357 non-duplicate articles, that provided data on 2824 patients. Among them, 10% (95% confidence interval [ CI] 4%-17%) developed an ESBL- PE UTI over their follow-up periods. The proportion of RTR affected by an ESBL- PE UTI was 2% in North America (95% CI 1%-3%), 5% in Europe (95% CI 4%-6%), 17% in South America (95% CI 10%-27%), and 33% in Asia (95% CI 27%-41%). In addition, patients affected with an ESBL- PE UTI were 2.75-times (95% CI 1.97-3.83) more likely to suffer a recurrent UTI. Conclusions Based on a limited number of studies, one in 10 RTR will develop a UTI caused by an ESBL- PE, and these patients face an almost 3 times greater risk of recurrence. A more rigorous monitoring of RTR, both during and after resolution of their infection, should be evaluated in order to reduce the incidence and the clinical impact of these resistant infections. [ABSTRACT FROM AUTHOR]

Kidney transplant recipients who are switched to atovaquone ( ATO) from trimethoprim-sulfamethoxazole ( TMP/ SMX) for Pneumocystis jirovecii pneumonia ( PJP) prophylaxis because of adverse events or complications may miss opportunities to be re-challenged with TMP/ SMX, the first-line agent. This single-site, retrospective study assessed kidney transplant recipients for documented reasons for switching from TMP/ SMX to alternate PJP prophylaxis and outcomes of TMP/ SMX re-challenge. Out of 166 patients, 155 initially received TMP/ SMX; of these, 31 were switched to ATO for various reasons. Fourteen patients receiving ATO were re-challenged with TMP/ SMX; all were successfully re-initiated on TMP/ SMX therapy. Most patients switched to ATO post kidney transplant secondary to non-hypersensitivity reasons should be re-challenged with TMP/ SMX because of the advantages it provides over other agents. [ABSTRACT FROM AUTHOR]

Fungal arteritis affecting graft arteries is a rare but life-threatening complication in kidney transplantation ( KT). Here, we report the case of a patient with Aspergillus arteritis who experienced renal artery rupture 8 days after KT. We also reviewed 50 other reported cases of fungal arteritis after KT. We found that fungal contamination can occur during kidney graft harvest, preservation, and/or transplantation. Typically, early diagnosis, timely antifungal treatment, and emergency surgery seem crucial for avoiding life-threatening vascular complications. [ABSTRACT FROM AUTHOR]

Background Superficial and deep fungal infections are more frequent in transplant recipients primarily because of the failure of cell-mediated immunity and lesser amount of antigen-presenting Langerhans cells in their epidermis. Here, we report seven cases of post-renal transplant subcutaneous phaeohyphomycosis, all of which manifested within 1 year after transplantation and were unresponsive to prolonged courses of itraconazole. This is the first case series, to our knowledge, of phaeohyphomycosis in transplant recipients in India. Method We performed a retrospective review of cases of phaeohyphomycosis among kidney transplant recipients for type of transplant, immunosuppression, histopathology, and treatment, with prospective follow-up of healed lesion. Results An overall incidence of 8.3% was noted, with a median duration of approximately 6 months post transplant to the onset of skin lesion. None of the lesions responded to itraconazole alone and 6/7 lesions were surgically excised. Histopathology showed various lesions and culture could isolate Neocytalidium and Exophiala jeanselmi in two cases. Conclusion Dematiaceous fungi are increasingly implicated in cutaneous lesions in transplant recipients. Histopathology and surgical excision are the appropriate tools for diagnosis and treatment, respectively. [ABSTRACT FROM AUTHOR]

Background Carbapenem-resistant Klebsiella pneumoniae ( CR- KP) infections in solid organ transplant patients are progressively increasing and are associated with worse outcomes, although potential risk factors and therapeutic strategies are still not well defined. Methods We conducted a retrospective matched-pair analysis in which we compared 26 recipients CR- KP-positive after kidney transplantation ( KT) with 52 CR- KP-negative patients transplanted in the same period, during a CR- KP outbreak that occurred in our hospital. Twenty-one patients (80%) received a combined antibiotic treatment. At the end of the follow-up, of the 26 CR- KP infected patients, 11 (42.3%) experienced at least one episode of re-infection, 9 (34.6%) remained colonized, and 6 (23.0%) had a symptomatic infection. Two of the 11 patients with re-infection died, while 9 were colonized at the end of the study. Results A significantly better patient ( P = .043) and graft ( P < .001) survival was observed in CR- KP-negative patients. Univariate analysis identified the following variables as potential risk factors associated with CR- KP infection after KT: lower body mass index ( P = .020); higher creatinine levels at post-transplant days 7 ( P = .009), 15 ( P = .026), and 30 ( P = .019); longer hospital stay ( P = .007); longer cold ischemia time ( P = .004); delayed graft function ( P = .020); and higher Clavien-Dindo score ( P = .006). Conclusion The study confirmed that a CR- KP positivity may affect the outcome of a kidney transplant population. In severe CR- KP infections with sepsis, a combined antibiotic treatment seems to be advisable. [ABSTRACT FROM AUTHOR]

Background Infections have increased in simultaneous pancreas/kidney transplant recipients ( SPKTRs) with cytomegalovirus ( CMV) infection being the most important viral infection with adverse impact on patient and allograft outcomes. Methods We studied all primary SPKTRs and deceased-donor kidney transplant recipients ( KTRs) between 2008 and 2015 for the development of CMV infection. A total of 21/62 SPKTRs (33.9%) and 90/335 KTRs (26.9%) were diagnosed with CMV infection. A control group of 41 SPKTRs without CMV infection was used for comparison. Results SPKTRs showed an increased incidence of CMV infection compared with KTRs. SPKTRs were more likely to develop CMV disease, CMV pneumonia, recurrent CMV infection, higher initial and peak CMV loads, and more need for intravenous antiviral therapy compared with KTRs ( P<.05). High-risk CMV serostatus (D+R−) and 2 HLA-B/- DR mismatches increased the risk of CMV infection in SPKTRs ( P<.05). No differences were observed for patient and allograft outcomes ( P>.05). SPKTRs with CMV infection were more likely to show concomitant Epstein-Barr virus ( EBV) viremia compared with SPKTRs without CMV infection ( P<.05). SPKTRs with CMV infection showed higher incidences of concomitant BK polyomavirus-associated nephropathy, EBV viremia, and sepsis compared with KTRs with CMV infection ( P<.05). Conclusion Our results suggest a higher incidence and more severe course of CMV infection in SPKTRs compared with KTRs. The increased incidence of concomitant infectious complications among SPKTRs with CMV infection suggests an overall impaired immunity, and calls for more intense screening. [ABSTRACT FROM AUTHOR]

A 74-year-old man with end-stage renal failure secondary to diabetes received a living donor renal transplant (cytomegalovirus [ CMV]-seropositive recipient from a CMV-seropositive donor). Computed tomography scan revealed a gallbladder with hemorrhage. On postoperative day 27, cholecystography revealed gallbladder perforation; he underwent an emergency operation. Histological examination of the gallbladder wall was positive for multiple viral inclusion bodies. We report a very rare case of both hemorrhagic and perforated CMV cholecystitis within a month following renal transplantation. [ABSTRACT FROM AUTHOR]

Pneumocystis pneumonia ( PCP) incidence was decreased in renal transplant thanks to prophylaxis, recommended during the first months after transplantation. However, many late PCP cases are observed after the first 6 months and recommendations to maintain or reintroduce prophylaxis are lacking. The objective of the study was to identify risk factors to guide the individual prescription of prophylaxis, 6 months after transplantation. Thirty-three late PCP cases were identified between 1995 and 2012 in Lille Hospital, France, and were compared to 72 randomized controls transplant recipients. In univariate analysis, age of donor (>48 years), retransplantation, a decrease glomerular filtration rate (≤45 mL/min), induction therapy mediated by anti-thymocyte globulin ( ATG), steroid maintenance, high calcineurin inhibitors ( CNI) doses (tacrolimus ≥0.5 mg/kg/day and cyclosporine ≥2.1 mg/kg/day), and cytomegalovirus ( CMV) infection were significantly associated with PCP. In multivariate analysis, ATG (hazard ratio [ HR]: 2.4 [1.1-5.4]), steroid therapy ( HR: 3.1 [1.20-7.84], CNI ( HR: 2.9 [1.28-6.38], and CMV ( HR: 6.1 [2.74-16.33] remained associated with late PCP. In conclusion, we confirm that intensive immunosuppressive regimen and CMV infection are critical risk factors for late PCP and should be taken into account to decide on maintenance or reintroduction of a prophylactic treatment. [ABSTRACT FROM AUTHOR]

Background This study aimed to evaluate renal function before, during, and after the course of tuberculosis ( TB) disease in kidney transplant recipients, and assess the risk factors for non-recovery of baseline renal function. Methods We performed a retrospective, single-center cohort study, including all patients with confirmed or presumed TB diagnosis after kidney transplant (n=34, 2.1%). Renal function was assessed by serum creatinine (Cr) and glomerular filtration rate ( GFR) adjusted for deaths and graft losses. Results A significant increase was seen in serum Cr during TB disease and treatment: 1.5 mg/dL at baseline (Crbase), 1.7 mg/dL at diagnosis ( P<.001 vs. Crbase), and 2.4 mg/dL during the peak ( P<.001 vs. Crbase). According to acute kidney injury (AKI) Kidney Disease: Improving Global Outcomes ( KDIGO) classification, 29 (85%) patients had AKI: 16 stage 1, 2 stage 2, and 11 stage 3. Three months after the end of the TB treatment, five patients (14.7%) had lost their graft and two others (5.9%) had died. The GFR was lower than the baseline (42.4 mL/min vs 51.6 mL/min, P=.007). In the univariate analysis, peak Cr (odds ratio [ OR] 1.276, 95% confidence interval [ CI] 0.955-1.705, P=.100), AKI KDIGO stages 2 or 3 ( OR 4.958, 95% CI 1.062-23.157, P=.042), severe disease ( OR 5.700, 95% CI 1.147-28.330, P=.033), and acute rejection ( AR) episodes after TB diagnosis ( OR 3.937, 95% CI 0.551-28.116, P=.172) were associated with non-recovery of baseline renal function. No variable was identified in the multivariable model. Conclusion Post-transplantation TB was associated with a high incidence of AKI, and complete recovery of baseline renal function was not achieved after treatment. The severity of TB disease, AKI, and AR episodes that occurred after TB diagnosis are potential causes for this outcome. [ABSTRACT FROM AUTHOR]

Background Most epidemiologic studies of opportunistic infections ( OI) following abdominal organ transplantation are derived prior to the era of contemporary immunosuppression and prophylaxis. These studies suggest that most OI occur within the first 6 months post transplant. Method In this single-center, retrospective cohort study, we describe the epidemiology of OI in 359 consecutive abdominal organ transplant recipients, in the era of contemporary prophylaxis practices and alemtuzumab induction in kidney and simultaneous pancreas-kidney transplant recipients. Results Ninety patients (25.1%) developed OI, with 53.3% of these occurring beyond 6 months. The most common OI were BK polyomavirus nephropathy (5.0%), cytomegalovirus (10.2%), varicella zoster virus (4.4%), and herpes simplex virus (1.1%), which typically occurred after discontinuation of antiviral prophylaxis, and Clostridium difficile infections (7.8%). Conclusion OI had no impact on patient or graft survival at 12 months post transplant. In the era of contemporary immunosuppression and prophylaxis, a significant proportion of OI occur beyond 6 months. Additional strategies may be important to reduce the incidence of such late-onset infections. [ABSTRACT FROM AUTHOR]

Background Latent tuberculosis ( TB) infection ( LTBI) is screened by using clinical assessment, tuberculin skin test ( TST), chest radiography, and recently by interferon-gamma release assays ( IGRA). The objective of this study was to evaluate the diagnostic potential of Quanti FERON®- TB Gold In-Tube test ( QFT) for diagnosing LTBI in patients planned for kidney transplantation. Methods All adult patients with end-stage renal disease, evaluated for kidney transplantation in a referral center from August 2008 till May 2013, were enrolled, after consenting in a prospective, observational, non-interventional study. LTBI diagnosis was conducted by TST, chest x-ray, and clinical assessment, followed by IGRA by QFT. Results Overall, 278 patients were enrolled and kidney transplantation was performed in 173 patients. Contributed follow-up was 836.5 patient-years, and TB-free transplant duration was 478.5 patient-years. By standard methods, LTBI was diagnosed in 14 patients. Peri-transplant chemoprophylaxis was given to 53 patients, which included recipients of organs from all deceased donors and living donors with LTBI. QFT was positive in 70 patients, negative in 200 patients, and indeterminate in 8 patients. The agreement between LTBI diagnosis using standard methods and IGRA by QFT was poor (kappa: 0.089+0.046, P-value=.017). Twenty-seven of the QFT-positive patients were transplanted and only one was given isoniazid preventive therapy. None of the transplant recipients developed TB after a median follow-up of 25 months (range 2-58 months, mean 27 months). Conclusions The agreement of the QFT with standard diagnosis of LTBI in kidney transplant recipients was poor. [ABSTRACT FROM AUTHOR]

Hepatitis E virus ( HEV) can cause chronic infection among immunocompromised patients, especially solid organ transplant recipients, and can evolve to cirrhosis. Several modes of transmission are known. Here we describe the first two cases, to our knowledge, of HEV infection transmitted by a kidney graft from the same infected donor that led to chronic hepatitis. Consequently, systematic screening of donors by HEV serology and HEV RNA detection by polymerase chain reaction, particularly in endemic regions, should be considered. [ABSTRACT FROM AUTHOR]

Background The role of cytomegalovirus ( CMV) in cancer development after transplantation remains uncertain. We aimed to determine the association between donor and recipient CMV serological status and the risk of cancer development after kidney transplantation. Methods Using data from the Australian and New Zealand Dialysis and Transplant ( ANZDATA) Registry, we assessed the association between CMV donor/recipient (D/R) serological status and the risk of solid organ cancers in primary adult deceased-donor kidney transplant patients between 1990 and 2012. Results Of 8140 recipients, a total of 895 (11%) recipients developed incident cancers during a follow-up time of 51 555 person-years. Human leukocyte antigen ( HLA) mismatches was an effect modifier between CMV serological status and cancer ( P=.03 for interaction). In recipients who have received 0-2 HLA- ABDR mismatched kidneys, the adjusted hazard ratios for cancer incidence among those with CMV D−/R−, CMV D−/R+, and CMV D+/R− were 0.47 (95% confidence interval [ CI]: 0.24-0.91), 1.42 (95% CI: 0.97-2.07), and 1.02 (95% CI: 0.67-1.57), respectively compared with the reference of CMV D+/R+. A similar association was not observed in those with >2 HLA- ABDR mismatches. Conclusion CMV D−/R− status was associated with a reduced risk of cancer in kidney transplant recipients who have received well-matched renal allografts, suggesting a potential role of HLA matching in cancer development. [ABSTRACT FROM AUTHOR]

We report a renal allograft transplant recipient with esophageal tuberculosis ( TB) coinfected with herpes simplex virus ( HSV) and Candida. The patient presented with oropharyngeal candidiasis and was started on fluconazole. Upper gastrointestinal endoscopy showed whitish patches with mucosal ulcers in the esophagus. Histopathological examination confirmed TB and HSV infection. The patient recovered after antiviral, antifungal, and anti-tubercular therapy with reduction in immunosuppression. In a TB-endemic zone, TB can coexist with opportunistic infections in an immunocompromised host. [ABSTRACT FROM AUTHOR]

Objectives Ureteral stents are used in kidney transplantation ( KTX) to decrease post-operative complications, but they are associated with BK polyomavirus viremia ( BKV). Our primary outcome was to determine the association between ureteral stent duration and BKV. Secondary outcome measures were the association between bacteriuria and stent duration or use of ureteral stent strings. Methods Between January 2010 and January 2015, 403 patients underwent KTX at the Virginia Mason Medical Center and met inclusion criteria. Stent duration was classified as short (<3 weeks) or long (>3 weeks). Multivariate logistic regression models were created to assess for factors associated with BKV. The covariates in the BKV model were chosen a priori based on stent duration and risk factors previously described in the literature. Results Ureteral stents were placed in 304 (75.4%) transplants. Stent strings were left attached in 166 (54.6%) patients. On multivariate analyses, long stent duration was significantly associated with increased risk of BKV compared with no stent (odds ratio [ OR] 1.92, P=.044, 95% confidence interval [ CI] 1.04-3.74). Short stent duration was not associated with BKV. Sixty-two (15.4%) patients had bacteriuria. Bacteriuria was associated with female gender ( OR 2.77, P<.001, 95% CI 1.58-4.95), and there was a dose-dependent effect with stent duration compared with no stent-short duration ( OR 2.46, P=.049, 95% CI 1.05-6.49) and long duration ( OR 3.58, P=.004, 95% CI 1.58-9.25). Stent strings were not associated with either complication. Conclusions The association between ureteral stents and BKV may be dose dependent. [ABSTRACT FROM AUTHOR]

Background: Although high-dose steroid therapy has been attempted for the management of clinically suspected allograft rejection, before testing for BK viral activity or acute cellular rejection accompanied by BK polyomavirus nephropathy, its long-term outcome remains unknown. We investigated the impact of high-dose steroids on BK viral activity and long-term graft outcomes in patients with BK viremia. Methods: The study population comprised 144 kidney transplant recipients with BK viremia. They were divided into 2 groups based on the amount of steroids administered: low-dose group (<2 g, n=123) or high-dose group (⩾2 g, n=21). Results: The baseline serum BK viral loads were 5.4±1.1 log cp/mL in the low-dose group and 6.0±1.3 in the high-dose group (P=.054). These changed to 5.2±1.3 and 6.1±1.4, 1 month after steroid treatment (P=.03) and 4.9±1.3 and 5.9±1.4 at 2 months (P=.033), respectively. From 3 months to 1 year, the serum BK viral titers were not different between groups. Kaplan-Meier analyses demonstrated that the rates of the decline of graft function and graft failure were higher in the high-dose group (P=.02 and P=.04, respectively). High-dose steroids (P=.012, hazard ratio [HR] 5.04, 95% confidence interval [CI] 1.42-17.85) and log serum BK viral load at 2 months after steroid treatment (P=.042, HR 1.52, 95% CI 1.02-2.28) were independent risk factors for the decline of graft function. Conclusion: High-dose steroids induced BK viral activation and subsequently resulted in poor long-term graft function and early graft failure in patients with BK viremia. [ABSTRACT FROM AUTHOR]

Background: Deceased organ donors, where the cause of death is meningitis or encephalitis, are a potential concern because of the risks of transmission of a potentially fatal infection to recipients. Methods: Using the UK Transplant Registry, a retrospective cohort analysis of deceased organ donors in the UK was undertaken to better understand the extent to which organs from deceased donors with meningitis and/or encephalitis (M/E) (of both known and unknown cause) have been used for transplantation, and to determine the associated recipient outcomes. Results: Between 2003 and 2015, 258 deceased donors with M/E were identified and the causative agent was known in 188 (72.9%). These donors provided 899 solid organs for transplantation (455 kidneys and 444 other organs). The only recorded case of disease transmission was from a donor with encephalitis of unknown cause at time of transplantation who transmitted a fatal nematode infection to 2 kidney transplant recipients. A further 3 patients (2 liver and 1 heart recipient) died within 30 days of transplantation from a neurological cause (cerebrovascular accident) with no suggestion of disease transmission. Overall, patient and graft survival in recipients of organs from donors with M/E were similar to those for all other types of deceased organ donor. Conclusion: Donors dying with M/E represent a valuable source of organs for transplantation. The risk of disease transmission is low but, where the causative agent is unknown, caution is required. [ABSTRACT FROM AUTHOR]

Background: Because of the strikingly increased risk of post-transplant lymphoproliferative disorder (PTLD) in Epstein-Barr virus (EBV)-seronegative kidney transplant recipients (KTRs) from EBV-seropositive donors--EBV(D+R-), special strategies need to be defined to prevent EBV transmission and EBV viremia. Methods: We studied all KTRs at our center between 2008 and 2012. Seventeen of 402 KTRs (4.2%) were identified as EBV(D+R-), among which 5 KTRs received kidneys from living donors and 12 KTRs from deceased donors. KTRs undergoing living donation were treated with a single dose of rituximab 4 weeks prior to transplantation. Assessment of EBV seroconversion and EBV viremia was performed. Results: Among 12 EBV-seronegative KTRs from deceased donors, all 12 KTRs (100%) showed EBV seroconversion, 7 KTRs (58%) showed active EBV viremia, and 1 KTR (8%) developed PTLD. In comparison, 3 of 5 KTRs from living donors, who received pretransplant rituximab, remained EBV-seronegative post transplantation, and no KTR developed EBV viremia (P<.05). All KTRs who received pretransplant rituximab showed excellent allograft function, with no increase in infections or malignancies. Conclusions: Our data suggest that rituximab-mediated elimination of B cells may prevent transmission of EBV to the recipient, as EBV persistence requires the establishment of a latent infection in recipient B cells. Pretransplant rituximab may prove useful to prevent primary EBV infection in EBV-seronegative KTRs. [ABSTRACT FROM AUTHOR]

Background: The cytomegalovirus (CMV) donor-positive/recipient-positive (D+/R+) population is the largest proportion of renal transplant recipients (RTR). Guidelines for prevention of CMV in the intermediate-risk D+/R+ population include prophylaxis with valganciclovir (VGCV) 900 mg/day for 3 months. This study is the first head-to- head analysis, to our knowledge, comparing the efficacy and safety CMV prophylaxis of VGCV 450 vs 900 mg/day for 3 months in D+/R+ RTR. Methods: A multicenter, retrospective analysis evaluated 478 adult RTR between January 2008 and October 2011. Study participants received VGCV 450 mg/day (Group 1; n=398) or 900 mg/day (Group 2; n=89)×3 months for CMV prophylaxis. All VGCV was adjusted for renal function. All groups included in this study received study-approved induction and maintenance immunosuppression regimens. The primary endpoint was incidence of CMV disease at 12 months. Results: The rates of graft loss, patient survival, T-cell and/or antibody-mediated rejection, hematological adverse events, opportunistic infections, and early VGCV discontinuation were evaluated. Patient demographics were comparable, but had significant differences in ethnicity and donor type between the groups. Conclusion: The occurrence of CMV disease at 12 months was similar between the groups (3.5% vs 3.4%; P=1.000). Log-rank test found no statistically significant difference in the time to development of CMV between the 2 groups (P=.939). [ABSTRACT FROM AUTHOR]

Background: Polyomavirus (PV) is a major cause of kidney graft disease. Monitoring by polymerase chain reaction (PCR) on blood is currently recommended. In order to avoid irreversible lesions, we investigated the clinical impact of preemptive reduction of immunosuppression (IS) in kidney transplant recipients (KTR) upon detection of high urinary PV (Upv) load, including BK virus and JC virus. Material and methods: From 2000 to 2011, in our single center, 789 consecutive KTR were distributed into 4 groups, according to the maximal Upv levels (by PCR) during the first year and the therapeutic option: (A) Upv <104 copies (cp)/mL (n=573), (B) ⩾104 Upv <107 cp/mL (n=100), and (C) Upv ⩾107 cp/mL (n=116); in group C, the IS drug doses were reduced in subgroup Ca (n=102) only, as 14 patients (subgroup Cb) were at risk for graft rejection. Results: The preemptive reduction of IS (group Ca) increased patient survival as compared with all other groups (P<.05), did not modify graft function, and increased graft survival vs group A (risk ratio: 5.7, confidence interval: 1.8-18.1, P=.003). Differences for risk factors are as follows (groups Ca vs A): incidence of human leukocyte antigen (HLA) immunization (>5% panel reactive antibodies): 3% vs 8% (P=.05), number of HLA mismatches: 2.7 vs 2.5 (P=.049), and incidence of acute rejection: 9.8% vs 24.2% (P=.005). PV-associated nephropathy occurred only in group Ca (2% of total grafts) without effect on patient or graft outcome. Conclusion: The reduction of IS in patients with high Upv loads is beneficial for patient survival and does not affect graft survival or graft function. [ABSTRACT FROM AUTHOR]

We report the case of a human immunodeficiency virus-seropositive patient whose initial kidney transplant failed because of BK polyomavirus-induced nephropathy, and who underwent a second transplantation 3 years later. BK viruria was detected 1 day after transplantation. After 1 month, BK viremia developed along with a donor-specific antibody. After decreasing tacrolimus and mycophenolic acid and 2 courses of intravenous immunoglobulins, BK viremia and donor-specific antibody permanently disappeared, with stable renal function. [ABSTRACT FROM AUTHOR]

Background Antibiotic resistance is an emerging phenomenon in kidney transplantation ( KT). Methods We compared species distribution and antimicrobial susceptibility patterns in 1052 isolates from urine cultures obtained in 2 different cohorts of kidney transplant recipients in a single center (Cohort A: 189 patients undergoing KT between January 2002 and December 2004 [336 isolates]; Cohort B: 115 patients undergoing KT between January 2011 and December 2013 [716 isolates]). Results Asymptomatic bacteriuria accounted for most of the isolates (86.9% in Cohort A and 92.3% in Cohort B). Klebsiella pneumoniae (9.5% vs. 15.6%), Pseudomonas aeruginosa (1.8% vs. 7.9%), and Enterobacter cloacae (0.6% vs. 3.1%) were significantly more common in Cohort B. The isolation of K. pneumoniae in Cohort B was associated with the occurrence of acute pyelonephritis (9.8% of all K. pneumoniae isolates vs. 2.8% of the remaining uropathogens; P = 0.001). Non-susceptibility rates among Enterobacteriaceae in Cohort B were higher for every class of antibiotics ( P ≤ 0.003) with the exception of fosfomycin. Compared to Cohort A, significant increases were seen in isolates from Cohort B for multidrug-resistant ( MDR) (43.9% vs. 67.8%, respectively; P = 0.001), extended-spectrum beta-lactamase ( ESBL)-producing (6.6% vs. 26.1%; P = 0.001), and carbapenemase-producing Enterobacteriaceae strains (0.0% vs. 5.0%; P = 0.001). Such differences were mostly attributable to K. pneumoniae (as 54.5% and 13.4% of isolates in Cohort B were ESBL-producing and carbapenemase-producing, respectively). MDR isolates were responsible for 69.1% of episodes of symptomatic urinary tract infection in Cohort B. Conclusion The increase in resistance rates among Enterobacteriaceae uropathogens is significant and may have an effect on KT programs. [ABSTRACT FROM AUTHOR]

Background Infections are the leading cause of hospitalization and mortality in transplant recipients. Nigeria has a growing number of renal transplant recipients. The aim of this study was to determine the pattern of infections in renal allograft recipients in one of the major renal transplant centers in Nigeria. Methods All case records of renal allograft recipients on follow-up were retrieved. Those that had infection at any time after transplantation were selected. Demographic and clinical information was collected and analyzed. Results Thirty-three case records were analyzed, out of which 24/33 (72.7%) were males, with a mean age of 42.3 years (± 7.38). The median duration of developing infection post transplant was 270 days (range 2-2190). Most of the infections occurred after 6 months in 15/33 (45.5%). Urinary tract infection was the most common infection, noted in 13/33 (39.4%), followed by pneumonia, which was seen in 12 (33.3%), 9/12 (75%) of which were culture-positive. There were 2 cases (5.6%) of tuberculosis and 1 case (2.8%) of cytomegalovirus colitis. Out of the 9 culture-positive pneumonia cases, 6 (66.7%) were caused by gram-negative pathogens, with Pseudomonas aeruginosa being the most common isolate seen in 3/9 (33.3%) of the patients. Among those with urinary tract infection, Escherichia coli and Klebsiella species were isolated with equal proportion in 3/13 (23.1%), while Enterococcus faecalis was the most common isolate in 4/13 (30.8%). Overall infection-related mortality was 10/33 (30.3%), out of which 5/10 (50%) of deaths were from pneumonia. Conclusion Post-transplant infection surveillance must be strengthened. The role of multidrug-resistant gram-negative bacteria in post-renal transplant infection in Nigeria needs to be evaluated. [ABSTRACT FROM AUTHOR]

Background Assessing the risk of cytomegalovirus ( CMV) viremia in kidney transplant recipients ( KTR) may be helpful to indicate in which patient it is worth starting antiviral treatment during preemptive strategy. Methods In 40 CMV-seropositive KTR preemptively treated with ganciclovir, we used interferon ( IFN)-γ ELISpot test to evaluate whether monitoring T cells directed against phosphoprotein (pp) 65 and immediate early ( IE)-1 antigens could predict the onset of viremia. Results CMV viremia occurred in 24 patients (60%) within 120 days after transplantation. Non-viremic patients had higher anti-pp65, anti- IE-1 T cells, and estimated glomerular filtration rate ( eGFR) in the first 90 days after transplantation. At logistic regression, anti-pp65, anti- IE-1 T cells, and eGFR measured at day 30 were significantly associated with CMV infection. Cutoff values of 15 spot-forming cells ( SFCs)/200,000 peripheral blood mononuclear cells ( PBMCs) for anti- IE, 40 SFCs/200,000 PBMCs for anti-pp65, and 46.6 mL/min/1.73 m2 for eGFR, respectively, predicted the risk of CMV infection with high sensitivity and specificity (area under the receiver operating characteristic curve >0.75). Using a classification tree model, we identified as high-risk patients those showing anti-pp65 <42 SFCs/200,000 PBMCs and eGFR <62 mL/min/1.73 m2, as well as anti-pp65 ≥42 and anti- IE-1 <6.5 SFCs/200,000 PBMCs. Conclusion Monitoring CMV-specific T-cell responses and eGFR in the first month post transplant can identify patients at high risk of CMV infection, for whom preemptive antiviral therapy is recommended. [ABSTRACT FROM AUTHOR]

Helicobacter cinaedi can cause bacteremia mainly in immunocompromised patients. We present the clinical characteristics of H. cinaedi bacteremia in 4 renal transplant patients. Interestingly, all cases showed triggers of bacterial translocation: 2 cases developed after colonic perforation caused by diverticulitis, 1 case developed post cholecystectomy, and the remaining patient had chronic diarrhea. Accordingly, bacterial translocation caused by severe gastrointestinal complication could be a cause of H. cinaedi bacteremia. [ABSTRACT FROM AUTHOR]

An 8-year-old girl with a renal transplant was admitted for myalgia and muscle weakness in both legs over the previous 2 weeks. She also had fever and intermittent epigastric pain. Based on these clinical manifestations, and laboratory and histopathological findings, the diagnosis was coincidence of lateonset cytomegalovirus (CMV)-induced myositis and gastritis in an immunocompromised child with a renal transplant. After administration of intravenous ganciclovir for 3 weeks, her symptoms resolved, with normalization of abnormal muscle enzymes, including lactate dehydrogenase, creatine kinase, aspartate aminotransferase, and the disappearance of CMV viremia. [ABSTRACT FROM AUTHOR]

Eumycetoma is an unusual infection in immunocompromised patients outside the tropics, caused by a variety of fungal pathogens. We describe the case of a 51-year-old renal transplant recipient who presented with a large pseudotumoral foot lesion necessitating complete surgical excision of the lesion. Cultures and molecular diagnosis confirmed Phaeoacremonium fuscum. This is the first case, to our knowledge, of fungating mycetoma caused by this fungal species in a solid organ transplant recipient. [ABSTRACT FROM AUTHOR]

Microsphaeropsis arundinis, a dematiaceous mold, is emerging as a cause of skin and soft tissue infection in immunocompromised hosts. Diagnosis is challenging because of the difficulty in identifying Microsphaeropsis species morphologically and few data are available to guide optimal management. We report 3 renal transplant recipients with M. arundinis soft tissue infection, where the etiological agent was diagnosed using DNA sequencing, and who were successfully treated with prolonged courses of extended-spectrum triazole antifungal agents. [ABSTRACT FROM AUTHOR]

Background. Little is known about the epidemiology of carbapenem-resistant Klebsiella pneumoniae (CRKP) bacteriuria following kidney transplantation. We determined the incidence of post-transplant CRKP bacteriuria in adults who underwent kidney transplant from 2007 to 2010 at 2 New York City centers. Methods. We conducted a case-control study to identify factors associated with CRKP bacteriuria compared with carbapenem-susceptible K. pneumoniae (CSKP) bacteriuria, assessed whether CRKP bacteriuria was associated with mortality or graft failure, and compared outcomes of treated episodes of CRKP and CSKP bacteriuria. Results. Of 1852 transplants, 20 (1.1%) patients developed CRKP bacteriuria. Factors associated with CRKP bacteriuria included receipt of multiple organs (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.1-20.4), deceased-donor allograft (OR 5.9, 95% CI 1.3-26.8), transplant admission length of stay (OR 1.1 per day, 95% CI 1.0-1.1), pre-transplant CRKP infection or colonization (OR 18.3, 95% CI 2.0-170.5), diabetes mellitus (OR 2.8, 95% CI 1.0-7.8), and receipt of antimicrobials other than trimethoprim-sulfamethoxazole (OR 4.3, 95% CI 1.6-11.2). Conclusion. Compared to CSKP bacteriuria, CRKP bacteriuria was associated with increased mortality (30% vs. 10%, P = 0.03) but not graft failure. Treated episodes of CRKP bacteriuria were less likely to achieve microbiologic clearance (83% vs. 97%; P = 0.05) and more likely to recur within 3 months (50% vs. 22%, P = 0.02) than CSKP episodes. CRKP bacteriuria after kidney transplant is associated with mortality and antimicrobial failure after treatment. [ABSTRACT FROM AUTHOR]

Introduction Valganciclovir ( vGCV) and valacyclovir ( vACV) are used in cytomegalovirus ( CMV) prophylaxis in renal transplant recipients. The aim of this study was to compare the economic impact of both regimens during 1-year follow-up. Methods A total of 117 renal transplant recipients at risk for CMV were randomized to 3-month prophylaxis either with vGCV (900 mg/day, n = 60) or vACV (8 g/day, n = 57) and their data used in a pharmacoeconomic analysis. The pharmacoeconomic evaluation involved all direct CMV-related expenses in the first year after transplantation. Sensitivity analysis was employed to examine the effects of various prices of antiviral drugs and diagnostic procedures on overall CMV-related costs. Simulation of the more expensive US healthcare perspective was performed, and a scenario involving costs of acute rejection ( AR) was examined. Results Overall CMV-related costs were significantly lower in the vACV arm; median United States dollars ( USD) 3473 (3108-3745) vs. USD 5810 (4409-6757; P < 0.001) per patient, respectively. Our data showed that the critical determinant of the major disparity between the prophylactic regimens was the prophylaxis price. Median cost of prophylaxis in the vACV group was USD 1729 (1527-2173) compared to USD 3968 (2683-4857) in the vGCV group ( P < 0.001). In sensitivity analysis of the overall CMV-related costs, the least and the most expensive pharmacotherapy and diagnostic scenarios were used; nevertheless, the vACV arm remained markedly less expensive. Simulation considering the higher physician/nurse and hospitalization fees of the US healthcare system and the scenario including expenditure associated with AR episodes also favored vACV. Conclusion VACV prophylaxis for CMV is associated with a significant 44% lower cost than vGCV at the first year after renal transplantation. [ABSTRACT FROM AUTHOR]

Renal transplant recipients ( RTRs) are subject to a variety of opportunistic infections. We present a rare case of varicella zoster virus-derived progressive outer retinal necrosis in an RTR, who presented with painless visual blurring. This clinical entity heralds an extremely poor visual prognosis and is an important condition to consider in any immunocompromised host. Early diagnosis by aqueous fluid sampling and immediate institution of combined systemic and intravitreal antiviral therapy was successful in this individual. [ABSTRACT FROM AUTHOR]

Ocular complications in patients who underwent renal transplantation are attributed to side effects of the immunosuppressive regimen. Progressive outer retinal necrosis ( PORN) syndrome is a clinical variant of necrotizing herpetic retinopathy and it occurs almost exclusively in patients with acquired immunodeficiency syndrome. We present a case of a human immunodeficiency virus-negative patient who underwent renal transplant and, after a few years, developed bilateral PORN associated with viral infections. Varicella zoster virus ( VZV) and BK virus were identified by polymerase chain reaction from the vitreous fluid. It is unclear which of the viruses identified had the dominant role in the pathogenesis of PORN and other organ damage, or whether their actions were synergistic. Adequate antiviral immune surveillance, as well as pre-transplant vaccination against VZV, may reduce the incidence of VZV infection and its complications. [ABSTRACT FROM AUTHOR]

Mucormycosis is an uncommon infectious complication after renal transplantation and is associated with fatal outcomes. We report 2 cases of transplant renal artery thrombosis and spontaneous rupture caused by mucormycosis. As stenosis, thrombosis, and spontaneous rupture of the transplant renal artery began to occur in both cases after renal transplantation, nephrectomy of the transplanted kidney was performed. Postoperative pathological findings in the transplanted kidney revealed an invasive mucormycosis infection in the renal artery. One patient survived, but the other patient died. This report also presents the diagnosis and treatment processes used for this transplant complication. [ABSTRACT FROM AUTHOR]

Multi-organ procurement is a risk factor for contamination of preservation fluid with intestinal flora including fungi (e.g., Candida). Transmission of fungal species to the graft vessel can cause mycotic arteritis. This is a very rare but life-threatening complication of renal transplantation. We present 2 cases of renal transplant recipients from the same multi-organ donor. Both recipients suffered from severe hemorrhages from renal graft anastomosis and renal artery pseudoaneurysm due to Candida albicans arteritis ( CAA). The culture of the preservation fluid revealed growth of Escherichia coli, but neither preservation fluid nor multiple routine blood cultures performed before hemorrhagic complications revealed fungal growth (media non-selective for fungal growth were applied). The first recipient suffered from sudden severe hemorrhage in the area of graft anastomosis on day 10 post surgery (without any preceding clinical or radiological symptoms). This led to urgent surgery and graftectomy, which was complicated by cardio-respiratory arrest with resuscitation in the operating room; despite resuscitation, irreversible brain damage, and subsequent death occurred in the intensive care unit ( ICU) 2 weeks later (on day 24 after transplantation). The second patient underwent urgent vascular surgery on day 22 (after transplantation), because of hemorrhage from a pseudoaneurysm of the graft artery. She required repeated vascular operations, extended antimicrobial and antifungal therapy, and ICU monitoring and, despite these interventions, she died on day 80 after transplantation as a result of Pseudomonas aeruginosa sepsis. Arteritis of the renal artery in both patients was caused by C. albicans. This was confirmed by histopathology: infiltration of renal artery with budding yeast forming pseudohyphae (Case 1), and the presence of C. albicans in the culture of the renal artery and surrounding tissue (Case 2). We conclude that organ preservation solution should be cultured with use of media selective for fungal growth. As soon as the positive culture is detected, appropriate measures protecting patients against CAA should be undertaken. [ABSTRACT FROM AUTHOR]

Background The use of potent immunosuppressive drugs and increased travel by renal transplant recipients ( RTR) has augmented the risk for infectious complications. Immunizations and changes in lifestyle are protective. The Kidney Disease: Improving Global Outcomes ( KDIGO) Transplant Work Group has developed guidelines on vaccination following solid organ transplantation. The degree of adherence to these guidelines is unknown, as is which barriers must be overcome to improve adherence. Methods We performed a cross-sectional national survey among Dutch nephrologists to assess vaccination policy and adherence to the KDIGO guidelines. In addition, to investigate awareness and attitude of RTR regarding their risk of infection, we performed a cross-sectional survey of RTR in our outpatient clinic. Results A total of 132 (63%) nephrologists completed the survey. Reported immunization rates were 90.8% for influenza and 27.3% for hepatitis B. However, pneumococcal, tetanus toxoid, and meningococcal immunization rates were low. Twenty-seven percent of respondents were familiar with the guideline contents. The most frequent perceived barrier to guideline adherence was expectation of low effectiveness. A total of 403 RTR (62%) completed the survey. Sixty-eight percent perceived more risk for complicated infection. A significant correlation was found between education level and variables concerning awareness and attitude toward risk of infection. Conclusions Our results show that nephrologists' knowledge of and adherence to the recommendations regarding immunization after renal transplantation is suboptimal. Most Dutch RTR are aware of their increased risk and the possible seriousness of infectious complications. However, their behavior does not match their awareness. This disparity points to an important role for nephrologists in providing adequate counseling. [ABSTRACT FROM AUTHOR]

Rhabdomyolysis is a pathological syndrome caused by skeletal muscle cell damage that affects the integrity of the cellular membrane and leads to the release of toxic intracellular constituents into the bloodstream. Although cytomegalovirus ( CMV) has rarely been reported as a cause of rhabdomyolysis, CMV infection could be considered as a possible cause because of its clinical significance in kidney transplant recipients ( KTRs). We report 2 cases of rhabdomyolysis associated with CMV infection in KTRs. A 64-year-old woman (Case 1) and a 65-year-old man (Case 2), who had each received a kidney from a living unrelated donor, were admitted with complaints of weakness in both legs and myalgia. Laboratory findings revealed highly increased creatine phosphokinase and myoglobinuria. In both cases, no recent alterations of medications had occurred, and other causes of rhabdomyolysis-such as trauma, alcohol, drugs, and electrolyte abnormalities - were excluded. CMV pp65 antigen was positive, and patients were diagnosed with rhabdomyolysis associated with CMV infection. Both patients recovered without complications after ganciclovir treatment. In conclusion, CMV infection should be considered as a possible cause of rhabdomyolysis in KTRs. [ABSTRACT FROM AUTHOR]

Background In renal transplantation, BK virus infection can result in significant graft nephropathy and loss. While reduction in immunosuppression ( IS) is considered standard therapy, adjunct agents may be warranted. Data are suggestive of a possible role of cidofovir for the management of BK. This study aims to describe the course of BK viremia ( BKV) in a large cohort of renal transplant patients receiving adjunct cidofovir. Methods We evaluated kidney and kidney-pancreas recipients who received cidofovir combined with reduced IS for management of high-level BKV or BK virus nephropathy ( BKVN). We examined the rate and timing of BKV clearance, and performed a multivariate analysis to identify risk factors associated with long-term (>6 months) viremia. Results In total, 75 patients received a median of 13 doses of cidofovir in conjunction with reduced IS; 32 patients (43%) had short-term BKV (≤6 months), and 43 (57%) had long-term BKV. Overall, 53 of 75 patients (71%) eventually cleared BKV at a median of 4.2 months (interquartile range 2.1-9.3 months). Independent factors associated with long-term BKV included older age (odds ratio [ OR] 1.1, P = 0.02), delayed graft function ( OR 31.4, P = 0.01), and higher peak BKV ( OR 12.8, P = 0.02), while BKV reduction by at least 1 log10copies/mL at 1 month of treatment was associated with clearance within 6 months ( OR 49.3, P < 0.01). Patients with earlier clearance maintained stable graft function and no graft losses, while long-term BKV was associated with a 15% decline in estimated glomerular filtration rate. Conclusions Adjunct cidofovir resulted in preservation of renal function when viral clearance occurred within 6 months of initiation. This retrospective review defines factors predicting response to cidofovir in conjunction with reduced IS for BKVN or high-level BKV. Still, considering cost, frequency of administration, and treatment duration, a randomized trial is necessary to define the exact utility of cidofovir in the setting of BK virus infection. [ABSTRACT FROM AUTHOR]

Rhodococcus equi is an animal pathogen that causes infrequent but challenging infections in immunocompromised individuals, few of which have been described in solid organ transplant recipients. Common clinical presentations include indolent cough, fever, and dyspnea, with necrotizing pneumonia and cavitation. We report a case of a dense right upper lung pneumonia with resultant R. equi bacteremia in a renal transplant recipient. Our patient initially responded to antibiotic treatment with resolution of bacteremia and clinical recovery, followed by interval progression in her right upper lobe consolidation on follow-up computed tomography scans. She underwent lobectomy for definitive therapy with resolution of symptoms. Lobectomy can be utilized in isolated infection after antibiotic failure with excellent clinical outcomes. [ABSTRACT FROM AUTHOR]

Background Invasive aspergillosis ( IA) has been considered an infrequent complication after renal transplantation. We aimed to evaluate the differences in clinical and epidemiologic characteristics of IA between renal and other types of transplantation. Methods We reviewed all cases of solid organ transplant ( SOT) recipients from Hospital Clinic at Barcelona, who had proven and probable IA, according to the EORTC/ MSG criteria, between June 2003 and December 2010. Results A total of 1762 transplants were performed. From this cohort, 27 cases of IA were diagnosed (1.5%): in 56% (15/27) liver, 33% (9/27) kidney, and 11% (3/27) combined transplant. The median onset time from renal and non-renal transplants to IA was 217 and 10 days, respectively ( P < 0.001). There were 6 cases (22%) of late IA (>6 months), all in kidney recipients ( P < 0.001). Renal transplant patients with IA more frequently had chronic lung disease (44% vs. 6%) and chronic heart failure (33% vs. 6%); they also had none of the classical risk factors for IA defined for liver transplantation (0% vs. 33%, P = 0.001), and therefore they did not receive antifungal prophylaxis (0% vs. 72%, P = 0.001). In 14/24 patients, serum galactomannan antigen was positive, and this related to higher mortality. Conclusions While classical risk factors described for IA in liver recipients are still valid, IA appears later in renal patients and is commonly associated with co-morbid conditions. [ABSTRACT FROM AUTHOR]

Campylobacter species are the leading cause of acute bacterial diarrhea in industrialized countries. However, bacteremia is detected in <1% of patients with Campylobacter enteritis and is most likely to occur in patients who are immunocompromised or of older age. To our knowledge, only 2 cases of Campylobacter jejuni bacteremia have been reported in renal transplant recipients ( RTRs). We present a case of an RTR with C. jejuni bacteremia presenting as self-limiting diarrhea followed by fever and cellulitis. The patient was successfully treated with a 2-week course of imipenem and developed no other complications. We review all cases of Campylobacter bacteremia in RTRs, and discuss clinical presentation and treatment of this potentially fatal disease. [ABSTRACT FROM AUTHOR]

We present a case of JC polyomavirus ( JCV)-associated nephropathy (Py VAN) in an asymptomatic deceased-donor kidney transplant recipient. Despite the presence of viral cytopathic effect in the kidney biopsy and positive BK polyomavirus ( BKV) in situ hybridization ( ISH), BKV real-time polymerase chain reaction ( PCR) results of plasma and urine were negative. JCV ISH was performed and was found to be positive. JCV real-time PCR on urine, plasma, and the kidney biopsy tissue was positive. Reduction in immunosuppression resulted in resolution of JCV viremia. This case highlights that JC-Py VAN is a distinct clinical entity and is likely to have a better clinical outcome than BK-Py VAN. Concurrent infection with BKV and JCV may occur, but may be difficult to confirm due to the potential for cross-reactivity between BKV and JCV ISH stains. [ABSTRACT FROM AUTHOR]

Background. In recent years, symptomatic hepatitis A virus (HAV) infection has been reported with increasing frequency in Korea. Therefore, HAV vaccination should be considered in kidney transplant recipients (KTRs). The study investigated the efficacy and safety of HAV vaccination in KTRs under modern triple immunosuppressive agents. Methods. We evaluated the seroprevalence of anti-HAV immunoglobulin-G (IgG) in KTRs who had visited the Seoul National University Hospital from March 2011 to August 2012. Seronegative patients were immunized with 2 doses of HAV vaccine at a 6-month interval. Seroconversion of anti-HAV IgG was determined 1 month after the second vaccine dose, and adverse effects were monitored after each vaccination. Results. Among a total 416 KTRs who were screened, 338 (81.2%) patients were seropositive for anti-HAV IgG. However, among patients who were under 40 years of age, only 31.8% were seropositive. Fifty-two seronegative recipients (mean age 34.1 years, 71.2% male) had received 2 doses of vaccine, and only 14 of these patients (26.9%) showed seroconversion. Vaccine responders had lower serum creatinine (1.19 ± 0.24 vs. 1.45 ± 0.49 mg/dL, P = 0.013), higher plasma hemoglobin levels (14.4 ± 1.9 vs. 12.8 ± 1.8 g/dL, P = 0.006), and had lower tacrolimus use than cyclosporine use (57.1% vs. 84.2%, P = 0.040) compared with nonresponders. Responders had a tendency of taking lower dose of prednisolone (3.5 ± 1.6vs.4.3 ± 1.2 mg/day, P = 0.076), and having fewer infection events (14.3 vs. 40.5%, P = 0.076). Multivariate analysis indicated that higher hemoglobin levels and lower serum creatinine levels were significant prognostic factors for seroconversion. Overall, the vaccine was well tolerated in all patients. Conclusion. HAV IgG screening is necessary for KTRs, especially young recipients. HAV vaccination was safe in KTRs; however, poor response to HAV vaccination makes it important to identify seronegative patients as early as possible and vaccinate them before end-stage renal disease occurs. [ABSTRACT FROM AUTHOR]

We present a unique case of acute bacterial prostatitis caused by a very rare human pathogen, Raoultella planticola, in a renal allograft recipient 3.5 months post transplantation. Only a few cases of human infection by this pathogen have been reported worldwide. The present study reports the case of a 67-year-old man who was admitted to our transplant unit 3.5 months post transplantation with fever, dysuria, suprapubic pain, symptoms and signs of acute prostatitis, and elevated markers of inflammation and prostate-specific antigen. R. planticola was isolated in the urine culture. The patient was treated with ciprofloxacin (based on the antibiogram) and had a full recovery, with satisfactory renal function. To the best of our knowledge, this is not only the first reported case of R. planticola prostatitis, but also the first report of such an infection in a solid organ transplant recipient or in a patient on immunosuppressive medication. [ABSTRACT FROM AUTHOR]

Hepatitis E virus ( HEV) has been identified as a cause of chronic viral hepatitis in immunocompromised patients. Some glomerular diseases were found to be associated with this infection. We report the first case, to our knowledge, of a kidney transplant recipient who developed an HEV infection and de novo membranous nephropathy ( MN) concomitantly. The patient displayed a hepatic cytolysis first and a nephrotic syndrome occurred 3 months later. HEV infection was diagnosed upon positive polymerase chain reaction on plasma and stool samples, and renal allograft biopsy revealed de novo MN. Typical causes of MN were definitively excluded. A 3-month course of ribavirin monotherapy allowed the patient to mount a sustained viral response that was rapidly followed by complete remission of the nephrotic syndrome. The chronology of the onset and remission of both diseases is highly suggestive of a causal relationship between hepatitis E and MN. [ABSTRACT FROM AUTHOR]