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Background/Objectives: The novel coronavirus disease 2019 (COVID-19) has led to significant morbidity and mortality among kidney transplant recipients. SARS-CoV-2 has been hypothesized to cause an unusual immunological dysregulation triggering alloimmunity and leading to graft rejection. Methods: This prospective observational cohort study assessed 321 kidney transplant recipients who had COVID-19 infection. After the infection, patients' sera were tested for the presence of anti-HLA de novo DSA and non-DSA specificities. Logistic regression analysis and a stepwise multivariable logistic regression analysis were used to analyze the independent risk factors associated with the development of antibodies, adjusting for known confounders. The variables evaluated were acute COVID-19 characteristics (i.e., presentation, and need for hospitalization), demographic characteristics (i.e., age, gender, and primary renal disease), clinical characteristics (i.e., various comorbidities), and post-COVID-19 sequelae. Results: Anti-HLA de novo DSA developed in 18.7% of patients, while anti-HLA class I and class II non-DSA antibodies developed de novo in 84 (26.3%) and 83 (25.9%) patients, respectively. The development of DSA, HLA-DQ, and HLA-DR antibodies was predicted by the history of graft rejection. Obesity appeared to be protective against the emergence of de novo DSA. De novo DSA and HLA-DR antibody formation was positively linked with intravenous immunoglobulin use, CMV-hyperimmune globulin use, and decreased doses of immunosuppression during acute infection. Better allograft function during the acute disease was a protective factor against the formation of HLA-DQ and HLA-DR antibodies. Positive predictors of de novo DSA development were graft biopsy and the reactivation of EBV after infection. Conclusions: These findings suggest that the SARS-CoV-2 virus has an immunomodulatory effect and may be associated with an increased mortality in this population. [ABSTRACT FROM AUTHOR]

Introduction. Anti-CMV immunoglobulin (CMV-HIG) contains antibodies against various infective pathogens and not only against the cytomegalovirus (CMV), thus possibly mimicking the convalescent plasma. Methods. A retrospective analysis concerning the practice of CMV-HIG off-label use during acute COVID- 19 in kidney transplant recipients (KTR). Results. From March 2020 to August 2022, 403 KTR (59.8% male) who developed COVID-19 were eligible for investigation. 151(44.4%) patients required hospitalization, and eighteen (5,6%) mechanical ventilation. Thirty-four (8.4%) patients received CMVHIG. Two patients had CMV reactivation and received CMVHIG 2 ml/kg in five doses. Others had hypogammaglobulinemia which was an additional off-label indication for using CMVHIG during acute COVID-19. 22 patients (6.5%) died, 4 of them from the CMVHIG group. Conclusion. A correction of hypogammaglobulinemia, potential remodeling of the immunological response, and CMV reactivation during acute infection, may justify the use of CMVHIG during acute COVID-19. [ABSTRACT FROM AUTHOR]