Association of Postoperative Urinary Output in the First 24 Hours with Delayed Graft Function After Living and Deceased Donor Kidney Transplant: A Systematic Review

Context: Delayed graft function (DGF) is an important clinical outcome following renal transplantation; therefore, it is important to be correctly diagnosed. The DGF is thought to correlate with the first 24-hour urine output (UOP1), and this clinical sign is expected to predict DGF. Objectives: This study aimed to discover whether the UOP1 correlates significantly to the DGF incidence and can be a DGF predicting factor. Data Sources: This study compared the incidence of DGF with the UOP1 reported by studies obtained from the electronic databases, namely MEDLINE, Cochrane, and EBSCO. Studies that performed multivariate or bivariate analysis and/or reported sensitivity and specificity were included in this review. Results: A total of 1719 studies were obtained from the database search, and 2 studies were enrolled from other sources. Out of 1721 studies, 9 studies were recruited in this review, 5 of which reported sensitivity and specificity. Overall, nine of these studies had a low to moderate risk of bias. Almost all studies reported a significant relationship between the UOP1 and DGF. All studies agreed that the UOP1 is a sensitive predictive factor in predicting DGF. The specificity reported by the studies examined in this review varied greatly. The use of optimum cut-off in each study is considered to be the cause of this variability. Conclusions: The UOP1 is significantly related to the incidence of DGF and is a proper parameter for the prediction of DGF events.

1336. Outcomes of COVID-19 in Recent Kidney Transplants Recipients at a Large Transplant Center in Miami

Background Outcomes of COVID-19 have been reported in deceased donor kidney transplant (DDKT) recipients. However, data is limited in patients that underwent recent DDKT. Methods This single-center retrospective study evaluated the differences in demographics and post-transplant outcomes between those who tested positive and negative for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) by polymerase chain reaction, after undergoing recent DDKT. The treatments and outcomes for the SARS-CoV-2-positive patients were assessed. Patients who underwent DDKT from 3/2020 to 8/2020 were included and followed until 9/2020. Results 201 DDKT recipients were analyzed [14(7%) SARS-CoV-2-positive and 187(93%) negative]. There was no difference in delayed graft function and biopsy-proven rejection between both groups. The patient survival at the end of the study follow-up was lower among SARS-CoV-2-positive patients (Table 1). The median time from DDKT to COVID-19 diagnosis was 45 (range: 8-90) days; 5(36%) patients required intensive care unit and 4(29%) required mechanical ventilation; steroids were used in all the patients, therapeutic plasma exchange (TPE) and convalescent plasma (CP) in 7(50%) patients each, remdesivir in 6(43%) and tocilizumab in 1(7%); 9(64%) patients recovered, 3(21%) died and two were still requiring mechanical ventilation at the end of the follow-up. Conclusion Our cohort demonstrated a lower survival rate among SARS-CoV-2-positive patients, which highlights the vulnerability of the transplant population. Transplant patients must comply with the CDC recommendations to prevent COVID-19. Disclosures All Authors: No reported disclosures

Highest Recorded Serum Creatinine

Serum creatinine is a commonly used laboratory marker to assess kidney function; however, there has not been an established level of serum creatinine to predict mortality. After extensive literature review, we present a case of the highest recorded serum creatinine of 73.8 mg/dL in a 23-year-old male with the history of pediatric deceased donor kidney transplant (DDKT). He initially presented with uremia and signs of acute renal allograft failure after two months of immunosuppressive medication nonadherence, ultimately requiring emergent hemodialysis, which was complicated by new onset seizures. This was the patient’s fourth episode of late acute rejection and emphasizes the need for education of immunosuppressant adherence and periodic monitoring of renal function in high-risk patients. Though there is no known creatinine level incompatible with life, this patient appears to have the highest known serum creatinine in a uremic patient on record.

Timing of Kidney Clamping and Deceased Donor Kidney Transplant Outcomes

BackgroundThe recognition that metabolism and immune function are regulated by an endogenous molecular clock generating circadian rhythms suggests that the magnitude of ischemia-reperfusion and subsequent inflammation on kidney transplantation, could be affected by the time of the day. MethodsAccordingly, we evaluated 5026 first kidney transplant recipients from deceased heart-beating donors. In a cause-specific multivariable analysis, we compare delayed graft function (DGF) and graft survival according to the time of kidney clamping and declamping. Participants were divided into clamping between midnight and noon (AM clamping group, 65%) or clamping between noon and midnight (PM clamping group, 35%), and similarly, AM declamping or PM declamping (25% / 75%). ResultsDGF occurred among 550 participants (27%) with AM clamping and 339 (34%) with PM clamping (adjusted OR = 0.81, 95%CI: 0.67 to 0.98, p= 0.03). No significant association of clamping time with overall death censored graft survival was observed (HR = 0.92, 95%CI: 0.77 to 1.10, p= 0.37). No significant association of declamping time with DGF or graft survival was observed. ConclusionsClamping between midnight and noon was associated with a lower incidence of DGF whilst the declamping time was not associated with kidney graft outcomes.

Mycophenolate mofetil versus azathioprine in kidney transplant recipients on steroid-free, low-dose cyclosporine immunosuppression (ATHENA): A pragmatic randomized trial

Background We compared protection of mycophenolate mofetil (MMF) and azathioprine (AZA) against acute cellular rejection (ACR) and chronic allograft nephropathy (CAN) in kidney transplant recipients on steroid-free, low-dose cyclosporine (CsA) microemulsion maintenance immunosuppression. Methods and findings ATHENA, a pragmatic, prospective, multicenter trial conducted by 6 Italian transplant centers, compared the outcomes of 233 consenting recipients of a first deceased donor kidney transplant induced with low-dose thymoglobulin and basiliximab and randomized to MMF (750 mg twice/day, n = 119) or AZA (75 to 125 mg/day, n = 114) added-on maintenance low-dose CsA microemulsion and 1-week steroid. In patients without acute clinical or subclinical rejections, CsA dose was progressively halved. Primary endpoint was biopsy-proven CAN. Analysis was by intention to treat. Participants were included between June 2007 and July 2012 and followed up to August 2016. Between-group donor and recipient characteristics, donor/recipient mismatches, and follow-up CsA blood levels were similar. During a median (interquartile range (IQR)) follow-up of 47.7 (44.2 to 48.9) months, 29 of 87 biopsied patients on MMF (33.3%) versus 31 of 88 on AZA (35.2%) developed CAN (hazard ratio (HR) [95% confidence interval (CI)]: 1.147 (0.691 to 1.904, p = 0.595). Twenty and 21 patients on MMF versus 34 and 14 on AZA had clinical [HR (95% CI): 0.58 (0.34 to 1.02); p = 0.057) or biopsy-proven subclinical [HR (95% CI): 1.49 (0.76 to 2.92); p = 0.249] ACR, respectively. Combined events [HR (95% CI): 0.85 (0.56 to 1.29); p = 0.438], patient and graft survival, delayed graft function (DGF), 3-year glomerular filtration rate (GFR) [53.8 (40.6;65.7) versus 49.8 (36.8;62.5) mL/min/1.73 m2, p = 0.50], and adverse events (AEs) were not significantly different between groups. Chronicity scores other than CAN predict long-term graft outcome. Study limitations include small sample size and unblinded design. Conclusions In this study, we found that in deceased donor kidney transplant recipients on low-dose CsA and no steroids, MMF had no significant benefits over AZA. This finding suggests that AZA, due to its lower costs, could safely replace MMF in combination with minimized immunosuppression. Trial registration ClinicalTrials.gov NCT00494741; EUDRACT 2006-005604-14.