Giovanni Varotti

Introduction. Hepatitis C virus (HCV) infection continues to represent a poor prognostic factor in kidney transplant (KTx) patients. New direct-acting antiviral agents (DAA) have dramatically changed the therapy management for HCV, showing promising results in terms of sustained virologic response. Timing for DAA therapy in HCV positive kidney waitlist patients continues to be controversial, and caution is recommended due to the potential difficult immunosuppressant dose adjustments, particularly in the early posttransplant period. We report a case of a KTx performed during antiviral DAA therapy. Report of Case. Patient was a 44-year-old man suffering from chronic HCV hepatitis associated with end-stage kidney disease (ESRD), waitlisted for a second KTx as a sensitized patient (panel-reactive antibody peak 85) in March 2019. Four months later, antiviral DAA therapy was started (glecaprevir/pibrentasvir 300mg/120mg daily, for 8 weeks). After 30 days, a left kidney was offered and, given the good compatibility, we decided to proceed with KTx without discontinuing the DAA therapy. A standard straightforward kidney transplant was performed. Immunosuppression included thymoglobulin and prednisone for induction and tacrolimus and mycophenolate for maintenance. After a transient delay graft function, creatinine levels progressively decreased. From postoperative day 3, tacrolimus reached target levels and remained stable. No episodes of acute rejection occurred. The 8-week DAA therapy was carried out without interruption. All HCV-RNA level controls resulted undetectable. On postoperative day 15, the patient was discharged and remains in healthy condition with normal renal function and HCV negative after 18 months of follow-up. Discussion. In this case, DAA therapy during the perioperative KTx period was well tolerated and effective. If confirmed, patients should not necessarily be suspended from the waiting list during DAA therapy for HCV eradication.

COVID‐19, the ongoing pandemic caused by SARS‐CoV‐2, has had a dramatic impact on transplant systems in the most affected countries, namely Italy. Preliminary data indicates that patients on hemodialysis therapy as well kidney transplant (KTx) recipients appear to be particularly susceptible to COVID‐19 illness due to immunosuppression and coexisting conditions. Currently, there is a lack of data concerning the biologic behavior, recurrence and long‐term morbidity of COVID‐19 and there are no experiences of transplants in patients who have previously had COVID‐19. We report what is likely to be the first case of a KTx performed after a recent COVID‐19 illness.

Kidney transplantation is the gold‐standard therapy for select HIV‐positive patients with ESRD. Since the Italian Ministry of Health defined the guidelines for organ donation from HIV‐positive persons in 2018, we report the first case of renal transplantation from an HIV‐positive cadaveric donor in two HIV‐positive recipients in Italy. The donor was a 50‐year‐old male, deceased due to post‐anoxic encephalopathy, with a history of HIV infection in HAART, undetectable viral load, and HCV‐related chronic hepatitis that had been previously treated. The first recipient was a 59‐year‐old female with a prior history of drug addiction, and she suffered from ESRD secondary to HIV nephropathy. The patient followed preoperative HAART with a good viral response and undetectable HIV viral load. She also had a history of HCV‐related chronic hepatitis that had been successfully treated. The right kidney was uneventfully transplanted. The patient developed an asymptomatic reinfection of endogenous BK virus. The second recipient was a 41‐year‐old male with ESRD secondary to polycystic kidney disease. The patient was HIV‐positive in HAART, with a good viro‐immunologic response and an undetectable HIV viral load. He suffered from a severe form of hemophilia A and HCV‐related chronic hepatitis, which had been previously treated with undetectable HCV RNA. The left kidney was uneventfully transplanted. At the end of follow‐up, both patients had a healthy condition with stable renal function, a persistently good viral response and undetectable HIV and HCV viral loads. These encouraging preliminary results seem to confirm the safety and effectiveness of kidney transplantation from select HIV‐positive donors.

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.

Carbapenem-resistantKlebsiella pneumoniae(CR-KP) infections in solid organ transplant recipients are associated with high morbidity and mortality. We report a case of a fatal donor-derived CR-KP infection in a combined kidney-pancreas transplant. Given the short interval of time between donor hospitalization and organ procurement, information concerning the donor CR-KP positivity arrived only 72 hours after transplant. Based on this experience, we believe that knowledge of the donor’s CR-KP status should be mandatory before procurement and, if positive, pancreas donation should be contraindicated.