Drew W. Charles

Introduction: People living with HIV (PLWH) have a higher incidence of end‐stage renal disease (ESRD) than HIV‐negative individuals and are less likely to receive a kidney transplant. We described attrition and delays across the transplant care continuum for PLWH with ESRD at the Medical University of South Carolina (MUSC) and explored factors associated with waitlisting. Methods: Retrospective review of electronic health records of PLWH with ESRD who received care at MUSC or were referred for kidney transplantation between May 1, 2012 and December 31, 2023. Progression through the transplant continuum (referral, evaluation initiation, evaluation completion, waitlisting, and transplantation) was quantified. Multivariable time‐to‐event analyses was performed. Results: Among 234 PLWH with ESRD, transplant referral occurred in 190 (80%), of whom 135 (71%) initiated evaluation, 75 (39%) completed evaluation, 62 (32%) were waitlisted, and 44 (23%) received a transplant. Among evaluation non‐completers, outstanding testing (42%) and excessive comorbidities (15%) were the most common reasons. Median time from dialysis to referral was 510 days (IQR 139–1665), and median time from evaluation to waitlisting was 306 days (IQR 186–520). In multivariable Cox regression, peritoneal dialysis was associated with shorter time to waitlisting (HR 2.60; 95% CI 1.17–5.75; p = 0.02) and Black race trended towards longer time to waitlisting (HR 0.30; 95% CI 0.08–1.11; p = 0.07). Conclusions: Although PLWH with ESRD at MUSC progressed through the transplant continuum, substantial delays were observed. Interventions to reduce structural and logistical barriers and streamline evaluation steps may improve timely access to kidney transplantation. image

Background: Cytomegalovirus (CMV) resistance remains a significant challenge in solid organ transplant (SOT) recipients and is associated with morbidity, mortality, and graft loss. Contemporary data describing institutional patterns of resistant CMV and real-world management practices remain limited. Methods: We conducted a retrospective review of SOT recipients with confirmed CMV resistance at a tertiary care transplant center between 2019 and 2023. Clinical characteristics, antiviral exposure, timing of Transplant Infectious Diseases (TID) consultation, and outcomes were abstracted through structured chart review. CMV resistance was defined by the presence of UL97 or UL54 mutations on genotypic testing. Results: Seventeen SOT recipients with confirmed CMV resistance were identified, most of whom were CMV donor-positive/recipient-negative and receiving valganciclovir prophylaxis at the time of resistance detection. The median time from transplant to CMV detection was 129 days (IQR: 56–167). Resistance was detected on the first genotypic assay in all cases, with UL97 mutations present in all patients. Among patients receiving prophylaxis at the initial CMV episode, 64% met criteria for valganciclovir underdosing. Early transplant infectious diseases consultation at the initial infection occurred in 35% of cases. Conclusions: In this single-center study, CMV resistance was detected during valganciclovir prophylaxis, often in the setting of underdosing during periods of dynamic renal function. Resistance was predominantly mediated by UL97 mutations and detected on initial genotypic testing. These findings describe care processes, including valganciclovir dose reassessment during dynamic renal function and earlier transplant infectious diseases involvement, that warrant further evaluation for improving CMV management in transplant recipients.

Divisha Sharma, Courtney E. Harris, Alexandra G. Mills, Drew W. Charles. Clin Transplant Res -0001;0:. https://doi.org/10.4285/ctr.25.0050

Background: Verruconis gallopava is a dematiaceous and environmental commensal that rarely causes infection in humans. Human infections are typically observed in immunocompromised individuals. Clinical presentations range from localized infectious (skin and lung) to disseminated disease with a predilection for the central nervous system. Currently, no standardized guidelines exist for the treatment of V. gallopava . Most mold-active triazoles, except isavuconazole, have demonstrated in vitro antifungal activity against this pathogen. Case Summary: We present a case of an immunocompromised male who underwent heart transplantation with subsequent syndrome of chronic pneumonia. Imaging suggested an atypical pulmonary process prompting empiric initiation of isavuconazonium. Despite treatment, the patient’s condition worsened, and fungal culture from sputum and bronchoalveolar lavage both grew V. gallopava . His symptoms persisted, and he was transitioned to liposomal amphotericin B and eventually oral posaconazole (POS) with clinical and radiographic resolution of his presenting syndrome. Conclusion: This case highlights the limited experience and clinical failure of isavuconazonium as empiric therapy for V. gallopava . Transitioning to POS led to clinical improvement, suggesting its potential as a treatment option. Further experience is needed to establish optimal therapeutic strategies for this rare but serious infection.