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Leston M, Elson W, Ordóñez-Mena JM, Kar D, Whitaker H, Joy M, Roberts N, Hobbs FDR, de Lusignan S. Disparities in COVID-19 mortality amongst the immunosuppressed: A systematic review and meta-analysis for enhanced disease surveillance. J Infect 2024; 88:106110. [PMID: 38302061 PMCID: PMC10943183 DOI: 10.1016/j.jinf.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Effective disease surveillance, including that for COVID-19, is compromised without a standardised method for categorising the immunosuppressed as a clinical risk group. METHODS We conducted a systematic review and meta-analysis to evaluate whether excess COVID-associated mortality compared to the immunocompetent could meaningfully subdivide the immunosuppressed. Our study adhered to UK Immunisation against infectious disease (Green Book) criteria for defining and categorising immunosuppression. Using OVID (EMBASE, MEDLINE, Transplant Library, and Global Health), PubMed, and Google Scholar, we examined relevant literature between the entirety of 2020 and 2022. We selected for cohort studies that provided mortality data for immunosuppressed subgroups and immunocompetent comparators. Meta-analyses, grey literature and any original works that failed to provide comparator data or reported all-cause or paediatric outcomes were excluded. Odds Ratios (OR) and 95% confidence intervals (CI) of COVID-19 mortality were meta-analysed by immunosuppressed category and subcategory. Subgroup analyses differentiated estimates by effect measure, country income, study setting, level of adjustment, use of matching and publication year. Study screening, extraction and bias assessment were performed blinded and independently by two researchers; conflicts were resolved with the oversight of a third researcher. PROSPERO registration number is CRD42022360755. FINDINGS We identified 99 unique studies, incorporating data from 1,542,097 and 56,248,181 unique immunosuppressed and immunocompetent patients with COVID-19 infection, respectively. Compared to immunocompetent people (pooled OR, 95%CI), solid organ transplants (2.12, 1.50-2.99) and malignancy (2.02, 1.69-2.42) patients had a very high risk of COVID-19 mortality. Patients with rheumatological conditions (1.28, 1.13-1.45) and HIV (1.20, 1.05-1.36) had just slightly higher risks than the immunocompetent baseline. Case type, setting income and mortality data matching and adjustment were significant modifiers of excess immunosuppressed mortality for some immunosuppressed subgroups. INTERPRETATION Excess COVID-associated mortality among the immunosuppressed compared to the immunocompetent was seen to vary significantly across subgroups. This novel means of subdivision has prospective benefit for targeting patient triage, shielding and vaccination policies during periods of high disease transmission.
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Affiliation(s)
- Meredith Leston
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom.
| | - Willam Elson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Jose M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Debasish Kar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Heather Whitaker
- Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, United Kingdom
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Old Campus Road, Old Campus Research Building, Headington, Oxford OX3 7DQ, United Kingdom
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, United Kingdom
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López V, Mazuecos A, Villanego F, López-Oliva M, Alonso A, Beneyto I, Crespo M, Díaz-Corte C, Franco A, González-Roncero F, Guirado L, Jiménez C, Juega J, Llorente S, Paul J, Rodríguez-Benot A, Ruiz JC, Sánchez-Fructuoso A, Torregrosa V, Zárraga S, Rodrigo E, Hernández D. Update of the recommendations on the management of the SARS-CoV-2 coronavirus pandemic (COVID-19) in kidney transplant patients. Nefrologia 2023; 43:531-545. [PMID: 37957107 DOI: 10.1016/j.nefroe.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/15/2023] Open
Abstract
SARS-CoV-2 infection (COVID-19) has had a significant impact on transplant activity in our country. Mortality and the risk of complications associated with COVID-19 in kidney transplant recipients (KT) were expected to be higher due to their immunosuppressed condition and the frequent associated comorbidities. Since the beginning of the pandemic in March 2020 we have rapidly improved our knowledge about the epidemiology, clinical features and management of COVID-19 post-transplant, resulting in a better prognosis for our patients. KT units have been able to adapt their programs to this new reality, normalizing both donation and transplantation activity in our country. This manuscript presents a proposal to update the general recommendations for the prevention and treatment of infection in this highly vulnerable population such as KT.
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Affiliation(s)
- Verónica López
- Unidad de Gestión Clínica de Nefrología, Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), RICORS2040 (RD21/0005/0012), Málaga, Spain.
| | | | | | | | - Angel Alonso
- Servicio de Nefrología, Complejo Hospitalario A Coruña, A Coruña, Spain
| | - Isabel Beneyto
- Servicio de Nefrología, Hospital Universitario Politécnico La Fe, Valencia, Spain
| | - Marta Crespo
- Servicio de Nefrología, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), RD16/0009/0013 (ISCIII FEDER REDinREN), Barcelona, Spain
| | - Carmen Díaz-Corte
- Servicio de Nefrología, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, Spain
| | - Antonio Franco
- Servicio de Nefrología, Hospital de Alicante, Alicante, Spain
| | | | - Luis Guirado
- Servicio de Nefrología, Fundación Puigvert, REDinREN RD16/0009/0019, Barcelona, Spain
| | | | - Javier Juega
- Servicio de Nefrología, Hospital Trias i Pujol, REDinREN RD16/0009/0032, Barcelona, Spain
| | - Santiago Llorente
- Servicio de Nefrología, Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Javier Paul
- Servicio de Nefrología, Hospital Miguel Servet, Zaragoza, Spain
| | - Alberto Rodríguez-Benot
- Servicio de Nefrología, Hospital Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba, Spain
| | - Juan Carlos Ruiz
- Servicio de Nefrología, Hospital Marqués de Valdecilla, IDIVAL, REDinREN RD16/0009/0027, Santander, Cantabria, Spain
| | - Ana Sánchez-Fructuoso
- Servicio de Nefrología, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Sofía Zárraga
- Servicio de Nefrología, Hospital de Cruces, Bilbao, Vizcaya, Spain
| | - Emilio Rodrigo
- Servicio de Nefrología, Hospital Marqués de Valdecilla, IDIVAL, REDinREN RD16/0009/0027, Santander, Cantabria, Spain
| | - Domingo Hernández
- Unidad de Gestión Clínica de Nefrología, Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), RICORS2040 (RD21/0005/0012), Málaga, Spain
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3
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López-Oliva MO, Pérez-Flores I, Molina M, José Aladrén M, Trujillo H, Redondo-Pachón D, López V, Facundo C, Villanego F, Rodríguez M, Carmen Ruiz M, Antón P, Rivas-Oural A, Cabello S, Portolés J, de la Vara L, Tabernero G, Valero R, Galeano C, Moral E, Ventura A, Coca A, Ángel Muñoz M, Hernández-Gallego R, Shabaka A, Ledesma G, Bouarich H, Ángeles Rodríguez M, Pérez Tamajón L, Cruzado L, Emilio Sánchez J, Jiménez C. Management of immunosuppressive therapy in kidney transplant recipients with COVID-19. A multicentre national study derived from the Spanish Society of Nephrology COVID registry. Nefrologia 2023; 43:442-451. [PMID: 37661514 DOI: 10.1016/j.nefroe.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/27/2022] [Indexed: 09/05/2023] Open
Abstract
INTRODUCTION SARS CoV2 infection has had a major impact on renal transplant patients with a high mortality in the first months of the pandemic. Intentional reduction of immunosuppressive therapy has been postulated as one of the cornerstone in the management of the infection in the absence of targeted antiviral treatment. This has been modified according to the patient`s clinical situation and its effect on renal function or anti-HLA antibodies in the medium term has not been evaluated. OBJECTIVES Evaluate the management of immunosuppressive therapy made during SARS-CoV2 infection, as well as renal function and anti-HLA antibodies in kidney transplant patients 6 months after COVID19 diagnosis. MATERIAL AND METHODS Retrospective, national multicentre, retrospective study (30 centres) of kidney transplant recipients with COVID19 from 01/02/20 to 31/12/20. Clinical variables were collected from medical records and included in an anonymised database. SPSS statistical software was used for data analysis. RESULTS renal transplant recipients with COVID19 were included (62.6% male), with a mean age of 57.5 years. The predominant immunosuppressive treatment prior to COVID19 was triple therapy with prednisone, tacrolimus and mycophenolic acid (54.6%) followed by m-TOR inhibitor regimens (18.6%). After diagnosis of infection, mycophenolic acid was discontinued in 73.8% of patients, m-TOR inhibitor in 41.4%, tacrolimus in 10.5% and cyclosporin A in 10%. In turn, 26.9% received dexamethasone and 50.9% were started on or had their baseline prednisone dose increased. Mean creatinine before diagnosis of COVID19, at diagnosis and at 6 months was: 1.7 ± 0.8, 2.1 ± 1.2 and 1.8 ± 1 mg/dl respectively (p < 0.001). 56.9% of the patients (N = 350) were monitored for anti-HLA antibodies. 94% (N = 329) had no anti-HLA changes, while 6% (N = 21) had positive anti-HLA antibodies. Among the patients with donor-specific antibodies post-COVID19 (N = 9), 7 patients (3.1%) had one immunosuppressant discontinued (5 patients had mycophenolic acid and 2 had tacrolimus), 1 patient had both immunosuppressants discontinued (3.4%) and 1 patient had no change in immunosuppression (1.1%), these differences were not significant. CONCLUSIONS The management of immunosuppressive therapy after diagnosis of COVID19 was primarily based on discontinuation of mycophenolic acid with very discrete reductions or discontinuations of calcineurin inhibitors. This immunosuppression management did not influence renal function or changes in anti-HLA antibodies 6 months after diagnosis.
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Affiliation(s)
| | | | - María Molina
- Servicio de Nefrología, Hospital U. Germans Trias y Pujol, Barcelona, Spain
| | | | | | | | - Verónica López
- Servicio de Nefrología, Hospital U. Carlos Haya, Málaga, Spain
| | - Carme Facundo
- Servicio de Nefrología, Hospital U. Fundación Puigvert, Barcelona, Spain
| | | | - Marisa Rodríguez
- Servicio de Nefrología, Hospital U. Gregorio Marañón, Madrid, Spain
| | - Maria Carmen Ruiz
- Servicio de Nefrología, Hospital U. Virgen de las Nieves, Granada, Spain
| | - Paula Antón
- Servicio de Nefrología, Hospital U. Bellvitge, Barcelona, Spain
| | - Alba Rivas-Oural
- Servicio de Nefrología, Hospital U. Central de Asturias, Oviedo, Spain
| | - Sheila Cabello
- Servicio de Nefrología, Hospital U. Son Espases, Palma de Mallorca, Spain
| | - José Portolés
- Servicio de Nefrología, Hospital U. de Albacete, Spain
| | | | | | - Rosalía Valero
- Servicio de Nefrología, Hospital U. Marqués de Valdecilla, Santander, Spain
| | - Cristina Galeano
- Servicio de Nefrología, Hospital U. Ramón y Cajal, Madrid, Spain
| | | | - Ana Ventura
- Servicio de Nefrología, Hospital U. La Fe, Valencia, Spain
| | - Armando Coca
- Servicio de Nefrología, Hospital Clínico Universitario, Valladolid, Spain
| | | | | | - Amir Shabaka
- Servicio de Nefrología, Hospital Fundación Alcorcón, Madrid, Spain
| | - Gabriel Ledesma
- Servicio de Nefrología, Hospital U. Infanta Sofía, Madrid, Spain
| | - Hanane Bouarich
- Servicio de Nefrología, Hospital U. Príncipe de Asturias, Madrid, Spain
| | | | | | | | - José Emilio Sánchez
- Servicio de Nefrología, Hospital de Cabueñes, Asturias, Coordinador Registro COVID S.E.N., Spain
| | - Carlos Jiménez
- Servicio de Nefrología, Hospital U. La Paz, Madrid, Spain
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4
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Lee IS, Okumura K, Misawa R, Sogawa H, Veillette G, John D, Diflo T, Nishida S, Dhand A. Inferior outcomes of liver transplantation for hepatocellular carcinoma during early-COVID-19 pandemic in the United States. World J Hepatol 2023; 15:554-563. [PMID: 37206654 PMCID: PMC10190691 DOI: 10.4254/wjh.v15.i4.554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/05/2023] [Accepted: 03/29/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Early in the coronavirus disease 2019 (COVID-19) pandemic, there was a significant impact on routine medical care in the United States, including in fields of transplantation and oncology.
AIM To analyze the impact and outcomes of early COVID-19 pandemic on liver transplantation (LT) for hepatocellular carcinoma (HCC) in the United States.
METHODS WHO declared COVID-19 as a pandemic on March 11, 2020. We retrospectively analyzed data from the United Network for Organ Sharing (UNOS) database regarding adult LT with confirmed HCC on explant in 2019 and 2020. We defined pre-COVID period from March 11 to September 11, 2019, and early-COVID period as from March 11 to September 11, 2020.
RESULTS Overall, 23.5% fewer LT for HCC were performed during the COVID period (518 vs 675, P < 0.05). This decrease was most pronounced in the months of March-April 2020 with a rebound in numbers seen from May-July 2020. Among LT recipients for HCC, concurrent diagnosis of non-alcoholic steatohepatitis significantly increased (23 vs 16%) and alcoholic liver disease (ALD) significantly decreased (18 vs 22%) during the COVID period. Recipient age, gender, BMI, and MELD score were statistically similar between two groups, while waiting list time decreased during the COVID period (279 days vs 300 days, P = 0.041). Among pathological characteristics of HCC, vascular invasion was more prominent during COVID period (P < 0.01), while other features were the same. While the donor age and other characteristics remained same, the distance between donor and recipient hospitals was significantly increased (P < 0.01) and donor risk index was significantly higher (1.68 vs 1.59, P < 0.01) during COVID period. Among outcomes, 90-day overall and graft survival were the same, but 180-day overall and graft were significantly inferior during COVID period (94.7 vs 97.0%, P = 0.048). On multivariable Cox-hazard regression analysis, COVID period emerged as a significant risk factor of post-transplant mortality (Hazard ratio 1.85; 95%CI: 1.28-2.68, P = 0.001).
CONCLUSION During COVID period, there was a significant decrease in LTs performed for HCC. While early postoperative outcomes of LT for HCC were same, the overall and graft survival of LTs for HCC after 180 days were significantly inferior.
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Affiliation(s)
- Inkyu S Lee
- Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Kenji Okumura
- Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Devon John
- Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Thomas Diflo
- Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
- Department of Medicine, Westchester Medical Center, Valhalla, NY 10595, United States
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5
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López V, Mazuecos A, Villanego F, López-Oliva M, Alonso A, Beneyto I, Crespo M, Díaz-Corte C, Franco A, González-Roncero F, Guirado L, Jiménez C, Juega J, Llorente S, Paul J, Rodríguez-Benot A, Ruiz JC, Sánchez-Fructuoso A, Torregrosa V, Zárraga S, Rodrigo E, Hernández D. [Update of the recommendations on the management of the SARS-CoV-2 coronavirus pandemic (COVID-19) in kidney transplant patients.]. Nefrologia 2022; 43:S0211-6995(22)00174-6. [PMID: 36405492 PMCID: PMC9664833 DOI: 10.1016/j.nefro.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022] Open
Abstract
SARS-CoV-2 infection (COVID-19) has had a significant impact on transplant activity in our country. Mortality and the risk of complications associated with COVID-19 in kidney transplant recipients (KT) were expected to be higher due to their immunosuppressed condition and the frequent associated comorbidities. Since the beginning of the pandemic in March 2020 we have rapidly improved our knowledge about the epidemiology, clinical features and management of COVID-19 post-transplant, resulting in a better prognosis for our patients. KT units have been able to adapt their programs to this new reality, normalizing both donation and transplantation activity in our country.This manuscript presents a proposal to update the general recommendations for the prevention and treatment of infection in this highly vulnerable population such as KT.
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Affiliation(s)
- Verónica López
- Unidad de Gestión Clínica de Nefrología. Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), RICORS2040 (RD21/0005/0012), Málaga, España
| | | | | | | | - Angel Alonso
- Servicio de Nefrología. Complejo Hospitalario A Coruña, España
| | - Isabel Beneyto
- Servicio de Nefrología. Hospital Universitario Politécnico La Fe, Valencia, España
| | - Marta Crespo
- Servicio de Nefrología. Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, España. RD16/0009/0013 (ISCIII FEDER REDinREN), España
| | - Carmen Díaz-Corte
- Servicio de Nefrología. Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Asturias, España
| | - Antonio Franco
- Servicio de Nefrología. Hospital de Alicante, Alicante, España
| | | | - Luis Guirado
- Servicio de Nefrología. Fundación Puigvert, REDinREN RD16/0009/0019, Barcelona, España
| | | | - Javier Juega
- Servicio de Nefrología. Hospital Trias i Pujol, REDinREN RD16/0009/0032, Barcelona, España
| | - Santiago Llorente
- Servicio de Nefrología. Hospital Virgen de la Arrixaca, Murcia, España
| | - Javier Paul
- Servicio de Nefrología. Hospital Miguel Servet, Zaragoza, España
| | - Alberto Rodríguez-Benot
- Servicio de Nefrología. Hospital Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Córdoba, España
| | - Juan Carlos Ruiz
- Servicio de Nefrología. Hospital Marqués de Valdecilla, IDIVAL, REDinREN RD16/0009/0027, Santander, España
| | - Ana Sánchez-Fructuoso
- Serivicio de Nefrología. Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, España
| | | | - Sofía Zárraga
- Servicio de Nefrología. Hospital de Cruces, Bilbao, España
| | - Emilio Rodrigo
- Servicio de Nefrología. Hospital Marqués de Valdecilla, IDIVAL, REDinREN RD16/0009/0027, Santander, España
| | - Domingo Hernández
- Unidad de Gestión Clínica de Nefrología. Hospital Regional Universitario de Málaga, Universidad de Málaga, Instituto Biomédico de Investigación de Málaga (IBIMA), RICORS2040 (RD21/0005/0012), Málaga, España
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Kute VB, Aziz F, Abraham A, Ray DS, Pathak V, Siddini V, Hegde U, Chauhan S, Meshram HS, Group ISOTSTUDY. Outcomes of Living Donor Kidney Transplant After SARS-CoV-2 Infection in Both the Donor and the Recipient: A Multicenter Study. EXP CLIN TRANSPLANT 2022; 20:908-916. [PMID: 36409050 DOI: 10.6002/ect.2022.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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7
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Dhand A, Okumura K, Nabors C, Nishida S. Solid organ transplantation from COVID positive donors in the United States: Analysis of United Network for Organ Sharing database. Transpl Infect Dis 2022; 25:e13925. [PMID: 35942924 PMCID: PMC9538265 DOI: 10.1111/tid.13925] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Significant uncertainties remain regarding the utilization of organs for solid organ transplantation (SOT) from donors with coronavirus disease 2019 (COVID-19). The aim of this study was to assess the trends in utilization of organs from donors with COVID-19 and their short-term outcomes. METHODS Deceased donors between March 2020 and December 2021 with a positive COVID nucleic acid test from respiratory tract within 14 days of transplantation were analyzed using the de-identified United Network for Organ Sharing (UNOS) database. Donor and recipient characteristics of COVID-19 positive (COVID+) organs were compared to COVID-19 negative (COVID-) organs during this period. We analyzed the trends in the utilization of SOT from COVID+ donors across the United States, donor characteristics, and the quality of donor organ and recipient outcomes (length of hospitalization, rates of organ rejection, delayed graft function, 30-day graft/patient survival). RESULTS During the study period, 193 COVID+ donors led to the transplantation of 281-kidneys, 106-livers, and 36-hearts in 414 adult recipients. COVID+ patients donated a median of two organs. These donors were younger and had a lower median Kidney Donor Profile Index (0.37 vs. 0.50, p < .001), lower median serum creatinine (0.8 vs. 1.0 mg/dl, p = .003), similar median serum total bilirubin (0.6 mg/dl, p = .46), and similar left ventricular ejection fraction (60%, p = .84) when compared to COVID- donors. Short-term outcomes, including 30-day graft/patient survival, were similar in both groups. CONCLUSIONS Analysis of short-term outcomes from the UNOS database indicates that a positive COVID test in an otherwise medically suitable donor should not preclude consideration of non-lung solid organ transplantation.
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Affiliation(s)
- Abhay Dhand
- Department of MedicineWestchester Medical Center/New York Medical CollegeValhallaNew YorkUSA,Department of SurgeryWestchester Medical Center/New York Medical CollegeValhallaNew YorkUSA
| | - Kenji Okumura
- Department of SurgeryWestchester Medical Center/New York Medical CollegeValhallaNew YorkUSA
| | - Christopher Nabors
- Department of MedicineWestchester Medical Center/New York Medical CollegeValhallaNew YorkUSA
| | - Seigo Nishida
- Department of SurgeryWestchester Medical Center/New York Medical CollegeValhallaNew YorkUSA
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8
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Opsomer R, Kuypers D. COVID-19 and solid organ transplantation: Finding the right balance. Transplant Rev (Orlando) 2022; 36:100710. [PMID: 35809422 PMCID: PMC9251959 DOI: 10.1016/j.trre.2022.100710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Roxanne Opsomer
- Catholic University of Leuven, Faculty of Medicine, Herestraat 49, 3000 Leuven, Belgium.
| | - Dirk Kuypers
- University Hospitals Leuven, Department of Nephrology and Renal Transplantation; Catholic University Leuven, Department of Microbiology, Immunology and Transplantation, Herestraat 49, 3000 Leuven, Belgium.
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9
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Okumura K, Nishida S, Sogawa H, Veillette G, Bodin R, Wolf DC, Dhand A. Inferior Liver Transplant Outcomes during early COVID-19 pandemic in United States. JOURNAL OF LIVER TRANSPLANTATION 2022; 7:100099. [PMID: 38013989 PMCID: PMC9110062 DOI: 10.1016/j.liver.2022.100099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background : Since its declaration as a global pandemic on March11th 2020, COVID-19 has had a significant effect on solid-organ transplantation. The aim of this study was to analyze the impact of COVID-19 on Liver transplantation (LT) in United States. Methods : We retrospectively analyzed the United Network for Organ Sharing database regarding characteristics of donors, adult-LT recipients, and transplant outcomes during early-COVID period (March 11- September 11, 2020) and compared them to pre-COVID period (March 11 - September 11, 2019). Results : Overall, 4% fewer LTs were performed during early-COVID period (4107 vs 4277). Compared to pre-COVID period, transplants performed in early-COVID period were associated with: increase in alcoholic liver disease as most common primary diagnosis (1315 vs 1187, P< 0.01), higher MELD score in the recipients (25 vs 23, P<0.01), lower time on wait-list (52 vs 84 days, P<0.01), higher need for hemodialysis at transplant (9.4 vs 11.1%, P=0.012), longer distance from recipient hospital (131 vs 64 miles, P<0.01) and higher donor risk index (1.65 vs 1.55, P<0.01). Early-COVID period saw increase in rejection episodes before discharge (4.6 vs 3.4%, P=0.023) and lower 90-day graft/patient survival (90.2 vs 95.1 %, P<0.01; 92.2 vs 96.5 %, P<0.01). In multivariable cox-regression analysis, early-COVID period was the independent risk factor for graft failure at 90-days post-transplant (Hazard Ratio 1.77, P<0.01). Conclusions : During early-COVID period in United States, overall LT decreased, alcoholic liver disease was primary diagnosis for LT, rate of rejection episodes before discharge was higher and 90-days post-transplant graft survival was lower.
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Key Words
- ALD, alcoholic related liver disease
- ALF, acute liver failure
- BMI, body mass index
- CI, confidence interval
- COD, causes of death
- COVID-19
- COVID-19 mortality
- COVID-19, Coronavirus disease 2019
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HR, hazard ratio
- ICU, intensive care units
- IQR, interquartile range
- LT, liver transplant
- MELD, model for end-stage liver disease
- MV, mechanical ventilation
- SARS-CoV-2, severe acute respiratory syndrome coronavirus-2
- SE, standard error
- UNOS, United Network for Organ Sharing
- United Network for Organ Sharing
- United Network for Organ Sharing database
- alcohol related liver disease
- graft failure
- liver transplant
- liver transplant recipients
- outcomes
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Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
| | - Roxana Bodin
- Department of Surgery, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
- Department of Medicine, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
| | - David C Wolf
- Department of Surgery, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
- Department of Medicine, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
- Department of Medicine, Westchester Medical Center / New York Medical College, Valhalla, NY, USA
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10
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López-Oliva MO, Pérez-Flores I, Molina M, José Aladrén M, Trujillo H, Redondo-Pachón D, López V, Facundo C, Villanego F, Rodríguez M, Carmen Ruiz M, Antón P, Rivas-Oural A, Cabello S, Portolés J, de la Vara L, Tabernero G, Valero R, Galeano C, Moral E, Ventura A, Coca A, Muñoz MÁ, Hernández-Gallego R, Shabaka A, Ledesma G, Martínez P, Ángeles Rodríguez M, Tamajón LP, Cruzado L, Emilio Sánchez J, Jiménez C. [Management of immunosuppressive therapy in kidney transplant recipients with COVID19. A multicentre national study derived form the S.E.N. COVID registry.]. Nefrologia 2022; 43:S0211-6995(22)00076-5. [PMID: 35528867 PMCID: PMC9055748 DOI: 10.1016/j.nefro.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/27/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION SARS CoV2 infection has had a major impact on renal transplant patients with a high mortality in the first months of the pandemic. Intentional reduction of immunosuppressive therapy has been postulated as one of the cornerstone in the management of the infection in the absence of targeted antiviral treatment. This has been modified according to the patient`s clinical situation and its effect on renal function or anti-HLA antibodies in the medium term has not been evaluated. OBJECTIVES Evaluate the management of immunosuppressive therapy made during SARS-CoV2 infection, as well as renal function and anti-HLA antibodies in kidney transplant patients 6 months after COVID19 diagnosis. MATERIAL AND METHODS Retrospective, national multicentre, retrospective study (30 centres) of kidney transplant recipients with COVID19 from 01/02/20 to 31/12/20. Clinical variables were collected from medical records and included in an anonymised database. SPSS statistical software was used for data analysis. RESULTS 615 renal transplant recipients with COVID19 were included (62.6% male), with a mean age of 57.5 years.The predominant immunosuppressive treatment prior to COVID19 was triple therapy with prednisone, tacrolimus and mycophenolic acid (54.6%) followed by m-TOR inhibitor regimens (18.6%). After diagnosis of infection, mycophenolic acid was discontinued in 73.8% of patients, m-TOR inhibitor in 41.4%, tacrolimus in 10.5% and cyclosporin A in 10%. In turn, 26.9% received dexamethasone and 50.9% were started on or had their baseline prednisone dose increased.Mean creatinine before diagnosis of COVID19, at diagnosis and at 6 months was: 1.7±0.8, 2.1±1.2 and 1.8±1 mg/dl respectively (p<0.001).56.9% of the patients (N=350) were monitored for anti-HLA antibodies. 94% (N=329) had no anti-HLA changes, while 6% (N=21) had positive anti-HLA antibodies. Among the patients with donor-specific antibodies post-COVID19 (N=9), 7 patients (3.1%) had one immunosuppressant discontinued (5 patients had mycophenolic acid and 2 had tacrolimus), 1 patient had both immunosuppressants discontinued (3.4%) and 1 patient had no change in immunosuppression (1.1%), these differences were not significant. CONCLUSIONS The management of immunosuppressive therapy after diagnosis of COVID19 was primarily based on discontinuation of mycophenolic acid with very discrete reductions or discontinuations of calcineurin inhibitors. This immunosuppression management did not influence renal function or changes in anti-HLA antibodies 6 months after diagnosis.
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Affiliation(s)
| | | | - María Molina
- Servicio de Nefrología, Hospital U. Germans Trias y Pujol, Barcelona, Spain
| | - Mª José Aladrén
- Servicio de Nefrología, Hospital U. Miguel Servet, Zaragoza, Spain
| | | | | | - Verónica López
- Servicio de Nefrología, Hospital U. Carlos Haya, Málaga, Spain
| | - Carme Facundo
- Servicio de Nefrología, Hospital U. Fundación Puigvert, Barcelona, Spain
| | | | - Marisa Rodríguez
- Servicio de Nefrología, Hospital U. Gregorio Marañón, Madrid, Spain
| | - Mª Carmen Ruiz
- Servicio de Nefrología, Hospital U. Virgen de las Nieves, Granada, Spain
| | - Paula Antón
- Servicio de Nefrología, Hospital U. Bellvitge, Barcelona, Spain
| | | | - Sheila Cabello
- Servicio de Nefrología, Hospital U. Son Espases, Palma de Mallorca, Spain
| | - José Portolés
- Servicio de Nefrología, Hospital U. Puerta de Hierro, Madrid, Spain
| | | | | | - Rosalía Valero
- Servicio de Nefrología, Hospital U. Marqués de Valdecilla, Santander, Spain
| | - Cristina Galeano
- Servicio de Nefrología, Hospital U. Ramón y Cajal, Madrid, Spain
| | | | - Ana Ventura
- Servicio de Nefrología, Hospital U. La Fe, Valencia, Spain
| | - Armando Coca
- Servicio de Nefrología, Hospital Clínico U. Valladolid, Spain
| | | | | | - Amir Shabaka
- Servicio de Nefrología, Hospital Fundación Alcorcón, Madrid, Spain
| | - Gabriel Ledesma
- Servicio de Nefrología, Hospital U. Infanta Sofía, Madrid, Spain
| | - Patricia Martínez
- Servicio de Nefrología, Hospital U. Príncipe de Asturias, Madrid, Spain
| | | | | | | | - J Emilio Sánchez
- Servicio de Nefrología, Hospital de Cabueñes, Asturias, Coordinador Registro COVID S.E.N, Spain
| | - Carlos Jiménez
- Servicio de Nefrología, Hospital U. La Paz, Madrid, Spain
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11
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Meshram HS, Kute VB, Chauhan S, Dave R, Patel H, Banerjee S, Desai S, Kumar D, Navadiya V, Mishra V. Mucormycosis as SARS-CoV2 sequelae in kidney transplant recipients: a single-center experience from India. Int Urol Nephrol 2021; 54:1693-1703. [PMID: 34792722 PMCID: PMC8600912 DOI: 10.1007/s11255-021-03057-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/11/2021] [Indexed: 12/19/2022]
Abstract
Purpose Coronavirus disease (COVID-19) sequelae in the transplant population are scarcely reported. Post-COVID-19 mucormycosis is one of such sequelae, which is a dreadful and rare entity. The purpose of this report was to study the full spectrum of this dual infection in kidney transplant recipients (KTR). Methods We did a comprehensive analysis of 11 mucormycosis cases in KTR who recovered from COVID-19 in IKDRC, Ahmedabad, Gujarat, India during the study period from Nov 2020 to May 2021. We also looked for the risk factors for mucormycosis with a historical cohort of 157 KTR who did not develop mucormycosis. Results The median age (interquartile range, range) of the cohort was 42 (33.5–50, 26–60) years with 54.5% diabetes. COVID-19 severity ranged from mild (n = 10) to severe cases (n = 1). The duration from COVID-19 recovery to presentation was 7 (7–7, 4–14) days. Ten cases were Rhino-orbital-cerebral-mucormycosis (ROCM) and one had pulmonary mucormycosis. Functional endoscopic sinus surgery (FESS) was performed in all cases of ROCM. The duration of antifungal therapy was 28 (24–30, 21–62) days. The mortality rate reported was 27%. The risk factors for post-transplant mucormycosis were diabetes (18% vs 54.5%; p-value = 0.01), lymphopenia [12 (10–18) vs 20 (12–26) %; p-value = 0.15] and a higher neutrophil–lymphocyte ratio [7 (4.6–8.3) vs 3.85 (3.3–5.8); p-value = 0.5]. Conclusion The morbidity and mortality with post-COVID-19 mucormycosis are high. Post-transplant patients with diabetes are more prone to this dual infection. Preparedness and early identification is the key to improve the outcomes.
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Affiliation(s)
- Hari Shankar Meshram
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Vivek B Kute
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India.
| | - Sanshriti Chauhan
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Ruchir Dave
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Himanshu Patel
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Subho Banerjee
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Sudeep Desai
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Deepak Kumar
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Vijay Navadiya
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Vineet Mishra
- Department of Gynecology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
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12
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Kute VB, Fleetwood VA, Meshram HS, Guenette A, Lentine KL. Use of Organs from SARS-CoV-2 Infected Donors: Is It Safe? A Contemporary Review. CURRENT TRANSPLANTATION REPORTS 2021; 8:281-292. [PMID: 34722116 PMCID: PMC8546195 DOI: 10.1007/s40472-021-00343-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW As the prevalence of individuals with recovered coronavirus disease 2019 (COVID-19) increases, determining if and when organs from these donors can be safely used is an important priority. We examined current knowledge of outcomes of transplant using donors with recovered COVID-19. RECENT FINDINGS A literature search of PubMed and Google scholar databases was conducted to identify articles with terms "SARS-CoV2," "COVID-19," "donor recovered," and "transplantation" published through 08/10/2021. We identified 25 reports detailing 94 recipients of both abdominal and thoracic transplants from donors with both prior and active COVID-19 infection. Rates of transmission to the recipient and of transplanted organ dysfunction were low among reports of donors with prior COVID-19 infection. End organ dysfunction and transmission were more common with active infection, although few reports are available. Standardized reporting is needed to better assess the impact of donor symptomatology, cycle thresholds, and individual recipient risk factors on postoperative outcomes. SUMMARY Available reports suggest that transplantation from COVID-19 donors may be feasible and safe, at least in short term follow-up. Nevertheless, there is a need for standardized testing and management protocols which should be tailored for available resources. While increased availability of COVID-19 vaccinations will mitigate risks of donor-derived COVID-19 and simplify management, continued vigilance is warranted during the ongoing public health emergency.
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Affiliation(s)
- Vivek B. Kute
- Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Vidya A. Fleetwood
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO USA
| | - Hari Shankar Meshram
- Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Alexis Guenette
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO USA
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO USA
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13
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Sandal S, Boyarsky BJ, Massie A, Chiang TPY, Segev DL, Cantarovich M. Immunosuppression practices during the COVID-19 pandemic: A multinational survey study of transplant programs. Clin Transplant 2021; 35:e14376. [PMID: 34050961 PMCID: PMC8209940 DOI: 10.1111/ctr.14376] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/03/2021] [Accepted: 05/24/2021] [Indexed: 12/17/2022]
Abstract
During the COVID-19 pandemic, there has been wide heterogeneity in the medical management of transplant recipients. We aimed to pragmatically capture immunosuppression practices globally following the early months of the pandemic. From June to September 2020, we surveyed 1267 physicians; 40.5% from 71 countries participated. Management decisions were made on a case-by-case basis by the majority (69.6%) of the programs. Overall, 76.8% performed ≥1 transplantation and many commented on avoiding high-risk transplantations. For induction, 26.5% were less likely to give T-cell depletion and 14.8% were more likely to give non-depleting agents. These practices varied by program-level factors more so than the COVID-19 burden. In patients with mild, moderate and severe COVID-19 symptoms 59.7%, 76.0%, and 79.5% decreased/stopped anti-metabolites, 23.2%, 45.4%, and 68.2% decreased/stopped calcineurin inhibitors, and 25.7%, 43.9%, and 57.7% decreased/stopped mTOR inhibitors, respectively. Also, 2.1%, 30.6%, and 46.0% increased steroids in patients with mild, moderate, and severe COVID-19 symptoms. For prevalent transplant recipients, some programs also reported decreasing/stopping steroids (1.8%), anti-metabolites (10.3%), calcineurin inhibitors (4.1%), and mTOR inhibitors (5.5%). Transplant programs changed immunosuppression practices but also avoided high-risk transplants and increased maintenance steroids. The long-term ramifications of these practices remain to be seen as programs face the aftermath of the pandemic.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Multi-Organ Transplant Program, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada.,Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Brian J Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Allan Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Teresa Po-Yu Chiang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marcelo Cantarovich
- Division of Nephrology, Multi-Organ Transplant Program, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada.,Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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