Epidemiology, risk factors, and clinical impact of early post-transplant infection in older kidney transplant recipients: the Korean organ transplantation registry study

Clinical and financial impacts of nursing education programs on recurrent urinary tract infections after kidney transplant: a cohort study

BACKGROUND

Urinary tract infections (UTIs) are the most prevalent infections among kidney transplant recipients, with recurrent cases imposing a significant financial burden due to increased hospitalizations and treatment costs.

OBJECTIVE

This study aims to investigate the incidence of recurrent UTIs and evaluate the financial impact of a comprehensive nursing education initiative.

METHODS

A retrospective cohort study was conducted with kidney transplant patients, divided into two groups: a control group prior to the intervention and a study group following the implementation of the education program. The intervention consisted of weekly training sessions focusing on infection prevention, catheter care, and hygiene. Patient outcomes were monitored for one year post-transplant, with a focus on UTI rates, patient adherence, knowledge, and healthcare costs.

RESULTS

The nursing education program resulted in a 26% reduction in UTI incidence and decreased average hospital stays from 8 days to 4 days. Healthcare costs per admission fell from $10,000 to $6,000, leading to total savings of $700,000 based on 175 admissions. The program resulted in a net saving of $650,000. Additionally, significant improvements were observed in patient knowledge, satisfaction, and compliance.

CONCLUSIONS

Nursing education on UTI prevention for kidney transplant patients effectively enhances clinical outcomes and reduces healthcare costs. These findings underscore the importance of integrating structured education programs into transplant care protocols to achieve sustainable health and economic benefits.

CLINICAL TRIAL NUMBER

Not Applicable.

Manifestation of Cytomegalovirus-Associated Gastritis and Colitis With Immunosuppression and Review of Literature

Cytomegalovirus (CMV) infection in immunocompromised patients can cause significant morbidity and mortality. Early recognition and treatment helps to improve outcome. We present a case of postrenal transplant CMV infection causing both upper and lower gastrointestinal infection and symptoms. Patient developed significant co-morbidity which required multiple hospital admissions and therapeutic interventions.

Clinical value of metagenomic sequencing in system evaluation of potential donors and donor-derived infection in kidney transplantation

OBJECTIVE

To explore the application and the clinical value of metagenomic sequencing in system evaluation of potential kidney donors, along with donor-derived infection in kidney transplantation.

METHODS

A prospective study was conducted on 40 voluntary renal donors in Ningbo Urology and Kidney Disease hospital from January 2021 to August 2023. The results of donor pathogen fed back by metagenomic sequencing were analyzed to understand the clinical significance of metagenomic sequencing in donor evaluation.

RESULTS

(1) Detection rate of pathogens. The probability of pathogens detected by traditional laboratories and metagenomic sequencing was 72.50% and 90.00%, respectively. Compared with traditional laboratory tests, metagenomic sequencing detected significantly more pathogens (P < 0.05). The percentage of co-infection of multiple pathogens detected by traditional laboratory tests (31.03%) in donors was significantly lower than that detected by metagenomic sequencing (88.89%) (P < 0.001). Traditional laboratory tests detected bacteria in 20 donors and fungi in 9 donors, but its performance on detecting viruses and mycoplasmas was limited. Metagenomic sequencing detected bacteria in 30 donors, fungi in 12 donors, viruses in 9 donors, and mycoplasmas in 9 donors. The positive rates of bacteria, viruses and mycoplasmas detected by metagenomic sequencing were significantly higher than those detected by traditional laboratory tests (P < 0.05). (2) Predictive value. The sensitivity, specificity, positive predictive value, and negative predictive value of metagenomic sequencing were 97.30%, 100.00%, 100% and 75.00%, respectively, while those of traditional laboratory tests were 78.39%, 100.00%, 100.00% and 27.27%, respectively. (3) The diagnostic efficiency of metagenomic sequencing was superior to that of traditional laboratory tests. (4) Time needed for result feedback. From specimen collection to the result feedback given to the clinician, the time required for traditional laboratory tests was longer than that for metagenomic sequencing, with significant differences (P < 0.001). In addition, the required time for traditional laboratory tests in detecting bacterial positivity was longer than that for metagenomic sequencing, with a statistically significant difference (P < 0.001).

CONCLUSION

This study probes into the application of metagenomic sequencing in the evaluation of donor pathogens, especially in negative samples detected by traditional laboratory tests. Our findings suggest that metagenomic sequencing can improve the sensitivity and specificity of diagnosis, increase the detection rate of pathogens, and minimize the turnover time.

Cefiderocol in the Successful Treatment of Complicated Hospital-Acquired K. pneumoniae NDM, OXA48 Intraabdominal Infection

Background

Klebsiella pneumoniae MDR/XDR constitutes a difficult to treat bacteria in a number of infections as there are few therapeutic options. Promising drugs in such cases can be cefiderocol, aztreonam and ceftazidime/avibactam or meropenem/vaborbactam.

Case Presentation

A 72-year-old female patient with sepsis caused by KP NDM, OXA 48 was admitted to the Intensive Care Unit, immediately after an emergency graftectomy (of a recently transplanted kidney) complicated with bleeding. Because of suspicion of intra-abdominal infection, a broad-spectrum empirical antibiotic therapy was initiated (meropenem, vancomycin, colistin). The patient underwent an abdominal revision 48 hours after admission. On the 3rd day of hospitalization, diagnosis of a septic shock with etiology of KP NDM, OXA 48 was made. The strain had sensitivity to a colistin and a cefiderocol. On 13th day in the ICU a relaparotomy was performed. Again, KP strains with sensitivity to cefiderocol only, were cultured from intra-abdominal fluid. Aztreonam, in combination with meropenem/vaborbactam, were included in the treatment and were used together with colistin and tigecycline. In the following days, the inflammatory markers decreased slightly, but the patient's general condition did not improve. On day 27 ceftazidime/avibactam and aztreonam were added, while colistin, meropenem/vaborbactam and fosfomycin were discontinued. On 37th day of hospitalization, cefiderocol became available in hospital and was included in the treatment. Cefiderocol monotherapy was continued for 8 days. After 4 days of cefiderocol treatment, the inflammatory markers CRP and PCT decreased and a significant improvement in patient's condition were observed. On day 56, the patient was transferred to another department.

Conclusion

A surgical debridement of a source infection, and usage of meropenem/vaborbactam or ceftazidime/avibactam together with aztreonam and colistin allowed survival of the patient but not full recovery. Ultimately, only the cefiderocol monotherapy was effective in treatment of the patient with septic shock of KP NDM OXA 48 etiology.

Kidney Transplantation in Older Recipients Regarding Surgical and Clinical Complications, Outcomes, and Survival: A Literature Review

Context: The best treatment for end-stage chronic kidney disease (ESKD) is kidney transplantation (KT). As a result of an aging population, each year more kidney transplants in older adults are performed. Nevertheless, older recipients, characterized by more comorbidities and frailty, raise concerns about the outcomes, potential complications, and the general approach. Aim: The aim of this literature review was to study the outcomes, graft and patient survival, as well as common complications, to establish safety and increase awareness of the potential complications of kidney transplantation in the older population. Methods: PubMed and Google scholar databases were searched. The cut-off age defining an old patient was 60 years. The inclusion criteria were as follows: first kidney transplantation, and studies in English language. The exclusion criteria were as follows: more than one organ transplant, dual transplants, articles published before 2015, meta-analysis, reviews, letter to the editor, case reports, and studies published only as a conference abstract. Comparative and noncomparative studies addressing patient survival, death-censored graft survival, surgical complications, and clinical complications, such as delayed graft function (DGF) and biopsy proven acute rejection (PBAR), were included. Results: After screening the papers, 17 studies met the inclusion criteria and were included for review. Eleven papers compared older recipients with younger recipients and in six papers only older patients were analysed. Two studies used paired deceased donors to eliminate donor bias. The rest of the studies used either deceased donors or both living and deceased donors. The majority of patients were male (61.83%) and received a kidney from a deceased donor (58.08%). Conclusions: Kidney transplantation is safe and can be beneficial for recipients over 60 years of age. Older patients suffered more infectious complications, which were also one of the main reasons for death. Most studies did not show a significant difference in death-censored graft survival compared to the younger population. More research is needed to establish the prevalence of surgical complications, and some clinical complications.

Recipient donor sex combinations in solid organ transplantation and impact on clinical outcome: A scoping review

INTRODUCTION

Solid organ transplantation (SOT) is a lifesaving treatment for end-stage organ failure. Although many factors affect the success of organ transplantation, recipient and donor sex are important biological factors influencing transplant outcome. However, the impact of the four possible recipient and donor sex combinations (RDSC) on transplant outcome remains largely unclear.

METHODS

A scoping review was carried out focusing on studies examining the association between RDSC and outcomes (mortality, graft rejection, and infection) after heart, lung, liver, and kidney transplantation. All studies up to February 2023 were included.

RESULTS

Multiple studies published between 1998 and 2022 show that RDSC is an important factor affecting the outcome after organ transplantation. Male recipients of SOT have a higher risk of mortality and graft failure than female recipients. Differences regarding the causes of death are observed. Female recipients on the other hand are more susceptible to infections after SOT.

CONCLUSION

Differences in underlying illnesses as well as age, immunosuppressive therapy and underlying biological mechanisms among male and female SOT recipients affect the post-transplant outcome. However, the precise mechanisms influencing the interaction between RDSC and post-transplant outcome remain largely unclear. A better understanding of how to identify and modulate these factors may improve outcome, which is particularly important in light of the worldwide organ shortage. An analysis for differences of etiology and causes of graft loss or mortality, respectively, is warranted across the RDSC groups.

PRACTITIONER POINTS

Recipient and donor sex combinations affect outcome after solid organ transplantation. While female recipients are more susceptible to infections after solid organ transplantation, they have higher overall survival following SOT, with causes of death differing from male recipients. Sex-differences should be taken into account in the post-transplant management.

Evolving Trends in Kidney Transplant Outcomes Among Older Adults: A Comparative Analysis Before and During the COVID-19 Pandemic

Background

Advancements in medical technology, healthcare delivery, and organ allocation resulted in improved patient/graft survival for older (age ≥65) kidney transplant (KT) recipients. However, the recent trends in these post-KT outcomes are uncertain in light of the mounting burden of cardiovascular disease, changing kidney allocation policies, heterogeneity in candidates' risk profile, and the coronavirus disease 2019 pandemic. Thus, we examined secular trends in post-KT outcomes among older and younger KT recipients over the last 3 decades.

Methods

We identified 73 078 older and 378 800 younger adult (aged 18-64) recipients using Scientific Registry of Transplant Recipients (1990-2022). KTs were grouped into 6 prepandemic eras and 1 postpandemic-onset era. Kaplan-Meier and Cox proportional hazards models were used to examine temporal trends in post-KT mortality and death-censored graft failure.

Results

From 1990 to 2022, a 19-fold increase in the proportion of older KT recipients was observed compared to a 2-fold increase in younger adults despite a slight decline in the absolute number of older recipients in 2020. The mortality risk for older recipients between 2015 and March 14, 2020, was 39% (adjusted hazard ratio [aHR] = 0.61, 95% confidence interval [CI], 0.50-0.75) lower compared to 1990-1994, whereas that for younger adults was 47% lower (aHR = 0.53, 95% CI, 0.48-0.59). However, mortality risk during the pandemic was 25% lower (aHR = 0.75, 95% CI, 0.61-0.93) in older adults and 37% lower in younger adults (aHR = 0.63, 95% CI, 0.56-0.70) relative to 1990-1994. For both populations, the risk of graft failure declined over time and was unaffected during the pandemic relative to the preceding period.

Conclusions

The steady improvements in 5-y mortality and graft survival were disrupted during the pandemic, particularly among older adults. Specifically, mortality among older adults reflected rates seen 20 y prior.

Maximizing opportunities for kidney transplantation in older adults

PURPOSE OF REVIEW

To summarize the current state of evidence related to the outcomes of older adults who need and receive kidney transplants, and strategies to facilitate appropriate transplant access in this at-risk group.

RECENT FINDINGS

Older adults are a rapidly growing subgroup of the kidney transplant waitlist. Compared to younger adults, older kidney transplant recipients have increased mortality after kidney transplant and lower death-censored graft survival. In determining suitability for transplantation in older patients, clinicians must balance procedural and immunosuppression-related risk with incremental survival when compared with dialysis. To appropriately increase access to transplantation in this population, clinicians and policy makers consider candidates' chronological age and frailty, as well as the quality of and waiting time for a donated allograft. Given risk of deterioration prior to transplant, candidates should be rapidly evaluated, listed, and transplanted using living donor and or less than ideal deceased donor organs when available.

SUMMARY

Access to transplantation for older adults can be increased through targeted interventions to address frailty and reduce waiting times through optimized organ use. Focused study and educational interventions for patients and providers are needed to improve the outcomes of this vulnerable group.

Recurrent Urinary Tract Infection in Living Donor Renal Transplant Recipients and the Role of Behavioral Education Program in Management: A Single-Center Experience

BACKGROUND

Urinary tract infections (UTIs) are the most prevalent type of kidney transplant (KT) recipients. We aimed to investigate the incidence, causes, and clinical impact of early recurrent UTI post-living donor KT and to examine the role of behavioral education program in management.

METHODS

This retrospective cohort chart-review study included all KT recipients with recurrent UTI necessitating hospital admission between September 2017 and August 2021. All patients with recurrent UTI were subjected to behavioral education for a month.

RESULTS

UTI was found in 14 of 145 patients (9.6%), with recurrent UTI in 11 (7.6%). A total of 93% of UTIs occurred during the first 6 months post-transplant and represented 52% of KT readmissions during the same period. A total of 64.3% of patients were older than 50 years. The mean (SD) length of hospital stay was 5 (2.5) days, with an equal incidence in both sexes. The most common bacterial isolates in early recurrent UTI were Escherichia coli in 80.9%. Both Extended-spectrum beta-lactamases and multidrug-resistant organisms (resistance in ≥3 drugs) were seen in 82.4% of isolates. Furthermore, the most effective antibiotic was meropenem, with 86.7% effectiveness. A total of 65% of UTIs were managed with a single antibacterial course. A total of 64.3% of patients were older than 50 years. In patients who developed UTI, the mean (SD) serum creatinine was 1.31 (0.52) mg/dL, with a mean increase in serum creatinine of 0.19 mg/dL on having the episodes; at 1 year post-transplant, serum creatinine declined to 1.23 (0.43) mg/dL. Four patients (36%) had no recurrence of UTI after behavioral education.

CONCLUSIONS

The multidrug-resistant bacterial isolates account for 82.4% of the UTIs. Therefore, antibiotic prescription should follow the antimicrobial stewardship guidelines. Behavioral education significantly reduced the incidence of recurrent UTI.

Infections following rejection therapies in kidney and liver transplant recipients

INTRODUCTION

Infections are known complications of solid-organ transplant. Treatment for rejection may increase risk of infection. We aimed to study frequency of infection and identify the risk factors for infections in solid organ transplant (SOT) (liver and kidney) recipients treated for rejection.

METHODS

This is a retrospective chart review of all liver and kidney transplant recipients treated for rejection at our institution from 2014 to 2020. We collected information on episodes of acute rejection in the first year of transplant and infections within 6 months following rejection treatment.

RESULTS

We identified 257 transplant patients treated for rejection. One hundred twelve (43.6%) developed infections, with a total of 226 infections. Urinary tracts infections were the most common, 72 (31.9%), followed by cytomegalovirus viremia in 37 (16.4%), bacteremia in 24 (10.6%), and BK virus in 14 (6.2%). Female sex (p = .047), elevated neutrophil count at rejection (p = .002), and increased number of rejection episodes (p = .022) were predictors of infection in kidney and simultaneous liver-kidney recipients. No specific type of induction or rejection therapy was identified as a risk factor for infection, likely due to the prophylaxis protocols at our institution. Infection post rejection treatment was associated with higher graft loss (p = .021) and mortality (p = .031) in kidney transplant recipients.

CONCLUSIONS

Infections are common complications after treatment of SOT rejection. Female gender, higher neutrophil at time of rejection, and increased numbers of rejection episodes were predictors of infections after rejection in simultaneous liver-kidney and kidney transplant patients. Infections were predictors of graft loss at 6 months and mortality at any point in follow-up in kidney transplant patients.

Bacterial Urinary Tract Infection and Early Asymptomatic Bacteriuria in Kidney Transplantation Still Negatively Affect Kidney Transplant Outcomes in the Era of Modern Immunosuppression and Cotrimoxazole Prophylaxis

Risk factors and consequences of urinary tract infection (UTI) post-kidney transplant have been variously reported by studies that were heterogenous in immunosuppressants and prophylactic protocols. We aimed to clarify the risks and consequences of UTI in kidney transplant recipients with post-transplantation cotrimoxazole prophylaxis in the context of modern immunosuppression. This retrospective cohort included kidney transplant recipients receiving tacrolimus, mycophenolate, prednisolone, and cotrimoxazole for bacterial UTI prophylaxis. Recipients were categorized into non-UTI and UTI groups. Asymptomatic bacteriuria (ASB) was screened in the first 3 months and was evaluated for association with UTI. Of 348 kidney transplant recipients, 129 were in the UTI group and 219 in the non-UTI group. UTI risk factors were female sex, body mass index ≥ 25 kg/m², human leukocyte antigen mismatch, and panel reactive antibody ≥ 50%. Recipients with recurrent UTI had inferior allograft function compared with non-UTI recipients. Patient survival was significantly lower in recipients with UTI in the first post-transplant month. Higher degree of immunosuppressions was associated with recurrent UTI and drug-resistant organisms. In conclusion, UTI continues to negatively affect graft function and survival of kidney transplant recipients. Treating ASB in the first 3 months did not reduce the UTI incidence in the first transplantation year.

Kidney Transplant-Associated Viral Infection Rates and Outcomes in a Single-Centre Cohort

BACKGROUND

Opportunistic infections remain a significant cause of morbidity and mortality after kidney transplantation. This retrospective cohort study aimed to assess the incidence and predictors of post-transplant DNA virus infections (CMV, EBV, BKV and JCV infections) in kidney transplant recipients (KTR) at a single tertiary centre and evaluate their impact on graft outcomes.

METHODS

KTR transplanted between 2000 and 2021 were evaluated. Multivariate logistic regression analysis and Cox proportional hazard analyses were used to identify factors associated with DNA virus infections and their impact on allograft outcomes respectively. A sub-analysis of individual viral infections was also conducted to describe the pattern, timing, interventions, and outcomes of individual infections.

RESULTS

Data from 962 recipients were evaluated (Mean age 47.3 ± 15 years, 62% male, 81% white). 30% of recipients (288/962) had infection(s) by one or more of the DNA viruses. Individually, CMV, EBV, BKV and JCV viruses were diagnosed in 13.8%. 11.3%, 8.9% and 4.4% of recipients respectively. Factors associated with increased risk of post-transplant DNA virus infection included recipient female gender, higher number of HLA mismatch, lower baseline estimated glomerular filtration rate (eGFR), CMV seropositive donor, maintenance with cyclosporin (rather than tacrolimus) and higher number of maintenance immunosuppressive medications. The slope of eGFR decline was steeper in recipients with a history of DNA virus infection irrespective of the virus type. Further, GFR declined faster with an increasing number of different viral infections. Death-censored graft loss adjusted for age, gender, total HLA mismatch, baseline eGFR and acute rejection was significantly higher in recipients with a history of DNA virus infection than those without infection (adjusted hazard ratio (aHR, 1.74, 95% CI, 1.08-2.80)). In contrast, dialysis-free survival did not differ between the two groups of recipients (aHR, 1.13, 95% CI, 0.88-1.47).

CONCLUSION

Post-transplant DNA viral infection is associated with a higher risk of allograft loss. Careful management of immunosuppression and close surveillance of at-risk recipients may improve graft outcomes.

Retrospective Analysis of the Risk Factors of Perioperative Bacterial Infection and Correlation with Clinical Prognosis in Kidney Transplant Recipients

Background

Infection remains a leading cause of morbidity and mortality in kidney transplant patients. This study aimed to investigate the risk factors of bacterial infection during the perioperative period of transplantation and the effects of infection on long-term clinical outcomes.

Methods

In total, 295 kidney transplantation recipients were included in this retrospective study and assigned to two groups: non-infected and infected. The tacrolimus concentration, pharmacogenomics, laboratory parameters, and clinical outcomes of both groups were evaluated.

Results

A relatively low incidence of urinary tract infection was observed in our cohort, and lung was identified as the most frequent site of infection. Gram-negative bacteria, such as Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae, were the most common infecting strains in kidney transplant recipients. Patients with diabetes showed greater susceptibility to infection. Compared with the non-infected group, tacrolimus concentration was significantly lower on day 7 and 14 in the infected group. White blood cell count, neutrophil count, and C-reactive protein (CRP) in the infected group were markedly higher post-transplantation, while albumin levels were lower relative to the non-infected group. ABCB1 (rs2032582) genotype showed clear associations with infection. Furthermore, the incidence of delayed graft function (DGF) and early acute rejection (AR) before infection was significantly greater in the infected group. Finally, early post-transplant infection was associated with a marked increase in the incidence of AR, post-transplant diabetes mellitus (PTDM), and secondary infection.

Conclusion

Pre-diabetes, longer duration of catheterization, lower albumin, higher CRP, tacrolimus concentration on the day 7 and 14, early AR before infection, and DGF were closely related to postoperative infection in kidney transplantation recipients. Moreover, bacterial infection during the perioperative period was closely associated with AR, PTDM and secondary infection.