COVID-19 early curative treatments in kidney transplant recipients: is it really reasonable at the Omicron era?

Objective

Data about efficacy and safety of the latest COVID-19 treatments as nirmatrelvir/ritonavir (n/r) or Sotrovimab is scarce in solid organ transplant recipients in the Omicron era. This study aims at describing the outcome of kidney transplant recipients (KTRs) presenting Omicron infection according to their management: n/r, sotrovimab or no specific treatment.

Patients and methods

We conducted a monocentric, retrospective observational study, including KTRs diagnosed Omicron infection between January and May 1st 2022 and compared their outcome (primary outcome defined as hospital admission for COVID-19 within a month after symptoms onset) according to early COVID-19 management.

Results

Forty-five patients were included: 22 treated (12 n/r, 10 sotrovimab) and 23 with no specific treatment. The groups were statistically comparable. Two patients were admitted for COVID-19: one in each group, resulting in a non-different probability of the primary outcome at on month (p=0.9). Three patients presented tacrolimus overdose including two with acute kidney injury.

Conclusions

There was no difference in outcome according to early therapeutic management: n/r, sotrovimab or no specific treatment. Our study both underlines a decreased severity of Omicron COVID-19 in KTRs (probably related to vaccinal immunity and decreased virulence of Omicron) and a potential severe adverse effects with n/r.

Sexually Transmitted Trichophyton mentagrophytes Genotype VII Infection among Men Who Have Sex with Men

Transmission of dermatophytes, especially Trichophyton mentagrophytes genotype VII, during sexual intercourse has been recently reported. We report 13 such cases in France. All patients were male; 12 were men who have sex with men. Our findings suggest sexual transmission of this pathogen within a specific population, men who have sex with men.

Factors Associated With Genotypic Resistance and Outcome Among Solid Organ Transplant Recipients With Refractory Cytomegalovirus Infection

Genotypically resistant cytomegalovirus (CMV) infection is associated with increased morbi-mortality. We herein aimed at understanding the factors that predict CMV genotypic resistance in refractory infections and disease in the SOTR (Solid Organ Transplant Recipients) population, and the factors associated with outcomes. We included all SOTRs who were tested for CMV genotypic resistance for CMV refractory infection/disease over ten years in two centers. Eighty-one refractory patients were included, 26 with genotypically resistant infections (32%). Twenty-four of these genotypic profiles conferred resistance to ganciclovir (GCV) and 2 to GCV and cidofovir. Twenty-three patients presented a high level of GCV resistance. We found no resistance mutation to letermovir. Age (OR = 0.94 per year, IC95 [0.089-0.99]), a history of valganciclovir (VGCV) underdosing or of low plasma concentration (OR= 5.6, IC95 [1.69-20.7]), being on VGCV at infection onset (OR = 3.11, IC95 [1.18-5.32]) and the recipients' CMV negative serostatus (OR = 3.40, IC95 [0.97-12.8]) were independently associated with CMV genotypic resistance. One year mortality was higher in the resistant CMV group (19.2 % versus 3.6 %, p = 0.02). Antiviral drugs severe adverse effects were also independently associated with CMV genotypic resistance. CMV genotypic resistance to antivirals was independently associated with a younger age, exposure to low levels of GCV, the recipients' negative serostatus, and presenting the infection on VGCV prophylaxis. This data is of importance, given that we also found a poorer outcome in the patients of the resistant group.

Specificities of Meningitis and Meningo-Encephalitis After Kidney Transplantation: A French Retrospective Cohort Study

Kidney transplant recipients develop atypical infections in their epidemiology, presentation and outcome. Among these, meningitis and meningoencephalitis require urgent and adapted anti-infectious therapy, but published data is scarce in KTRs. The aim of this study was to describe their epidemiology, presentation and outcome, in order to improve their diagnostic and management. We performed a retrospective, multicentric cohort study in 15 French hospitals that included all 199 cases of M/ME in KTRs between 2007 and 2018 (0.9 case per 1,000 KTRs annually). Epidemiology was different from that in the general population: 20% were due to Cryptococcus neoformans, 13.5% to varicella-zoster virus, 5.5% to Mycobacterium tuberculosis, and 4.5% to Enterobacteria (half of which produced extended spectrum beta-lactamases), and 5% were Post Transplant Lymphoproliferative Disorders. Microorganisms causing M/ME in the general population were infrequent (2%, for Streptococcus pneumoniae) or absent (Neisseria meningitidis). M/ME caused by Enterobacteria, Staphylococci or filamentous fungi were associated with high and early mortality (50%-70% at 1 year). Graft survival was not associated with the etiology of M/ME, nor was impacted by immunosuppression reduction. Based on these results, we suggest international studies to adapt guidelines in order to improve the diagnosis and the probabilistic treatment of M/ME in SOTRs.

Viral loads in clinical samples of men with monkeypox virus infection: a French case series

BACKGROUND

Monkeypox virus (MPXV) is currently spreading among men who have sex with men, outside of sub-Saharan Africa, and close contact during sex seems to be one of the key pathways of viral transmission in the current outbreak. Our aim was to describe the distribution of MPXV in the human body, as it might play a role in its dissemination through sexual contact.

METHODS

The study population in this case series consisted of patients with confirmed MPXV infection attending the Pitié-Salpêtrière Hospital (Paris, France), who had been sampled from multiple anatomical sites, including skin, anus, throat, blood, urine, and semen, at diagnosis and 2 weeks later. We compared the proportion of positive samples and MPXV viral loads (given as PCR cycle thresholds [Ct]) between anatomical sites, and between day 0 (D0) and D14.

FINDINGS

Overall, 356 samples were collected between May 20 and June 13, 2022, from 50 men with a median age of 34 years (IQR 29-40). 22 (44%) of the 50 men were classified as HIV-negative on day (D)0, and 22 (44%) were living with HIV. At D0, MPXV detection was more frequent from skin (44 [88%] of 50), anus (30 [71%] of 42), and throat (36 [77%] of 47) than from blood (13 [29%] of 45), urine (nine [22%] of 41), or semen (13 [54%] of 24). Viral loads were significantly higher from skin lesions (Ct 19·8) and anal samples (Ct 20·9) than from throat (Ct 27·2), blood (Ct 32·8), urine (31·1), or semen samples (Ct 27·8). When analysing the 107 samples taken from 24 patients at D14, the proportion of positive samples strongly decreased between D0 and D14 at all sites: skin (four [22%] of 18), anus (two [9%] of 22), throat (none of 21), blood (one [5%] of 21), urine (none of 14), and semen (two [9%] of 11).

INTERPRETATION

These data contribute to a better understanding of how the virus might spread between sexual partners over a relatively short period of time. High MPXV viral loads from skin and mucosa, including genital and anal sites, suggest that transmission most likely occurs through direct body contact rather than through the respiratory route or contact with body fluids, which should help to refine the prevention messages delivered to individuals most exposed to the virus.

FUNDING

None.

Corrigendum to Persistent Aseptic Pyelonephritis After Acute Bacterial Pyelonephritis: Possible Role of Corticosteroids Kidney International Reports, Volume 7, Issue 8, August 2022, Pages 1897-1900

[This corrects the article DOI: 10.1016/j.ekir.2022.05.025.].

Immunosuppressive therapy after solid organ transplantation and the gut microbiota: Bidirectional interactions with clinical consequences

Our understanding of the involvement of the gut microbiota (GM) in human health has expanded exponentially over the last few decades, particularly in the fields of metabolism, inflammation, and immunology. Immunosuppressive treatment (IST) prescribed to solid organ transplant (SOT) recipients produces GM changes that affect these different processes. This review aims at describing the current knowledge of how IST changes the GM. Overall, SOT followed by IST results in persistent changes in the GM, with a consistent increase in proteobacteria including opportunistic pathobionts. In mice, Tacrolimus induces dysbiosis and metabolic disorders, and alters the intestinal barrier. The transfer of the GM from Tacrolimus-treated hosts confers immunosuppressive properties, suggesting a contributory role for the GM in this drug's efficacy. Steroids induce dysbiosis and intestinal barrier alterations, and also seem to depend partly on the GM for their immunosuppressive and metabolic effects. Mycophenolate Mofetil, frequently responsible for digestive side effects such as diarrhea and colitis, is associated with pro-inflammatory dysbiosis and increased endotoxemia. Alemtuzumab, m-TOR inhibitors, and belatacept have shown more marginal impact on the GM. Most of these observations are descriptive. Future studies should explore the underlying mechanism of IST-induced dysbiosis in order to better understand their efficacy and safety characteristics.

High Mortality and Graft Loss after Infective Endocarditis in Kidney Transplant Recipients: A Case-Controlled Study from Two Centers

Kidney transplant recipients (KTRs) tend to develop infections with characteristic epidemiology, presentation, and outcome. While infective endocarditis (IE) is among such complications in KTRs, the literature is scarce. We describe the presentation, epidemiology, and factors associated with IE in KTRs. We performed a retrospective case/control study which included patients from two centers. First episodes of definite or possible IE (Duke criteria) in adult KTRs from January 2010 to December 2018 were included, as well as two controls per case, and followed until 31 December 2019. Clinical, biological, and microbiological data and the outcome were collected. Survival was studied using the Kaplan-Meier method. Finally, we searched for factors associated with the onset of IE in KTRs by the comparison of cases and controls. Seventeen cases and 34 controls were included. IE was diagnosed after a mean delay of 78 months after KT, mostly on native valves of the left heart only. Pathogens of digestive origin were most frequently involved (six Enterococcus spp, three Streptococcus gallolyticus, and one Escherichia coli), followed by Staphylococci (three cases of S. aureus and S. epidermidis each). Among the risk factors evaluated, age, vascular nephropathy, and elevated calcineurin inhibitor through levels were significantly associated with the occurrence of IE in our study. Patient and death-censored graft survival were greatly diminished five years after IE, compared to controls being 50.3% vs. 80.6% (p < 0.003) and 29.7% vs. 87.5% (p < 0.002), respectively. IE in KTRs is a disease that carries significant risks both for the survival of the patient and the transplant.

Gut microbiota composition alterations are associated with the onset of diabetes in kidney transplant recipients

Background

The gut dysbiosis associated with diabetes acquired before or after kidney transplantation (KT) has not been explored.

2658. Meningitis in Kidney Transplant Recipients: TransMéninges, a French Multicentric Retrospective Cohort Study

Background

The management of meningitis requires the prompt introduction of high-dose probabilistic anti-infectious therapy. The literature reporting on meningitis in kidney transplant recipients (KTR) is scarce and no recommendation exists for this specific population.

Methods

We retrospectively included all adult KTRs diagnosed with meningitis (cerebro-spinal fluid (CSF) cell count >10/mm³ or positive fungal antigen or direct examination) between 2007 and 2018 in 16 French hospitals. Clinical, biological, and therapeutic data, and 1-year kidney and patient survival were collected.

Results

Meningitis occurred in 134 KTRs (mean age 57+/11.8 years, 56% male), after a median time of 27 months (IQR 8–65); 25% of patients received an immunosuppressive treatment before kidney transplantation, induction treatment included lymphocyte-depleting antibodies in 63%, and 53% presented diabetes (34% before and 19% after the transplantation). The etiologies included Cryptococcus neoformans (30%), Herpesviridae (22%, including Varicella-Zoster Virus 15%), idiopathic forms (11%), Gram-negative bacilli (8% of which 20% produced an extended spectrum β-lactamase), %), infusion of intravenous immunoglobulins (6%), post-transplant lymphoproliferative disorders (5%), Aspergillus fumigatus (4%), Listeria monocytogenes (4%), Enterovirus (4%), and Mycobacterium tuberculosis (3%).

The most common symptoms were fever (82.5%), headaches (75%), encephalitis (55%), and convulsion (22.5%). CSF hypercellularity (found in 92% of the cases) was lymphocytic in 65% of the cases and neutrophilic in 35%. Initial anti-infectious therapy was inappropriate in 27% of the cases. One-year patient, graft, and death-censored graft survival rates were 84%, 76%, and 89%, respectively.

Conclusion

Meningitis after kidney transplantation encompasses a wide range of causes, with C. neoformans and VZV explaining more than 50% of the cases. Gram-negative bacilli are the most represented bacteria with a high rate of antimicrobial resistance. Treatment guidelines should be reconsidered in the specific population of KTRs as the etiology greatly differs from what is observed in the general population.

Disclosures

All authors: No reported disclosures.

Post-malaria neurological syndrome: four cases, review of the literature and clarification of the nosological framework

BACKGROUND

Post-malaria neurological syndrome (PMNS) is a debated entity, defined by neurological complications following a post-malaria symptom-free period and a negative blood smear. Four cases of PMNS are hereby reported and a review the literature performed to clarify the nosological framework of this syndrome.

METHODS

A French teaching hospital infectious diseases database was investigated for all PMNS cases occurring between 1999 and 2016 and the PubMed database for cases reported by other institutions after 1997. A case was defined by the de novo appearance of neurological signs following a post-malaria symptom-free period, a negative blood smear, and no bacterial or viral differential diagnoses.

RESULTS

Four patients from the database and 48 from PubMed, including 4 following Plasmodium vivax infection were found matching the definition. In the institution, the estimated PMNS incidence rate was 1.7 per 1000 malaria cases overall. Of the 52 patients (mean age 33 years), 65% were men. Malaria was severe in 85% of cases, showed neurological involvement in 53%, and treated with quinine in 60%, mefloquine in 46%, artemisinin derivatives in 41%, antifolic drugs in 30%, doxycycline in 8% and other types in 8%. The mean symptom-free period was 15 days. PMNS signs were confusion (72%), fever (46%), seizures (35%), cerebellar impairment (28%), psychosis (26%), and motor disorders (13%). Cerebrospinal fluid analyses showed high protein levels in 77% (mean 1.88 g/L) and lymphocytic meningitis in 59.5% (mean 48 WBC/mm3) of cases. Electroencephalograms were pathological in 93% (14/15) of cases, and brain MRIs showed abnormalities in 43% (9/21) of cases with white matter involvement in 100%. Fourteen patients were treated with steroids. The 18 patients with follow-up data showed no sequelae. The mean time to recovery was 17.4 days.

CONCLUSION

PMNS is a rare entity englobing neurological signs after severe or non-severe malaria. It appears after a symptom-free period. PMNS occurred following treatment of malaria with a wide range of anti-malarials. The disease is self-limiting and associated with good outcome. MRI patterns underline a possible link with acute disseminated encephalomyelitis (ADEM) or auto-immune encephalitis. Plasmodium falciparum and Plasmodium vivax should be added to the list of pathogens causing ADEM.

[Diagnostic procedure for acute kidney failure]

A diagnostic procedure for acute kidney injury. The definition of acute kidney injury (AKI) is universal since 2011. It is simple, based on the increase in serum creatinine on a short time period. AKI may be life-threatening, which is why the priority is to rule out hyperkalemia, pulmonary edema, or severe acidosis. Then, a panel of clinical, biological and radiological analyses is required to establish the mechanism of AKI and treat it appropriately. Basically, a three steps process is suggested: an obstruction of the urinary cavities is looked for; circumstances of renal hypoperfusion are considered, and urinary electrolytes measured; by elimination, a diagnosis of parenchymal AKI is eventually made. In that case AKI is in most cases due to an acute tubular necrosis, which implies to collect positive and negative signs: a recent history of hypotension, intake of toxic drugs, etc.; proteinuria should be low, i.e. less than 1 g/L, and urinary cells in normal count. In the presence of extra-renal symptoms, and of urinary abnormalities such as abundant proteinuria and hematuria or leucocyturia, a specialized care is urgently needed and a renal biopsy often indicated.

Dynamic respiratory endoscopy of Standardbred racehorses during qualifying races

REASON FOR PERFORMING STUDY

Examination of the equine upper airway during racing has not previously been documented.

OBJECTIVE

To describe the feasibility and appearance of the upper airways by overground respiratory endoscopic examination during racing conditions.

METHODS

Overground videoendoscopic examinations were performed on 46 Standardbred racehorses during qualifying races. Examined horses' speeds were recorded throughout the race with a portable GPS device.

RESULTS

The procedure did not interfere with performance as there were no significant differences in race times between races in which horses were examined with the endoscope in place and prior unexamined races. Airway obstructions during or after the race were documented in 21 horses. Most previously reported causes of upper airway obstruction were observed; surprisingly bilateral ventro-medial arytenoid displacement (VMAD; n = 5) was seen during exercise as frequently as dorsal displacement of the soft palate (DDSP). Although DDSP (n = 10) was the most common diagnosis made, many displacements (n = 5) occurred after the race. Horses that demonstrated DDSP after the race had slower speeds than unaffected horses during the race.

CONCLUSIONS

Racing endoscopy permits the diagnosis of upper airway obstructions without affecting performance. The occurrence of DDSP immediately after exercise may be clinically relevant. During racing VMAD may be an important anomaly.

POTENTIAL RELEVANCE

Racing endoscopy could be used to correlate the sensitivity of diagnostic endoscopy during race-training or treadmill examination. The pathogenesis and significance of VMAD deserves further investigation.

Prevalence of gastric ulcer syndrome in high-level endurance horses

REASONS FOR PERFORMING THE STUDY

Equine gastric ulcers syndrome (EGUS) prevalence studies are rare in the endurance horse and none has been carried out to date in horses competing at high level.

OBJECTIVES

To determine the prevalence of EGUS in high-level endurance horses.

METHODS

Thirty endurance horses competing at high level were selected and submitted to 2 gastroscopic examinations. The first gastroscopy was performed during the interseason period, and the second during the competition season within 2-3 days following a ride of 90-160 km. Data related to housing, feeding, training system as well as age, breed and gender were recorded for each horse.

RESULTS

The prevalence of squamous gastric ulcers was 48% during the interseason period (mean score 0.85 ± 0.13 on a scale from 0-4) and 93% during the competition season (mean score 1.60 ± 1.15) with a highly significant difference between the seasons (P = 0.001). Most of the lesions were situated in the squamous portion of the stomach but 33.3% of horses showed also glandular lesions. Significant influence of training and performance level on the gastric score (according to the distance of the ride preceding the second gastroscopy) was shown (P = 0.038). There was also a significant influence of housing on the gastric score (P = 0.002) showing higher scores in the horses kept totally on pasture (mean score: 2.14 ± 0.14) vs. horses housed in a mixed environment (stable + pasture, mean score: 1.43 ± 0.17). Both the pastured and (stabled + pastured) groups were receiving a grain supplement but the pastured group received a higher daily starch intake, which might explain the higher ulcer prevalence. There was no influence of age, breed or gender on the gastric scores.

CONCLUSIONS

The high prevalence of gastric lesions observed in this study is probably related to the high level of training and performance of the horses examined compared to the population of horses included in the prior study.

POTENTIAL RELEVANCE

This prevalence of EGUS in high-level endurance horses is comparable to the prevalence established in racing horses. The equine veterinarians may take into consideration EGUS as a potential cause of poor performance.

Electrochemotherapy in veterinary oncology

Electropermeabilization is a method that uses electric field pulses to induce an electrically mediated reorganization of the plasma membrane of cells. Electrochemotherapy combines local or systemic administration of chemotherapeutic drugs such as bleomycin or cisplatin that have poor membrane permeability with electropermeabilization by direct application of electric pulses to the tumors. Preclinical studies have demonstrated excellent antitumor effectiveness of electrochemotherapy on different animal models and various tumor types, minimal toxicity, and safety of the procedure. Based on results of preclinical studies, clinical studies were conducted in human patients, which demonstrated pronounced antitumor effectiveness of electrochemotherapy with 80-85% objective responses of the treated cutaneous and SC tumors. Clinical studies in veterinary oncology have demonstrated that electrochemotherapy is very effective in the treatment of cutaneous and SC tumors of different histologic types in cats, dogs, and horses. The results of these studies have also demonstrated approximately 80% long-lasting objective responses of tumors treated by electrochemotherapy. Primary tumors of different histologic types were treated. Electrochemotherapy in veterinary oncology has future promise to be highly effective, and could be used to treat primary or recurrent solitary or multiple cutaneous and SC tumors of different histology or as an adjuvant treatment to surgery.

Electrochemotherapy of horses. A preliminary clinical report

Sarcoids are skin spontaneous tumours detected in horses. It can be cured by chemotherapy by using cisplatin. A multisequence treatment must be performed. Problems are present due to the poor diffusion of the hydrophilic product in the tumours. Electropulsation is known to drastically enhance the effect of antitumoral drugs in vivo. Taking into account the very successful results of the group in Ljubljana (Slovenia), we started a research clinical program where electropulsation was applied after local cisplatin injection. The size of sarcoids is large (several centimeters). A specially designed set of wire contact electrodes was built. The distance between the electrodes was 0.9 cm and their length was 0.9 cm. The contact with the skin was obtained by a conductive paste. A PS15 Jouan Electropulsator was used to deliver eight pulses of 0.1 ms at a 1-Hz frequency with a 1.3-kV voltage. The animal was anesthesized. Intratumoral cisplatin injections were operated every 0.6 cm (0.2 ml at a 1-mg/ml concentration). Five minutes after the first drug injection, multiple electrotreatments were applied by moving the electrodes between the pulse applications. This allows the treatment of all the tumour surface. Several successive treatments were performed with a delay of 2 weeks between each. All lesions completely responded. The sarcoids disappear after only 2 or 3 electrochemotherapies. Objective responses were obtained in 100% of the treated lesions. All horses tolerated the treatment well. No adverse effect from the electric pulses was observed even in the case of a high number of pulses, or when several consecutive treatments were applied. No regrowth was observed in the 18 months follow-up period.

Plasma fibrinogen measurement in the horse: comparison of Millar's technique with a chronometric technique and the QBC-Vet Autoreader

Plasma fibrinogen is widely used in horse practice as an unspecific positive marker of inflammatory diseases; it is also lowered in disseminated intravascular coagulation. Three fibrinogen measurement methods--Millar's heat-denaturation in a microhaematocrit tube, automated reader for heat-denaturation, and chronometric measurement of clot formation after addition of excess thrombin-were compared by means of Passing-Bablock's regression and Bland-Altman difference plots, in blood plasma of 30 clinically healthy and 57 diseased horses. Correlations between the three techniques were excellent (r >0.92). The two heat-denaturation techniques correlated very closely up to 6 g l(-1), above which the results obtained by Millar's technique started to fall below those obtained by the automatic reader. There was proportional bias between Millar's technique and the chronometric technique, with the latter producing results some 30% lower, indicating that reference intervals and decision limits should be adapted accordingly.