Session Name: Pancreas and Islet: All Topics
Session Date & Time: None. Available on demand.
*Purpose: Lymphocyte depleting induction is associated with increased risk of infection. Our institution adopted a stratified induction protocol with the intent to decrease risk for recipients exposed to SARS-CoV-2. Baseline protocol was 6-7.5 mg/kg thymoglobulin with a 3 dose steroid taper. This was modified to a protocol based on immunologic risk. Low risk group included KTA (PRA <20%) was basiliximab 40 mg and 4 week steroid taper; intermediate group was KTA (PRA 20-80%) or SPK (PRA <80%) and consisted of thymo 2 mg/kg and basiliximab 40 mg with 4 week steroid taper; high risk group included any recipient with PRA >80%, PTA, positive DSA and induction was unchanged from the pre-SARS-CoV-2 protocol. All recipients received tacrolimus/MMF maintenance. The primary objective was to evaluate the effect of adjusting induction immunosuppression on acute cellular rejection (AR) and infection rates.
*Methods: Outcomes of all adult transplants performed between March 24-October 18, 2020 were reviewed. Time to first infection and AR was analyzed using Kaplan-Meier curves. Patients were censored at the earliest of death, graft failure or 10/22/20.
*Results: 81 patients were assessed: 61 KTA, 2 PTA, 18 SPK. Demographics: 69.1% Caucasian, 59.3% male, 84.0% primary transplant and 76.5% deceased donor. 2 grafts were lost: one due to thrombosis on POD 0 and the other due to primary non function. There were 2 deaths: one due to CVA/MDR TB and another due to NSTEMI.
Populations of the 3 risk groups: low (16), intermediate (33) and high (32). In the low risk group there were 2 (12.5%) AR within 6 weeks of transplant. One of these patients developed AMR, BK and CMV.
The intermediate group included 6 (18.2%) recipients who developed AR. 2 of these recipients developed 2 AR episodes, the first episodes were within 4 weeks of transplant. The first had Banff 1A in addition to AMR followed by borderline AR a month after initial biopsy. The second had 2 episodes of borderline AR and that graft ultimately failed due to primary non function. Of note the pathology of the other 4 recipients was consistent with borderline AR.
There were 2 (6.3%) AR in the high risk group. The first was 1A within 6 weeks of transplant, this patient also developed EBV and CMV. The second was IIA within 3 weeks of transplant.
There was no significant difference in AR rates among these groups (log rank p-value 0.396).
No significant difference in overall infection rate (p-value 0.482), bacterial (p-value 0.906), fungal (p-value 0.553) or viral (p-value 0.494). An asymptomatic recipient tested positive for SARS-CoV-2 in the high risk group 2 months following KTA.
*Conclusions: Optimal induction regimens for pancreas and kidney transplant in the SARS-CoV-2 era remain unclear. Although rejection rates in the abbreviated induction groups were slightly higher, most were borderline. Short-term infection rate did not seem to be impacted. Tailored induction regimens stratified by risk may be safe and effective during this pandemic era and beyond.
To cite this abstract in AMA style:Sarumi H, Vassar K, Jackson S, Pruett T, Kandaswamy R. Induction Immunosuppression Efficacy in Pancreas and Kidney Transplantation in the SARS-CoV-2 Era [abstract]. Am J Transplant. 2021; 21 (suppl 3). https://atcmeetingabstracts.com/abstract/induction-immunosuppression-efficacy-in-pancreas-and-kidney-transplantation-in-the-sars-cov-2-era/. Accessed June 12, 2021.
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