Am J Transplant. 2020;00:1-4. | 1 amjtransplant.com | BACKG ROU N DCoronavirus Disease 2019 (COVID-19) is a novel viral disease with over 93 000 confirmed cases worldwide,1 in which knowledge regarding disease epidemiology and clinical presentation has been evolving in the past 4 months since the initial identification. In the general population, the reported case fatality rate is about 1%-6%.2 Solid organ transplant (SOT) recipients are under chronic immunosuppression, and respiratory infections may present atypically, often with two or more infectious processes presenting simultaneously.3 There have been currently only a couple of reports of COVID-19 among SOT recipients. Hence, in such a high risk population, a strong clinical suspicion is crucial. Herein we present the case of a COVID-19 infection in a kidney transplant recipient. | C A S E REP ORTA 50-year-old man with end-stage renal disease due to IgA nephropathy, recipient of a 3rd deceased-donor kidney transplant in 2016 with serum creatinine (Cr) of 1.3 mg/dL and estimated glomerular filtration rate (eGFR) of 60 mL/min, was admitted on February 28 to the emergency room (ER) with a 24-hour history of fever (38.2°C/100.8°F) and vomiting. He reported no other symptoms, nor had a history of travels abroad nor exposure to patients infected or suspected of contagious COVID-19. Previous medical history included an elective splenectomy performed in 2003 due to immune thrombocytopenia, and an Epstein-Barr virus (EBV)-associated post-transplant lymphoproliferative disease (PTLD) in 2005, treated with rituximab and withdrawal of immunosuppression, achieving complete response of the PTLD, but leading to rejection and failure of the 2nd kidney graft. Following PTLD remission and a negative EBV viral load, he received a 3rd kidney transplant with induction immunosuppression (IS) with thymoglobulin, tacrolimus, everolimus and steroids, and maintenance IS with tacrolimus, everolimus and prednisone 5 mg QD. He was also under treatment with losartan 50 mg bid due to arterial hypertension.At first evaluation in the ER the patient presented signs of mild dehydration. Physical examination was otherwise unremarkable, including breath sounds on chest auscultation. On blood workup acute phase reactants were normal, such as a C-reactive protein (CRP) of <0.50 mg/dL (normal range <1.0 mg/dL) and white blood cells (WBC) count of 8.58 × 10 9 /L, but a mild kidney function impairment (Cr

IMPORTANCEOpioid prescriptions for treatment of pain in emergency departments (EDs) are associated with long-term opioid use. The temporal pattern of opioid prescribing in the context of the opioid epidemic remains unknown. OBJECTIVE To examine the temporal pattern of opioid prescribing within an ED for varying pain conditions between 2009 and 2018. DESIGN, SETTING, AND PARTICIPANTS A population-based, cross-sectional study was conducted at the ED of an urban academic medical center. All patients treated within that ED between January 1, 2009, and December 31, 2018, were included. MAIN OUTCOMES AND MEASURESThe proportion of patients prescribed an opioid for treatment of pain in the ED temporally by condition, condition type, patient demographics, and physician prescriber.

This paper is part of a supplement that represents a collection of COVIDrelated articles selected for publication by the editors of AJOG MFM without additional financial support.

Background and Aims Anti-glomerular basement membrane (anti-GBM) disease is an aggressive and rare glomerulopathy characterized by rapidly progressive loss of kidney function, leading to end stage kidney disease (ESKD) in a significant amount of cases. The main objective of our study was to determine whether anti-GBM titer correlated with the rate of activity in renal biopsy and long-term kidney survival in patients with anti-GBM, hence identifying patients who would potentially benefit from more intensive treatments. Method A retrospective analysis was performed on the cases of anti-GBM from our center that had both a positive biopsy and serology, from 2007 to 2019. Epidemiological data, anti-GBM levels on admission, kidney function at admission, discharge and follow-up, treatment and kidney biopsy findings were collected. All biopsies were reevaluated by a single, blinded pathologist and nephrologist. Based on a recent study by van Daalen et al, a chronicity and activity histopathological score was developed. The score was divided in glomerular and interstitial sections. In the glomerular section, a sclerotic pattern (&gt;50% of glomeruli) was given 0 points in activity and 3 in chronicity, a mixed pattern was given 1 point in activity and chronicity, and a crescentic pattern (&gt;50% with cellular crescents) was given 3 points in activity and 0 in chronicity. In the interstitial section, the presence of fibrosis and atrophy was given between 0 and 3 points in chronicity and the presence of tubulitis or interstitial infiltrate were given points in activity (0 to 1 and 0 to 3 respectively). The presence of neutrophils in the infiltrate was given one extra point in activity. Spearman correlation was performed between anti-GBM levels and our biopsy score. Results Twelve cases were identified, with a median Anti-GBM titer at admission of 292 U/mL (IQR 40-1517). Ten patients were treated with cyclophosphamide, 1 with rituximab plus cyclophosphamide and 1 with only rituximab. All patients received treatment with metilprednisona and plasma exchange with a median number of sessions of 8 (range: 6-12). Only one patient was not in ESKD during follow-up (35 months), so correlation with long-term kidney survival could not be performed. On the other hand, high antibody titers correlated with more activity on biopsy (correlation coefficient 0.592, p= 0.042) and less chronicity (correlation coefficient -0.657, p= 0.02). Conclusion These results suggest that patients who present with higher titers have more acute inflammation and less chronicity in renal parenchima, and therefore could benefit from more intensive treatment that changes the natural history of this aggressive disease. It would be interesting to study this score in larger and multicentric cohorts in order to produce more definitive conclusions.

Background and Aims The relation between inflammation and cardiovascular disease is well established. Dialysis patients are at a higher risk of cardiovascular death, mostly attributed to cardiovascular disease. This study evaluated the potential benefits of citrate (CD) vs. acetate dialysate (AD) regarding the patients’ inflammatory status. Method Single-center, cross-over, prospective study, with a follow-up of a total of 24 dialysis sessions, 12 with each dialysate. Blood samples were taken on the twelfth dialysis session with each type of dialysate. Every patient acted as its own control. The pre-dialysis parameters analyzed were procalcitonin (PCT), high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6). Results Pre-dialysis hsRCP [AD: 4,32 (1,27 – 12,16) vs. CD: 4,08 (0,98 – 8,65) mg/L, p = 0,031], PCT [AD: 0,44 (0,28 – 0,74) vs. CD: 0,38 (0,29 – 0,44) ng/mL, p = 0,037], and IL-6 [AD: 13,7 (7,85 – 29,03) vs. CD: 11,8 (5 – 27,13) pg/mL, p = 0,029] are significativly higher after twelve dialysis sessions with AD vs. CD. Conclusion Even in the medium term, the use of citrate instead of acetate as the dialysate acidifier, reduces the measured inflammatory parameters and could therefore be considered a more biocompatible dialysate option.