Invasive fungal infections are a feared complication in kidney transplant recipients (KTRs). Here we present the University of Wisconsin experience with 5 invasive fungal infections-aspergillosis, cryptococcosis, histoplasmosis, blastomycosis, and coccidioidomycosis-in KTRs transplanted between 01/01/1994 and 06/30/2014. During this period, there were 128 cases of fungal infections; aspergillosis was the most common (72), followed by cryptococcosis (29), histoplasmosis (14), blastomycosis (10), and coccidioidomycosis (3). The mean interval from transplant to fungal infection was 3.19 ± 3.58 years (range 5 days-15.8 years). By 6 months postinfection, there were 53 (41%) graft failures and 24 (19%) deaths. Graft failure occurred in 46%, 38%, 21%, 40%, and 67% of patients with aspergillosis, cryptococcosis, histoplasmosis, blastomycosis, and coccidioidomycosis, respectively. Anti-thymocyte globulin (ATG) induction (HR, 1.49; 95% CI, 1.03-2.16; P = .04), diabetes (HR, 1.53; 95% CI, 1.05-2.21; P = .03), and age (HR, 1.47; 95% CI, 1.27-1.70; P ≤ .001) were associated with an increased risk for infection in univariate analysis. Multivariate adjustment retained ATG induction and older age. A large proportion of kidney transplant recipients with invasive fungal infections suffer graft failure within 3 years. Preventive, therapeutic, and monitoring strategies are needed to improve graft and patient outcomes.

The incidence, risk factors, and outcomes of kidney transplant recipients (KTRs) with post‐transplant erythrocytosis (PTE) in the modern era of strong, protocolized immunosuppressive management are unknown. In this study, we aim to identify the incidence and risk factors of PTE and outcomes associated with PTE. This study examined adult KTRs transplanted at our hospital between 01/2001 and 12/2016. Controls were KTRs without PTE and selected in a 1:5 ratio using incident density sampling. Patient survival, graft survival, and vascular thromboembolism (VTE) incidence were outcomes of interest. Of 4,317 kidney transplants during the study period, 214 (5%) had PTE and were compared with controls. In the multivariate analysis, recipients with older age (HR: 0.97, 95% CI 0.96‐0.99, p = .001) were less likely to develop PTE, while male gender (HR: 3.2; 95% CI: 1.92‐5.3, p < .001) and non‐preemptive transplant (HR: 3.86, 95% CI 1.56‐9.56, p = .003) were associated with increased risk of PTE. After adjustment for confounding factors, PTE was not associated with patient mortality (HR: 0.99, 95% CI 0.69‐1.42, p = .97), graft failure (HR: 1.11, 95% CI 0.68‐1.80, p = .69), or VTE (HR: 1.07, 95% CI 0.59‐1.96, p = .81). The incidence of PTE is still substantial in this era, but with proper management PTE does not impact patient or graft survival.

Purpose Antimicrobial stewardship programs (ASPs) are essential entities that promote the appropriate use of antimicrobials, leading to improved patient outcomes and reduced resistance. Application to the immunocompromised host is a natural progression for expansion. Cytomegalovirus (CMV) infection is a common complication following solid organ transplant with significant implications on graft survival, making it an attractive ASP target. The aim of this piece is to review our center‐specific experience with the development, implementation, and maintenance of a CMV stewardship initiative at a large transplant center. Methods Our CMV stewardship initiative began in 2018. Herein, we review 3 years’ experience and quality‐related improvement that occurred from initiation to present state and share our stewardship algorithms. Special attention is paid to the impact of the program as well as our increased understanding of the complex interplay between prevention, treatment, and host development of CMV‐specific cell‐mediated immunity (CMI). Results We found our stewardship initiative not only reduced the incidence of ganciclovir resistance but also streamlined care via a centralized and structured approach. This objective, protocolized program has resulted in a significant shift away from a reactive to a proactive state and in turn, reduced CMV treatment rates (26% at initiation to 12% in the current state, p = .012). Conclusion A dedicated multidisciplinary team focused on CMV stewardship is imperative in providing a patient‐centered approach focused on development of CMV‐specific CMI, and as a result prevention of CMV disease. We believe these programs will be the new gold standard for CMV management.

Frailty is commonly assessed during kidney transplant recipient (KTR) evaluation.However, individual frailty components may have varying impact on post-transplant outcomes. In this single-center study of 825 KTRs, we determined the association between the individual components of a modified Fried frailty score and delayed graft function (DGF), early hospital readmission (EHR), cardiovascular (CV) events, acute rejection (AR), death censored graft failure (DCGF), and death. Sum frailty ≥3 was significantly associated with EHR (aOR = 3.62; 95% CI: 1.21-10.80). Among individual components, only grip strength was significantly associated with EHR (aOR = 1.54; 95% CI: 1.03-2.31). The addition of grip strength to a model with the other four components resulted in Net Reclassification Improvement (NRI) of 20.51% (p = .01). Similarly, only grip strength was significantly associated with CV events (aOR = 1.79; 95% CI: 1.12-2.86). The addition of grip strength to a model with the other four components resulted in NRI of 27.37% (p = .006). No other frailty components were associated with the outcomes of interest. Based on our findings, handgrip strength may be an important tool while assessing frailty, mainly predicting early readmission and cardiovascular events post-transplant.

Introduction: Delayed graft function (DGF) is a common complication among deceased donor kidney transplant recipients (DDKTs) and is associated with worse outcomes. The effect on outcomes of concordance versus discordance in DGF between two different recipients of kidneys from the same donor is largely unknown. Methods: We reviewed all adult DDKTs for which both kidneys were transplanted to two different recipients at our center between 2014-2019. DDKTs were divided into four groups based on the DGF status: concordance no DGF (cc-no-DGF); discordance no DGF(dd-no-DGF); discordance DGF (dd-DGF) and concordance in DGF (cc-DGF). Acute rejection (AR) and death censored graft failure (DCGF) were outcomes of interest.Results: A total of 578 DDKTs fulfilled our selection criteria, 280were in cc-no-DGF, 83 in dd-no-DGF, 83 in dd-DGF, and 132 in cc-DGF. Compared to cc-no-DGF, in univariate analysis, dd-DGF was associated with an increased risk of AR (HR: 1.60; 95% CI: 1.0-2.56) but cc-DGF was not (HR: 1.01; 95% CI: 0.63-1.62). dd-DGF was not associated with an increased risk of AR in multivariate analysis. In multivariate analysis, dd-DGF was associated with an increased risk of DCGF (HR: 2.70; 95% CI: 1.05-6.93) but cc-DGFwas not (HR: 2.36; 95% CI: 0.97-5.70). Conclusion:Discordance in DGF is associated with worse outcomes and may need closefollow-up and monitoring to improve the outcomes.