Background Kidney transplant (KT) recipients are considered a high-risk group for unfavorable outcomes in the course of coronavirus disease 2019 (COVID-19). Aim To describe the clinical aspects and outcomes of COVID-19 among KT recipients. Methods This multicenter cohort study enrolled 1,680 KT recipients diagnosed with COVID-19 between March and November 2020, from 35 Brazilian centers. The main outcome was the 90-day cumulative incidence of death, for the entire cohort and according to acute kidney injury (AKI) and renal replacement therapy (RRT) requirement. Fatality rates were analyzed according to hospitalization, intensive care unit (ICU) admission, and mechanical ventilation (MV) requirement. Multivariable analysis was performed by logistic regression for the probability of hospitalization and death. Results The median age of the recipients was 51.3 years, 60.4% were men and 11.4% were Afro-Brazilian. Comorbidities were reported in 1,489 (88.6%), and the interval between transplantation and infection was 5.9 years. The most frequent symptoms were cough (54%), myalgia (40%), dyspnea (37%), and diarrhea (31%), whereas the clinical signs were fever (61%) and hypoxemia (13%). Hospitalization was required in 65.1%, and immunosuppressive drugs adjustments were made in 74.4% of in-hospital patients. ICU admission was required in 34.6% and MV in 24.9%. In the multivariable modeling, the variables related with the probability of hospitalization were age, hypertension, previous cardiovascular disease, recent use of high dose of steroid, and fever, dyspnea, diarrhea, and nausea or vomiting as COVID-19 symptoms. On the other hand, the variables that reduced the probability of hospitalization were time of COVID-19 symptoms, and nasal congestion, headache, arthralgia and anosmia as COVID-19 symptoms. The overall 90-day cumulative incidence of death was 21.0%. The fatality rates were 31.6%, 58.2%, and 75.5% in those who were hospitalized, admitted to the ICU, and required MV, respectively. At the time of infection, 23.2% had AKI and 23.4% required RRT in the follow-up. The cumulative incidence of death was significantly higher among recipients with AKI (36.0% vs. 19.1%, P < 0.0001) and in those who required RRT (70.8% vs. 10.1%, P < 0.0001). The variables related with the probability of death within 90 days after COVID-19 were age, time after transplantation, presence of hypertension, previous cardiovascular disease, use of tacrolimus and mycophenolate, recent use of high dose of steroids, and dyspnea as COVID-19 symptom. On the other hand, the variables that reduced the risk of death were time of symptoms, and headache and anosmia as COVID-19 symptoms. Conclusion The patients diagnosed with COVID-19 were long-term KT recipients and most of them had some comorbidities. One in every five patients died, and the rate of death was significantly higher in those with AKI, mainly when RRT was required.

This analysis, using data from the Brazilian kidney transplant (KT) COVID‐19 study, seeks to develop a prediction score to assist in COVID‐19 risk stratification in KT recipients. In this study, 1379 patients (35 sites) were enrolled, and a machine learning approach was used to fit models in a derivation cohort. A reduced Elastic Net model was selected, and the accuracy to predict the 28‐day fatality after the COVID‐19 diagnosis, assessed by the area under the ROC curve (AUC‐ROC), was confirmed in a validation cohort. The better calibration values were used to build the applicable ImAgeS score. The 28‐day fatality rate was 17% ( n = 235), which was associated with increasing age, hypertension and cardiovascular disease, higher body mass index, dyspnea, and use of mycophenolate acid or azathioprine. Higher kidney graft function, longer time of symptoms until COVID‐19 diagnosis, presence of anosmia or coryza, and use of mTOR inhibitor were associated with reduced risk of death. The coefficients of the best model were used to build the predictive score, which achieved an AUC‐ROC of 0.767 (95% CI 0.698–0.834) in the validation cohort. In conclusion, the easily applicable predictive model could assist health care practitioners in identifying non‐hospitalized kidney transplant patients that may require more intensive monitoring. Trial registration: ClinicalTrials.gov NCT04494776.

Background. The chronic use of immunosuppressive drugs is a key risk factor of death because of coronavirus disease 2019 in kidney transplant recipients (KTRs), although no evident association between the class of immunosuppressive and outcomes has been observed. Thus, we aimed to compare COVID-19-associated outcomes among KTRs receiving 3 different immunosuppressive maintenance regimes. Methods. This study included data from 1833 KTRs with COVID-19 diagnosed between March 20 and April 21 extracted from the national registry before immunization. All patients were taking calcineurin inhibitor associated with mycophenolate acid (MPA, n = 1258), azathioprine (AZA, n = 389), or mammalian targets of rapamycin inhibitors (mTORi, n = 186). Outcomes within 30 and 90 d were assessed. Results. Compared with patients receiving MPA, the 30-d (79.9% versus 87.9% versus 89.2%; P < 0.0001) and 90-d (75% versus 83.5% versus 88.2%; P < 0.0001) unadjusted patient survivals were higher in those receiving AZA or mTORi, respectively. Using adjusted multivariable Cox regression, compared with patients receiving AZA, the use of MPA was associated with a higher risk of death within 30 d (adjusted hazard ratio [aHR], 1.70; 95% confidence interval [CI], 1.21-2.40; P = 0.003), which was not observed in patients using mTORi (aHR, 0.78; 95% CI, 0.45-1.35; P = 0.365). At 90 d, although higher risk of death was confirmed in patients receiving MPA (aHR, 1.46; 95% CI, 1.09-1.98; P = 0.013), a reduced risk was observed in patients receiving mTORi (aHR, 0.59; 95% CI, 0.35-0.97; P = 0.04) compared with AZA. Conclusions. This national cohort data suggest that, in KTRs receiving calcineurin inhibitor and diagnosed with COVID-19, the use of MPA was associated with higher risk of death, whereas mTORi use was associated with lower risk of death.

Uma das complicações mais frequentes da fístula arteriovenosa (FAV) para hemodiálise é o desenvolvimento de um aneurisma. A formação de aneurismas geralmente decorre de um enfraquecimento da parede venosa devido às repetidas punções, e sua rotura causa hemorragia intensa que pode levar à morte. Descrevemos o caso de uma paciente com dois aneurismas saculares de FAV, tratados através de aneurismorrafia, detalhando a técnica cirúrgica utilizada e a evolução pós-operatória. A técnica de rafia simples da parede constitui uma boa alternativa no reparo da parede da FAV quando o aneurisma é de curta extensão, evitando a colocação de um material protético e a confecção de duas anastomoses.

Renal transplant surgery may be associated with important perioperative complications. In this scenario, the anesthetic technique should provide optimal conditions for the surgical team, guarantee hemodynamic stability and kidney perfusion, and adequate analgesia. Preoperative evaluation should always be performed. In the intraoperative period, standard monitoring is sufficient in most cases. General balanced anesthesia, alone or in combination with spinal anesthesia or peripheral block, is the technique of choice. Management of blood pressure during the surgery is crucial. Before reperfusion, a mean arterial blood pressure of 65 mmHg is recommended, increasing to 80–90 mmHg when reperfusion is imminent until the end of surgery. Vasopressors, such as ephedrine, may be necessary to achieve blood pressure targets. Mannitol and furosemide are commonly used to increase urine output. In the postoperative period, analgesia should be ensured.