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Original Clinical Science—General

Incidence and Outcomes of COVID-19 in Kidney and Liver Transplant Recipients With HIV: Report From the National HOPE in Action Consortium

Mehta, Sapna A. MD1; Rana, Meenakshi M. MD2; Motter, Jennifer D. MHS3; Small, Catherine B. MD4; Pereira, Marcus R. MD5; Stosor, Valentina MD6; Elias, Nahel MD7; Haydel, Brandy CCRC8; Florman, Sander MD8; Odim, Jonah MD9; Morsheimer, Megan MD9; Robien, Mark MD9; Massie, Allan B. PhD3; Brown, Diane RN, MSN10; Boyarsky, Brian J. MD3; Garonzik-Wang, Jacqueline MD, PhD3; Tobian, Aaron A.R. MD, PhD11; Werbel, William A. MD10; Segev, Dorry L. MD, PhD3; Durand, Christine M. MD10; on behalf of the HOPE in Action Investigators

Author Information
doi: 10.1097/TP.0000000000003527

Abstract

INTRODUCTION

Solid organ transplant recipients have been classified by the Centers for Disease Control as a higher-risk population for severe coronavirus disease 2019 (COVID-19), and there have been many reports of high mortality in this population.1-9 In contrast, evidence suggests that individuals with well-controlled HIV infection have similar outcomes compared with individuals without HIV, and data suggest that certain HIV antiretroviral drugs have in vitro activity against SARS-CoV-2.10-12

In a large multicenter series of 482 transplant recipients with COVID-19, overall mortality was 18.7% and 20.5% in hospitalized recipients.7 A multicenter series of 286 individuals with HIV and COVID-19 reported overall mortality of 9.5% and 16.5% among those hospitalized.13 The combined impact of impaired T-cell immunity from HIV infection and chronic transplant immunosuppressant medications is not clear.14 In 3 case reports of COVID-19 in transplant recipients with HIV, no deaths were reported.15-17

The objective of our study was to describe the incidence, clinical presentation, and outcomes of COVID-19 among kidney and liver transplant recipients with HIV within the HOPE in Action Multicenter Consortium, a national prospective cohort study of transplantation from donors with and without HIV.

MATERIALS AND METHODS

Participants received transplants within the HOPE in Action Pilot Study of solid organ transplantation (NCT02602262) or the HOPE in Action U01 trials of HIV+ deceased donor kidney (U01AI134591, NCT03500315) or liver transplantation (U01AI138897, NCT03734393). There are 34 transplant centers participating in these HOPE in Action Multicenter Consortium studies (Table S1, SDC, http://links.lww.com/TP/C45).

Candidates with HIV met standard clinical criteria for transplant at the local center, as well as the following HIV-specific inclusion criteria: no active opportunistic infections, HIV RNA below the limit of detection, CD4 T-cell count ≥200 or ≥100 cells/μL (kidney and liver candidates, respectively) as per the Department of Health and Human Services HOPE Act Safeguards and Research Criteria.18 Protocols were approved by each site’s Institutional Review Board and each site had an Open Variance approved by the United Network for Organ Sharing. All participants provided written informed consent.

Candidates received organs from donors with or without HIV based on organ availability. The decision to accept donor organs was made by the transplant center team. Immunosuppression and antimicrobial prophylaxis varied by center; all kidney recipients received induction with lymphocyte depletion (antithymocyte globulin or alemtuzumab) or anti-interleukin-2 receptor (IL-2R) blockade with basiliximab. At transplant, recipient characteristics, history, donor type, and donor-recipient virologic and immunologic measures were collected. At follow-up, physical examination, medications, serious adverse events (as defined by Division of AIDS Table for Grading serious adverse events, Version 2.0), hospitalizations, infections, and laboratory values were collected. HIV RNA PCR was performed at baseline, weeks 1, 2, 3, 4, 13, 26, then every 6 mo. CD4+ T-cells were measured at baseline, weeks 4, 8, 13, 26, then every 6 mo.

All sites were required to report any participants with a positive RT-PCR test for SARS-CoV-2 in an inpatient or outpatient, regardless of severity. Patient characteristics, symptoms, management of immunosuppression, and COVID-19 treatment strategies, laboratory values and imaging studies were collected. Three centers had SARS-CoV-2 antibody testing available; 2 centers used in-house IgG and/or IgA assays and 1 center used the Pylon COVID-19 IgG assays (ET HealthCare, Palo Alto, CA).

Statistical Analysis

Baseline characteristics between recipients diagnosed with COVID-19 and the overall HOPE in the Action Multicenter cohort (ie, SARS-CoV-2 negative recipients) were compared using the Wilcoxon rank-sum test for nonnormally distributed continuous variables and Fisher exact test for binary and categorical variables. We plotted recipients’ lymphocyte and CD4 count pre–, at, and post–COVID-19 diagnosis stratified by recipient outcome (ie, survived versus died). We then compared these measurements at COVID-19 diagnosis between those who survived and died using the Wilcoxon rank-sum test. Statistical analyses were conducted using Stata MP 16.0 (Austin, TX).

RESULTS

From March 1, 2016 to September 25, 2020, there have been 291 transplants in HIV-positive recipients (n = 217 kidney, n = 63 liver, n = 11 simultaneous liver-kidney) within the HOPE in Action Multicenter Consortium Studies. From March 20, 2020 to September 25, 2020, there have been 11 cases of COVID-19 reported within this cohort (n = 8 kidney, n = 3 liver). Of these transplant recipients, 5 had donors with HIV (n = 2 kidney, n = 3 liver). The median age of recipients with COVID-19 was 59.0 y (range 50–68) (Table 1). Among the 11 recipients with COVID-19 compared with the HOPE cohort, 91% versus 77% were male (P = 0.5), 36% versus 66% were Black (P = 0.06), and 55% versus 12% were Hispanic/Latino (P = 0.001). Most (73%) of the COVID-19 cases occurred in New York City, the initial epicenter of the pandemic in the United States, whereas in the overall cohort, 34% of transplants were performed in New York City (P = 0.02).

TABLE 1. - Clinical characteristics of transplant recipients with HIV and COVID-19, stratified by donor HIV status
HIV+ donor HIV− donor
Characteristics 1 2 3 4 5 6 7 8 9a 10a 11a
Age at diagnosis, y 58 56 68 65 62 50 59 65 62 55 50
Male sex Y Y N Y Y Y Y Y Y Y Y
Race White Black White Asian White Black Other Black White White Black
Latino/Hispanic ethnicity Y N Y Y N N Y N Y Y N
New York City Y Y Y Y N Y Y N Y Y N
BMI, kg/m2 28.6 19.5 32.0 20.0 34.5 25.5 34.7 27.3 20.6 24.3 30.0
Comorbidities HTN, DM, CAD HTN, DM, HBV, DLBCLb HTN, HCVc, KSd HTN, DM, HCVc HCVc HTN, CAD HTN HCV HTN, HF, DM, ESRDe HTN, DM, HCVc HTN, HBV, NASH, asthma
Transplant
 Organ Kidney Kidney Liver Liver Liver Kidney Kidney Kidney Kidney Kidney Kidney
 Days posttransplant 289 139 353 77 287 1078 223 821 592 539 446
 Induction Anti-IL2R, steroids ATG, steroids Steroids Steroids Steroids Anti-IL2R, steroids ATG, steroids ATG, steroids Anti-IL2R, steroids Anti-IL2R, steroids Anti-IL2R, steroids
 Immunosuppression FK, MMF, prednisone FK, MMF FK, prednisone FK, MMF, prednisone FK, MMF FK, MMF FK, MMF, prednisone FK, MMF, Prednisone Prednisone FK, MMF, prednisone FK, MMF
HIV
 Years HIV+ 10 20 20 31 21 18 14 20 19 19 23
 Prior CD4f (%) 601 (35) 82 (6) 112 (29) 528 (24) 549 (28) 384 (38.4) 298 (28) 72 (12) 102 (29) 290 (35) 395 (28)
 HIV RNAf, copies/mL <20 <20 <20 <20 <20 <20 <20 <20 <20 <20 <20
 ART DTG/3TC/ABC+MVC/Placebo g DTG/3TC/ABC BIC/FTC/TAF DTG/RPV/FTC/TAF DTG/FTC/TAF DTG/RPV DTG/RPV BIC/TAF/FTC DTG/DRV/RTV DTG/RPV DTG/FTC/TAF + MVC/Placebog
aFalse positive HIV.
bIn remission since 2008.
cCured pretransplant.
dVisceral KS, in remission, posttransplant/last chemotherapy (liposomal doxorubicin) 5 wks pre-COVID diagnosis.
ePosttransplant graft loss d 401 posttransplant.
fMost recent pre-COVID.
gEnrolled in maraviroc vs placebo clinical trial.
3TC, lamivudine; ABC, abacavir; ATG, antithymocyte globulin; ART, antiretroviral therapy; BMI, body mass index, BIC, bictegravir; CAD, coronary artery disease; COVID-19, coronavirus disease 2019; DLBCL, diffuse large B-cell lymphoma; DM, diabetes; DTG, dolutegravir; ESRD, end-stage renal disease; FK, tacrolimus; FP, false positive; FTC, emtricitabine; HBV, hepatitis B virus; HCV, hepatitis C virus; HD, hemodialysis; HF, heart failure; HTN, hypertension; KS, Kaposi sarcoma; MMF, mycophenolate mofetil; MVC, maraviroc; N, no; NASH, nonalcoholic steatohepatitis; POD, postoperative day; RPV, rilpivirine; RTV, ritonavir; TAF, tenofovir alafenamide; Y, yes.

For the 11 recipients with COVID-19, the median time from transplant to SARS-CoV-2 diagnosis was 353 d (range 77–1078) (Table 1). For the 8 kidney recipients, induction immunosuppression included anti-IL2R in 5 (63%) and antithymocyte globulin in 3 (37%). Among all recipients with COVID-19, none had been treated for acute rejection in the 30 d before COVID-19 diagnosis and 4 (40%) had a history of rejection since transplant. The median BMI was 27.3 kg/m2. Most recipients had at least 1 comorbidity that included hypertension (82%), diabetes (45%), and coronary artery disease (18%) (Table 1). The median duration of HIV infection was 20 y. All recipients had well-controlled HIV infection with a median CD4 count of 298 cells/μL and undetectable viral load <20 copies/mL before COVID-19 diagnosis. For antiretroviral therapy, 1 recipient was on a boosted-protease inhibitor (darunavir/cobicistat) and 5 recipients were on regimens containing tenofovir alafenamide (TAF); no recipients were on tenofovir disproxil fumarate (TDF).

Clinically, the median duration of COVID-19 symptoms before presentation was 2 d (range: 0–7) (Figure 1). Seven (64%) patients reported fever as a presenting symptom and 1 patient had temperature ≥37.5 °C at presentation. The majority of patients had cough (64%) or dyspnea (91%) with 4 patients also reporting diarrhea (36%) (Table 1). Ten patients (91%) were admitted to the hospital; the median hospital length of stay (LOS) was 21 d (range: 4–42) (Figure 1). Five required treatment in an intensive care unit (ICU), of whom 1 declined transfer and elected for palliative care. Three of the 4 patients transferred to the ICU died.

FIGURE 1.
FIGURE 1.:
Clinical course of HIV-positive transplant recipients with COVID-19. Duration of hospitalization and time to death in recipients. Recipients above the solid line received an HIV-positive donor organ and those below received an HIV-negative donor organ. Time of diagnosis is marked by an arrow. Recipients who died are indicated with an asterisk. COVID-19, coronavirus disease 2019; D−/R+, donor-negative recipient-positive; D+/R+, donor-positive recipient-positive; ICU, intensive care unit; KT, kidney transplant; LT, liver transplant.

Among 10 hospitalized patients, the median white blood cell count on COVID-19 admission was 3.5 × 103 cells/μL (range: 1.5–9.2), median absolute neutrophil count was 2.6 × 103 cells/μL (range: 0.68–8.4), and median absolute lymphocyte count (ALC) was 0.3 × 103 cells/μL (range: 0.1–1); 70% had an ALC <0.5 × 103 cells/μL (Table 1). Nine recipients had ALC data pre– and at COVID-19 diagnosis, all of whom had a decline in ALC (Figure 2). Among hospitalized patients, 7 had CD4 T cell data at COVID-19 diagnosis; all had a decrease from pre–COVID-19 levels and 6 (86%) were <200 cells/μL. Of the 9 recipients who had chest imaging performed, 6 (67%) had bilateral pulmonary infiltrates. Inflammatory markers were elevated in the majority of patients when performed (Table 2).

TABLE 2. - Natural history of COVID-19 in HIV-infected transplant recipients, stratified by donor HIV status
HIV+ donor HIV− donor
Signs on presentation 1 2 3 4 5 6 7 8 9a 10a 11a
Temperature, °C 36.9 37.1 37.1 36.4 36.4 37.2 37.0 37.9 37.1 37.0 37.0
O2 saturation, % 92 89 93 94 95 98 87 98 96 100 100
Respiratory rate, bpm 28 23 20 20 18 20 26 17 15 20 18
Laboratory findings
 WBC,103 cells/Μl 7.0 3.3 3.7 1.5 4.2 3.2 2.3 2.2 5.3 9.2 ND
 ANC,103 cells /Μl 5.6 2.6 2.6 0.68 2.46 2.7 1.9 1.5 5.0 8.4 ND
 ALC, 103 cells/Μl 1.0 0.10 0.70 0.24 0.85 0.30 0.10 0.39 0.30 0.14 ND
 CD4, cells/μL, (%) ND 33 (20) 186 (29) 57 (20) 544 (41) 122 (33) ND ND 50 (19) 94 (48) ND
 Creatinine, mg/Dl 0.90 1.48 1.17 1.19 0.97 1.48 1.17 1.7 9.4 3.94 ND
 CRP, mg/L 16.3 >200 157.5b 259 ND 231.3b 209b ND 398.9b 205.7 ND
 Ferritin, ng/Ml ND 7673 908b 1919 18 5517b 2871b ND 5661 6185 ND
 D-dimer, ng/Ml ND 25 524 >10 000b 9610 280 >20 000b 184 ND 1980 5945b ND
 IL-6 initial, pg/Ml ND 136 278b 17.7 ND 108b 9 ND 128.4 ND ND
Imaging
 CXR, bilateral opacity Y N N Y ND Y Y N Y Y ND
 Disease course
 Days in hospital 4 10 21 18 32 33 20 41 28 10 NA
 Intensive care unit N N N N N Y Y Y N c Y N
 O2 support, maximum NC NRB NRB NC None Intubated ECMO Intubated BiPAP Intubated None
Therapies used
 Immunomodulators HCQ HCQ HCQ, AZI HCQ, AZI NA AZI, CP, Remdesivir HCQ, AZI AZI, CP, Remdesivir, HCQ HCQ, AZI None
 Immunotherapy None TCZ TCZ Steroidsd NA Steroidsd IVIG, TCZ, Steroidsd Steroidsd Steroidsd Steroidsd None
 Change in IS Reduced FK Held MMF None Held MMF, Held FK None Held MMF, Held FK Held MMF, Reduced FK Held MMF, Increased FK None Held MMF Reduced MMF
 Anticoagulation N Full PPx Full Fulle Full Full Fulle Full Full N
Complications
 Thrombotic N Y N Y N N N N N N N
 Kidney injury or failure AKI N N AKI N CVVH AKI AKI NA AKI N
 Secondary infection N N N N N N Bacterial LRTI Fungal N N N
Outcome
 Survived Y Y Y Y Y N N Y N N Y
aHOPE donor with false positive HIV screening test.
bMultiple values, peak reported.
cICU care recommended but recipient opted for palliative care.
dHigh-dose steroids.
ePatient was on anticoagulation before COVID-19 diagnosis.
ALC, absolute lymphocyte count; ANC, absolute neutrophil count; AKI, acute kidney injury; AZI, azithromycin; BiPAP, bilevel positive airway pressure; bpm, breaths per minute; COVID-19, coronavirus disease 2019; CP, convalescent plasma; CRP, C-reactive protein; CVVH, continuous veno-venous hemofiltration; CXR, chest radiograph; ECMO, extracorporeal membrane oxygenation; FK, tacrolimus; Full, full-dose anticoagulation; HCQ, hydroxychloroquine; ICU, intensive care unit; IS, immunosuppression; LRTI, lower respiratory tract infection; MMF, mycophenolate mofetil; N, no; NA, not applicable; NC, nasal cannula; ng, nanogram; ND, no data; NRB, nonrebreather mask; PPx, prophylactic; sx, symptom; TCZ, tocilizumab; WBC, white blood cell count; Y, yes.

FIGURE 2.
FIGURE 2.:
Lymphocyte and CD4 counts in HIV-positive transplant recipients pre– and post–COVID-19, stratified by recipient outcome. Lymphocyte counts before and after COVID-19 diagnosis are shown in recipients who (A) survived and (B) died. CD4 counts before and after COVID-19 diagnosis are shown in recipients who (C) survived and (D) died. Blue vs black line indicates lymphocyte depleting vs nonlymphocyte depleting induction. Recipient numbers are shown next to each line, and measurements taken at the time of transplant are indicated by a red arrow. COVID-19, coronavirus disease 2019.

The majority of patients (73%) had their immunosuppressive therapy reduced at the time of COVID-19 diagnosis, including having the antimetabolite held (55%) or dose reduced (9%), or having the calcineurin inhibitor held (18%) or dose reduced (18%). Among the 10 hospitalized recipients, 7 received hydroxychloroquine and 6 received azithromycin as COVID-19 therapy. Six hospitalized patients received high-dose steroids, 3 received tocilizumab, 2 received remdesivir, and 2 received convalescent plasma. The majority of hospitalized patients (78%) received therapeutic or prophylactic anticoagulation (Table 2).

Seven patients required high levels of oxygen support including nonrebreather mask (n = 2), bilevel positive airway pressure (n = 1), mechanical ventilation with intubation (n = 3), and extracorporeal membrane oxygenation (n = 1). Two patients developed thrombotic complications and 5 patients had acute kidney injury.

Four recipients (36%) died due to COVID-19, 3 who required invasive ventilation or extracorporeal membrane oxygenation and 1 who elected for palliative care and noninvasive ventilation. All recipients who died lived in New York City and were recipients of kidneys from HIV-negative donors. Median ALC in those who died was 0.2 × 103 cells/μL (range: 1–3) compared to 0.5 × 103 cells/μL (range: 0.16–1.3) in survivors (P = 0.09). Median CD4 in those who died was 341 cells/μL (range: 290–395) pre–COVID-19 and 94 cells/μL (range: 50–122) at COVID-19 admission, respectively, compared to 112 cells/μL (range: 72–601) pre–COVID-19 and 122 cells/μL (range: 33–544) at COVID-19 admission among those who survived (P = 0.7). Five patients were tested for SARS-CoV-2 IgG following their COVID-19 diagnosis, of whom 4 were seropositive and 1 seronegative, albeit in this case, testing was only performed 3 d after initial diagnosis by PCR.

DISCUSSION

Within HOPE in Action, a prospective multicenter cohort of kidney and liver transplant recipients with HIV, there have been 11 cases of COVID-19 among 291 recipients (4%). Most cases occurred in New York City, among kidney transplant recipients who were primarily Black and Hispanic males. The majority of recipients with COVID-19 (91%) required hospitalization, of whom 4 (50%) received care in the ICU. There were 4 deaths for an overall mortality of 36%.

The majority of transplant recipients who developed SARS-CoV-2 in our cohort were men (91%), and either Black or Hispanic (91%). This is consistent with gender and racial disparities reported in patients with SARS-CoV-2.19-21 COVID-19-associated hospitalization rates have been higher in men compared with women.22 In addition, age-adjusted hospitalization rates for Black and Hispanic populations with SARS-CoV-2 infection are 5 and 4 times higher when compared with White, non-Hispanic populations.23 Racial disparities may reflect social and structural determinants of health such as poor access to healthcare, economic and housing disadvantages, and higher prevalence of comorbidities such as HIV and kidney disease.19,23 Most recipients in our study had comorbidities associated with worse outcomes, including diabetes and hypertension, and all were from urban centers with limited potential for social distancing.

Similar to other cohorts with HIV and SARS-CoV-2 coinfection, patients in our cohort had well-controlled HIV infection, with virologic suppression on antiretroviral therapy. The first case of SARS-CoV-2 infection and HIV was described in Wuhan city, China,24 and subsequent case series in patients living with HIV20,25-27 have suggested similar clinical outcomes compared to the general population. A large multicenter study of 286 individuals with HIV and COVID-19 reported a 16.5% mortality overall.13 Two case-control studies of patients with COVID-19 and HIV at large NYC centers found no significant differences in presentation or outcomes compared to matched HIV-negative controls.28,29 The study by Sigel et al29 included 4 transplant recipients with HIV and reported a 3.85-folder higher risk of death in that small subgroup. Similarly, we observed a relatively high mortality of 36% in our series of transplant recipients with HIV.

Several HIV antiretrovirals have been purported to have antiviral effects versus SARS-CoV-2, including protease inhibitors and tenofovir derivatives.10,30 Most patients in our cohort were not on a boosted protease-inhibitor (91%), and no patients had a protease inhibitor added to treat SARS-CoV-2 infection. A randomized-controlled trial comparing lopinavir-ritonavir to standard of care for SARS-CoV-2 infection showed no benefit31 and an randomized-controlled trial of darunavir for 5 d did not show an effect.30 Due to drug–drug interactions protease inhibitors are not recommended in transplant recipients and have been associated with graft loss.32,33 In vitro data,10,11 as well as a Spanish cohort study, suggested that TDF may prevent or attenuate COVID-19.34 In our cohort, no recipients were on TDF. Five recipients were on TAF, a prodrug of tenofovir; however, in the Spanish study, only TDF not TAF was associated with a lower risk of COVID-19 and hospitalization.34 In kidney transplant recipients, TAF is preferred over TDF due to a lower risk of kidney toxicity.

Transplant recipients with HIV in our cohort exhibited typical symptoms of cough and dyspnea, yet only 1 had temperature >37.5 °C, while a significant proportion endorsed diarrhea (36%). This is consistent with other series of COVID-19 in transplant recipients describing “atypical” presentations commonly including diarrhea.3,5,35-37 Absolute lymphocyte counts were very low in our patients (all ≤1.0 × 103 cells/μL), which has been associated with poor COVID-19 outcomes.14 In a multicenter study of HIV and COVID-19, CD4 <200 cells/μl was associated with worse outcomes (though it was not specified whether CD4 was pre–COVID-19 or at COVID-19).13 In our series, CD4 counts declined in all patients with measurements at COVID-19 hospitalization, falling to <200 cells/μL in 6/7. Future studies of COVID-19 and HIV, which include longitudinal CD4 data, might determine whether low CD4 count is a risk factor for severe disease or merely a marker of severe illness, a distinction which could impact targeted prevention.

The vast majority of our patients required hospitalization and high-level respiratory support and/or ICU care. This is similar to 2 transplant cohorts in NYC3,28 and a larger national transplant cohort,7 which reported hospitalization in 76%–78% and mechanical ventilation in 31%–39%.3,5 In our series, 4 kidney recipients with HIV (36%) died. This high mortality contrasts with single patient case reports of mild SARS-CoV-2 in transplant recipients with HIV15-17 and appears higher than what has been reported in other transplant cohorts.3-5,38 However, our sample size is quite small and recipients in our study were older with comorbidities associated with COVID-19 mortality.13,39 Thus, it remains unclear whether HIV, transplant or the combination drive worse outcomes; larger, ideally prospective studies adjusting for important demographic and biological factors might isolate these effects.

Our study is limited by the small number of COVID-19 cases. Additionally, a large proportion of our transplant recipients reside in New York City and geographic differences in incidence and disease severity have been described.40 A majority of our HOPE kidney recipients are Black or Hispanic, groups which have been disproportionately affected by COVID-19 with worse outcomes.19,21 The types and availability of COVID-19 directed therapies at each transplant center varied, and mortality rates have also changed over time. For example, patients hospitalized early in the pandemic did not have access to antiviral or convalescent plasma subsequently available through clinical trials and expanded access protocols.

Strengths of our study include identification of COVID-19 cases through mandatory reporting in a national prospective multicenter cohort. Patients were similar with longstanding HIV infection and recent transplantation allowing a focus on the unique intersection of well-controlled HIV infection and transplant-related immunosuppression. As clinical trial participants, patients were connected to care at the time of COVID-19 diagnosis and had detailed clinical and laboratory data available including longitudinal absolute lymphocyte and CD4 counts.

In summary, we observed a modest incidence of COVID-19 in a large prospective cohort of transplants recipients with HIV, affecting Black and Hispanic recipients in New York City most severely. Mortality in this cohort was high, suggesting potentially higher risk with the convergence of HIV and immunosuppressants, and highlighting structural and systemic factors.

ACKNOWLEDGMENTS

From Columbia University Medical Center: Dominique Piquant. From Drexel University: Dong Heun Lee, MD, Carolyn Edwards, RN, MSN. From Duke University: Cameron Wolfe, MBBS, Katherine Link, RN. From Emory University Transplant Center: Rachel Friedman-Moraco, MD, Thomas Pearson, MD, Aneesh K. Mehta, MD, G. Marshall Lyon, MD, William Kitchens, MD, PhD, Jeryl Huckaby, MSCRA, CCRC, Rivka Elbein, RN, BSN, April Roberson, RN, Elizabeth Ferry, RN. From Indiana University: Oluwafisayo Adebiyi, MD, Margaret Adebiyi, Jeanne M. Chen, BS, PharmD. From Massachusets General Hospital: Margret Thomas, BS. From MedStar Georgetown Transplant Institute: Alexander Gilbert, MD, Margaret Coakley, RN, Aleya Akhran, RN, Joseph Timpone, MD, Alyssa Stucke, BS. From Johns Hopkins University School of Medicine/Johns Hopkins Hospital: Oyinkansola Kusemiju, MPH, Yolanda Eby, MS, Reinaldo Fernandez, BS, Charles Kirby, BS, Jernelle Miller, BA, Gilad Bismut, BA, Ethan Klock, BS, Haley Schmidt, BA, Willa V. Cochran, CRNP, Michelle Morrison, BSN, Brian Boyarsky, MD, Sarah Rasmussen, BA, Juli Bollinger, MS, Jeremy Sugarman, MD. From Methodist Health System Clinical Research Institute: Jose A. Castillo-Lugo, MD, Keaton White, LVN. From New York University Langone Transplant Institute: Rebecca Dieter, PharmD, Elizabeth J. Klein, BA. From Northwestern University: Lorenzo Gallon, MD, Leah Goudy, RN, Grace Gallo. From Ochsner Clinic Foundation: Jonathan Hand, MD, Angela R. Smith, MBA. From Perelman School of Medicine at the University of Pennsylvania: Emily Blumberg, MD, Ty Dunn, MD, Deirdre Sawinski, MD. From Rush University Medical Center: Carlos A. Q. Santos, MDMPHS, Mark Mall, RN. From The Mount Sinai Hospital, Recanati-Miller Transplantation Institute: Sander Florman, MD, Brandy M. Haydel, CCRC. From University of Alabama at Birmingham: Shikha Mehta, MD, Jayme E. Locke, MD, MPH FACS, FAST, Darnell Mompoint-Williams, CRNP, DNP, Katherine Basinger, RN, CCRP. From University of Arkansas for Medical Sciences: Emmanouil Giorgakis, MD, MSc, FRCS, Lyle Burdine, MD, PhD, Pamela Buckner, BSN, RN, CPN. From University of California, Los Angeles: Joanna Schaenman, MD, PhD, Janette Gadzhyan. From University of California, San Diego: Saima Aslam, MD, MS, Phirum Nguyen, BS. From University of California, San Francisco: Peter Stock, MD, PhD, Jennifer Price, MD, Rodney Rogers, Ada Chao. From University of Cincinnati: Senu Apewokin, MD, FACP, Samantha Kramer, Kathleen Harrison. From University of Colorado, Denver: Esther Benamu, MD, Alyssa Jeffers, MPH. From University of Illinois at Chicago: Mario Spaggiari, MD, Kelly Bruno. From University of Maryland, Institute of Human Virology: Jennifer Husson, MD, Alicia Jeffery, MA, Gregory Brogden. From University of Miami, Miami Transplant Institute: Michele I. Morris, MD, Jacques Simkins, MD, Carlos Munoz, CRC. From University of Minnesota: Timothy Pruett, MD, Mary Farnsworth, CCRC. From University of Pittsburgh Medical Center: Fernanda Silveira, MD, Ghady Haidar, MD, Kailey Hughes, MPH. From University of Texas Southwestern Medical Center: David Wojciechowski, DO, Emily Carlson. From University of Virginia: Avinash Agarwal, MD, Jamie Nagy, BA. From Virginia Commonwealth University: Gaurav Gupta, MD, Nathan Brigle. From Weill Cornell Medicine: Elliot DeHaan, MD, Melissa D. Eddie, MS, RN, Thangamani Muthukumar, MD. From Yale School of Medicine: Maricar Malinis, MD, Ricarda Tomlin, BS, CCRP.

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