Immunosuppression, viral infections and early kidney allograft function: Findings from a South African cohort

Background. Kidney transplantation remains the optimal treatment for end-stage renal disease, offering superior survival and quality of life compared with dialysis. However, data from low- and middle-income countries (LMICs), particularly in Africa, remain scarce. Objective. To assess early post-transplant renal function and its associations with demographic, viral and immunosuppressive factors in a South African cohort using linear mixed-effects models. Methods. This retrospective cohort study included 299 adult kidney transplant recipients treated at a private hospital in Pretoria between 1999 and 2019. Recipients with complete demographic, treatment and laboratory data, and at least 1 year of follow-up, were included. The primary outcome was estimated glomerular filtration rate (eGFR) over the first year post transplant, modelled using linear mixed- effects regression. Results. Most recipients (73.9%) were of European ancestry and 64.2% were male. Tacrolimus use was associated with significantly higher eGFR. Older donor age and post-transplant cytomegalovirus, Epstein-Barr virus and BK virus infections were associated with reduced eGFR. Recipient ancestry was not independently associated with eGFR in adjusted models. Interaction effects revealed complex relationships between ancestry, immunosuppression and viral status. Conclusion. This study provides real-world data on early post-transplant kidney function in an LMIC setting. While eGFR at 1 year is a surrogate marker for long-term function, it remains a relevant endpoint in under-resourced settings. Our findings highlight the importance of viral monitoring, judicious immunosuppressive selection and the need for inclusive, longitudinal transplant data in African populations.