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Vernooij RW, Michael M, Ladhani M, Webster AC, Strippoli GF, Craig JC, Hodson EM. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2024; 5:CD003774. [PMID: 38700045 PMCID: PMC11066972 DOI: 10.1002/14651858.cd003774.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND The risk of cytomegalovirus (CMV) infection in solid organ transplant recipients has resulted in the frequent use of prophylaxis to prevent the clinical syndrome associated with CMV infection. This is an update of a review first published in 2005 and updated in 2008 and 2013. OBJECTIVES To determine the benefits and harms of antiviral medications to prevent CMV disease and all-cause death in solid organ transplant recipients. SEARCH METHODS We contacted the information specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 5 February 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing antiviral medications with placebo or no treatment, comparing different antiviral medications or different regimens of the same antiviral medications for CMV prophylaxis in recipients of any solid organ transplant. Studies examining pre-emptive therapy for CMV infection are studied in a separate review and were excluded from this review. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility, risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS This 2024 update found four new studies, bringing the total number of included studies to 41 (5054 participants). The risk of bias was high or unclear across most studies, with a low risk of bias for sequence generation (12), allocation concealment (12), blinding (11) and selective outcome reporting (9) in fewer studies. There is high-certainty evidence that prophylaxis with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment is more effective in preventing CMV disease (19 studies: RR 0.42, 95% CI 0.34 to 0.52), all-cause death (17 studies: RR 0.63, 95% CI 0.43 to 0.92), and CMV infection (17 studies: RR 0.61, 95% CI 0.48 to 0.77). There is moderate-certainty evidence that prophylaxis probably reduces death from CMV disease (7 studies: RR 0.26, 95% CI 0.08 to 0.78). Prophylaxis reduces the risk of herpes simplex and herpes zoster disease, bacterial and protozoal infections but probably makes little to no difference to fungal infection, acute rejection or graft loss. No apparent differences in adverse events with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment were found. There is high certainty evidence that ganciclovir, when compared with aciclovir, is more effective in preventing CMV disease (7 studies: RR 0.37, 95% CI 0.23 to 0.60). There may be little to no difference in any outcome between valganciclovir and IV ganciclovir compared with oral ganciclovir (low certainty evidence). The efficacy and adverse effects of valganciclovir or ganciclovir were probably no different to valaciclovir in three studies (moderate certainty evidence). There is moderate certainty evidence that extended duration prophylaxis probably reduces the risk of CMV disease compared with three months of therapy (2 studies: RR 0.20, 95% CI 0.12 to 0.35), with probably little to no difference in rates of adverse events. Low certainty evidence suggests that 450 mg/day valganciclovir compared with 900 mg/day valganciclovir results in little to no difference in all-cause death, CMV infection, acute rejection, and graft loss (no information on adverse events). Maribavir may increase CMV infection compared with ganciclovir (1 study: RR 1.34, 95% CI: 1.10 to 1.65; moderate certainty evidence); however, little to no difference between the two treatments were found for CMV disease, all-cause death, acute rejection, and adverse events at six months (low certainty evidence). AUTHORS' CONCLUSIONS Prophylaxis with antiviral medications reduces CMV disease and CMV-associated death, compared with placebo or no treatment, in solid organ transplant recipients. These data support the continued routine use of antiviral prophylaxis in CMV-positive recipients and CMV-negative recipients of CMV-positive organ transplants.
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Affiliation(s)
- Robin Wm Vernooij
- Department of Nephrology and Hypertension and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Maleeka Ladhani
- Nephrology, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney at Westmead, Westmead, Australia
- Centre for Transplant and Renal Medicine, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elisabeth M Hodson
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Deng R, Yuan G, Ye Y, Luo W, Zhong J, Wang H, Wei X, Luo X, Xiong A. Qualitative evaluation of connective tissue disease with cytomegalovirus infection: A meta-analysis of case reports. Semin Arthritis Rheum 2024; 65:152396. [PMID: 38340610 DOI: 10.1016/j.semarthrit.2024.152396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND The primary therapies for connective tissue disease include glucocorticoids and immunosuppressants. However, their prolonged usage can precipitate opportunistic infections, such as cytomegalovirus infection. When managing connective tissue disease complicated by cytomegalovirus infection, judicious selection of treatment modalities is crucial. This involves assessing the necessity for antiviral therapy and contemplating the reduction or cessation of glucocorticoids and immunosuppressants. OBJECTIVE This investigation sought to methodically review existing literature regarding treating connective tissue disease patients with cytomegalovirus infection. METHODS On July 5, 2023, an exhaustive literature search was conducted. Data analysis utilized the Kruskal-Wallis test or one-way analysis of variance, supplemented by Bonferroni post hoc testing. RESULTS Our meta-analysis incorporated 88 studies encompassing 146 connective tissue disease patients with CMV infections. The results indicated that patients with connective tissue disease and cytomegalovirus disease benefitted more from antiviral therapy than those not receiving such treatment (P = 0.003, P < 0.005). Furthermore, the strategic reduction of glucocorticoids and/or immunosuppressants was beneficial (P = 0.037, P < 0.05). Poor clinical outcomes with glucocorticoid-immunosuppressant combination therapy compared to other treatment modalities. The findings also suggested that CMV infection patients fare better without Cyclosporine A than using it (P = 0.041, P < 0.05). CONCLUSION Antiviral therapy is a viable treatment option in cases of connective tissue disease co-occurring with cytomegalovirus disease. Additionally, when connective tissue disease is stable, there is potential merit in reducing glucocorticoids and/or immunosuppressants, especially avoiding the combination of these drugs. For all cytomegalovirus infection patients, Cyclosporine A may be avoided wherever possible for selecting immunosuppressive agents if its use is not deemed essential in the treatment regimen.
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Affiliation(s)
- Ruiting Deng
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Gaodi Yuan
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Yiman Ye
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Wenxuan Luo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Jiaxun Zhong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Haolan Wang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China
| | - Xin Wei
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China.
| | - Xiongyan Luo
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China.
| | - Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong Hospital of Beijing Anzhen Hospital Capital Medical University, Nanchong, Sichuan, China; Inflammation and Immunology Key Laboratory of Nanchong City, Nanchong, Sichuan, China; Nanchong Central Hospital, (Nanchong Clinical Research Center), Nanchong, Sichuan, China.
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Ruenroengbun N, Sapankaew T, Chaiyakittisopon K, Phoompoung P, Ngamprasertchai T. Efficacy and Safety of Antiviral Agents in Preventing Allograft Rejection Following CMV Prophylaxis in High-Risk Kidney Transplantation: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Front Cell Infect Microbiol 2022; 12:865735. [PMID: 35433502 PMCID: PMC9010655 DOI: 10.3389/fcimb.2022.865735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/07/2022] [Indexed: 11/15/2022] Open
Abstract
Many antiviral agents have been studied in clinical trials for allograft rejection prevention following cytomegalovirus (CMV) prophylaxis in high-risk kidney transplant patients. However, data on the most effective and safest treatment are lacking. We conducted a systematic review and network meta-analysis to rank CMV prophylaxis agents for allograft rejection prevention following CMV prophylaxis in high-risk kidney transplant patients according to their efficacy and safety. We conducted searches on the MEDLINE, Embase, SCOPUS, and CENTRAL databases, as well as the reference lists of selected studies up to December 2021, for published and peer-reviewed randomized controlled trials assessing the efficacy of CMV prophylaxis agents in high-risk kidney transplant patients. Thirteen studies were independently selected by three reviewers and included post-kidney transplant patients indicated for CMV prophylaxis who had been randomized to receive prophylactic antiviral agents or standard of care. The reviewers independently extracted data from the included studies, and direct and network meta-analyses were applied to assess the study outcomes. The probability of efficacy and safety was evaluated, and the drugs were assigned a numerical ranking. We evaluated the risk of bias using the Cochrane Risk of Bias 2.0 tool. The primary outcome was an incidence of biopsy-proven acute rejection, whereas the secondary outcome was a composite of major adverse drug reactions. Each outcome referred to the definition provided in the original studies. Valganciclovir, valacyclovir, and ganciclovir were identified to significantly decrease the incidence of biopsy-proven acute rejection with pooled risk differences (RDs) of −20.53% (95% confidence interval [CI] = −36.09% to −4.98%), −19.3% (95% CI = −32.7% to −5.93%), and −10.4% (95% CI = −19.7% to −0.12%), respectively. The overall major adverse drug reaction was 5.7% without a significant difference when compared with placebo. Valganciclovir had the best combined efficacy and safety among the examined antiviral agents and was the most effective and safest antiviral agent overall for allograft rejection prevention following CMV prophylaxis. Valacyclovir was the optimal alternative antiviral agent for patients who were unable to tolerate intravenous ganciclovir or access oral valganciclovir as financial problem. However, compliance and dose-related toxicities should be closely monitored.
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Affiliation(s)
- Narisa Ruenroengbun
- Department of Pharmaceutics (Clinical Pharmacy), Faculty of Pharmacy, Slipakorn University, Nakornprathom, Thailand
| | - Tunlanut Sapankaew
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Kamolpat Chaiyakittisopon
- Department of Community Pharmacy and Administrations, Faculty of Pharmacy, Slipakorn University, Nakornprathom, Thailand
| | - Pakpoom Phoompoung
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thundon Ngamprasertchai
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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NKG2C Natural Killer Cells in Bronchoalveolar Lavage Are Associated With Cytomegalovirus Viremia and Poor Outcomes in Lung Allograft Recipients. Transplantation 2019; 103:493-501. [PMID: 30211828 DOI: 10.1097/tp.0000000000002450] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is a risk factor for chronic lung allograft dysfunction (CLAD), which limits survival in lung allograft recipients. Natural killer (NK) cells that express the NKG2C receptor mediate CMV-specific immune responses. We hypothesized that NKG2C NK cells responding to CMV in the lung allograft would reduce CMV-related inflammation and would improve CLAD-free survival. METHODS We prospectively followed 130 subjects who underwent lung transplantation from 2012 to 2016. Bronchoalveolar lavage (BAL) NK cells were immunophenotyped for NKG2C, maturation, and proliferation markers. CMV viral load, serologies, serial spirometry, and mortality were recorded from medical records. Natural killer cell subset association with CMV endpoints were made using generalized estimating equation-adjusted linear models. BAL NKG2C NK cell association with CLAD-free survival was assessed by Cox proportional hazards modeling. RESULTS NKG2C NK cells were more mature and proliferative than NKG2C NK cells and represented a median of 7.8% of BAL NK cells. The NKG2C NK cell proportion increased prior to the first detection of viremia and was nearly tripled in subjects with high level viremia (>1000 copies/mL) compared with no detected viremia. Subjects with increased BAL NKG2C NK cells, relative to the median, had a significantly increased risk for CLAD or death (hazard ratio, 4.2; 95% confidence interval, 1.2-13.3). CONCLUSIONS The BAL NKG2C NK cell proportion may be a relevant biomarker for assessing risk of CMV viremia and quantifying potential CMV-related graft injury that can lead to CLAD or death.
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Cowley NJ, Owen A, Shiels SC, Millar J, Woolley R, Ives N, Osman H, Moss P, Bion JF. Safety and Efficacy of Antiviral Therapy for Prevention of Cytomegalovirus Reactivation in Immunocompetent Critically Ill Patients: A Randomized Clinical Trial. JAMA Intern Med 2017; 177:774-783. [PMID: 28437539 PMCID: PMC5818821 DOI: 10.1001/jamainternmed.2017.0895] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
IMPORTANCE Latent cytomegalovirus (CMV) infection is present in more than half the adult population, and a viral reactivation (ie, when the virus becomes measurable in body fluids such as blood) can occur in up to one-third of these individuals during episodes of critical illness. OBJECTIVE To determine whether antiviral therapy is safe and effective for preventing CMV reactivation in a general population of critically ill patients. DESIGN, SETTING, AND PARTICIPANTS A single-center, open-label, randomized, controlled clinical trial recruited 124 CMV-seropositive patients undergoing mechanical ventilation for at least 24 hours in the intensive care unit between January 1, 2012, and January 31, 2014. The mean baseline Acute Physiology and Chronic Health Evaluation II score of all patients was 17.6. INTERVENTIONS Patients were randomized to receive anti-CMV prophylaxis with valacyclovir hydrochloride (n = 34) or low-dose valganciclovir hydrochloride (n = 46) for up to 28 days to suppress viral reactivation, or to a control group with no intervention (n = 44). MAIN OUTCOMES AND MEASURES Time to first CMV reactivation in blood within the 28-day follow-up period following initiation of the study drug. RESULTS Among the 124 patients in the study (46 women and 78 men; mean [SD] age, 56.9 [16.9] years), viral reactivation in the blood occurred in 12 patients in the control group, compared with 1 patient in the valganciclovir group and 2 patients in the valacyclovir group (combined treatment groups vs control: hazard ratio, 0.14; 95% CI 0.04-0.50). Although this trial was not powered to assess clinical end points, the valacyclovir arm was halted prematurely because of higher mortality; 14 of 34 patients (41.2%) had died by 28 days, compared with 5 of 37 (13.5%) patients in the control arm at the point of the decision to halt this arm. Other safety end points showed similar outcomes between groups. CONCLUSIONS AND RELEVANCE Antiviral prophylaxis with valacyclovir or low-dose valganciclovir suppresses CMV reactivation in patients with critical illness. However, given the higher mortality, a large-scale trial would be needed to determine the clinical efficacy and safety of CMV suppression. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01503918.
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Affiliation(s)
- Nicholas J Cowley
- Institute of Clinical Sciences, University of Birmingham, Birmingham, England2Department of Anaesthesia and Intensive Care, Worcester Royal Hospital, Worcestershire Acute National Health Service Trust, Worcester, England
| | - Andrew Owen
- Institute of Clinical Sciences, University of Birmingham, Birmingham, England3University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, England
| | - Sarah C Shiels
- University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, England
| | - Joanne Millar
- University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, England
| | - Rebecca Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, England
| | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, England
| | - Husam Osman
- University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, England
| | - Paul Moss
- University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, England5Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, England
| | - Julian F Bion
- Institute of Clinical Sciences, University of Birmingham, Birmingham, England3University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, England
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Khalifa R, Asaad A, Hussein M. Human leukocyte antigen-A genotype as a predictor of cytomegalovirus-pp65 antigenemia and cytomegalovirus disease in solid-organ transplant recipients. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2016. [DOI: 10.1016/j.ejmhg.2015.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Watson SI, Chen YF, Nguyen-Van-Tam JS, Myles PR, Venkatesan S, Zambon M, Uthman O, Chilton PJ, Lilford RJ. Evidence synthesis and decision modelling to support complex decisions: stockpiling neuraminidase inhibitors for pandemic influenza usage. F1000Res 2016; 5:2293. [PMID: 28413608 PMCID: PMC5365214 DOI: 10.12688/f1000research.9414.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 12/03/2022] Open
Abstract
Objectives: The stockpiling of neuraminidase inhibitor (NAI) antivirals as a defence against pandemic influenza is a significant public health policy decision that must be made despite a lack of conclusive evidence from randomised controlled trials regarding the effectiveness of NAIs on important clinical end points such as mortality. The objective of this study was to determine whether NAIs should be stockpiled for treatment of pandemic influenza on the basis of current evidence. Methods: A decision model for stockpiling was designed. Data on previous pandemic influenza epidemiology was combined with data on the effectiveness of NAIs in reducing mortality obtained from a recent individual participant meta-analysis using observational data. Evidence synthesis techniques and a bias modelling method for observational data were used to incorporate the evidence into the model. The stockpiling decision was modelled for adults (≥16 years old) and the United Kingdom was used as an example. The main outcome was the expected net benefits of stockpiling in monetary terms. Health benefits were estimated from deaths averted through stockpiling. Results: After adjusting for biases in the estimated effectiveness of NAIs, the expected net benefit of stockpiling in the baseline analysis was £444 million, assuming a willingness to pay of £20,000/QALY ($31,000/QALY). The decision would therefore be to stockpile NAIs. There was a greater probability that the stockpile would not be utilised than utilised. However, the rare but catastrophic losses from a severe pandemic justified the decision to stockpile. Conclusions: Taking into account the available epidemiological data and evidence of effectiveness of NAIs in reducing mortality, including potential biases, a decision maker should stockpile anti-influenza medication in keeping with the postulated decision rule.
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Affiliation(s)
- Samuel I. Watson
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Yen-Fu Chen
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | | | - Puja R. Myles
- School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Sudhir Venkatesan
- School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | | | - Olalekan Uthman
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Peter J. Chilton
- Warwick Business School, University of Warwick, Coventry, CV47AL, UK
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Watson SI, Chen YF, Nguyen-Van-Tam JS, Myles PR, Venkatesan S, Zambon M, Uthman O, Chilton PJ, Lilford RJ. Evidence synthesis and decision modelling to support complex decisions: stockpiling neuraminidase inhibitors for pandemic influenza usage. F1000Res 2016; 5:2293. [PMID: 28413608 PMCID: PMC5365214 DOI: 10.12688/f1000research.9414.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2016] [Indexed: 11/13/2023] Open
Abstract
Objectives: The stockpiling of neuraminidase inhibitor (NAI) antivirals as a defence against pandemic influenza is a significant public health policy decision that must be made despite a lack of conclusive evidence from randomised controlled trials regarding the effectiveness of NAIs on important clinical end points such as mortality. The objective of this study was to determine whether NAIs should be stockpiled for treatment of pandemic influenza on the basis of current evidence. Methods: A decision model for stockpiling was designed. Data on previous pandemic influenza epidemiology was combined with data on the effectiveness of NAIs in reducing mortality obtained from a recent individual participant meta-analysis using observational data. Evidence synthesis techniques and a bias modelling method for observational data were used to incorporate the evidence into the model. The stockpiling decision was modelled for adults (≥16 years old) and the United Kingdom was used as an example. The main outcome was the expected net benefits of stockpiling in monetary terms. Health benefits were estimated from deaths averted through stockpiling. Results: After adjusting for biases in the estimated effectiveness of NAIs, the expected net benefit of stockpiling in the baseline analysis was £444 million, assuming a willingness to pay of £20,000/QALY ($31,000/QALY). The decision would therefore be to stockpile NAIs. There was a greater probability that the stockpile would not be utilised than utilised. However, the rare but catastrophic losses from a severe pandemic justified the decision to stockpile. Conclusions: Taking into account the available epidemiological data and evidence of effectiveness of NAIs in reducing mortality, including potential biases, a decision maker should stockpile anti-influenza medication in keeping with the postulated decision rule.
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Affiliation(s)
- Samuel I. Watson
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Yen-Fu Chen
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | | | - Puja R. Myles
- School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Sudhir Venkatesan
- School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | | | - Olalekan Uthman
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Peter J. Chilton
- Warwick Business School, University of Warwick, Coventry, CV47AL, UK
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Luscalov S, Loga L, Dican L, Junie LM. Cytomegalovirus infection in immunosuppressed patients after kidney transplantation. Med Pharm Rep 2016; 89:343-6. [PMID: 27547053 PMCID: PMC4990428 DOI: 10.15386/cjmed-587] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/25/2015] [Indexed: 12/15/2022] Open
Abstract
The first kidney transplantation was performed in 1951 and ever since then living donor transplantation became a more and more important solution for patients with end-stage renal disease (ESRD). Renal transplantation is a life-saving procedure. Morbidity and mortality on waiting-lists are strongly correlated with the time of dialysis and end-stage renal disease is one of the most important causes of death; this is the reason why transplantation has to be performed as soon as possible in order to reduce the time of dialysis. Once the transplantation is performed, a number of complications may occur in post-transplant evolution, the most important of which is rejection. The rejection may appear through several mechanisms, but one of the most frequent causes of rejection is cytomegalovirus (CMV) infection. It is very important to have a precocious and fast diagnosis of CMV infection in order to maintain the functionality and survival of the graft. PP65 CMV antigenemia has proven its effectiveness in detecting and monitoring the CMV infection in transplanted patients. In the laboratory of the Clinical Institute of Urology and Renal Transplantation (ICUTR) of Cluj Napoca the CMV infection is evidenced by two methods: PP65antigenemia and IgM antibody identification by chemiluminiscence.
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Affiliation(s)
- Simona Luscalov
- Department of Microbiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Lucia Dican
- Departament of Biochemistry, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Lia Monica Junie
- Department of Microbiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Wang Z, Vathsala A, Tiong HY. Haematuria in postrenal transplant patients. BIOMED RESEARCH INTERNATIONAL 2015; 2015:292034. [PMID: 25918706 PMCID: PMC4395992 DOI: 10.1155/2015/292034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/20/2015] [Accepted: 02/20/2015] [Indexed: 12/25/2022]
Abstract
Haematuria has a prevalence of 12% in the postrenal transplant patient population. It heralds potentially dangerous causes which could threaten graft loss. It is important to consider causes in light of the unique, urological, and immunological standpoints of these patients. We review the literature on common causes of haematuria in postrenal transplant patients and suggest the salient approach to the evaluation of this condition. A major cause of haematuria is urinary tract infections. There should be a higher index of suspicion for mycobacterial, fungal, and viral infection in this group of immunosuppressed patients. Measures recommended in the prevention of urinary tract infections include early removal of foreign bodies as well as prophylactic antibiotics during the early transplant phase. Another common cause of haematuria is that of malignancies, in particular, renal cell carcinomas. When surgically managing cancer in the setting of a renal transplant, one has to be mindful of the limited retropubic space and the need to protect the anastomoses. Other causes include graft rejections, recurrences of primary disease, and calculus formation. It is important to perform a comprehensive evaluation with the aid of an experienced multidisciplinary transplant team.
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Affiliation(s)
- Ziting Wang
- Department of Urology, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
| | - Anantharaman Vathsala
- Division of Nephrology, Department of Medicine, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
- National University Centre for Organ Transplantation, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
| | - Ho Yee Tiong
- Department of Urology, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
- National University Centre for Organ Transplantation, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
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Le Page AK, Mackie FE, McTaggart SJ, Kennedy SE. Cytomegalovirus & Epstein Barr Virus serostatus as a predictor of the long-term outcome of kidney transplantation. Nephrology (Carlton) 2014; 18:813-9. [PMID: 23927085 DOI: 10.1111/nep.12149] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2013] [Indexed: 01/09/2023]
Abstract
AIM Cytomegalovirus (CMV) and Epstein Barr Virus (EBV) disease and asymptomatic infection have been associated with poor outcomes in kidney transplantation. Recipients who acquire primary infection through transplantation from a seropositive donor may be at particular risk of complications. The primary aim of this study was to evaluate the relationship between donor/recipient (D/R) CMV and EBV serostatus pretransplant and allograft and patient survival in a large cohort of kidney transplant recipients. METHODS Data were obtained from the Australian and New Zealand Dialysis and Transplant Registry and the Australian and New Zealand Organ Donation Registry on 4516 first deceased donor kidney transplants performed between 1998 and 2010. Graft and patient survival were analysed using the Kaplan-Meier method. RESULTS Pretransplant CMV D/R serostatus was available for the whole cohort, with EBV D/R serostatus available for 2566 transplants (56.8%). Serostatus for both viruses was significantly associated with donor and recipient age and recipient smoking status. For both viruses the majority of transplants were in a D+/R+ serostatus setting: 45.3% for CMV and 77.9% for EBV. D/R serostatus for either virus did not have a significant effect on graft or patient survival. CONCLUSION We conclude that in the current era of viral prophylaxis and surveillance, long-term outcome for the kidney transplant population is unaffected by D/R CMV and EBV serostatus.
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Affiliation(s)
- Amelia K Le Page
- Department of Nephrology, Sydney Children's Hospital, Sydney, New South Wales, Australia; ANZDATA Registry, Adelaide, South Australia, Australia
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Abbey A, Elsmore AC. Shortness of breath in a patient with inflammatory bowel disease. BMJ Case Rep 2014; 2014:bcr-2014-205269. [PMID: 25301420 DOI: 10.1136/bcr-2014-205269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cytomegalovirus (CMV) is an important cause of morbidity and mortality in immunocompromised patients. Although immunosuppressive therapy is the mainstay of medical treatment for patients with inflammatory bowel disease, the importance of CMV as a cause of pneumonia in this group is less well recognised. This case report presents a case of shortness of breath, dyspnoea and fever in a 51-year-old man with Crohn's disease on azathioprine and highlights the importance of considering CMV as a cause of pneumonia in this group.
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Affiliation(s)
- Aoife Abbey
- Department of Critical Care, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Amy C Elsmore
- Department of Critical Care, University Hospital Coventry & Warwickshire, Coventry, UK
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Clajus C, Blasi F, Welte T, Greer M, Fuehner T, Mantero M. Therapeutic approach to respiratory infections in lung transplantation. Pulm Pharmacol Ther 2014; 32:149-54. [PMID: 25038552 PMCID: PMC7110868 DOI: 10.1016/j.pupt.2014.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 07/09/2014] [Indexed: 01/22/2023]
Abstract
Lung transplant recipients (LTRs) are at life-long risk for infections and disseminated diseases owing to their immunocompromised state. Besides organ failure and sepsis, infection can trigger acute and chronic graft rejection which increases mortality. Medical prophylaxis and treatment are based on comprehensive diagnostic work-up including previous history of infection and airway colonisation to reduce long-term complications and mortality. Common bacterial pathogens include Pseudomonas and Staphylococcus, whilst Aspergillus and Cytomegalovirus (CMV) are respectively the commonest fungal and viral pathogens. Clinical symptoms can be various in lung transplant recipients presenting an asymptomatic to severe progress. Regular control of infection parameters, daily lung function testing and lifelong follow-up in a specialist transplant centre are mandatory for early detection of bacterial, viral and fungal infections. After transplantation each patient receives intensive training with rules of conduct concerning preventive behaviour and to recognize early signs of post transplant complications. Early detection of infection and complications are important goals to reduce major complications after lung transplantation.
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Affiliation(s)
- Carolina Clajus
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ospedale Maggiore, Policlinico Cà Granda Milano, Italy
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Thomas Fuehner
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ospedale Maggiore, Policlinico Cà Granda Milano, Italy
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Abstract
OBJECTIVE To provide an approach to the care of liver transplant (LT) patients, a growing patient population with unique needs. METHODS A literature search of PubMed for guidelines and review articles using the keywords "liver transplantation", "long term complications" and "medical management" was conducted, resulting in 77 articles. RESULTS As a result of being on immunosuppression, LT recipients are at increased risk of infections and must be screened regularly for metabolic complications and malignancies. DISCUSSION Although immunosuppression is key to maintaining allograft health after transplantation, it comes with its own set of medical issues to follow. Physicians following LT recipients must be aware of the greater risk for hypertension, diabetes, dyslipidemia, renal failure, metabolic bone disease and malignancies in these patients, all of whom require regular monitoring and screening. Vaccination, quality of life, sexual function and pregnancy must be specifically addressed in transplant patients.
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Evans R, Bhagani S, Haque T, Harber M. Infectious Complications of Transplantation. PRACTICAL NEPHROLOGY 2014. [PMCID: PMC7121279 DOI: 10.1007/978-1-4471-5547-8_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Post-transplant infection is a common cause of graft deterioration, morbidity and mortality. It is also responsible for delayed discharge, multiple, often prolonged admissions and thus a significant clinical challenge. Infections can be donor derived, pre-existing in the recipient, nosocomial and opportunistic. For each of these categories, it is often possible to significantly reduce hazard and thus the adverse consequences by first identifying patients at high risk. As always, clinical vigilance is vital, but equally important is the establishment of robust clinical systems for prevention, screening and rapid treatment.
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Tengsupakul S, Birge ND, Bendel CM, Reed RC, Bloom BA, Hernandez N, Schleiss MR. Asymptomatic DNAemia heralds CMV-associated NEC: case report, review, and rationale for preemption. Pediatrics 2013; 132:e1428-34. [PMID: 24144715 PMCID: PMC3813390 DOI: 10.1542/peds.2013-0087] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2013] [Indexed: 02/07/2023] Open
Abstract
Human cytomegalovirus (CMV) infection may be acquired in very low birth weight and extremely low birth weight (ELBW) infants from breast milk. The clinical relevance of such infections is uncertain. There is no consensus on whether screening breast milk for CMV, freezing/pasteurizing milk before feeding, or performing virological monitoring on at-risk infants is warranted. We describe an ELBW infant who acquired CMV postnatally from breast milk and developed CMV sepsis syndrome and clinical evidence of necrotizing enterocolitis (NEC) at ≈ 5 weeks of age. The availability of serial dried blood spots from day of life (DOL) 4 to 21, coincidentally obtained for a metabolic study, provided the novel opportunity to retrospectively test for and quantify the magnitude of CMV DNAemia. DNAemia was present for several weeks before the onset of severe CMV disease, first being noted on DOL 18 and increasing in magnitude daily to 4.8 log10 genomes/mL on DOL 21, approximately 8 days before the onset of abdominal distension and 15 days before the onset of CMV sepsis syndrome and NEC. After surgical resection, supportive care, and ganciclovir therapy, the infant recovered. This case underscores the importance of including CMV infection in the differential diagnosis of sepsis and NEC in premature infants. This case also suggests the value of prospective virological monitoring in at-risk low birth weight and ELBW infants. Future studies should examine the potential utility of preemptive monitoring for, and possibly treatment of, CMV DNAemia in premature infants, which may herald the onset of serious disease.
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Affiliation(s)
- Supatida Tengsupakul
- Department of Pediatrics, University of Minnesota, 2001 6th Street SE, Minneapolis, MN 55455.
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Ganciclovir-resistant cytomegalovirus infections among lung transplant recipients are associated with poor outcomes despite treatment with foscarnet-containing regimens. Antimicrob Agents Chemother 2013; 58:128-35. [PMID: 24145525 DOI: 10.1128/aac.00561-13] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Ganciclovir-resistant cytomegalovirus (CMV) infections are reported infrequently among lung transplant recipients receiving extended valganciclovir prophylaxis. We performed a single-center, retrospective review of ganciclovir-resistant CMV infections in a program that employed valganciclovir prophylaxis for ≥6 months after lung transplant. CMV infections were diagnosed in 28% (170/607) of patients. UL97 mutations were detected in 9.4% (16/170) of CMV-infected patients at a median of 8.5 months posttransplant (range, 5 to 21) and despite prophylaxis for a median of 7 months (range, 4 to 21). UL97 mutations were canonical; 25% (4/16) of strains carried concurrent UL54 mutations. Ganciclovir-resistant CMV was more likely with breakthrough infections (75% [12/16] versus 19% [30/154]; P = 0.00001) and donor positive/recipient negative (D+/R-) serostatus (75% versus 45% [69/154]; P = 0.03). The median whole-blood CMV load was 4.13 log10 copies/cm(3) (range, 2.54 to 5.53), and 93% (14/15) of patients had low-moderate immune responses (Cylex Immunoknow). Antiviral therapy was successful, failed, or eradicated viremia followed by relapse in 12% (2/16), 31% (5/16), and 56% (9/16) of patients, respectively. Eighty-seven percent (14/16) of patients were treated with foscarnet-containing regimens; toxicity developed in 78% (11/14) of these. Median viral load half-life and time to viremia eradication among foscarnet-treated patients were 2.6 and 23 days, respectively, and did not correlate with protection from relapse. Sixty-nine percent (11/16) of patients developed CMV pneumonitis, and 25% (4/16) died of it. Serum viral load was independently associated with death among foscarnet-treated patients (P = 0.04). In conclusion, ganciclovir-resistant CMV infections remained a major cause of morbidity and mortality following lung transplantation. Foscarnet-based regimens often eradicated viremia rapidly but were ineffective in the long term and limited by toxicity.
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Abstract
Modern post-transplant care pathways commonly encompass periods of critical care support. Infectious events account for many of these interactions making critical care physicians integral members of multidisciplinary transplant teams. Despite continuing advances in clinical care and infection prophylaxis, the morbidity and mortality attributable to infection post-transplant remains considerable. Emerging entities constantly add to the breadth of potential opportunistic pathogens. Individualized risk assessments, rapid and thorough diagnostic evaluation, and prompt initiation of appropriate antimicrobial therapies are essential. The approach to managing transplant recipients with infection in critical care is discussed and common and emerging opportunistic pathogens are reviewed.
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Affiliation(s)
| | - Atul Humar
- Transplant Infectious Diseases, Alberta Transplant Institute, University of Alberta, 6–030 Katz Center for Health Research, 11361–87 Ave, Edmonton, Alberta T6G 2E1, Canada
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Detection of cytomegalovirus drug resistance mutations by next-generation sequencing. J Clin Microbiol 2013; 51:3700-10. [PMID: 23985916 DOI: 10.1128/jcm.01605-13] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Antiviral therapy for cytomegalovirus (CMV) plays an important role in the clinical management of solid organ and hematopoietic stem cell transplant recipients. However, CMV antiviral therapy can be complicated by drug resistance associated with mutations in the phosphotransferase UL97 and the DNA polymerase UL54. We have developed an amplicon-based high-throughput sequencing strategy for detecting CMV drug resistance mutations in clinical plasma specimens using a microfluidics PCR platform for multiplexed library preparation and a benchtop next-generation sequencing instrument. Plasmid clones of the UL97 and UL54 genes were used to demonstrate the low overall empirical error rate of the assay (0.189%) and to develop a statistical algorithm for identifying authentic low-abundance variants. The ability of the assay to detect resistance mutations was tested with mixes of wild-type and mutant plasmids, as well as clinical CMV isolates and plasma samples that were known to contain mutations that confer resistance. Finally, 48 clinical plasma specimens with a range of viral loads (394 to 2,191,011 copies/ml plasma) were sequenced using multiplexing of up to 24 specimens per run. This led to the identification of seven resistance mutations, three of which were present in <20% of the sequenced population. Thus, this assay offers more sensitive detection of minor variants and a higher multiplexing capacity than current methods for the genotypic detection of CMV drug resistance mutations.
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Abstract
Lung transplantation has become an accepted therapeutic procedure for the treatment of end‐stage pulmonary parenchymal and vascular disease. Despite improved survival rates over the decades, lung transplant recipients have lower survival rates than other solid organ transplant recipients. The morbidity and mortality following lung transplantation is largely due to infection‐ and rejection‐related complications. This article will review the common infections that develop in the lung transplant recipient, including the general risk factors for infection in this population, and the most frequent bacterial, viral, fungal and other less frequent opportunistic infections. The epidemiology, diagnosis, prophylaxis, treatment and outcomes for the different microbial pathogens will be reviewed. The effects of infection on lung transplant rejection will also be discussed.
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Affiliation(s)
- Sergio R Burguete
- Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center at San Antonio, Texas 78229-3900, USA
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22
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Abstract
Lung transplantation may be the only intervention that can prolong survival and improve quality of life for those individuals with advanced lung disease who are acceptable candidates for the procedure. However, these candidates may be extremely ill and require ventilator and/or circulatory support as a bridge to transplantation, and lung transplantation recipients are at risk of numerous post-transplant complications that include surgical complications, primary graft dysfunction, acute rejection, opportunistic infection, and chronic lung allograft dysfunction (CLAD), which may be caused by chronic rejection. Many advances in pre- and post-transplant management have led to improved outcomes over the past decade. These include the creation of sound guidelines for candidate selection, improved surgical techniques, advances in donor lung preservation, an improving ability to suppress and treat allograft rejection, the development of prophylaxis protocols to decrease the incidence of opportunistic infection, more effective therapies for treating infectious complications, and the development of novel therapies to treat and manage CLAD. A major obstacle to prolonged survival beyond the early post-operative time period is the development of bronchiolitis obliterans syndrome (BOS), which is the most common form of CLAD. This manuscript discusses recent and evolving advances in the field of lung transplantation.
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Hodson EM, Ladhani M, Webster AC, Strippoli GFM, Craig JC. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2013:CD003774. [PMID: 23450543 DOI: 10.1002/14651858.cd003774.pub4] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The risk of cytomegalovirus (CMV) infection in solid organ transplant recipients has resulted in the frequent use of prophylaxis with the aim of preventing the clinical syndrome associated with CMV infection. This is an update of a review first published in 2005 and updated in 2008. OBJECTIVES To determine the benefits and harms of antiviral medications to prevent CMV disease and all-cause mortality in solid organ transplant recipients. SEARCH METHODS We searched MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials (CENTRAL) in The Cochrane Library to February 2004 for the first version of this review. The Cochrane Renal Group's specialised register was searched to February 2007 and to July 2011 for the first and current updates of the review without language restriction. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing antiviral medications with placebo or no treatment, comparing different antiviral medications and comparing different regimens of the same antiviral medications in recipients of any solid organ transplant. Studies examining pre-emptive therapy were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility, risk of bias and extracted data. Results were reported as risk ratios (RR) or risk differences (RD) with 95% confidence intervals (CI) for dichotomous outcomes and by mean difference (MD) with 95% CI for continuous outcomes. Statistical analyses were performed using the random-effects model. Subgroup analysis and univariate meta-regression were performed using restricted maximum-likelihood to estimate the between study variance. Multivariate meta-regression was performed to investigate whether the results were altered after allowing for differences in drugs used, organ transplanted, and recipient CMV serostatus at the time of transplantation. MAIN RESULTS We identified 37 studies (4342 participants). Risk of bias attributes were poorly performed or reported with low risk of bias reported for sequence generation, allocation concealment, blinding and selective outcome reporting in 25% or fewer studies.Prophylaxis with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment significantly reduced the risk for CMV disease (19 studies; RR 0.42, 95% CI 0.34 to 0.52), CMV infection (17 studies; RR 0.61, 95% CI 0.48 to 0.77), and all-cause mortality (17 studies; RR 0.63, 95% CI 0.43 to 0.92) primarily due to reduced mortality from CMV disease (7 studies; RR 0.26, 95% CI 0.08 to 0.78). Prophylaxis reduced the risk of herpes simplex and herpes zoster disease, bacterial and protozoal infections but not fungal infection, acute rejection or graft loss.Meta-regression showed no significant difference in the relative benefit of treatment (risk of CMV disease or all-cause mortality) by organ transplanted or CMV serostatus; no conclusions were possible for CMV negative recipients of negative organs.Neurological dysfunction was more common with ganciclovir and valaciclovir compared with placebo/no treatment. In direct comparison studies, ganciclovir was more effective than aciclovir in preventing CMV disease (7 studies; RR 0.37, 95% CI 0.23 to 0.60) and leucopenia was more common with aciclovir. Valganciclovir and IV ganciclovir were as effective as oral ganciclovir. The efficacy and adverse effects of valganciclovir/ganciclovir did not differ from valaciclovir in three small studies. Extended duration prophylaxis significantly reduced the risk of CMV disease compared with three months therapy (2 studies; RR 0.20, 95% CI 0.12 to 0.35). Leucopenia was more common with extended duration prophylaxis but severe treatment associated adverse effects did not differ between extended and three month durations of treatment. AUTHORS' CONCLUSIONS Prophylaxis with antiviral medications reduces CMV disease and CMV-associated mortality in solid organ transplant recipients. These data suggest that antiviral prophylaxis should be used routinely in CMV positive recipients and in CMV negative recipients of CMV positive organ transplants.
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Affiliation(s)
- Elisabeth M Hodson
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia.
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The contribution of systematic reviews to the practice of pediatric nephrology. Pediatr Nephrol 2013; 28:197-206. [PMID: 22476252 DOI: 10.1007/s00467-012-2155-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2011] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 10/28/2022]
Abstract
The key to accurate decision-making is to use the best available evidence. Systematic reviews aim to identify and combine evidence using systematic methods to minimize bias to provide reliable data for patient care. While systematic reviews can address different clinical questions, the methodology is most developed for systematic reviews of randomized controlled trials. Such systematic reviews include all available trial evidence, enhance the precision of the estimates of treatment effects, and identify where evidence is lacking or where sufficient evidence is already available. However the term "systematic review" does not guarantee that a review covers all the available data, that the validity of included studies has been appropriately assessed, or that data have been combined appropriately in meta-analyses. Biases in systematic review include those related to identifying data (publication bias, language bias, selective reporting of outcomes) and those due to the design and conduct of trials (selection bias, performance bias, detection bias, attrition bias). Thus, readers should read a systematic review carefully before accepting its results and conclusions. This review examines the information that can be provided by systematic reviews of randomized controlled trials together with the biases that can potentially jeopardize the results and conclusions.
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Clinical outcome with low-dose valacyclovir in high-risk renal transplant recipients: a 10-year experience. Nephrol Dial Transplant 2012; 28:758-65. [DOI: 10.1093/ndt/gfs531] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Doesch AO, Repp J, Hofmann N, Erbel C, Frankenstein L, Gleissner CA, Schmidt C, Ruhparwar A, Zugck C, Schnitzler P, Ehlermann P, Dengler TJ, Katus HA. Effects of oral valganciclovir prophylaxis for cytomegalovirus infection in heart transplant patients. DRUG DESIGN DEVELOPMENT AND THERAPY 2012; 6:289-95. [PMID: 23091373 PMCID: PMC3472651 DOI: 10.2147/dddt.s36578] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is a serious complication following heart transplantation. This study (June 2003-January 2010) retrospectively assessed the effects of oral valganciclovir prophylaxis in adult heart transplant recipients during the first year after transplantation. METHODS In patients with normal renal function, 900 mg of oral valganciclovir was administered twice daily for 14 days after heart transplant followed by 900 mg per day for following 6 months. In the event of renal insufficiency, valganciclovir was adjusted according to the manufacturer's recommendations. Antigenemia testing for pp65 antigen and simultaneous polymerase chain reaction (PCR) were used to document exposure to CMV. From 2003 to 2010, 146 patients (74.0% men) of mean age 50.7 ± 10.3 years at the time of heart transplant were included. RESULTS A total of 16 patients (11.0% of total, 75.0% male) had a positive pp65 and PCR result (ie, CMV infection) during the year following heart transplant; three of these patients had discontinued valganciclovir prophylaxis within the first 6 months following transplant because of leukopenia, including one patient developed CMV colitis. Two further patients developed CMV pneumonia during prophylactic valganciclovir therapy. Eight patients had positive pp65 and PCR tests in the 6-12 months after heart transplant following cessation of routine prophylaxis. One of these patients developed CMV pneumonia and another developed CMV colitis and CMV pneumonia. Thirty-seven of the 146 (25.3%) patients were CMV donor-seropositive/recipient-seronegative, and seven (18.9% of this subgroup) had a positive CMV test. In patients who were CMV donor-seropositive/recipient-seronegative, the risk of a positive CMV test (ie, CMV infection) was significantly elevated (P = 0.023). CONCLUSION CMV prophylaxis with oral valganciclovir for 6 months following heart transplant is clinically feasible. In line with previous studies, CMV donor-seropositive/recipient-seronegative patients have a significantly elevated risk of CMV infection. In patients who prematurely discontinue valganciclovir, close monitoring of CMV antigenemia appears warranted. No significantly elevated rate of CMV infection was observed after 6 months of valganciclovir prophylaxis.
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Six-month low-dose valganciclovir prophylaxis in cytomegalovirus D+/R- kidney transplant patients receiving thymoglobulin induction. Transplant Proc 2012; 45:175-7. [PMID: 23267799 DOI: 10.1016/j.transproceed.2012.04.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 04/17/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND The use of T-cell-depleting antibody, such as thymoglobulin, is a risk factor for cytomegalovirus (CMV) infection. We studied the effectiveness of 6 months of low-dose valganciclovir prophylaxis in CMV-naive kidney transplant recipients of CMV-positive donor kidney (D+/R-) receiving thymoglobulin induction. METHODS We included all D+/R- kidney transplant patients between October 2005 and December 2010 who received valganciclovir 450 mg daily for 6 months as per center protocol. CMV infection was confirmed by positive viremia. Kaplan-Meier and multivariate Cox proportional regression analyses were employed to compare the risk of CMV infection between patients with and without the use of thymoglobulin induction. RESULTS Out of 170 D+/R- kidney transplant patients, 42 cases of CMV infection (24.6%) were diagnosed after a median follow-up of 3.2 years: six patients from the noninduction (9.4%) and 36 from the induction cohort (34.0%). The induction with thymoglobulin was associated with four times greater risk of developing CMV infection (adjusted hazard ratio: AHR 4.15, 95% 1.75, 9.86, P = .001). The use of thymoglobulin was associated with leukopenia but not neutropenia. CONCLUSIONS Additional measures are needed to reduce the elevated incidence of CMV infection in D+/R- kidney transplant patients receiving induction with thymoglobulin.
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Cukuranovic J, Ugrenovic S, Jovanovic I, Visnjic M, Stefanovic V. Viral infection in renal transplant recipients. ScientificWorldJournal 2012; 2012:820621. [PMID: 22654630 PMCID: PMC3357934 DOI: 10.1100/2012/820621] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 01/10/2012] [Indexed: 12/18/2022] Open
Abstract
Viruses are among the most common causes of opportunistic infection after transplantation. The risk for viral infection is a function of the specific virus encountered, the intensity of immune suppression used to prevent graft rejection, and other host factors governing susceptibility. Although cytomegalovirus is the most common opportunistic pathogen seen in transplant recipients, numerous other viruses have also affected outcomes. In some cases, preventive measures such as pretransplant screening, prophylactic antiviral therapy, or posttransplant viral monitoring may limit the impact of these infections. Recent advances in laboratory monitoring and antiviral therapy have improved outcomes. Studies of viral latency, reactivation, and the cellular effects of viral infection will provide clues for future strategies in prevention and treatment of viral infections. This paper will summarize the major viral infections seen following transplant and discuss strategies for prevention and management of these potential pathogens.
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Affiliation(s)
| | | | - Ivan Jovanovic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia
| | - Milan Visnjic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia
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Emery VC, Asher K, Sanjuan CDJ. Importance of the cytomegalovirus seropositive recipient as a contributor to disease burden after solid organ transplantation. J Clin Virol 2012; 54:125-9. [PMID: 22445261 PMCID: PMC3355300 DOI: 10.1016/j.jcv.2012.02.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 02/13/2012] [Accepted: 02/25/2012] [Indexed: 02/07/2023]
Abstract
Background The incidence of cytomegalovirus (CMV) syndrome/disease after adult solid organ transplantation in the era effective antiviral therapy has not been fully assessed. Objective To determines the incidence of CMV syndrome/disease after solid organ transplantation in the UK. Study design A retrospective analysis of 1807 solid organ transplants from 12 UK solid organ transplant centres representing 32.7% of all transplant activity occurring in the UK between 1/04/2004 and 31/03/2006. Patients were categorised into those experiencing an episode of symptomatic CMV infection after transplant or those who remained free of symptoms. All patients were followed up for 2 years for the occurrence of CMV syndrome/disease. Results The majority of the transplant centres used valganciclovir prophylaxis in the high risk D+R− patients (91.6%) whereas management of the lower risk D+R+ and D−R+ patients was more variable with deployment of both prophylactic and pre-emptive strategies in ∼50% of centres. CMV syndrome/disease occurred in 20.5% of the D+R− patients representing 55 cases whereas the incidence was only 8.1% and 9% in the D+R+ and D−R+ group, respectively (p < 0.001 compared to the D+R− group), but representing a further 58 cases of CMV syndrome/disease. CMV viraemia in the D+R− group was associated with a high probability (65%) of CMV syndrome/disease in renal transplant recipients whereas this was less apparent in the intermediate risk groups. Conclusions CMV syndrome/disease remains an important healthcare burden after solid organ transplantation with the intermediate risk groups contributing similar numbers of cases as the high risk group.
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Affiliation(s)
- Vincent C Emery
- Department of Infection (Royal Free Campus), University College Medical School, Rowland Hill Street, Hampstead, London NW3 2QG, UK.
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Patel M, Stefanidou M, Long CB, Fazzari MJ, Tesfa L, Del Rio M, Lamour J, Ricafort R, Madan RP, Herold BC. Dynamics of cell-mediated immune responses to cytomegalovirus in pediatric transplantation recipients. Pediatr Transplant 2012; 16:18-28. [PMID: 21762326 PMCID: PMC3214231 DOI: 10.1111/j.1399-3046.2011.01531.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CMI responses, combined with quantification of CMV DNA (DNAemia), may identify transplantation recipients at risk for invasive disease. PBMC were collected in pediatric transplantation candidates at one, three, and six months post-transplant in 10 subjects (six renal, three cardiac, one stem cell) and at single time points in eight HC and 14 children greater than one yr post-transplant (LTTx). Cells were stimulated with anti-CD3mAb or CMV pp65 peptide pools and responses assessed by IFNG enzyme-linked immunosorbent spot assay and cytokine secretion. IFNG responses to anti-CD3mAb were significantly lower pretransplant relative to HC and were further decreased at one and three months post-transplant, but recovered to levels comparable to HC by six months. Responses to pp65 among CMV-seropositive recipients followed a similar pattern but recovered by three months. CMV-seropositive LTTx and HC showed a Th1 cytokine response to pp65 stimulation. Three LTTx subjects developed CMV DNAemia; two demonstrated decreased responses to anti-CD3mAB (and pp65 in the CMV seropositive subject) at the onset of DNAemia, which recovered as DNAemia resolved. Monitoring CMI in children is feasible and may provide an adjunct biomarker to predict CMV progression and recovery.
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Affiliation(s)
- Manisha Patel
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | | | | | | | - Lydia Tesfa
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marcela Del Rio
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | - Jacqueline Lamour
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | - Rosanna Ricafort
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | - Rebecca P. Madan
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
| | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, NY, USA
,Children’s Hospital at Montefiore, Bronx, NY, USA
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De Keyzer K, Van Laecke S, Peeters P, Vanholder R. Human cytomegalovirus and kidney transplantation: a clinician's update. Am J Kidney Dis 2011; 58:118-26. [PMID: 21684438 DOI: 10.1053/j.ajkd.2011.04.010] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 04/13/2011] [Indexed: 01/15/2023]
Abstract
Infection with human cytomegalovirus (CMV) is an important cause of morbidity and mortality in kidney transplant recipients. CMV disease is diagnosed based on the detection of viral replication by phosphoprotein 65 antigenemia or CMV DNA polymerase chain reaction in combination with typical signs and symptoms. Risk factors include CMV-seronegative recipients receiving a CMV-seropositive transplant, older donor age, exposure to cyclosporine and/or antilymphocyte antibody, rejection episodes, and impaired transplant function. Current preventive strategies in kidney transplant recipients include pre-emptive therapy with valganciclovir or intravenous ganciclovir and universal prophylaxis with valacyclovir, valganciclovir, or ganciclovir for 3-6 months after kidney transplantation and for 1-3 months after treatment with antilymphocyte antibody. Established disease should be treated using either intravenous ganciclovir or oral valganciclovir until CMV replication can no longer be detected. In addition to direct effects, CMV infection also induces a wide range of indirect effects, such as decreased transplant and recipient survival and susceptibility to rejection and opportunistic infections. In this review, we highlight the most relevant topics on CMV and kidney transplantation based on current evidence and guidelines.
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Affiliation(s)
- Karen D. Sims
- Discovery Medicine, Virology, Bristol-Myers Squibb, PO Box 5400, Princeton, NJ 08543-5400, USA
| | - Emily A. Blumberg
- Division of Infectious Diseases, University of Pennsylvania Medical Center, University of Pennsylvania School of Medicine, 3 Silverstein Pavilion, Suite E, 3400 Spruce Street, Philadelphia, PA 19104, USA
- Corresponding author.
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Tayebi-Khosroshahi H, Makhdami N, Heris HK, Habibzadeh A, Zadimani A, Badrogli N. Universal prophylaxis with gancyclovir preparation is not necessary in our kidney allograft recipients. Transplant Proc 2011; 43:547-50. [PMID: 21440757 DOI: 10.1016/j.transproceed.2011.01.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is a common cause of morbidity, graft loss, and mortality among kidney recipients due to its direct and indirect influences on organs and systems. In this study, we evaluated CMV infection in transplant recipients in Iran. MATERIALS AND METHODS We performed a retrospective study of 104 renal allograft recipients and their donors transplanted between January 2005 and January 2010. We included all patients (recipients and donors) with least one valid laboratory result for CMV immunoglobulin (Ig)G and CMV IgM. We evaluated the occurrence of CMV disease in allograft recipients in at least the first 3 years after renal transplantation. RESULTS Fifty-seven renal allograft recipients (54.8%) were males and 47 (45.2%) were females. The overall mean (±standard error) age was 40.32±13.30 years. CMV IgG was positive in 95 cases (91.3%), negative in 9 (8.7%). Serologically, 76.9% patients were D+/R+ 14.4% D-/R+, and 8.7% D+R-. Due to the proccurrence of rejection rendering them high-risk patients for CMV infection about 15% of subjects were treated with anti thymocyte globulin (ATG) followed by prophylactic intravenous gancyclovir for 2 weeks, at doses based on allograft function. Confirmed CMV infection and CMV disease occurred in less than 5% of recipients in the first year after transplantation. About 6% of renal allograft recipients died due to infections during the first 3 years posttransplantation but CMV disease was not confirmed in these patients. CONCLUSION Due to the living donor-based renal transplantation program, the selection of low-risk patients (panel-reactive antibodies 30%), the low percent of D+/R- patients (8.7%) and the low use of ATG for induction therapy in the Iranian model, universal prophylaxis with gancyclovir is not routinely recommended for our cases.
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Affiliation(s)
- H Tayebi-Khosroshahi
- Kidney Transplant Center, Department of Internal Medicine, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
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Abstract
Human cytomegalovirus continues to impact adversely on the outcome of solid organ and stem cell transplantation and remains a major cause of congenital abnormalities. In the absence of a vaccine, antiviral drugs have been the mainstay of therapy. Although very few anticytomegalovirus drugs are currently licensed, there are multiple opportunities within the viral life cycle for drug development. In this article we summarize some of the key new antiviral agents undergoing preclinical and clinical development against a range of targets in the viral life cycle, highlighting those where further development is warranted or being undertaken.
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Affiliation(s)
| | - Richard SB Milne
- Medical Research Council Centre for Medical Molecular Virology, Division of Infection & Immunity, Department of Infection, University College Medical School (Royal Free Campus), Rowland Hill Street, Hampstead, London NW3 2QG, UK
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Abstract
Human cytomegalovirus (CMV), one of the eight herpesviruses that commonly infect humans, is best known for its propensity to cause disease in immunocompromised patients, especially transplant recipients, patients with advanced AIDS, and congenitally infected newborns. Advances in molecular virology coupled with improvements in diagnostic methods and treatment options have vastly improved our understanding of and ability to manage CMV, but many uncertainties remain, including the mechanisms of persistence and pathogenesis and its hypothesized roles in a variety of human illnesses. Here we review recent advances that are reshaping our view and approach to this fascinating virus.
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Affiliation(s)
- Michael Boeckh
- Division of Vaccine and Infectious Disease and
Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
Department of Medicine, University of Washington, Seattle, Washington, USA.
Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - Adam P. Geballe
- Division of Vaccine and Infectious Disease and
Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
Department of Medicine, University of Washington, Seattle, Washington, USA.
Division of Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
Department of Microbiology, University of Washington, Seattle, Washington, USA
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24 weeks of valganciclovir prophylaxis in children after renal transplantation: a 4-year experience. Transplantation 2011; 91:245-50. [PMID: 21076375 DOI: 10.1097/tp.0b013e3181ffffd3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is the most common opportunistic infection after solid-organ transplant. Valganciclovir prophylaxis significantly reduces disease, but limited data are available on its use in children. Recently, an increase in delayed-onset CMV disease has been noted with some arguing that longer prophylaxis may decrease late-onset disease. METHODS Single-center, retrospective analysis of pediatric renal transplant patients receiving 24 weeks valganciclovir prophylaxis (15 mg/kg/day, maximum 900 mg/day) from January 2004 to December 2008, aiming to measure the incidence of CMV disease and toxicity of valganciclovir. RESULTS We enrolled 111 patients, 60% males, 46% African Americans, and median age at transplant 14.5 years (range 1.4-20.4 years). Sixty-nine percent of donors and 44% of recipients were seropositive pretransplant. Median duration of valganciclovir use was 5.9 months (range 0.5-24 months). CMV viremia and disease occurred in 27% and 4.5%, respectively. All patients with disease presented after prophylaxis ended and all were D+/R-. Thymoglobulin use (P = 0.04) and positive donor CMV status (P = 0.02) were associated with a higher risk of CMV viremia. Twenty-four percent had hematologic toxicity directly associated with valganciclovir. CONCLUSIONS Valganciclovir use in children was effective as prophylaxis against CMV disease; no children at our institution developed disease while on therapy. Our regimen of 24 weeks of prophylaxis was associated with a lower rate of late-onset disease than previous reports with 12-week regimens. Further controlled studies should be considered to compare longer versus shorter periods of prophylaxis and dose reductions and their impact on prevention of late-onset disease, resistance, cost, and toxicity.
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Kalil AC, Sun J, Florescu DF. IMPACT trial results should not change current standard of care of 100 days for cytomegalovirus prophylaxis. Am J Transplant 2011; 11:18-21. [PMID: 21199346 PMCID: PMC3059768 DOI: 10.1111/j.1600-6143.2010.03342.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The results of the IMPACT trial showed a significant reduction in cytomegalovirus disease with 200-day valganciclovir prophylaxis compared to the standard 100-day regimen with the same drug. These results may have the potential to change the standard of care in most transplant centers. However, we have concerns with the design, execution and statistical analysis of this trial. Our study aimed to describe each of these issues and to provide possible solutions for the better understanding of the IMPACT trial. We conclude that the IMPACT trial does not have the strength of evidence to change current clinical practice of 100-day cytomegalovirus prophylaxis. Further, based on all available evidence, we consider that another clinical trial to test 200-day CMV prophylaxis is not necessary.
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Affiliation(s)
- Andre C Kalil
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE,Corresponding Author: Andre Kalil, M.D., Associate Professor of Medicine, University of Nebraska, Director, Transplant ID Program, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, Office: (402) 559-8650, Fax: (402) 559-5581,
| | | | - Diana F Florescu
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE
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Death with functioning kidney transplant: an obituarial analysis. Int Urol Nephrol 2010; 42:929-34. [PMID: 20521168 PMCID: PMC2995205 DOI: 10.1007/s11255-010-9721-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 02/18/2010] [Indexed: 11/01/2022]
Abstract
BACKGROUND Death with a functioning kidney graft (DWFG) is now a major cause of graft loss after renal transplantation, occurring in up to 40% of cases. Its occurrence provides insight into the medical care of subjects with a functioning kidney transplant. In this study, we used the time to DWFG as an endpoint, to test whether improved medical care has contributed to better kidney transplant outcomes. METHODS We used single-center data from the Milwaukee Regional Medical Center and Froedtert Hospital, on kidney-only transplants from 1969 through 2005. A total of 3,157 kidney transplants were done at our center during this time. There were 714 deaths with functioning kidney. We also recorded the major causes of DWFG over the time period from 1969 through 2005 divided into 3 epochs. The data were analyzed as a serial collection of yearly obituaries. RESULTS The time to DWFG has increased to 10 years despite a 20-year increase in the mean age of transplant recipients over the same time period. CONCLUSIONS Better pre-transplant evaluation, improved treatments for hypertension and hyperlipidemia, improved management of acute myocardial infarction, superior immunosuppressive protocols and better prophylaxis and treatment of infectious diseases have all likely contributed to this trend.
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HODSON ELISABETHM, CRAIG JONATHANC. How to apply results from randomized trials and systematic reviews to individual patient care. Nephrology (Carlton) 2010; 15:277-80. [DOI: 10.1111/j.1440-1797.2010.01281.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Características de los fármacos antivíricos frente a virus del grupo herpes actualización 2009. Enferm Infecc Microbiol Clin 2010; 28:199.e1-199.e33. [DOI: 10.1016/j.eimc.2009.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Revised: 11/23/2009] [Accepted: 11/24/2009] [Indexed: 11/20/2022]
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Bugano D, Campos S, Afonso J, Caramori M, Teixeira R, Carraro R, Strabelli T, Machado C, Samano M, Pêgo-Fernandes P, Jatene F. Impact of Cytomegalovirus Infection in Lung Transplant Patients Under Universal Prophylaxis: Single-Center Experience in Brazil. Transplant Proc 2010; 42:525-30. [DOI: 10.1016/j.transproceed.2010.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ranganathan K, Worley S, Michaels MG, Arrigan S, Aurora P, Ballmann M, Boyer D, Conrad C, Eichler I, Elidemir O, Goldfarb S, Mallory GB, Mogayzel PJ, Parakininkas D, Solomon M, Visner G, Sweet SC, Faro A, Danziger-Isakov L. Cytomegalovirus immunoglobulin decreases the risk of cytomegalovirus infection but not disease after pediatric lung transplantation. J Heart Lung Transplant 2010; 28:1050-6. [PMID: 19782286 DOI: 10.1016/j.healun.2009.04.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 04/08/2009] [Accepted: 04/29/2009] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) has been associated with morbidity, including chronic allograft rejection, in transplant recipients. Data from adult centers suggests that CMV hyperimmune globulin (CMVIG) and ganciclovir together are superior in preventing CMV viremia than ganciclovir alone. METHODS A retrospective review of pediatric lung transplant recipients at 14 sites in North America and Europe was conducted to evaluate the effect of adding cytomegalovirus immunoglobulin (CMVIG) prophylaxis to at least 3 weeks of intravenous ganciclovir therapy in pediatric lung transplant recipients. Data were recorded for the first year after transplantation. Associations between time to CMV and risk factors, including CMVIG use, were assessed by multivariable Cox proportional hazards models. RESULTS Of 599 patients whose records were reviewed, 329 received at least 3 weeks of ganciclovir, with 62 (19%) receiving CMVIG. CMVIG was administered more frequently with CMV donor-positive/recipient-negative serostatus (p < 0.05). In multivariable models, patients who did not receive CMVIG as part of their prophylaxis were 3 times more likely to develop CMV infection (hazard ratio, 3.4; 95% confidence interval, 1.2-9.5) independent of CMV serostatus. However, CMVIG administration was not associated with decreased risk of episodes of CMV disease. Receipt of CMVIG was not associated with decreased risks of post-transplant morbidities (acute rejection, respiratory viral infection or early bronchiolitis obliterans) or morbidity within the first year after pediatric lung transplantation. CONCLUSION The use of CMVIG in addition to antiviral prophylaxis in pediatric lung transplantation requires further evaluation.
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Luan FL, Stuckey LJ, Park JM, Kaul D, Cibrik D, Ojo A. Six-month prophylaxis is cost effective in transplant patients at high risk for cytomegalovirus infection. J Am Soc Nephrol 2009; 20:2449-58. [PMID: 19762495 DOI: 10.1681/asn.2008111166] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The risk of late-onset cytomegalovirus (CMV) infection remains a concern in seronegative kidney and/or pancreas transplant recipients of seropositive organs despite the use of antiviral prophylaxis. The optimal duration of prophylaxis is unknown. We studied the cost effectiveness of 6- versus 3-mo prophylaxis with valganciclovir. A total of 222 seronegative recipients of seropositive kidney and/or pancreas transplants received valganciclovir prophylaxis for either 3 or 6 mo during two consecutive time periods. We assessed the incidence of CMV infection and disease 12 mo after completion of prophylaxis and performed cost-effectiveness analyses. The overall incidence of CMV infection and disease was 26.7% and 24.4% in the 3-mo group and 20.9% and 12.1% in the 6-mo group, respectively. Six-month prophylaxis was associated with a statistically significant reduction in risk for CMV disease (HR, 0.35; 95% CI, 0.17 to 0.72), but not infection (HR, 0.65; 95% CI, 0.37 to 1.14). Cost-effectiveness analyses showed that 6-mo prophylaxis combined with a one-time viremia determination at the end of the prophylaxis period incurred an incremental cost of $34,362 and $16,215 per case of infection and disease avoided, respectively, and $8,304 per one quality adjusted life-year gained. Sensitivity analyses supported the cost effectiveness of 6-mo prophylaxis over a wide range of valganciclovir and hospital costs, as well as variation in the incidence of CMV disease. In summary, 6-mo prophylaxis with valganciclovir combined with a one-time determination of viremia is cost effective in reducing CMV infection and disease in seronegative recipients of seropositive kidney and/or pancreas transplants.
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Affiliation(s)
- Fu L Luan
- Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA.
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Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6:e1000100. [PMID: 19621070 PMCID: PMC2707010 DOI: 10.1371/journal.pmed.1000100] [Citation(s) in RCA: 10533] [Impact Index Per Article: 702.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement--a reporting guideline published in 1999--there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
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Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339:b2700. [PMID: 19622552 PMCID: PMC2714672 DOI: 10.1136/bmj.b2700] [Citation(s) in RCA: 12509] [Impact Index Per Article: 833.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2009] [Indexed: 02/06/2023]
Abstract
Systematic reviews and meta-analyses are essential to summarise evidence relating to efficacy and safety of healthcare interventions accurately and reliably. The clarity and transparency of these reports, however, are not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users. Since the development of the QUOROM (quality of reporting of meta-analysis) statement-a reporting guideline published in 1999-there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realising these issues, an international group that included experienced authors and methodologists developed PRISMA (preferred reporting items for systematic reviews and meta-analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions. The PRISMA statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this explanation and elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA statement, this document, and the associated website (www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.
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Abstract
Donor-derived infectious diseases are infections that are present in an organ donor and have the potential to be transmitted to at least 1 transplant recipient. Several recent transmissions have been covered by the lay media and in the medical literature, including a recent transmission of HIV and hepatitis C virus from 1 donor to 4 recipients. These reports have highlighted the importance and clinical impact of this rare complication of organ transplantation. Donor-derived infectious diseases appear to complicate less than 1% of all transplant procedures, but, when a transmission occurs, significant morbidity and mortality can occur. A number of guidelines and policies define the optimal screening of organ donors to prevent the transmission of infectious diseases. Unfortunately, there are significant limitations in our screening methods, and only some pathogens are screened for routinely. The regulatory framework related to and the epidemiology, identification, and management of donor-derived infectious disease transmission shall be reviewed.
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Prophylaxis and Treatment of Cytomegalovirus Infection Postrenal Transplantation in Two Madrid Units. Transplant Proc 2009; 41:2416-8. [DOI: 10.1016/j.transproceed.2009.06.161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Osawa R, Singh N. Cytomegalovirus infection in critically ill patients: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R68. [PMID: 19442306 PMCID: PMC2717427 DOI: 10.1186/cc7875] [Citation(s) in RCA: 141] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 03/25/2009] [Accepted: 05/14/2009] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The precise role of cytomegalovirus (CMV) infection in contributing to outcomes in critically ill immunocompetent patients has not been fully defined. METHODS Studies in which critically ill immunocompetent adults were monitored for CMV infection in the intensive care unit (ICU) were reviewed. RESULTS CMV infection occurs in 0 to 36% of critically ill patients, mostly between 4 and 12 days after ICU admission. Potential risk factors for CMV infection include sepsis, requirement of mechanical ventilation, and transfusions. Prolonged mechanical ventilation (21 to 39 days vs. 13 to 24 days) and duration of ICU stay (33 to 69 days vs. 22 to 48 days) correlated significantly with a higher risk of CMV infection. Mortality rates in patients with CMV infection were higher in some but not all studies. Whether CMV produces febrile syndrome or end-organ disease directly in these patients is not known. CONCLUSIONS CMV infection frequently occurs in critically ill immunocompetent patients and may be associated with poor outcomes. Further studies are warranted to identify subsets of patients who are likely to develop CMV infection and to determine the impact of antiviral agents on clinically meaningful outcomes in these patients.
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Affiliation(s)
- Ryosuke Osawa
- Infectious Diseases Section, VA Medical Center, University Drive C, Pittsburgh, PA 15420 USA.
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Wong SSY, Yuen KY. Antiviral therapy for respiratory tract infections. Respirology 2008; 13:950-71. [PMID: 18922142 PMCID: PMC7192202 DOI: 10.1111/j.1440-1843.2008.01404.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 07/10/2008] [Accepted: 08/04/2008] [Indexed: 12/24/2022]
Abstract
Viruses are important pathogens causing respiratory tract infections both in the community and health-care facility settings. They are extremely common causes of morbidity in the competent hosts and some are associated with significant mortality in the compromised individuals. With wider application of molecular techniques, novel viruses are being described and old viruses are found to have new significance in different epidemiological and clinical settings. Some of these emerging pathogens may have the potential to cause pandemics or global spread of a severe disease, as exemplified by severe acute respiratory syndrome and avian influenza. Antiviral therapy of viral respiratory infections is often unnecessary in the competent hosts because most of them are selflimiting and effective agents are not always available. In the immunocompromised individuals or for infections caused by highly pathogenic viruses, such as avian influenza viruses (AIV), antiviral treatment is highly desirable, despite the fact that many of the agents may not have undergone stringent clinical trials. In immunocompetent hosts, antiviral therapy can be stopped early because adaptive immune response can usually be mounted within 5-14 days. However, the duration of antiviral therapy in immunosuppressed hosts depends on clinical and radiological resolution, the degree and duration of immunosuppression, and therefore maintenance therapy is sometimes needed after the initial response. Immunotherapy and immunoprophylaxis appear to be promising directions for future research. Appropriate and targeted immunomodulation may play an important adjunctive role in some of these infections by limiting the extent of end-organ damage and multi-organ failure in some fulminant infections.
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Affiliation(s)
- Samson S Y Wong
- Department of Microbiology, Research Centre of Infection and Immunology, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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