Cytomegalovirus prophylaxis with valganciclovir in cytomegalovirus-seropositive kidney-transplant patients

Opportunistic infections after conversion to belatacept in kidney transplantation

BACKGROUND

Belatacept (bela) rescue therapy seems to be a valuable option for calcineurin inhibitor chronic toxicity in kidney transplantation. Nevertheless, the risk of infection associated with bela is not well reported.

METHODS

We report the rate of opportunistic infections (OPI) after a switch to bela in a multicentric cohort of 280 kidney transplant patients.

RESULTS

Forty-two OPI occurred in 34 patients (12.1%), on average 10.8 ± 11.3 months after the switch. With a cumulative exposure of 5128 months of bela treatment, we found an incidence of 0.008 OPI/month of exposure, and 9.8 OPI/100 person-years. The most common OPI was cytomegalovirus (CMV) disease in 18/42 OPI (42.9%) and pneumocystis pneumonia in 12/42 OPI (28.6%). Two patients presented a progressive multifocal leucoencephalopathy and two patients developed a cerebral Epstein-Barr virus-induced post-transplant lymphoproliferative disease. OPI led to death in 9/34 patients (26.5%) and graft failure in 4/34 patients (11.8%). In multivariate analysis, estimated glomerular filtration rate <25/mL/min/1.73 m2 on the day of the switch and the use of immunosuppressive agents before transplantation were associated with the occurrence of OPI. We found a higher rate of infection-related hospitalization (24.1 versus 12.3/100 person-years, P = 0.0007) and also a higher rate of OPI (13.2 versus 6.7/100 person-years, P = 0.005) in the early conversion group (within 6 months).

CONCLUSIONS

The risk of OPI is significant post-conversion to bela and may require additional monitoring and prophylactic therapy, particularly regarding pneumocystis pneumonia and CMV disease. These data need to be confirmed in a larger case-control study.

Age matters: older age as a risk factor for CMV reactivation in the CMV serostatus-positive kidney transplant recipient

Evaluate risk factors for cytomegalovirus (CMV) reactivation during the first year after kidney transplantation in the CMV-seropositive older recipient. Retrospective single-center study. Between 2011 and 2015, 91 patients ≥ 65 years received a kidney transplant; these were matched with 91 controls, aged 40-60. Risk of CMV reactivation in the CMV-seropositive recipients was analyzed. Sixty-three older and 54 younger recipients were included; 50% had received CMV-directed prophylaxis. CMV reactivation was significantly more frequent in the older group (71.4% vs 44.4%, p = 0.003) and occurred earlier (p = 0.003). A multivariate model showed that only age was associated with CMV reactivation (OR 2.48, p = 0.03). After excluding patients that received thymoglobulin, older age group remained the only risk factor of CMV reactivation (OR 3.81, p = 0.014). Recurrent event analysis showed that the older cohort had an HR of 1.94 (p = 0.01) of CMV viremia; there was significant episode-cohort interaction (p < 0.01). While the older group had a higher risk of infection (HR = 2.43), after the initial episode the relative hazards were approximately equal (HR = 1.08, at period 2). This suggests that it is key to specifically avoid the first episode of reactivation. Universal prophylaxis or a hybrid prophylaxis model should be considered in the CMV-seropositive kidney transplant recipient aged ≥ 65 years.

Belatacept and mediastinal histoplasmosis in a kidney transplant patient

Background: In transplantation immunosuppression enhances the appearance of opportunist infections. An ideal balance between the prevention of rejection, the lowest risk of infections and the highest rates of graft survival is a continuous challenge. Lower doses of immunosuppression may diminish the risk of infections, metabolic and hemodynamic complications or even of malignancy, but may expose patients to episodes of acute rejection. New drugs are being developed to improve graft survival at the lowest risk of side effects. Belatacept has recently been introduced in kidney transplantation to inhibit the co-ligand signal of T cell stimulation. It is a drug with a safe profile, is well-tolerated and appears to improve long-term survival of kidney grafts. However, there may be an increase in opportunistic infections which may be facilitated by T cell depression, as Aspergillus sp., Cryptococcus neoformans or tuberculosis.

Case Presentation: We describe a 59-year-old female who developed fever, clinical wasting and a mediastinal mass 31 months after receiving a living non-related kidney transplant while on belatacept therapy. A mediastinal node biopsy disclosed the presence of Histoplasma capsulatum. Infection successfully resolved after appropriate antifungal treatment.

Conclusions: To our knowledge, this is the first reported case of Histoplasma capsulatum in a kidney transplanted patient on belatacept therapy

Historical comparison of prophylactic ganciclovir for gastrointestinal cytomegalovirus infection in kidney transplant recipients

BACKGROUND

Cytomegalovirus (CMV) can cause morbidity in kidney transplant recipients. The gastrointestinal (GI) tract is a major target for CMV disease. The aim of this study was to evaluate the benefit of ganciclovir prophylaxis on GI CMV infection in intermediate-risk CMV seropositive transplant recipients.

METHODS

Since January 2009, intravenous ganciclovir (5 mg/kg, twice daily) was administered for 14 days after kidney transplantation in 41 patients. The historical control group consisted of 45 patients who received kidney transplantations between January 2007 and December 2008. To evaluate the effects of prophylaxis on GI CMV infection, we performed routine endoscopic examinations with mucosal biopsies at the time of transplantation as well as 1, 3, and 6 months thereafter.

RESULTS

The average age of the 86 studied patients was 43.7 ± 10.6 years (range = 14-63) and the male-to-female ratio 1:1.3. Forty-three (50%) patients underwent deceased donor transplantations and 84 (97.7%) patients were CMV seropositive at that time. The incidence of GI CMV infection was significantly lower among the prophylaxis than the historical control group (24.4% vs 48.9%, P = .026). Patient age, numbers of deceased donors, and tacrolimus trough levels at 1 and 3 months posttransplant were significantly lower in the prophylaxis than the historical control group. Logistic regression analysis revealed ganciclovir prophylaxis to be the only significant risk factor for GI CMV infection.

CONCLUSION

Prophylactic treatment with ganciclovir decreased the incidence GI CMV infection among seropositive kidney transplant recipients.

Post-transplant aspergillosis and the role of combined neurosurgical and antifungal therapies under belatacept immunosuppression

Opportunistic CNS-infection represent a major threat to patients after organ transplantation due to the need for ongoing immunosuppression and belatacept is a novel CTL4A inhibitor, which is increasingly used for patients following cadaveric kidney transplantation. Among the CNS infections, intracranial Aspergillus is a particular challenge and poses difficulties for its insidious onset, a timely and accurate diagnosis, and its management due to high mortality rates. To this end we want to illustrate the management of this scenario as encountered in a 71-year-old female patient, who was admitted into our institution in June 2007 with speech difficulties and gait instability 1.5 years after cadaveric kidney transplantation. On imaging, both a mediastinal and left frontal mass were found. Radiographically guided sampling of the mediastinal mass and a stereotactic biopsy of the left frontal brain lesion revealed Aspergillus fumigatus. With modification of immunosuppression and directed antifungal therapy there was complete resolution of the chest lesion; the brain lesion initially responded well but later progressed in size. Surgical intervention via a left fronto-temporal craniotomy with intraoperative image guidance was performed for a gross total resection of the lesion. Twenty-four months from resection, she remains on voriconazole with no evidence of recurrence and complete neurologic recovery and preserved renal function.

[Cytomegalovirus effects in solid organ transplantation and the role of antiviral prophylaxis]

Cytomegalovirus (CMV) belongs to β-Herpesviridae family. Morbidity related to this infectious agent remains a serious concern in the context of immunosuppression. Occurence of CMV infection within the first 3 months post-renal transplantation without any antiviral prophylaxis is about 70% of patients. Direct and indirect effects of CMV infection in the setting of organ transplantation are described in this review. A 3 to 6 months course of prophylaxis with valganciclovir is advised concerning high-risk transplant recipients (D+/R-) but recommendation regarding intermediate-risk transplant recipients (CMV-seropositive patients) is still unclear. Recent studies highlight a benefit of long time prophylaxis (until 6 months) in terms of CMV disease occurence among D+/R- patients. News assays that measures IFNγ responses to a variety of CMV epitopes (Quantiferon(®) and Elispot IFNγ) are developped to predict CMV disease onset after discontinuation of antiviral prophylaxis. These assays could contribute to adapt prophylaxis to each recipient.

Antiviral therapy for respiratory tract infections

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.