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Pan X, Peng J, Zhu R, An N, Pei J. Non-invasive biomarkers of acute rejection in pediatric kidney transplantation: New targets and strategies. Life Sci 2024; 348:122698. [PMID: 38710278 DOI: 10.1016/j.lfs.2024.122698] [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: 02/01/2024] [Revised: 04/17/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
Kidney transplantation is the preferred treatment for pediatric end-stage renal disease. However, pediatric recipients face unique challenges due to their prolonged need for kidney function to accommodate growth and development. The continual changes in the immune microenvironment during childhood development and the heightened risk of complications from long-term use of immunosuppressive drugs. The overwhelming majority of children may require more than one kidney transplant in their lifetime. Acute rejection (AR) stands as the primary cause of kidney transplant failure in children. While pathologic biopsy remains the "gold standard" for diagnosing renal rejection, its invasive nature raises concerns regarding potential functional impairment and the psychological impact on children due to repeated procedures. In this review, we outline the current research status of novel biomarkers associated with AR in urine and blood after pediatric kidney transplantation. These biomarkers exhibit superior diagnostic and prognostic performance compared to conventional ones, with the added advantages of being less invasive and highly reproducible for long-term graft monitoring. We also integrate the limitations of these novel biomarkers and propose a refined monitoring model to optimize the management of AR in pediatric kidney transplantation.
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Affiliation(s)
- Xingyu Pan
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Jinpu Peng
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Rong Zhu
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Nini An
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Jun Pei
- Department of Pediatric surgrey, Guizhou Provincial People's Hospital, Guiyang 550002, China.
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2
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Bertazza Partigiani N, Negrisolo S, Carraro A, Marzenta D, Manaresi E, Gallinella G, Barzon L, Benetti E. Pre-Existing Intrarenal Parvovirus B19 Infection May Relate to Antibody-Mediated Rejection in Pediatric Kidney Transplant Patients. Int J Mol Sci 2023; 24:ijms24119147. [PMID: 37298109 DOI: 10.3390/ijms24119147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/01/2023] [Accepted: 05/20/2023] [Indexed: 06/12/2023] Open
Abstract
Viral infections can lead to transplant dysfunction, and their possible role in rejection is described. In total, 218 protocol biopsies performed in 106 children at 6, 12 and 24 months after transplantation were analyzed according to Banff '15. RT-PCR for cytomegalovirus, Epstein-Barr virus, BK virus and Parvovirus B19 was performed on blood and bioptic samples at the time of transplant and each protocol biopsy. The prevalence of intrarenal viral infection increases between 6 and 12 months after transplantation (24% vs. 44%, p = 0.007). Intrarenal Parvovirus B19 infection is also associated with antibody-mediated rejection (ABMR) (50% ABMR vs. 19% T-cell-mediated rejection, p = 0.04). Moreover, Parvovirus infection is higher at 12 months of follow-up and it decreases at 48 months (40.4% vs. 14%, p = 0.02), while in 24% of grafts, Parvovirus is already detectable at the moment of transplantation. Intrarenal Parvovirus B19 infection seems to be related to ABMR in pediatric kidney recipients. The graft itself may be the way of transmission for Parvovirus, so performance of a PCR test for Parvovirus B19 should be considered to identify high-risk patients. Intrarenal Parvovirus infection presents mainly during the first-year post-transplantation; thus, we recommend an active surveillance of donor-specific antibodies (DSA) in patients with intrarenal Parvovirus B19 infection during this period. Indeed, it should be considered a treatment with intravenous immunoglobulins in patients with intrarenal Parvovirus B19 infection and DSA positivity, even in the absence of ABMR criteria for kidney biopsy.
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Affiliation(s)
- Nicola Bertazza Partigiani
- Pediatric Nephrology, Department of Women's and Children's Health, University Hospital of Padua, 35128 Padua, Italy
- Department of Women's and Children's Health, University of Padua, 35128 Padua, Italy
| | - Susanna Negrisolo
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women's and Children's Health, University of Padova, 35127 Padua, Italy
- Pediatric Research Institute "IRP Città della Speranza", 35127 Padua, Italy
| | - Andrea Carraro
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women's and Children's Health, University of Padova, 35127 Padua, Italy
| | - Diana Marzenta
- Pediatric Nephrology, Department of Women's and Children's Health, University Hospital of Padua, 35128 Padua, Italy
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women's and Children's Health, University of Padova, 35127 Padua, Italy
| | - Elisabetta Manaresi
- Department of Pharmacy and Biotechnology, University of Bologna, 40138 Bologna, Italy
| | - Giorgio Gallinella
- Department of Pharmacy and Biotechnology, University of Bologna, 40138 Bologna, Italy
| | - Luisa Barzon
- Department of Molecular Medicine, University of Padua, 35121 Padua, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Department of Women's and Children's Health, University Hospital of Padua, 35128 Padua, Italy
- Laboratory of Immunopathology and Molecular Biology of the Kidney, Department of Women's and Children's Health, University of Padova, 35127 Padua, Italy
- Pediatric Research Institute "IRP Città della Speranza", 35127 Padua, Italy
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3
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van der Velden FJS, de Vries G, Martin A, Lim E, von Both U, Kolberg L, Carrol ED, Khanijau A, Herberg JA, De T, Galassini R, Kuijpers TW, Martinón-Torres F, Rivero-Calle I, Vermont CL, Hagedoorn NN, Pokorn M, Pollard AJ, Schlapbach LJ, Tsolia M, Elefhteriou I, Yeung S, Zavadska D, Fink C, Voice M, Zenz W, Kohlmaier B, Agyeman PKA, Usuf E, Secka F, de Groot R, Levin M, van der Flier M, Emonts M. Febrile illness in high-risk children: a prospective, international observational study. Eur J Pediatr 2023; 182:543-554. [PMID: 36243780 PMCID: PMC9899189 DOI: 10.1007/s00431-022-04642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/21/2022] [Accepted: 09/30/2022] [Indexed: 02/07/2023]
Abstract
To assess and describe the aetiology and management of febrile illness in children with primary or acquired immunodeficiency at high risk of serious bacterial infection, as seen in emergency departments in tertiary hospitals. Prospective data on demographics, presenting features, investigations, microbiology, management, and outcome of patients within the 'Biomarker Validation in HR patients' database in PERFORM, were analysed. Immunocompromised children (< 18 years old) presented to fifteen European hospitals in nine countries, and one Gambian hospital, with fever or suspected infection and clinical indication for blood investigations. Febrile episodes were assigned clinical phenotypes using the validated PERFORM algorithm. Logistic regression was used to assess the effect size of predictive features of proven/presumed bacterial or viral infection. A total of 599 episodes in 482 children were analysed. Seventy-eight episodes (13.0%) were definite bacterial, 67 episodes probable bacterial (11.2%), and 29 bacterial syndrome (4.8%). Fifty-five were definite viral (9.2%), 49 probable viral (8.2%), and 23 viral syndrome (3.8%). One hundred ninety were unknown bacterial or viral infections (31.7%), and 108 had inflammatory or other non-infectious causes of fever (18.1%). Predictive features of proven/presumed bacterial infection were ill appearance (OR 3.1 (95% CI 2.1-4.6)) and HIV (OR 10.4 (95% CI 2.0-54.4)). Ill appearance reduced the odds of having a proven/presumed viral infection (OR 0.5 (95% CI 0.3-0.9)). A total of 82.1% had new empirical antibiotics started on admission (N = 492); 94.3% proven/presumed bacterial (N = 164), 66.1% proven/presumed viral (N = 84), and 93.2% unknown bacterial or viral infections (N = 177). Mortality was 1.9% (N = 11) and 87.1% made full recovery (N = 522). Conclusion: The aetiology of febrile illness in immunocompromised children is diverse. In one-third of cases, no cause for the fever will be identified. Justification for standard intravenous antibiotic treatment for every febrile immunocompromised child is debatable, yet effective. Better clinical decision-making tools and new biomarkers are needed for this population. What is Known: • Immunosuppressed children are at high risk for morbidity and mortality of serious bacterial and viral infection, but often present with fever as only clinical symptom. • Current diagnostic measures in this group are not specific to rule out bacterial infection, and positivity rates of microbiological cultures are low. What is New: • Febrile illness and infectious complications remain a significant cause of mortality and morbidity in HR children, yet management is effective. • The aetiology of febrile illness in immunocompromised children is diverse, and development of pathways for early discharge or cessation of intravenous antibiotics is debatable, and requires better clinical decision-making tools and biomarkers.
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Affiliation(s)
- Fabian J S van der Velden
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Gabriella de Vries
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Alexander Martin
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Emma Lim
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ulrich von Both
- Division Paediatric Infectious Diseases, Dr. Von Hauner Children's Hospital, University Hospital LMU Munich, Munich, Germany
| | - Laura Kolberg
- Division Paediatric Infectious Diseases, Dr. Von Hauner Children's Hospital, University Hospital LMU Munich, Munich, Germany
| | - Enitan D Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK.,Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Aakash Khanijau
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK.,Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jethro A Herberg
- Section of Paediatric Infectious Disease, Wright-Fleming Institute, Imperial College London, London, UK
| | - Tisham De
- Section of Paediatric Infectious Disease, Wright-Fleming Institute, Imperial College London, London, UK
| | - Rachel Galassini
- Section of Paediatric Infectious Disease, Wright-Fleming Institute, Imperial College London, London, UK
| | - Taco W Kuijpers
- Department of Pediatric Immunology, Rheumatology and Infectious Diseases, Amsterdam University Medical Center, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Federico Martinón-Torres
- Pediatrics Department, Translational Pediatrics and Infectious Diseases, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain.,Grupo de Genetica, Vacunas, Infecciones y Pediatria, Instituto de Investigacion Sanitaria de Santiago, Universidad de Santiago, Santiago de Compostela, Spain.,Consorcio Centro de Investigacion Biomedicaen Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Irene Rivero-Calle
- Pediatrics Department, Translational Pediatrics and Infectious Diseases, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Clementien L Vermont
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nienke N Hagedoorn
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marko Pokorn
- University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Luregn J Schlapbach
- Neonatal and Pediatric Intensive Care Unit, Children's Research Center, University Children's Hospital Zürich, University of Zürich, Zurich, Switzerland
| | - Maria Tsolia
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens, Children's Hospital 'P, and A. Kyriakou', Athens, Greece
| | - Irini Elefhteriou
- 2nd Department of Pediatrics, National and Kapodistrian University of Athens, Children's Hospital 'P, and A. Kyriakou', Athens, Greece
| | - Shunmay Yeung
- Clinical Research Department, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, UK
| | - Dace Zavadska
- Department of Pediatrics, Rīgas Stradina Universitāte, Children's Clinical University Hospital, Riga, Latvia
| | - Colin Fink
- Micropathology Ltd, University of Warwick, Warwick, UK
| | - Marie Voice
- Micropathology Ltd, University of Warwick, Warwick, UK
| | - Werner Zenz
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Benno Kohlmaier
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Effua Usuf
- Medical Research Council Unit, Serrekunda, The Gambia
| | - Fatou Secka
- Medical Research Council Unit, Serrekunda, The Gambia
| | - Ronald de Groot
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael Levin
- Section of Paediatric Infectious Disease, Wright-Fleming Institute, Imperial College London, London, UK
| | - Michiel van der Flier
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands.,Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases & Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK. .,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK. .,NIHR Newcastle Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Trust and Newcastle University, Newcastle upon Tyne, UK.
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4
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Serkies K, Dębska-Ślisień A, Kowalczyk A, Lizakowski S, Małyszko J. Malignancies in adult kidney transplant candidates and recipients: current status. Nephrol Dial Transplant 2022:6674222. [PMID: 35998321 DOI: 10.1093/ndt/gfac239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Posttransplant malignancies, particularly recurrent and de novo, in solid organs including kidney transplant recipients (KTRs) are a significant complication associated with substantial mortality, largely attributed to long-term immunosuppression necessary to maintain allograft tolerance. Older age at transplantation and oncogenic virus infection along with pretransplant malignancies are among the main factors contributing to the risk of cancer in this population. As the mean age of transplant candidates rises, the rate of transplant recipients with pretransplant malignancies also increases. The eligibility criteria for transplantation in patients with prior cancer have recently changed. The overall risk of posttransplant malignancies is at least double after transplantation including KTRs relative to the general population, most pronounced for skin cancers associated with UV radiation and virally-mediated tumors. The risk of renal cell carcinoma is specifically increased in the kidney transplant population. The therapy of cancer in transplant patients is associated with risk of higher toxicity, and graft rejection and/or impairment, which poses a unique challenge in the management. Reduction of immunosuppression and the use of mTOR inhibitors are common after cancer diagnosis, although optimal immunosuppression for transplant recipients with cancer remains undefined. Suboptimal cancer treatment contributing to a worse prognosis has been reported for malignancies in this population. In this article, we focus on the prevalence and outcomes of posttransplant malignancies, cancer therapy including a short overview of immunotherapy, cancer screening and prevention strategies, and immunosuppression as a cancer risk factor. The 2020/2021 recommendations of the Kidney Diseases Improving Global Outcome (KDIGO) and American Society of Transplantation (AST) for transplant candidates with a history of cancer are presented.
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Affiliation(s)
- Krystyna Serkies
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Poland
| | - Alicja Dębska-Ślisień
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Poland
| | - Anna Kowalczyk
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Poland
| | - Sławomir Lizakowski
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Poland
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5
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Charnaya O, Levy Erez D, Amaral S, Monos DS. Pediatric Kidney Transplantation-Can We Do Better? The Promise and Limitations of Epitope/Eplet Matching. Front Pediatr 2022; 10:893002. [PMID: 35722502 PMCID: PMC9204054 DOI: 10.3389/fped.2022.893002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/16/2022] [Indexed: 12/02/2022] Open
Abstract
Kidney transplant is the optimal treatment for end-stage kidney disease as it offers significant survival and quality of life advantages over dialysis. While recent advances have significantly improved early graft outcomes, long-term overall graft survival has remained largely unchanged for the last 20 years. Due to the young age at which children receive their first transplant, most children will require multiple transplants during their lifetime. Each subsequent transplant becomes more difficult because of the development of de novo donor specific HLA antibodies (dnDSA), thereby limiting the donor pool and increasing mortality and morbidity due to longer time on dialysis awaiting re-transplantation. Secondary prevention of dnDSA through increased post-transplant immunosuppression in children is constrained by a significant risk for viral and oncologic complications. There are currently no FDA-approved therapies that can meaningfully reduce dnDSA burden or improve long-term allograft outcomes. Therefore, primary prevention strategies aimed at reducing the risk of dnDSA formation would allow for the best possible long-term allograft outcomes without the adverse complications associated with over-immunosuppression. Epitope matching, which provides a more nuanced assessment of immunological compatibility between donor and recipient, offers the potential for improved donor selection. Although epitope matching is promising, it has not yet been readily applied in the clinical setting. Our review will describe current strengths and limitations of epitope matching software, the evidence for and against improved outcomes with epitope matching, discussion of eplet load vs. variable immunogenicity, and conclude with a discussion of the delicate balance of improving matching without disadvantaging certain populations.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniella Levy Erez
- Schneider Children's Medical Center, Institute of Pediatric Nephrology, Petah Tikvah, Israel
- Departments of Pediatric Nephrology and Biostatistics, Epidemiology and Informatics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sandra Amaral
- Departments of Pediatric Nephrology and Biostatistics, Epidemiology and Informatics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Dimitrios S. Monos
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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6
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Levi S, Davidovits M, Alfandari H, Dagan A, Borovitz Y, Bilavsky E, Landau D, Haskin O. EBV, CMV, and BK viral infections in pediatric kidney transplantation: Frequency, risk factors, treatment, and outcomes. Pediatr Transplant 2022; 26:e14199. [PMID: 34817112 DOI: 10.1111/petr.14199] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/26/2021] [Accepted: 11/06/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Improved short- and long-term outcomes of kidney transplantation have been achieved over the past decades due to improved immunosuppression. This may have increased the risk for infections and, particularly, for the viral infections: cytomegalovirus (CMV), Epstein-Barr virus (EBV), and polyoma BK virus (BKV). METHODS A retrospective review of viremic CMV, EBV, and BKV infections in pediatric renal transplant recipients treated and followed by a national referral center over a 10-year period. RESULTS Sixty-seven patients (68% males) received 68 kidney grafts (62% from living donors) during the study period; the mean follow-up period was 5.2 ± 2.4 years. Twenty-seven viremic episodes were documented (CMV: 13, EBV: 6, BKV: 8) in 24 patients (35.2%). The median time (interquartile range) to viremia post-transplant was 11 (4-38) months. The viral infection rate was significantly higher in the years 2014-2015 than in previous years (61% vs. 29%, p = .017). Compared to patients who did not develop viremia, patients with viremias were younger at the time of transplantation, were more likely to receive thymoglobulin induction pre-transplant and to develop an acute rejection. Multiple logistic regression modeling identified transplant year and recipient's age as significant risk factors for viremia. Graft outcome and eGFR at the last follow-up was similar between patients who did and did not develop viremia. CONCLUSIONS Viral infections continue to be a major cause of morbidity in pediatric kidney transplant recipients. However, with close monitoring and prompt intervention, patient and renal outcomes remain favorable.
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Affiliation(s)
- Shelly Levi
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Miriam Davidovits
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadas Alfandari
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Dagan
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Borovitz
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efraim Bilavsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pediatrics C, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Daniel Landau
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Haskin
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Yeo WS, Ng QX. Biomarkers of immune tolerance in kidney transplantation: an overview. Pediatr Nephrol 2022; 37:489-498. [PMID: 33712863 DOI: 10.1007/s00467-021-05023-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 02/09/2021] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Abstract
Kidney failure, one of the most prevalent diseases in the world and with increasing incidence, is associated with substantial morbidity and mortality. Currently available modes of kidney replacement therapy include dialysis and kidney transplantation. Though kidney transplantation is the preferred and ideal mode of kidney replacement therapy, this modality, however, is not without its risks. Kidney transplant recipients are constantly at risk of complications associated with immunosuppression, namely, opportunistic infections (e.g., Epstein-Barr virus and cytomegalovirus infections), post-transplant lymphoproliferative disorder, and complications associated with immunosuppressants (e.g., calcineurin inhibitor- and corticosteroid-associated new onset diabetes after transplantation and calcineurin inhibitor-associated nephrotoxicity). Transplantation tolerance, an acquired state in which immunocompetent recipients have developed donor-specific unresponsiveness, may be the Holy Grail in enabling optimal allograft survival and obviating the risks associated with immunosuppression in kidney transplant recipients. This review aims to discuss the biomarkers available to predict, identify, and define the transplant immune tolerant state and various tolerance induction strategies. Regrettably, pediatric patients have not been included in any tolerance studies and this should be the focus of future studies.
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Affiliation(s)
- Wee-Song Yeo
- Mount Elizabeth Hospital, 3 Mount Elizabeth, Singapore, 228510, Singapore.
| | - Qin Xiang Ng
- MOH Holdings Pte Ltd, 1 Maritime Square, Singapore, 099253, Singapore
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8
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Jain A, Daoud D, Kees-Folts D, Freeman MA, Butt F, Abendroth CS, Shike H, Kadry Z. Steroid-free maintenance immunosuppression using alemtuzumab in pediatric kidney transplantation: Long-term longitudinal follow-up. Pediatr Transplant 2022; 26:e14173. [PMID: 34687570 DOI: 10.1111/petr.14173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/17/2021] [Accepted: 10/05/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is a scarcity of long-term data on steroid-free immunosuppression using alemtuzumab in pediatric kidney transplantation (KTx). This study examines long-term outcomes with alemtuzumab without steroid maintenance therapy in pediatric KTx. METHODS From July 2005 to June 2015, 71 pediatric KTx recipients received alemtuzumab without steroid maintenance. They were followed from 4.1 to 14.1 years post KTx. RESULTS Patient survival: One child expired with a functioning graft from post-transplant lymphoproliferative disorder (PTLD). Patient survival was 98.6%. Graft survival: Eighteen grafts were lost (16 from chronic rejection). Graft survival at 5 and 10 years was 92.3% and 61.3%, respectively. Rejection: Twenty-three (32.4%) patients were free from T-cell-mediated rejection (TCMR), 16 (22.5%) had >3 episodes. Sixteen (22.5%) were treated for antibody-mediated rejection (AMR). Infection: Twenty-three children developed Epstein-Barr virus (EBV), 5 developed cytomegalovirus (CMV), and 20 developed BK virus infection. Four (5.6%) developed PTLD. Twenty-two (31.0%) required treatment for neutropenia. Growth parameters: Mean height and weight increased by 0.56 and 0.69 SDS (standard deviation score), respectively. Body mass index increased by 5.1 kg/m2 at 10 years. Less than 40% required antihypertensive medications at all-time points. CONCLUSION Alemtuzumab, without corticosteroid maintenance, offers 98.6% patient survival at 14 years with five and 10-year graft survival of 92.3% and 61.3%, respectively. TCMR and AMR requiring treatment were 67.4% and 22.5%, respectively. CMV, EBV, and BK viremia rates were 7.0%, 32.4%, and 28.2%, respectively. Thirty-one percent were treated for neutropenia; 5.6% developed PTLD. There were improvements in growth parameters and blood pressure.
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Affiliation(s)
- Ashokkumar Jain
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Deborah Daoud
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Deborah Kees-Folts
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Michael A Freeman
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Fauzia Butt
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Catherine S Abendroth
- Department of Pathology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Hiroko Shike
- Department of Pathology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Zakiyah Kadry
- Division of Transplantation, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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9
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Cheyssac E, Savadogo H, Lagoutte N, Baudouin V, Charbit M, Novo R, Sellier-Leclerc AL, Fila M, Decramer S, Merieau E, Zaloszyc A, Harambat J, Roussey G. Valganciclovir is not associated with decreased EBV infection rate in pediatric kidney transplantation. Front Pediatr 2022; 10:1085101. [PMID: 36704127 PMCID: PMC9871758 DOI: 10.3389/fped.2022.1085101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Primary infection or reactivation of Epstein-Barr Virus (EBV) is a significant cause of morbidity and mortality in pediatric kidney transplantation. Valganciclovir (VGC) treatment is recommended for prophylaxis of cytomegalovirus infection, but its role for the prevention of EBV infection remains controversial. PATIENTS AND METHODS All pediatric kidney transplant recipients aged <18 years old were considered for inclusion in this retrospective study. EBV negative recipients with an EBV positive donor (a group at risk of primary infection) or EBV positive recipients (a group at risk of reactivation) were included. Severe infection was defined by post-transplant lymphoproliferative disorder (PTLD), symptomatic EBV infection or by asymptomatic EBV infection with a viral load >4.5 log/ml. Outcomes were compared between patients receiving VGC prophylaxis (group P+) and those not receiving VGC prophylaxis (group P-). RESULTS A total of 79 patients were included, 57 (72%) in the P+ group and 22 (28%) in the P- group; 25 (31%) were at risk of primary infection and 54 (69%) at risk of reactivation. During the first year post-transplant, the occurrence of severe EBV infection was not different between the P+ group (n = 13, 22.8%) and the P- group (n = 5, 22.7%) (p = 0.99). Among patients at risk of primary infection, the rate of severe EBV infection was not different between the two groups (42.1% in P+ vs. 33.3% in P-). A higher frequency of neutropenia was found in the P+ group (66.6%) than in the P- group (33.4%) (p < 0.01). CONCLUSION Our observational study suggests no effect of VGC for the prevention of EBV infection in pediatric kidney transplant recipients, irrespective of their EBV status. Adverse effects revealed an increased risk of neutropenia.
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Affiliation(s)
- Elodie Cheyssac
- Department of Pediatric Nephrology, Robert Debré University Hospital, APHP, Paris, France
| | - Hamidou Savadogo
- Department of Pediatrics, Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
| | - Nathan Lagoutte
- Department of Pediatrics, Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
| | - Véronique Baudouin
- Department of Pediatric Nephrology, Robert Debré University Hospital, APHP, Paris, France
| | - Marina Charbit
- Department of Pediatric Nephrology, Necker Enfants Malades University Hospital, APHP, Paris, France
| | - Robert Novo
- Pediatric Nephrology Unit, Lille University Hospital, Lille, France
| | | | - Marc Fila
- Pediatric Nephrology Unit, Montpellier University Hospital, Montpellier, France
| | - Stéphane Decramer
- Pediatric Nephrology Unit, Toulouse University Hospital, Toulouse, France
| | - Elodie Merieau
- Department of Pediatrics, Tours University Hospital, Tours, France
| | - Ariane Zaloszyc
- Department of Pediatrics, Strasbourg University Hospital, France, Strasbourg, France
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | - Gwenaelle Roussey
- Department of Pediatrics, Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
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10
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Job KM, Roberts JK, Enioutina EY, IIIamola SM, Kumar SS, Rashid J, Ward RM, Fukuda T, Sherbotie J, Sherwin CM. Treatment optimization of maintenance immunosuppressive agents in pediatric renal transplant recipients. Expert Opin Drug Metab Toxicol 2021; 17:747-765. [PMID: 34121566 PMCID: PMC10726690 DOI: 10.1080/17425255.2021.1943356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
Introduction: Graft survival in pediatric kidney transplant patients has increased significantly within the last three decades, correlating with the discovery and utilization of new immunosuppressants as well as improvements in patient care. Despite these developments in graft survival for patients, there is still improvement needed, particularly in long-term care in pediatric patients receiving grafts from deceased donor patients. Maintenance immunosuppressive therapies have narrow therapeutic indices and are associated with high inter-individual and intra-individual variability.Areas covered: In this review, we examine the impact of pharmacokinetic variability on renal transplantation and its association with age, genetic polymorphisms, drug-drug interactions, drug-disease interactions, renal insufficiency, route of administration, and branded versus generic drug formulation. Pharmacodynamics are outlined in terms of the mechanism of action for each immunosuppressant, potential adverse effects, and the utility of pharmacodynamic biomarkers.Expert opinion: Acquiring abetter quantitative understanding of immunosuppressant pharmacokinetics and pharmacodynamic components should help clinicians implement treatment regimens to maintain the balance between therapeutic efficacy and drug-related toxicity.
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Affiliation(s)
- Kathleen M Job
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jessica K Roberts
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Sílvia M IIIamola
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Shaun S Kumar
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jahidur Rashid
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robert M Ward
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Tsuyoshi Fukuda
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph Sherbotie
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Catherine M Sherwin
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
- Department of Pediatrics, Boonshoft School of Medicine, Dayton Children’s Hospital, Wright State University, Dayton, OH, USA
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
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11
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Abstract
Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD) in children and confers improved survival, skeletal growth, heath-related quality of life, and neuropsychological development compared with dialysis. Kidney transplantation in children with ESRD results in 10-year patient survival exceeding 90%. Therefore, the long-term management of these patients is focused on maintaining quality of life and minimizing long-term side effects of immunosuppression. Optimal management of pediatric kidney transplant recipients includes preventing rejection and infection, identifying and reducing the cardiovascular and metabolic effects of long-term immunosuppressive therapy, supporting normal growth and development, and managing a smooth transition into adulthood.
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Affiliation(s)
- Pamela D Winterberg
- Division of Pediatric Nephrology, Emory University School of Medicine, Children's Pediatric Institute, 2015 Uppergate Drive NE, 5th Floor, Atlanta, GA 30322, USA.
| | - Rouba Garro
- Division of Pediatric Nephrology, Emory University School of Medicine, Children's Pediatric Institute, 2015 Uppergate Drive NE, 5th Floor, Atlanta, GA 30322, USA
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12
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Nakanishi K, Kaito H, Ogi M, Takai D, Fujimura J, Horinouchi T, Yamamura T, Minamikawa S, Ninchoji T, Nozu K, Imadome KI, Iijima K. Three Severe Cases of Viral Infections with Post-Kidney Transplantation Successfully Confirmed by Polymerase Chain Reaction and Flow Cytometry. Case Rep Nephrol Dial 2018; 8:198-206. [PMID: 30397600 PMCID: PMC6206958 DOI: 10.1159/000493092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 08/20/2018] [Indexed: 11/19/2022] Open
Abstract
Viral infections in patients with post-kidney transplantation are often difficult to diagnose as well as treat. We herein report three cases with severe viral infections after kidney transplantation. All their causative pathogens could be detected promptly by polymerase chain reaction and flow cytometry during the early stages of infection. These examinations would also be of great use to monitor therapeutic responses and disease activity. It is indeed true that no specific treatment is available for most of the viral infections, but we should be aware that some infections, such as Epstein-Barr virus infection, can be treatable with prompt and specific treatment, such as rituximab.
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Affiliation(s)
- Keita Nakanishi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Kaito
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Miki Ogi
- Hyogo Prefectural Institute of Public Health and Consumer Sciences Public Health Science Research Center, Kobe, Japan
| | - Denshi Takai
- Hyogo Prefectural Institute of Public Health and Consumer Sciences Public Health Science Research Center, Kobe, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shogo Minamikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ken-Ichi Imadome
- Division of Advanced Medicine for Virus Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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13
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Caliento R, Sarmento DJDS, Silva ÉMP, Tozetto-Mendoza TR, Tobouti PL, Benini V, Braz-Silva PH, Gallottini M. Oral shedding of HSV-1 and EBV and oral manifestations in paediatric chronic kidney disease patients and renal transplant recipients. Acta Odontol Scand 2018; 76:539-544. [PMID: 29409366 DOI: 10.1080/00016357.2018.1437218] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Previous research demonstrated that salivary shedding of HSV-1 and EBV occurs often in adult renal transplant recipients, but there is a lack of studies on the presence of them in the saliva of paediatric population. Therefore, the objective of this study is to describe oral characteristics and to compare the shedding profile of HSV-1 and EBV in the saliva of children with renal transplant to that of chronic kidney disease patients and controls. METHODS This is a cross-sectional study involving 100 children, being 25 renal transplant recipients, 25 chronic kidney disease patients and 50 healthy children. Demographic and oral clinical characteristics were assessed. Saliva samples were collected and submitted to screening for EBV and HSV-1 by using nested polymerase chain reaction technique. Fisher's exact, Pearson's chi-square and Kruskal-Wallis tests were used for statistical analysis at a significance level of 5%. RESULTS Oral shedding of HSV-1 (28%) and EBV (60%) were significantly higher in renal transplant recipients compared to the other groups. Single vesicles in the oral mucosa were statistically associated with the presence of HSV-1 (p = .035). In children with chronic kidney disease, there was a higher prevalence of pale oral mucosa (32%) and enamel hypoplasia (40%) compared to paediatric renal transplant recipients and controls. Dental calculus (36%), candidiasis (8%), drug-induced gingival overgrowth (16%), mouth blisters (8%), xerostomia (12%) and salivary gland enlargement (20%) were more common in paediatric renal transplant recipients. CONCLUSIONS Therefore, it can be concluded that salivary shedding of HSV-1 and EBV in paediatric patients was more often found in renal transplant recipients than in the renal failure and control children. Transplanted recipients showed more oral manifestations than renal failure and control children did.
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Affiliation(s)
- Rubens Caliento
- Department of Stomatology, Division of Oral Pathology, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | | | | | | | - Priscila Lie Tobouti
- Department of Stomatology, Division of Oral Pathology, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Vanda Benini
- Department of Nephrology, School of Medicine, Irmandade Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Paulo Henrique Braz-Silva
- Laboratory of Virology, Institute of Tropical Medicine, University of São Paulo, São Paulo, Brazil
- Department of Stomatology, Division of General Pathology, School of Dentistry, University of São Paulo, São Paulo, Brazil
| | - Marina Gallottini
- Department of Stomatology, Division of Oral Pathology, School of Dentistry, University of São Paulo, São Paulo, Brazil
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14
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Yeo WS, Zhang YC. Bioengineering in renal transplantation: technological advances and novel options. Pediatr Nephrol 2018; 33:1105-1111. [PMID: 28589209 DOI: 10.1007/s00467-017-3706-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/07/2017] [Accepted: 05/11/2017] [Indexed: 01/03/2023]
Abstract
End-stage kidney disease (ESKD) is one of the most prevalent diseases in the world with significant morbidity and mortality. Current modes of renal replacement therapy include dialysis and renal transplantation. Although dialysis is an acceptable mode of renal replacement therapy, it does have its shortcomings, which include poorer life expectancy compared with renal transplantation, risk of infections and vascular thrombosis, lack of vascular access and absence of biosynthetic functions of the kidney. Renal transplantation, in contrast, is the preferred option of renal replacement therapy, with improved morbidity and mortality rates and quality of life, compared with dialysis. Renal transplantation, however, may not be available to all patients with ESKD. Some of the key factors limiting the availability and efficiency of renal transplantation include shortage of donor organs and the constant risk of rejection with complications associated with over-immunosuppression respectively. This review focuses chiefly on the potential roles of bioengineering in overcoming limitations in renal transplantation via the development of cell-based bioartificial dialysis devices as bridging options before renal transplantation, and the development of new sources of organs utilizing cell and organ engineering.
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Affiliation(s)
- Wee-Song Yeo
- Division of Pediatric Nephrology, Dialysis and Renal Transplantation, Shaw-National Kidney Foundation, National University Hospital Children's Kidney Centre, Khoo Teck Puat-National University, Children's Medical Institute, National University Health System, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Yao-Chun Zhang
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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15
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Laurent A, Klich A, Roy P, Lina B, Kassai B, Bacchetta J, Cochat P. Pediatric renal transplantation: A retrospective single-center study on epidemiology and morbidity due to EBV. Pediatr Transplant 2018; 22:e13151. [PMID: 29430795 DOI: 10.1111/petr.13151] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2017] [Indexed: 11/29/2022]
Abstract
Pediatric R-Tx patients are at high risk of developing EBV primary infection. Although high DNA replication is a risk factor for PTLD, some patients develop PTLD with low viral load. In this retrospective single-center study including all pediatric patients having received R-Tx (2003-2012 period), we aimed to identify risk factors for uncontrolled reactions to EBV (defined as the presence of a viral load >10 000 copies/mL or PTLD). A Cox proportional hazard model was performed. A total of 117 patients underwent R-Tx at a mean age of 9.7 ± 5.3 years, 46 of them being seronegative for EBV at the time of R-Tx. During follow-up, 54 patients displayed positive EBV viral load, 22 of whom presenting with primary infection. An uncontrolled reaction to EBV was observed in 24 patients, whilst 4 patients developed PTLD. Univariate and multivariate analyses suggested the following risk factors for an uncontrolled reaction: age below 5 years, graft from a deceased donor, ≥5 HLA mismatches, EBV-seronegative status at the time of R-Tx, and a secondary post-Tx loss of anti-EBNA. Monitoring anti-EBNA after R-Tx may contribute to the early identification of patients at risk for uncontrolled reaction.
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Affiliation(s)
- A Laurent
- Hospices Civils de Lyon, Service de Néphrologie, Rhumatologie et Dermatologie pédiatriques, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Lyon, France
| | - A Klich
- Hospices Civils de Lyon, Service de Biostatistique et de Bioinformatique, Lyon, France.,Université de Lyon, Lyon, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - P Roy
- Hospices Civils de Lyon, Service de Biostatistique et de Bioinformatique, Lyon, France.,Université de Lyon, Lyon, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - B Lina
- Laboratoire de Virologie, Institut des Agents Infectieux IAI, Hospices Civils de Lyon, Hopital de la Croix Rousse, Lyon, France.,CIRI, Centre International de Recherche en Infectiologie, Virpath, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, École Normale Supérieure de Lyon, Université de Lyon, Lyon, France
| | - B Kassai
- Université de Lyon, Lyon, France.,Centre d'Investigation Clinique de Lyon, 1407 Inserm-Hospices Civils de Lyon, Groupement Hospitalier Est, Hôpital Femme-Mère-Enfant, EPICIME, Bron, France
| | - J Bacchetta
- Hospices Civils de Lyon, Service de Néphrologie, Rhumatologie et Dermatologie pédiatriques, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Lyon, France.,CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France.,Laboratoire de Virologie, Institut des Agents Infectieux IAI, Hospices Civils de Lyon, Hopital de la Croix Rousse, Lyon, France
| | - P Cochat
- Hospices Civils de Lyon, Service de Néphrologie, Rhumatologie et Dermatologie pédiatriques, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Lyon, France
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16
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Dharnidharka VR. Comprehensive review of post-organ transplant hematologic cancers. Am J Transplant 2018; 18:537-549. [PMID: 29178667 DOI: 10.1111/ajt.14603] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 11/17/2017] [Accepted: 11/17/2017] [Indexed: 01/25/2023]
Abstract
A higher risk for a variety of cancers is among the major complications of posttransplantation immunosuppression. In this part of a continuing series on cancers posttransplantation, this review focuses on the hematologic cancers after solid organ transplantation. Posttransplantation lymphoproliferative disorders (PTLDs), which comprise the great majority of hematologic cancers, represent a spectrum of conditions that include, but are not limited to, the Hodgkin and non-Hodgkin lymphomas. The oncogenic Epstein-Barr virus is a key pathogenic driver in many PTLD cases, through known and unknown mechanisms. The other hematologic cancers include leukemias and plasma cell neoplasms (multiple myeloma and plasmacytoma). Clinical features vary across malignancies and location. Preventive screening strategies have been attempted mainly for PTLDs. Treatments include the chemotherapy regimens for the specific cancers, but also include reduction of immunosuppression, rituximab, and other therapies.
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Affiliation(s)
- Vikas R Dharnidharka
- Division of Pediatric Nephrology, Washington University School of Medicine, Saint Louis, MO, USA
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17
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Markolović M, Ćupić M. The prevalence of herpesvirus infections in children and young adults transplant recipients - kidney and hematopoetic stem cells. MEDICINSKI PODMLADAK 2018. [DOI: 10.5937/mp69-16747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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18
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Abstract
Safe and efficacious vaccines are arguably the most successful medical interventions of all time. Yet the ongoing discovery of new pathogens, along with emergence of antibiotic-resistant pathogens and a burgeoning population at risk of such infections, imposes unprecedented public health challenges. To meet these challenges, innovative strategies to discover and develop new or improved anti-infective vaccines are necessary. These approaches must intersect the most meaningful insights into protective immunity and advanced technologies with capabilities to deliver immunogens for optimal immune protection. This goal is considered through several recent advances in host-pathogen relationships, conceptual strides in vaccinology, and emerging technologies. Given a clear and growing risk of pandemic disease should the threat of infection go unmet, developing vaccines that optimize protective immunity against high-priority and antibiotic-resistant pathogens represents an urgent and unifying imperative.
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Affiliation(s)
- Michael R Yeaman
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90024.,Division of Molecular Medicine, Department of Medicine, Harbor-UCLA Medical Center, Torrance, California 90509; .,Division of Infectious Diseases, Department of Medicine, Harbor-UCLA Medical Center, Torrance, California 90509.,Los Angeles Biomedical Research Institute, Torrance, California 90502
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19
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Yang CH, Chen XX, Chen L, Zheng DH, Liu QS, Xie WF, Zhou TB, Drummen GPC. Relationship between cytotoxic T-lymphocyte antigen 4 -318C/T (rs5742909) gene polymorphism and the risk of acute rejection in renal transplantation. Pediatr Transplant 2017; 21. [PMID: 28449371 DOI: 10.1111/petr.12920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2017] [Indexed: 01/17/2023]
Abstract
Results on the relationship between CTLA4 -318C/T (rs5742909) gene polymorphism and risk of acute rejection in renal transplantation are still conflicting. This meta-analysis was performed to update the association between CTLA4 -318C/T and risk of acute rejection in renal transplantation. The association investigations were identified from PubMed and Cochrane Library, and eligible studies were included and synthesized using meta-analysis method. Twelve reports were included in this meta-analysis for the association of CTLA4 -318C/T gene polymorphism with acute rejection risk in renal transplantation, consisting of 728 acute rejection patients and 1628 non-acute rejection controls. The association between CTLA4 -318C/T gene polymorphism and acute rejection risk in renal transplantation for overall populations was not found in this meta-analysis (T allele: OR=0.96, 95% CI: 0.60-1.54, P=.88; TT genotype: OR=0.90, 95% CI: 0.47-1.71, P=.74; CC genotype: OR=1.00, 95% CI: 0.62-1.59, P=.98). Interestingly, T allele was associated with the risk of acute rejection in renal transplantation in African population. In conclusion, CTLA4 -318C/T gene polymorphism is not associated with the risk of acute rejection in renal transplantation in overall populations.
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Affiliation(s)
- Chun-Hua Yang
- Department of Emergency, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xue-Xia Chen
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Chen
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dong-Hua Zheng
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiong-Shan Liu
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wen-Feng Xie
- Department of Critical Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tian-Biao Zhou
- Department of Nephrology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Gregor P C Drummen
- Cellular Stress and Ageing Program, Bionanoscience and Bio-Imaging Program, Bio&Nano-Solutions, Düsseldorf, Germany
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20
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Ebens CL, Smith AR, Verghese PS. Kidney transplant after hematopoietic cell transplant in pediatrics: Infectious and immunosuppressive considerations. Pediatr Transplant 2017; 21. [PMID: 28452096 DOI: 10.1111/petr.12929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 11/25/2022]
Abstract
Pediatric patients requiring kidney transplant after hematopoietic cell transplant receive multiple courses of immunosuppression placing them at risk for infection. To elucidate potential risk factors for infection, we compared the immunosuppressive regimens and infectious complications of pediatric kidney transplant recipients at a single institution who had previously undergone hematopoietic cell transplant from different donors to similar patients reported in the literature. Among the initial four post-hematopoietic cell transplant kidney transplant patients reviewed, viremia episodes were universal, including BK virus, Epstein-Barr virus, and human herpesvirus-6, with one death from presumed BK virus encephalitis. No viremia was reported in five similar cases in the literature. Risk factors for increased infection include use of lymphodepleting serotherapy in HCT conditioning, multiple HCTs, limited immune reconstitution time between transplants, increased pre-KTx viral burden, and use of T-cell-depleting versus -suppressive induction immunosuppression for KTx. These findings suggest that pediatric post-HCT KTx recipients are at increased risk for viral infections, likely benefitting from thorough pre-KTx evaluation of immune reconstitution and preferential use of non-T-cell-depleting induction therapy for KTx. We applied these recommendations to one subsequent post-HCT patient requiring KTx at our institution with excellent outcomes one year post-KTx.
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Affiliation(s)
- Christen L Ebens
- Department of Pediatrics, Division of Blood and Marrow Transplant, University of Minnesota, Minneapolis, MN, USA
| | - Angela R Smith
- Department of Pediatrics, Division of Blood and Marrow Transplant, University of Minnesota, Minneapolis, MN, USA
| | - Priya S Verghese
- Department of Pediatrics, Division of Nephrology, University of Minnesota, Minneapolis, MN, USA
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21
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The Effects of Tacrolimus on T-Cell Proliferation Are Short-Lived: A Pilot Analysis of Immune Function Testing. Transplant Direct 2017; 3:e199. [PMID: 28795150 PMCID: PMC5540637 DOI: 10.1097/txd.0000000000000715] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/21/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Optimal immunosuppression after organ transplant should balance the risks of rejection, infection, and malignancy while minimizing barriers to adherence including frequent or time-sensitive dosing. There is currently no reliable immune function assay to directly measure the degree of immunosuppression after transplantation. METHODS We developed an immune function assay to mea//sure T-cell proliferation after exposure to immunosuppression in vivo. We tested the assay in mice, and then piloted the approach using single time point samples, 11 pediatric kidney transplant recipients prescribed tacrolimus, mycophenolate, and prednisone 6 months to 5 years posttransplant, with no history of rejection, opportunistic infection, or cancer. Twelve healthy adults were controls. RESULTS We demonstrated that our assay can quantify suppression of murine T-cell proliferation after tacrolimus treatment in vivo. In humans, we found a mean 25% reduction in CD4 and CD8 T-cell proliferation in pediatric renal transplant recipients on triple immunosuppression compared with adult healthy controls, but the pilot results were not statistically significant nor correlated with serum tacrolimus levels. We observed that cell processing and washing reduced the effects of tacrolimus on T-cell proliferation, as did discontinuation of tacrolimus treatment shortly before sampling. CONCLUSIONS T-cell proliferation is currently not suitable to measure immunosuppression because sample processing diminishes observable effects. Future immune function testing should focus on fresh samples with minimal washing steps. Our results also emphasize the importance of adherence to immunosuppressive treatment, because T-cell proliferation recovered substantially after even brief discontinuation of tacrolimus.
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22
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Dharnidharka VR. Peripheral Blood Epstein-Barr Viral Nucleic Acid Surveillance as a Marker for Posttransplant Cancer Risk. Am J Transplant 2017; 17:611-616. [PMID: 27458691 DOI: 10.1111/ajt.13982] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 01/25/2023]
Abstract
Several viruses, such as Epstein-Barr virus, are now known to be associated with several human cancers, but not all patients with these viral infections develop cancer. In transplantation, such viruses often have a prolonged time gap from infection to cancer development, and many are preceded by a period of circulating and detectable nucleic acids in the peripheral blood compartment. The interpretation of a viral load as a measure of posttransplant risk of developing cancer depends on the virus, the cancer and associated pathogenic factors. This review describes the current state of knowledge regarding the utility and limitations of peripheral blood nucleic acid testing for Epstein-Barr virus in surveillance and risk prediction for posttransplant lymphoproliferative disorders.
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Affiliation(s)
- V R Dharnidharka
- Division of Pediatric Nephrology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO
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23
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Jalanko H, Mattila I, Holmberg C. Renal transplantation in infants. Pediatr Nephrol 2016; 31:725-35. [PMID: 26115617 DOI: 10.1007/s00467-015-3144-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 05/27/2015] [Accepted: 06/08/2015] [Indexed: 01/28/2023]
Abstract
Renal transplantation (RTx) has become an accepted mode of therapy in infants with severe renal failure. The major indications are structural abnormalities of the urinary tract, congenital nephrotic syndrome, polycystic diseases, and neonatal kidney injury. Assessment of these infants needs expertise and time as well as active treatment before RTx to ensure optimal growth and development, and to avoid complications that could lead to permanent neurological defects. RTx can be performed already in infants weighing around 5 kg, but most operations occur in infants with a weight of 10 kg or more. Perioperative management focuses on adequate perfusion of the allograft and avoidance of thrombotic and other surgical complications. Important long-term issues include rejections, infections, graft function, growth, bone health, metabolic problems, neurocognitive development, adherence to medication, pubertal maturation, and quality of life. The overall outcome of infant RTx has dramatically improved, with long-term patient and graft survivals of over 90 and 80 %, respectively.
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Affiliation(s)
- Hannu Jalanko
- Department Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, PO Box 281, Helsinki, 00290, Finland.
| | - Ilkka Mattila
- Department of Cardiac and Transplantation Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Christer Holmberg
- Department Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, PO Box 281, Helsinki, 00290, Finland
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Cytomegalovirus Infection in Pediatric Renal Transplantation and the Impact of Chemoprophylaxis With (Val-)Ganciclovir. Transplantation 2016; 100:862-70. [DOI: 10.1097/tp.0000000000000888] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Höcker B, Zencke S, Pape L, Krupka K, Köster L, Fichtner A, Dello Strologo L, Guzzo I, Topaloglu R, Kranz B, König J, Bald M, Webb NJA, Noyan A, Dursun H, Marks S, Ozcakar ZB, Thiel F, Billing H, Pohl M, Fehrenbach H, Schnitzler P, Bruckner T, Ahlenstiel-Grunow T, Tönshoff B. Impact of Everolimus and Low-Dose Cyclosporin on Cytomegalovirus Replication and Disease in Pediatric Renal Transplantation. Am J Transplant 2016; 16:921-9. [PMID: 26613840 DOI: 10.1111/ajt.13649] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 11/16/2015] [Accepted: 11/20/2015] [Indexed: 01/25/2023]
Abstract
In order to investigate the hypothesis that the mammalian target of rapamycin inhibitor everolimus (EVR) shows anticytomegalovirus (CMV) activity in pediatric patients, we analyzed the impact of EVR-based immunosuppressive therapy on CMV replication and disease in a large cohort (n = 301) of pediatric kidney allograft recipients. The EVR cohort (n = 59), who also received low-dose cyclosporin, was compared with a control cohort (n = 242), who was administered standard-dose cyclosporin or tacrolimus and an antimetabolite, mostly mycophenolate mofetil (91.7%). Multivariate analysis revealed an 83% lower risk of CMV replication in the EVR cohort than in the control cohort (p = 0.005). In CMV high-risk (donor+/recipient-) patients (n = 88), the EVR-based regimen was associated with a significantly lower rate of CMV disease (0% vs. 14.3%, p = 0.046) than the standard regimen. In patients who had received chemoprophylaxis with (val-)ganciclovir (n = 63), the CMV-free survival rates at 1 year and 3 years posttransplant (100%) were significantly (p = 0.015) higher in the EVR cohort (n = 15) than in the control cohort (n = 48; 1 year, 75.0%; 3 years, 63.3%). Our data suggest that in pediatric patients at high risk of CMV, an EVR-based immunosuppressive regimen is associated with a lower risk of CMV disease than a standard-dose calcineurin inhibitor-based regimen.
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Affiliation(s)
- B Höcker
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - S Zencke
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - L Pape
- Hanover Medical School, Hanover, Germany
| | - K Krupka
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - L Köster
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany.,Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - A Fichtner
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | | | - I Guzzo
- IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - R Topaloglu
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - B Kranz
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital, Münster, Germany
| | - J König
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital, Münster, Germany
| | - M Bald
- Olga Children's Hospital, Clinic of Stuttgart, Stuttgart, Germany
| | - N J A Webb
- Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Center, Manchester, UK
| | - A Noyan
- Department of Pediatric Nephrology, Adana Teaching and Research Center, Baskent University, Adana, Turkey
| | - H Dursun
- Department of Pediatric Nephrology, Adana Teaching and Research Center, Baskent University, Adana, Turkey
| | - S Marks
- Great Ormond Street Hospital, London, UK
| | - Z B Ozcakar
- Ankara University Faculty of Medicine, Ankara, Turkey
| | - F Thiel
- University Children's Hospital, Hamburg, Germany
| | - H Billing
- University Children's Hospital, Tübingen, Germany
| | - M Pohl
- University Children's Hospital, Freiburg, Germany
| | | | - P Schnitzler
- Department of Infectious Diseases, Virology, University Hospital Heidelberg, Heidelberg, Germany
| | - T Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | | | - B Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
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Abstract
The kidney is involved in a wide range of bacterial, viral, fungal, and parasitic diseases. In most systemic infections, renal involvement is a minor component of the illness, but in some, renal failure may be the presenting feature and the major problem in management. Although individual infectious processes may have a predilection to involve the renal vasculature, glomeruli, interstitium, or collecting systems, a purely anatomic approach to the classification of infectious diseases affecting the kidney is rarely helpful because most infections may involve several different aspects of renal function. In this chapter, a microbiological classification of the organisms affecting the kidney is adopted. Although they are important causes of renal dysfunction in infectious diseases, urinary tract infections and hemolytic uremic syndrome (HUS) are not discussed in detail because they are considered separately in chapters XX and XX, respectively.
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Affiliation(s)
- Ellis D. Avner
- Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Hospital, Health System of Wisconsin, Milwaukee, Wisconsin USA
| | - William E. Harmon
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts USA
| | - Patrick Niaudet
- Service de Néphrologie Pédiatrique, Hôpital Necker-Enfants Malades, Université Paris-Descartes, Paris, France
| | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Stuart L. Goldstein
- Division of Nephrology and Hypertension, The Heart Institute, Cincinnati Children’s Hospital Medical Center, College of Medicine, Cincinnati, Ohio USA
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Abstract
Renal transplantation in paediatric patients usually provides excellent short-term and medium-term results. Early diagnosis of chronic kidney disease and active therapy of end-stage renal disease before and after transplantation enables the majority of children to grow and develop normally. The adverse effects of immunosuppressive medication and reduced graft function might, however, hamper long-term outcomes in these patients and can lead to metabolic complications, cardiovascular disease, reduced bone health, and malignancies. The neurocognitive development and quality of life of paediatric transplant recipients largely depend on the primary diagnosis and on graft function. Poor adherence to immunosuppression is an important risk factor for graft loss in adolescents, and controlled transition to adult care is of utmost importance to ensure a continued normal life. In this Review, we discuss the outcomes and long-term effects of renal transplantation in paediatric recipients, including consequences on growth, development, bone, metabolic, and cardiovascular disorders. We discuss the key problems in the care of paediatric renal transplant recipients and the remaining challenges that should be the focus of future research.
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Hashim F, Gregg JA, Dharnidharka VR. Efficacy of Extended Valganciclovir Prophylaxis in Preventing Cytomegalovirus Infection in Pediatric Kidney Transplantation. ACTA ACUST UNITED AC 2014; 7:152-157. [PMID: 25821528 PMCID: PMC4366268 DOI: 10.2174/1874303x01407010152] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 10/01/2014] [Accepted: 10/02/2014] [Indexed: 12/11/2022]
Abstract
Cytomegalovirus (CMV) is one of the most frequent opportunistic infection in renal transplant (RTx)
recipients. Valganciclovir (VGC) has been showed to be safe and highly effective in prophylaxis of CMV infection in
RTx recipients. Recently, an increase in delayed onset CMV disease has been noted with some arguing that longer
prophylaxis may decrease the late-onset disease. We retrospectively tested the hypothesis that extended term prophylaxis (ETP) of VGC for 12 months is more effective
than short term prophylaxis (STP) of 6 months in preventing CMV infection and disease in pediatric RTx performed at the
University of Florida from July 2003 to December 2010. In this period, all recipients underwent prospective CMV PCR
(Polymerase Chain Reaction) monitoring and were maintained on similar immunosuppression. Eighty six patients received RTx during that period. All eligible subjects had to have at least 12 months of graft survival and
18 months of follow up, leaving 73 eligible subjects in final study group. CMV infection or disease occurred in 6/29 (20%) in
the STP group vs 6/44 (14%) in the ETP group with no statistical significant difference (P= 0.42). Donor positive/recipients
negative CMV serology status (D+/R-) were associated with a higher risk of CMV infection in both univariate and
multivariate analysis (P=0.01). Anemia and Leucopenia directly associated with VGC were similar in both groups (P=0.58
and P=0.2 respectively). Biopsy-proven acute rejection was also non-significant in both groups (P=0.39). Although ETP for CMV from 6 months to 12 months is safe and has minimal adverse effect, it did not reduce CMV
infection or disease. Further controlled studies in pediatrics age group are considered to compare longer versus shorter
periods of prophylaxis and their impact on prevention of CMV infection, resistance, cost, and toxicity.
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Affiliation(s)
- Faris Hashim
- Divisions of Transplant Nephrology, University of Florida College of Medicine, Gainesville, FL USA
| | - Jon A Gregg
- Pediatric Nephrology and Transplant Nephrology, University of Florida College of Medicine, Gainesville, FL USA
| | - Vikas R Dharnidharka
- Divisions of Transplant Nephrology, University of Florida College of Medicine, Gainesville, FL USA
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