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Wareham NE, Li Q, Sengeløv H, Da Cunha-Bang C, Gustafsson F, Heilmann C, Perch M, Rasmussen A, Sørensen SS, Mocroft A, Lundgren JD. "Risk of de novo or secondary cancer after solid organ or allogeneic haematopoietic stem cell transplantation". J Cancer Res Clin Oncol 2019; 145:3125-3135. [PMID: 31587105 DOI: 10.1007/s00432-019-03039-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/25/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Solid organ (SOT) and allogeneic haematopoietic stem cell (HSCT) transplant recipients have elevated risks of de novo or secondary cancer. We explored risk factors hereof. METHODS Among SOT and HSCT between January 2004 and December 2014, standardised incidence ratio (SIR) of de novo/secondary cancer compared with the Danish population was determined and risk factors were identified using Poisson regression. RESULTS During a median of 3.4 (IQR 1.3-6.4) and 2.6 (0.8-5.4) person-years (PY) after SOT and HSCT, a total of 212/1656 (13%) and 75/992 (8%) persons developed cancer; SIR 3.61 (3.0-4.3) and 2.2 (1.6-3.0), resp.). SIR correlated with younger age and was highest for skin and haematological cancers for both types of transplantation. Within the cohort, cancer was associated with older age (adjusted incidence rate ratio > 50 vs ≤ 19 years, among SOT and HSCT: 9.4 (3.4-25.7) and 25.4 (5.1-126.0), resp.) and current elevated C-reactive protein (CRP) (≥ 10 vs < 10 mg/L: 2.5 (1.8-3.4) and 2.3 (1.4-3.9), resp.), but neither with prior cancer nor type of immunosuppressants. CONCLUSION Rates of de novo or secondary cancers are elevated in both SOT and HSCT compared with the general population and mainly for skin and haematological cancers. Among transplant recipients, older age and current elevated CRP are risk factors.
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Affiliation(s)
- Neval E Wareham
- CHIP, Department of Infectious Diseases, Centre for Cardiac, Pulmonary and Infectious Diseases Vascular, University of Copenhagen, Rigshospitalet, Section 2100, Blegdamsvej 9, 2100 Copenhagen, Copenhagen Ø, Denmark.
| | - Qiuju Li
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), University College London, London, UK
| | - Henrik Sengeløv
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Michael Perch
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | | | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), University College London, London, UK
| | - Jens D Lundgren
- CHIP, Department of Infectious Diseases, Centre for Cardiac, Pulmonary and Infectious Diseases Vascular, University of Copenhagen, Rigshospitalet, Section 2100, Blegdamsvej 9, 2100 Copenhagen, Copenhagen Ø, Denmark
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Khurana MP, Lodding IP, Mocroft A, Sørensen SS, Perch M, Rasmussen A, Gustafsson F, Lundgren JD. Risk Factors for Failure of Primary (Val)ganciclovir Prophylaxis Against Cytomegalovirus Infection and Disease in Solid Organ Transplant Recipients. Open Forum Infect Dis 2019; 6:ofz215. [PMID: 31211159 PMCID: PMC6559280 DOI: 10.1093/ofid/ofz215] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/07/2019] [Indexed: 12/21/2022] Open
Abstract
Background Rates and risk factors for cytomegalovirus (CMV) prophylaxis breakthrough and discontinuation were investigated, given uncertainty regarding optimal dosing for CMV primary (val)ganciclovir prophylaxis after solid organ transplantation (SOT). Methods Recipients transplanted from 2012 to 2016 and initiated on primary prophylaxis were followed until 90 days post-transplantation. A (val)ganciclovir prophylaxis score for each patient per day was calculated during the follow-up time (FUT; score of 100 corresponding to manufacturers’ recommended dose for a given estimated glomerular filtration rate [eGFR]). Cox models were used to estimate hazard ratios (HRs), adjusted for relevant risk factors. Results Of 585 SOTs (311 kidney, 117 liver, 106 lung, 51 heart) included, 38/585 (6.5%) experienced prophylaxis breakthrough and 35/585 (6.0%) discontinued prophylaxis for other reasons. CMV IgG donor+/receipient- mismatch (adjusted HR [aHR], 5.37; 95% confidence interval [CI], 2.63 to 10.98; P < 0.001) and increasing % FUT with a prophylaxis score <90 (aHR, 1.16; 95% CI, 1.04 to 1.29; P = .01 per 10% longer FUT w/ score <90) were associated with an increased risk of breakthrough. Lung recipients were at a significantly increased risk of premature prophylaxis discontinuation (aHR, 20.2 vs kidney; 95% CI, 3.34 to 121.9; P = .001), mainly due to liver or myelotoxicity. Conclusions Recipients of eGFR-adjusted prophylaxis doses below those recommended by manufacturers were at an increased risk of prophylaxis breakthrough, emphasizing the importance of accurate dose adjustment according to the latest eGFR and the need for novel, less toxic agents.
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Affiliation(s)
- Mark P Khurana
- Centre for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Correspondence: M. P. Khurana, BSc, Department of Infectious Diseases, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark ()
| | - Isabelle P Lodding
- Centre for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Amanda Mocroft
- Institute for Global Health, Infection and Population Health, University College of London (UCL), London, United Kingdom
| | - Søren S Sørensen
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Michael Perch
- Section for Lung Transplantation, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Abdominal Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens D Lundgren
- Centre for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Wareham NE, Mocroft A, Sengeløv H, Da Cunha-Bang C, Gustafsson F, Heilmann C, Iversen M, Kirkby NS, Rasmussen A, Sørensen SS, Lundgren JD. The value of EBV DNA in early detection of post-transplant lymphoproliferative disorders among solid organ and hematopoietic stem cell transplant recipients. J Cancer Res Clin Oncol 2018; 144:1569-1580. [PMID: 29804164 DOI: 10.1007/s00432-018-2674-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/17/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Emerging EBV DNAemia in plasma is considered an early sign of post-transplant lymphoproliferative disorder (PTLD). The aim of this study was to quantify the extent of benefit from screening for EBV DNAemia to detect emerging PTLD among solid organ (SOT) or hematopoietic stem cell transplant recipients (HSCT). METHODS We used receiver operating characteristic (ROC) curves for assessing ability of models to predict PTLD. Among 2642 recipients transplanted between January 2004 and December 2014, 79 (3%) developed PTLD. RESULTS EBV DNAemia was observed in 331/1784 recipients (18.6%, 95% CI 16.8-20.4) with measured EBV DNA. The area under the curve (AUC) of the ROC of EBV DNAemia to identify persons with subsequent PTLD was 72% (95% CI, 64-79%) among SOT and 59% (51-68%) among HSCT. Including clinical predictors such as age, gender, transplant year and type, high-risk EBV serostatus, and routine biochemistry in addition to EBV DNAemia increased AUC to 83% (75-90%) among SOT and 84% (79-89%) among HSCT. Among HSCT, including additional factors such as T-cell-depleting treatment, acute graft vs. host disease and donor match increased AUC to 85% (78-91%). CONCLUSIONS We constructed a model to better predict PTLD compared to EBV DNA screening alone which could have clinical implications.
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Affiliation(s)
- Neval E Wareham
- CHIP, Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Finsencentret, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.
| | - Amanda Mocroft
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global health, University College London, London, UK
| | - Henrik Sengeløv
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Martin Iversen
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Nikolai S Kirkby
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | | | - Jens D Lundgren
- CHIP, Department of Infectious Diseases, Section 2100, Rigshospitalet, University of Copenhagen, Finsencentret, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
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Lodding IP, da Cunha Bang C, Sørensen SS, Gustafsson F, Iversen M, Kirkby N, Perch M, Rasmussen A, Sengeløv H, Mocroft A, Lundgren JD. Cytomegalovirus (CMV) Disease Despite Weekly Preemptive CMV Strategy for Recipients of Solid Organ and Hematopoietic Stem Cell Transplantation. Open Forum Infect Dis 2018; 5:ofy080. [PMID: 29876364 PMCID: PMC5961206 DOI: 10.1093/ofid/ofy080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 04/13/2018] [Indexed: 11/20/2022] Open
Abstract
Background Transplant recipients presenting with cytomegalovirus (CMV) disease at the time of diagnosis of CMV DNAemia pose a challenge to a preemptive CMV management strategy. However, the rate and risk factors of such failure remain uncertain. Methods Solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT) recipients with a first episode of CMV polymerase chain reaction (PCR) DNAemia within the first year posttransplantation were evaluated (n = 335). Patient records were reviewed for presence of CMV disease at the time of CMV DNAemia diagnosis. The distribution and prevalence of CMV disease were estimated, and the odds ratio (OR) of CMV disease was modeled using logistic regression. Results The prevalence of CMV disease increased for both SOT and HSCT with increasing diagnostic CMV PCR load and with screening intervals >14 days. The only independent risk factor in multivariate analysis was increasing CMV DNAemia load of the diagnostic CMV PCR (OR = 6.16; 95% confidence interval, 2.09–18.11). Among recipients receiving weekly screening (n = 147), 16 (10.8%) had CMV disease at the time of diagnosis of CMV DNAemia (median DNAemia load 628 IU/mL; interquartile range, 432–1274); 93.8% of these cases were HSCT and lung transplant recipients. Conclusions Despite application of weekly screening intervals, HSCT and lung transplant recipients in particular presented with CMV disease at the time of diagnosis of CMV DNAemia. Additional research to improve the management of patients at risk of presenting with CMV disease at low levels of CMV DNAemia and despite weekly screening is warranted.
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Affiliation(s)
- I P Lodding
- Centre for Health, Immunity and Infectious Diseases (CHIP), Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - C da Cunha Bang
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - S S Sørensen
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark
| | - F Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - M Iversen
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - N Kirkby
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - M Perch
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - A Rasmussen
- Abdominal Surgery, Rigshospitalet, Copenhagen, Denmark
| | - H Sengeløv
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - A Mocroft
- Institute for Global Health, Infection and Population Health, University College of London, United Kingdom
| | - J D Lundgren
- Centre for Health, Immunity and Infectious Diseases (CHIP), Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
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