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Ranawaka R, Dayasiri K, Sandamali E, Gamage M. Management strategies for common viral infections in pediatric renal transplant recipients. World J Transplant 2024; 14:89978. [PMID: 38576764 PMCID: PMC10989477 DOI: 10.5500/wjt.v14.i1.89978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 03/15/2024] Open
Abstract
Viral infections have been considered as a major cause of morbidity and mortality after kidney transplantation in pediatric cohort. Children are at high risk of acquiring virus-related complications due to immunological immaturity and the enhanced alloreactivity risk that led to maintenance of high immunosuppressive regimes. Hence, prevention, early detection, and prompt treatment of such infe ctions are of paramount importance. Among all viral infections, herpes viruses (herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus), hepatitis B and C viruses, BK polyomavirus, and respiratory viruses (respiratory syncytial virus, parainfluenza virus, influenza virus and adenovirus) are common in kidney transplant recipients. These viruses can cause systemic disease or allograft dysfunction affecting the clinical outcome. Recent advances in tech nology and antiviral therapy have improved management strategies in screening, monitoring, adoption of prophylactic or preemptive therapy and precise trea tment in the immunocompromised host, with significant impact on the outcome. This review discusses the etiology, screening and monitoring, diagnosis, pre vention, and treatment of common viral infections in pediatric renal transplant recipients.
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Affiliation(s)
- Randula Ranawaka
- Department of Paediatrics, Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo 0094, Sri Lanka
| | - Kavinda Dayasiri
- Department of Paediatrics, Facullty of Medicine, University of Kelaniya, Ragama 0094, Sri Lanka
| | - Erandima Sandamali
- Department of Nursing, Faculty of Allied Health Sciences, University of Ruhuna, Galle 0094, Sri Lanka
| | - Manoji Gamage
- Division of Nutrition, Ministry of Health, Colombo 0094, Sri Lanka
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2
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Jones BP, Vali S, Saso S, Devaney A, Bracewell-Milnes T, Nicopoullos J, Thum MY, Kaur B, Roufosse C, Stewart V, Bharwani N, Ogbemudia A, Barnardo M, Dimitrov P, Klucniks A, Katz R, Johannesson L, Diaz Garcia C, Udupa V, Friend P, Quiroga I, Smith JR. Living donor uterus transplant in the UK: A case report. BJOG 2024; 131:372-377. [PMID: 37607687 DOI: 10.1111/1471-0528.17639] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/24/2023]
Affiliation(s)
- Benjamin P Jones
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Saaliha Vali
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Cutrale Perioperative and Ageing Group, Sir Michael Uren Hub, Imperial College London, London, UK
| | - Srdjan Saso
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Andrea Devaney
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Timothy Bracewell-Milnes
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Lister Fertility Clinic, The Lister Hospital, London, UK
| | - James Nicopoullos
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Lister Fertility Clinic, The Lister Hospital, London, UK
| | - Meen-Yau Thum
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Lister Fertility Clinic, The Lister Hospital, London, UK
| | - Baljeet Kaur
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- North West London Pathology, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Candice Roufosse
- North West London Pathology, Charing Cross Hospital, Imperial College NHS Trust, London, UK
- Centre for Inflammatory Disease, Department Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Victoria Stewart
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Nishat Bharwani
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Division of Surgery and Cancer, Imperial College London, London, UK
| | - Ann Ogbemudia
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Martin Barnardo
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Dimitrov
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Andris Klucniks
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard Katz
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | - Cesar Diaz Garcia
- IVI London, IVIRMA Global, London, UK
- EGA Institute for Women's Health, University College London, London, UK
| | - Venkatesha Udupa
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Friend
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Isabel Quiroga
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Richard Smith
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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3
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Xia J, Li X, Gui G, Wu J, Gong S, Shang Y, Fan J. Early immune surveillance to predict cytomegalovirus outcomes after allogeneic hematopoietic stem cell transplantation. Front Cell Infect Microbiol 2022; 12:954420. [PMID: 35992173 PMCID: PMC9382130 DOI: 10.3389/fcimb.2022.954420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThere is no method of predicting human cytomegalovirus (HCMV) outcomes in allogeneic hematopoietic stem cell transplant recipients clinically, leading in some cases to excessive or insufficient antiviral therapy. We evaluated the early immune response of recipients with disparate HCMV outcomes.MethodsThe HCMV outcomes of recipients were determined by long-term monitoring of HCMV DNA levels posttransplant. HCMV IgG and IgM concentrations at 1 week before and 1 week after transplantation, absolute lymphocyte counts, and HCMV-specific IFN-γ secreting cells at 1 month posttransplant were evaluated based on HCMV outcome.ResultsAll recipients were negative for HCMV IgM. Significant differences between recipients with and without HCMV reactivation were observed in pre- and post-transplant HCMV IgG antibody levels, absolute lymphocyte counts, and HCMV-specific IFN-γ secreting cells (P < 0.05). HCMV IgG antibody levels significantly increased after transplantation in recipients with HCMV reactivation (P = 0.032), but not in those without reactivation. Multivariate analysis revealed that except for the absolute lymphocyte count these biomarkers were related to HCMV reactivation, independent of other clinical factors. In time-to-event analyses, lower levels of these biomarkers were associated with an increased 150-day cumulative incidence of HCMV reactivation (log-rank P < 0.05). In recipients with HCMV reactivation, the duration of HCMV DNAemia had negative correlation with HCMV-specific IFN-γ-secreting cells (P = 0.015, r = -0.372). The relationships between the peak HCMV DNA load and absolute lymphocyte count and HCMV-specific IFN-γ-secreting cells followed the same trends (P = 0.026, r = -0.181 and P = 0.010, r = -0.317).ConclusionsHCMV IgG, absolute lymphocyte count, and HCMV-specific IFN-γ secreting cells represent the humoral and cellular immune response. Early monitoring of these immune markers could enable prediction of HCMV outcomes posttransplant and assessment of the severity of HCMV DNAemia.
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Affiliation(s)
- Jintao Xia
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xuejie Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Genyong Gui
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shengnan Gong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuxin Shang
- Department of Life Sciences, Faculty of Natural Sciences, Imperial College London South Kensington Campus, London, United Kingdom
| | - Jun Fan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Jun Fan,
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4
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Abstract
Uterine transplantation (UTx) is a fertility restoring treatment for women with absolute uterine factor infertility. At a time when there is no question of the procedure's feasibility, and as the number of livebirths begins to increase exponentially, various important reproductive, fetal, and maternal medicine implications have emerged. Detailed outcomes from 17 livebirths following UTx are now available, which are reviewed herein, along with contextualized extrapolation from pregnancy outcomes in other solid organ transplants. Differences in recipient demographics and reproductive aspirations between UTx and other transplant recipients make extrapolating management strategies and outcomes in other solid organ transplants inappropriate. Whereas preterm delivery remains prominent, small for gestational age or hypertensive disorders do not appear to be as prevalent following UTx when compared to other solid organ transplants. Given the primary objective of undertaking UTx is to achieve a livebirth, publication of reproductive outcomes is essential at this early stage, to reflect on and optimize the management of future cases.
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5
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Andrade-Sierra J, Heredia-Pimentel A, Rojas-Campos E, Ramírez Flores D, Cerrillos-Gutierrez JI, Miranda-Díaz AG, Evangelista-Carrillo LA, Martínez-Martínez P, Jalomo-Martínez B, Gonzalez-Espinoza E, Gómez-Navarro B, Medina-Pérez M, Nieves-Hernández JJ. Cytomegalovirus in renal transplant recipients from living donors with and without valganciclovir prophylaxis and with immunosuppression based on anti-thymocyte globulin or basiliximab. Int J Infect Dis 2021; 107:18-24. [PMID: 33862205 DOI: 10.1016/j.ijid.2021.04.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In our population, anti-thymocyte globulin (ATG) of 1 mg/Kg/day for 4 days is used; which permits not using valgancyclovir (VGC) prophylaxis in some renal transplant recipients (RTR) with moderate risk (R+), to reduce costs. This study aimed to determine the incidence and risk of developing cytomegalovirus (CMV), with or without prophylaxis, when exposed to low doses of ATG or basiliximab (BSL). PATIENTS AND METHODS A retrospective cohort included 265 RTR with follow-up of 12 months. Prophylaxis was used in R-/D+ and some R+. Tacrolimus (TAC), mycophenolate mofetil, and prednisone were used in all patients. Logistic regression analysis was performed to estimate the risk of CMV in RTR with or without VGC. RESULTS Cytomegalovirus was documented in 46 (17.3%) patients: 20 (43.5%) with CMV infection, and 26 (56.5%) with CMV disease. Anti-thymocyte globulin was used in 39 patients (85%): 32 R+, six D+/R-, and one D-/R-. ATG was used in 90% (27 of 30) of patients with CMV and without prophylaxis. The multivariate analysis showed an association of risk for CMV with the absence of prophylaxis (RR 2.29; 95% CI 1.08-4.86), ATG use (RR 3.7; 95% CI 1.50-9.13), TAC toxicity (RR 3.77; 95% CI 1.41-10.13), and lymphocytes at the sixth post-transplant month (RR 1.77; 95% CI 1.0-3.16). CONCLUSIONS Low doses of ATG favored the development of CMV and a lower survival free of CMV compared with BSL. In scenarios where resources for employing VGC are limited, BSL could be an acceptable strategy.
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Affiliation(s)
- Jorge Andrade-Sierra
- Department of Physiology, University Health Sciences Center, University of Guadalajara, Guadalajara, Jalisco, Mexico; Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico.
| | - Alejandro Heredia-Pimentel
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Enrique Rojas-Campos
- Medical Research Unit in Renal Diseases, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Diana Ramírez Flores
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - José I Cerrillos-Gutierrez
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Alejandra G Miranda-Díaz
- Department of Physiology, University Health Sciences Center, University of Guadalajara, Guadalajara, Jalisco, Mexico
| | - Luis A Evangelista-Carrillo
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Petra Martínez-Martínez
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Basilio Jalomo-Martínez
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Eduardo Gonzalez-Espinoza
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Benjamin Gómez-Navarro
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Miguel Medina-Pérez
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Juan José Nieves-Hernández
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
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6
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Veit T, Pan M, Munker D, Arnold P, Dick A, Kunze S, Meiser B, Schneider C, Michel S, Zoller M, Böhm S, Walter J, Behr J, Kneidinger N, Kauke T. Association of CMV-specific T-cell immunity and risk of CMV infection in lung transplant recipients. Clin Transplant 2021; 35:e14294. [PMID: 33749938 DOI: 10.1111/ctr.14294] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Protecting against CMV infection and maintaining CMV in latent state are largely provided by CMV-specific T-cells in lung transplant recipients. The aim of the study was to assess whether a specific T-cell response is associated with the risk for CMV infection in seronegative patients who are at high risk for delayed CMV infection. METHODS All CMV-seronegative recipients (R-) from CMV-seropositive donors (D+) between January 2018 and April 2019 were included and retrospectively screened for CMV infection before and after assessment of CMV-specific cell-mediated immunity. RESULTS Thirty-one of the 50 patients (62%) developed early-onset CMV infection. Lower absolute neutrophil counts were significantly associated with early-onset CMV infection. Antiviral prophylaxis was ceased after 137.2 ± 42.8 days. CMV-CMI were measured at a median of 5.5 months after LTx. 19 patients experienced early and late-onset CMV infection after prophylaxis withdrawal within 15 months post transplantation. Positive CMV-CMI was significantly associated with lower risk of late-onset CMV infection after transplantation in logistic and cox-regression analysis (OR=0.05, p = .01; OR=2,369, p = .026). CONCLUSION D+/R- lung transplant recipients are at high risk of developing early and late-onset CMV infection. Measurement of CMV-CMI soon after transplantation might further define the CMV infection prediction risk in LTx recipients being at high risk for CMV viremia.
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Affiliation(s)
- Tobias Veit
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Ming Pan
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Laboratory for Immunogenetics, University of Munich, LMU, Munich, Germany
| | - Dieter Munker
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Paola Arnold
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Andrea Dick
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Laboratory for Immunogenetics, University of Munich, LMU, Munich, Germany
| | - Susanne Kunze
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Laboratory for Immunogenetics, University of Munich, LMU, Munich, Germany
| | - Bruno Meiser
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Transplant Center, University of Munich, LMU, Munich, Germany
| | - Christian Schneider
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Department of Thoracic Surgery, University of Munich, LMU, Munich, Germany
| | - Sebastian Michel
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Clinic of Cardiac Surgery, University of Munich, LMU, Munich, Germany
| | - Michael Zoller
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Department of Anaesthesiology, University of Munich, LMU, Munich, Germany
| | - Stephan Böhm
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Faculty of Medicine, Virology, Max von Pettenkofer Institute, University of Munich, LMU, Munich, Germany
| | - Julia Walter
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Department of Thoracic Surgery, University of Munich, LMU, Munich, Germany
| | - Jürgen Behr
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Nikolaus Kneidinger
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Teresa Kauke
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Laboratory for Immunogenetics, University of Munich, LMU, Munich, Germany.,Department of Thoracic Surgery, University of Munich, LMU, Munich, Germany
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7
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Britt WJ. Human Cytomegalovirus Infection in Women With Preexisting Immunity: Sources of Infection and Mechanisms of Infection in the Presence of Antiviral Immunity. J Infect Dis 2020; 221:S1-S8. [PMID: 32134479 PMCID: PMC7057782 DOI: 10.1093/infdis/jiz464] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Human cytomegalovirus (HCMV) infection remains an important cause of neurodevelopmental sequelae in infants infected in utero. Unique to the natural history of perinatal HCMV infections is the occurrence of congenital HCMV infections (cCMV) in women with existing immunity to HCMV, infections that have been designated as nonprimary maternal infection. In maternal populations with a high HCMV seroprevalence, cCMV that follows nonprimary maternal infections accounts for 75%-90% of all cases of cCMV infections as well as a large proportion of infected infants with neurodevelopmental sequelae. Although considerable effort has been directed toward understanding immune correlates that can modify maternal infections and intrauterine transmission, the source of virus leading to nonprimary maternal infections and intrauterine transmission is not well defined. Previous paradigms that included reactivation of latent virus as the source of infection in immune women have been challenged by studies demonstrating acquisition and transmission of antigenically distinct viruses, a finding suggesting that reinfection through exposure to an exogenous virus is responsible for some cases of nonprimary maternal infection. Additional understanding of the source(s) of virus that leads to nonprimary maternal infection will be of considerable value in the development and testing of interventions such as vaccines designed to limit the incidence of cCMV in populations with high HCMV seroprevalence.
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Affiliation(s)
- William J Britt
- Departments of Pediatrics, Microbiology, Neurobiology, University of Alabama School of Medicine, Birmingham, Alabama
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8
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Silva JT, Fernández-Ruiz M, Aguado JM. Prevention and therapy of viral infections in patients with solid organ transplantation. Enferm Infecc Microbiol Clin 2020; 39:87-97. [PMID: 32143894 DOI: 10.1016/j.eimc.2020.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 12/28/2022]
Abstract
Solid organ transplantation (SOT) is the best treatment option for end-stage organ disease. The number of SOT procedures has been steadily increasing worldwide during the past decades. This trend has been accompanied by the continuous incorporation of new antimicrobial drugs and by the refinement of strategies aimed at minimizing the risk of opportunistic infection. Nonetheless, viral infections, which can occur at any stage of the post-transplant period, remain a clinical challenge that negatively impacts both patient and graft outcomes. This review offers an overview of the most relevant viral infections in the SOT population, with a focus on herpesviruses (cytomegalovirus, Epstein-Barr virus, varicella-zoster virus, and herpes simplex virus 1 and 2) and polyomaviruses (human BK polyomavirus). In addition, the currently recommended prophylactic and treatment approaches are summarized, as well as the new antiviral agents in different phases of clinical development.
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Affiliation(s)
- Jose Tiago Silva
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine, Universidad Complutense, Madrid, Spain.
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9
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Azoulay E, Russell L, Van de Louw A, Metaxa V, Bauer P, Povoa P, Montero JG, Loeches IM, Mehta S, Puxty K, Schellongowski P, Rello J, Mokart D, Lemiale V, Mirouse A. Diagnosis of severe respiratory infections in immunocompromised patients. Intensive Care Med 2020; 46:298-314. [PMID: 32034433 PMCID: PMC7080052 DOI: 10.1007/s00134-019-05906-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/19/2019] [Indexed: 12/23/2022]
Abstract
An increasing number of critically ill patients are immunocompromised. Acute hypoxemic respiratory failure (ARF), chiefly due to pulmonary infection, is the leading reason for ICU admission. Identifying the cause of ARF increases the chances of survival, but may be extremely challenging, as the underlying disease, treatments, and infection combine to create complex clinical pictures. In addition, there may be more than one infectious agent, and the pulmonary manifestations may be related to both infectious and non-infectious insults. Clinically or microbiologically documented bacterial pneumonia accounts for one-third of cases of ARF in immunocompromised patients. Early antibiotic therapy is recommended but decreases the chances of identifying the causative organism(s) to about 50%. Viruses are the second most common cause of severe respiratory infections. Positive tests for a virus in respiratory samples do not necessarily indicate a role for the virus in the current acute illness. Invasive fungal infections (Aspergillus, Mucorales, and Pneumocystis jirovecii) account for about 15% of severe respiratory infections, whereas parasites rarely cause severe acute infections in immunocompromised patients. This review focuses on the diagnosis of severe respiratory infections in immunocompromised patients. Special attention is given to newly validated diagnostic tests designed to be used on non-invasive samples or bronchoalveolar lavage fluid and capable of increasing the likelihood of an early etiological diagnosis.
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Affiliation(s)
- Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France. .,Université de Paris, Paris, France.
| | - Lene Russell
- Department of Intensive Care, Rigshospitalet and Copenhagen Academy for Medical Simulation and Education, University of Copenhagen, Copenhagen, Denmark
| | - Andry Van de Louw
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, NOVA Medical School, New University of Lisbon, Lisbon, Portugal
| | - José Garnacho Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James Street, Dublin 8, Ireland
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Kathryn Puxty
- Department of Intensive Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care (CEMIC), Medical University of Vienna, Vienna, Austria
| | - Jordi Rello
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto Salud Carlos III, Madrid, Spain.,CRIPS Department, Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
| | - Djamel Mokart
- Critical Care Department, Institut Paoli Calmettes, Marseille, France
| | - Virginie Lemiale
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Adrien Mirouse
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.,Université de Paris, Paris, France
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10
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Fu L, Santhanakrishnan K, Al-Aloul M, Jones NP, Steeples LR. Management of Ganciclovir Resistant Cytomegalovirus Retinitis in a Solid Organ Transplant Recipient: A Review of Current Evidence and Treatment Approaches. Ocul Immunol Inflamm 2019; 28:1152-1158. [PMID: 31621449 DOI: 10.1080/09273948.2019.1645188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: Cytomegalovirus retinitis (CMVR) is a serious and potentially sight-threatening infection in immunocompromised individuals. Strategies for the management of drug-resistant CMVR are described. Methods: A case of severe bilateral CMVR in a single lung transplant patient, with UL97 mutation conferring ganciclovir-resistance, is presented. Treatment with standard antiviral agent and adjuvant leflunomide, immunosuppression modifications (calcineurin inhibitors and corticosteroid), intravitreal antiviral therapy and novel use of CMV-immunoglobulin is described. A literature review to support drug-resistant CMVR management is presented. Results: Severe and progressive CMV retinitis was refractory to intravitreal foscarnet and systemic leflunomide. Drug-toxicity restricted systemic antiviral therapy options. The use of combined leflunomide and CMV-immunoglobulins, in the absence of viremia, has not been previously reported. Loss of ganciclovir-resistance was eventually observed permitting successful treatment with systemic and intravitreal ganciclovir. Conclusions: Drug-resistant CMVR is a complex clinical challenge. Multiple systemic and local treatment strategies may be necessary but toxicity, resistance, and co-morbidities may severely restrict available options.
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Affiliation(s)
- L Fu
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre , Manchester, UK.,Centre for Ophthalmology and Vision Sciences, Faculty of Medical and Human Sciences, University of Manchester , Manchester, UK
| | - K Santhanakrishnan
- Department of Cardiothoracic Transplant, Wythenshawe Hospital, Manchester University NHS Foundation Trust , Manchester, UK
| | - M Al-Aloul
- Department of Cardiothoracic Transplant, Wythenshawe Hospital, Manchester University NHS Foundation Trust , Manchester, UK
| | - N P Jones
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre , Manchester, UK.,Centre for Ophthalmology and Vision Sciences, Faculty of Medical and Human Sciences, University of Manchester , Manchester, UK
| | - L R Steeples
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre , Manchester, UK.,Centre for Ophthalmology and Vision Sciences, Faculty of Medical and Human Sciences, University of Manchester , Manchester, UK
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11
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Heliövaara E, Husain S, Martinu T, Singer LG, Cypel M, Humar A, Keshavjee S, Tikkanen J. Drug-resistant cytomegalovirus infection after lung transplantation: Incidence, characteristics, and clinical outcomes. J Heart Lung Transplant 2019; 38:1268-1274. [PMID: 31570289 DOI: 10.1016/j.healun.2019.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/28/2019] [Accepted: 09/03/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection and development of CMV drug resistance can cause significant morbidity and mortality in patients with lung transplantation (LTX). We investigated the incidence of CMV drug resistance in adult patients with LTX and characterized this patient group and its outcomes. METHODS We analyzed a single-center retrospective cohort of 735 patients who received LTX between January 2012 and October 2017. We assessed the incidences of CMV UL97 and UL54 genotyping for clinically suspected drug resistance and confirmed drug resistance. Case-matched controls (3 control patients for each resistant patient) were identified by matching for CMV serological status, development of CMV disease or significant viremia (≥3,000 IU/ml), and transplantation date. RESULTS The incidence of drug-resistant CMV was 1.98% (11/556) in donor and/or recipient CMV-positive patients and 4.7% (7/150) in donor-positive/recipient-negative patients. Altogether, 27 patients were tested for drug resistance, and 11 strains were resistant, 8 sensitive, and 8 inconclusive. No differences in immunosuppression, acute rejection, or pre-transplant sensitization were seen between case-matched groups. The peak CMV viral load and mean duration of viremia were significantly higher in the resistant group (324,000 vs. 117,000 mean IU/ml, p = 0.048 and 140 vs. 55 days, p < 0.001, respectively). The resistant group had increased overall mortality after onset of viremia compared with controls (3-year mortality 70% vs. 30%; p = 0.01). CONCLUSIONS Drug-resistant CMV infection is rare, but patients who develop it have decreased overall survival. Peak CMV viral load and duration of CMV viremia were associated with development of resistant CMV infection.
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Affiliation(s)
- Elina Heliövaara
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Atul Humar
- Division of Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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12
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Expression pattern of co-inhibitory molecules on CMV-specific T-cells in lung transplant patients. Clin Immunol 2019; 208:108258. [PMID: 31499181 DOI: 10.1016/j.clim.2019.108258] [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: 07/10/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Cytomegalovirus infection (CMVi) occurs frequently in transplant patients. Co-inhibitory molecules on CMV-specific T-cells (TCMV) in patients after lung transplantation were investigated. METHODS 59 lung transplant patients were stratified according to anti-CMV serostatus at time of transplantation. The co-inhibitors Programmed-Death-Receptor-1 (PD1) and B-and-T-Lymphocyte-Attenuator (BTLA) were detected on TCMV by flow cytometry (FACS). RESULTS TCMV were detectable in CMV sero-positive patients (R+) and in CMV sero-negative patients with a lung graft of a CMV sero-positive donor (D+/R-); in both cases, the frequency of TCMV was higher than in healthy controls (HC). PD-1 on TCMV was increased in D+/R+ and D+/R- patients as compared to HC. BTLA was significantly enhanced on TCMV of D+/R- patients vs. HC. R+ patients with CMV reactivation in the past had an increased fraction of BTLA+ TCMV. CONCLUSION In conclusion, the expression pattern of co-inhibitory molecules on TCMV is altered in patients after lung transplantation.
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13
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Yasri S, Wiwanitkit V. Probability of Ganciclovir Resistance in Cytomegalovirus-Infected Pediatric Kidney Transplant Recipients after Cessation of Standard Antiviral Prophylaxis: Estimated Risk on Thai cases. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2019; 30:1000-1001. [PMID: 31464265 DOI: 10.4103/1319-2442.265448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sora Yasri
- KMT Primary Care Center, Bangkok, Thailand
| | - Viroj Wiwanitkit
- Faculty of Medicine, University of Nis, Nis, Serbia; Joseph Ayobabalola University, Ikeji-Arakeji, Nigeria
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14
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Lim CC, Tan BH, Tung YT, Huang H, Hao Y, Mok IYJ, Lee PH, Choo JCJ. Risk-stratified approach to anti-viral prophylaxis against cytomegalovirus disease in glomerulonephritis and renal vasculitis treated with potent immunosuppressants. Infect Dis (Lond) 2019; 51:745-752. [PMID: 31407631 DOI: 10.1080/23744235.2019.1648855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Aim: Cytomegalovirus (CMV) reactivation and disease in immunocompromised individuals is associated with significant morbidity and mortality. Preventive measures such as anti-viral prophylaxis or surveillance and pre-emptive therapy effectively reduced CMV disease in solid organ transplant but have not been evaluated among patients with glomerulonephritis at-risk for CMV disease after immunosuppressive therapy. We evaluated the utility and outcomes of a risk-stratified approach to anti-viral prophylaxis for adults with glomerulonephritis treated with potent immunosuppressants. Methods: Single-center retrospective cohort study of adults with glomerulonephritis and renal vasculitis prescribed methylprednisolone, cyclophosphamide or rituximab in a tertiary referral centre. A risk-stratified approach to CMV anti-viral prophylaxis was implemented in March 2015. We compared the incidence of CMV disease in the pre-implementation (January 2008-December 2014) and post-implementation (June 2015-June 2017) groups. Results: We studied 119 individuals: 85 in the pre-implementation group and 34 in the post-implementation group. The post-implementation group had worse kidney function, greater proteinuria, higher prednisolone dose and more received intravenous methylprednisolone and plasma exchanges but CMV disease within 6 months was similar to the pre-implementation group (2.9% vs. 3.5%, p = 1.00). Among individuals in the post-implementation group who satisfied criteria to receive anti-viral prophylaxis (n = 21), CMV disease was more frequent in the group not given prophylaxis compared to those given prophylaxis as recommended (8.3% versus 0%, p = 1.00). Adverse events related to anti-viral prophylaxis occurred in 40%. Conclusion: This study provided pilot data for future randomized controlled trials to evaluate CMV preventive strategies in selected high-risk patients with glomerulonephritis or renal vasculitis.
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Affiliation(s)
- Cynthia Ciwei Lim
- Department of Renal Medicine, Singapore General Hospital , Singapore
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital , Singapore
| | - Yu Tzu Tung
- Department of Pharmacy, Singapore General Hospital , Singapore
| | - Huijun Huang
- Yong Loo Lin School of Medicine, National University of Singapore , Singapore
| | - Ying Hao
- Health Service Research Unit, Division of Medicine, Singapore General Hospital , Singapore
| | - Irene Y J Mok
- Department of Renal Medicine, Singapore General Hospital , Singapore
| | - Puay Hoon Lee
- Department of Pharmacy, Singapore General Hospital , Singapore
| | - Jason C J Choo
- Department of Renal Medicine, Singapore General Hospital , Singapore
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15
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El Helou G, Razonable RR. Letermovir for the prevention of cytomegalovirus infection and disease in transplant recipients: an evidence-based review. Infect Drug Resist 2019; 12:1481-1491. [PMID: 31239725 PMCID: PMC6556539 DOI: 10.2147/idr.s180908] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022] Open
Abstract
Cytomegalovirus (CMV) is a leading opportunistic infection in immune compromised patients, including allogeneic hematopoietic stem cell (HSCT) or solid organ transplant (SOT) recipients, where primary infection or reactivation is associated with increased morbidity and mortality. Antiviral drugs are the mainstay for the prevention of CMV infection and disease, most commonly with valganciclovir. However, valganciclovir use is often associated with adverse drug reactions, most notably leukopenia and neutropenia, and its widespread use has led to emergence of antiviral resistance. Foscarnet and cidofovir, however, are associated with nephrotoxicity. Letermovir, a novel CMV viral terminase inhibitor drug, was recently approved for CMV prophylaxis in allogeneic HSCT recipients. It has a favorable pharmacokinetic and tolerability profile. The aim of this paper is to review the evidence supporting the use of letermovir in allogeneic HSCT recipients, and how the drug impacts our contemporary clinical practice. In addition, we discuss the ongoing clinical trial of letermovir for the prevention of CMV in SOT recipients. The use of letermovir for treatment of CMV infection and disease is not yet approved. However, because of a unique mechanism of activity, we provide our perspective on the potential role of letermovir in the treatment of ganciclovir-resistant CMV infection and disease. Furthermore, drug-resistant CMV has emerged during use of letermovir for prophylaxis and treatment. Caution is advised on its use in order to preserve its therapeutic lifespan.
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Affiliation(s)
- Guy El Helou
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
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16
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The Membrane-Spanning Peptide and Acidic Cluster Dileucine Sorting Motif of UL138 Are Required To Downregulate MRP1 Drug Transporter Function in Human Cytomegalovirus-Infected Cells. J Virol 2019; 93:JVI.00430-19. [PMID: 30894470 DOI: 10.1128/jvi.00430-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 01/08/2023] Open
Abstract
The human cytomegalovirus (HCMV) UL138 protein downregulates the cell surface expression of the multidrug resistance-associated protein 1 (MRP1) transporter. We examined the genetic requirements within UL138 for MRP1 downregulation. We determined that the acidic cluster dileucine motif is essential for UL138-mediated downregulation of MRP1 steady-state levels and inhibition of MRP1 efflux activity. We also discovered that the naturally occurring UL138 protein isoforms, the full-length long isoform of UL138 and a short isoform missing the N-terminal membrane-spanning domain, have different abilities to inhibit MRP1 function. Cells expressing the long isoform of UL138 show decreased MRP1 steady-state levels and fail to efflux an MRP1 substrate. Cells expressing the short isoform of UL138 also show decreased MRP1 levels, but the magnitude of the decrease is not the same, and they continue to efficiently efflux an MRP1 substrate. Thus, the membrane-spanning domain, while dispensable for a UL138-mediated decrease in MRP1 protein levels, is necessary for a functional inhibition of MRP1 activity. Our work defines the genetic requirements for UL138-mediated MRP1 downregulation and anticipates the possible evolution of viral escape mutants during the use of therapies targeting this function of UL138.IMPORTANCE HCMV UL138 curtails the activity of the MRP1 drug transporter by reducing its steady-state levels, leaving cells susceptible to killing by cytotoxic agents normally exported by MRP1. It has been suggested in the literature that capitalizing on this UL138-induced vulnerability could be a potential antiviral strategy against virally infected cells, particularly those harboring a latent infection during which UL138 is one of the few viral proteins expressed. Therefore, identifying the regions of UL138 required for MRP1 downregulation and predicting genetic variants that may be selected upon UL138-targeted chemotherapy are important ventures. Here we present the first structure-function examination of UL138 activity and determine that its transmembrane domain and acidic cluster dileucine Golgi sorting motif are required for functional MRP1 downregulation.
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