1
|
Kirisri S, Vongsakulyanon A, Kantachuvesiri S, Razonable RR, Bruminhent J. Predictors of CMV Infection in CMV-Seropositive Kidney Transplant Recipients: Impact of Pretransplant CMV-Specific Humoral Immunity. Open Forum Infect Dis 2021; 8:ofab199. [PMID: 34113686 PMCID: PMC8186243 DOI: 10.1093/ofid/ofab199] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/14/2021] [Indexed: 12/29/2022] Open
Abstract
Background Although cytomegalovirus (CMV)-seropositive solid organ transplant recipients have a relatively lower risk of CMV infection than CMV-seronegative recipients who receive allograft from CMV-seropositive donors, some patients remain at risk of CMV infection after transplant. We investigated the pretransplant CMV-specific humoral immunity (CHI) and other CMV infection predictors in CMV-seropositive kidney transplant (KT) recipients. Methods This retrospective study was conducted on adult CMV-seropositive KT recipients during 2017 and 2018. The cumulative incidence of CMV infection was estimated using the Kaplan-Meier method. CHI, measured with an enzyme-linked fluorescent immunoassay and other predictors for CMV infection, was analyzed using Cox proportional hazards models. Results Of the 340 CMV-seropositive KT recipients (37% female; mean ± SD age, 43 ± 11 years), 69% received deceased-donor allograft and 64% received induction therapy. During a mean follow-up of 14 months, the cumulative incidence of CMV infection was 14.8%. In multivariate analysis, low pretransplant CHI (defined as anti-CMV immunoglobulin [IgG] titer <20 AU/mL) was significantly associated with CMV infection (hazard ratio [HR], 2.98; 95% CI, 1.31–6.77; P = .009). Other significant predictors of CMV infection included older donor age (HR, 1.03; 95% CI, 1.01–1.06; P = .005), antithymocyte induction therapy (HR, 2.90; 95% CI, 1.09–7.74; P = .033), and prolonged cold ischemic time (HR, 1.06; 95% CI, 1.02–1.10; P = .002). Conclusions A low pretransplant CHI is independently associated with post-transplant CMV infection in CMV-seropositive KT recipients. A quantitative anti-CMV IgG assay could potentially stratify CMV-seropositive patients at risk of CMV infection after KT.
Collapse
Affiliation(s)
- Similan Kirisri
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Apirom Vongsakulyanon
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Kantachuvesiri
- Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Raymund R Razonable
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - Jackrapong Bruminhent
- Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
2
|
Perricone C, Triggianese P, Bartoloni E, Cafaro G, Bonifacio AF, Bursi R, Perricone R, Gerli R. The anti-viral facet of anti-rheumatic drugs: Lessons from COVID-19. J Autoimmun 2020; 111:102468. [PMID: 32317220 PMCID: PMC7164894 DOI: 10.1016/j.jaut.2020.102468] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023]
Abstract
The outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has posed the world at a pandemic risk. Coronavirus-19 disease (COVID-19) is an infectious disease caused by SARS-CoV-2, which causes pneumonia, requires intensive care unit hospitalization in about 10% of cases and can lead to a fatal outcome. Several efforts are currently made to find a treatment for COVID-19 patients. So far, several anti-viral and immunosuppressive or immunomodulating drugs have demonstrated some efficacy on COVID-19 both in vitro and in animal models as well as in cases series. In COVID-19 patients a pro-inflammatory status with high levels of interleukin (IL)-1B, IL-1 receptor (R)A and tumor necrosis factor (TNF)-α has been demonstrated. Moreover, high levels of IL-6 and TNF-α have been observed in patients requiring intensive-care-unit hospitalization. This provided rationale for the use of anti-rheumatic drugs as potential treatments for this severe viral infection. Other agents, such as hydroxychloroquine and chloroquine might have a direct anti-viral effect. The anti-viral aspect of immunosuppressants towards a variety of viruses has been known since long time and it is herein discussed in the view of searching for a potential treatment for SARS-CoV-2 infection.
Collapse
Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Paola Triggianese
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Angelo F Bonifacio
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Bursi
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Perricone
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy
| | - Roberto Gerli
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy.
| |
Collapse
|
3
|
Patel SY, Carbone J, Jolles S. The Expanding Field of Secondary Antibody Deficiency: Causes, Diagnosis, and Management. Front Immunol 2019; 10:33. [PMID: 30800120 PMCID: PMC6376447 DOI: 10.3389/fimmu.2019.00033] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022] Open
Abstract
Antibody deficiency or hypogammaglobulinemia can have primary or secondary etiologies. Primary antibody deficiency (PAD) is the result of intrinsic genetic defects, whereas secondary antibody deficiency may arise as a consequence of underlying conditions or medication use. On a global level, malnutrition, HIV, and malaria are major causes of secondary immunodeficiency. In this review we consider secondary antibody deficiency, for which common causes include hematological malignancies, such as chronic lymphocytic leukemia or multiple myeloma, and their treatment, protein-losing states, and side effects of a number of immunosuppressive agents and procedures involved in solid organ transplantation. Secondary antibody deficiency is not only much more common than PAD, but is also being increasingly recognized with the wider and more prolonged use of a growing list of agents targeting B cells. SAD may thus present to a broad range of specialties and is associated with an increased risk of infection. Early diagnosis and intervention is key to avoiding morbidity and mortality. Optimizing treatment requires careful clinical and laboratory assessment and may involve close monitoring of risk parameters, vaccination, antibiotic strategies, and in some patients, immunoglobulin replacement therapy (IgRT). This review discusses the rapidly evolving list of underlying causes of secondary antibody deficiency, specifically focusing on therapies targeting B cells, alongside recent advances in screening, biomarkers of risk for the development of secondary antibody deficiency, diagnosis, monitoring, and management.
Collapse
Affiliation(s)
- Smita Y. Patel
- Clinical Immunology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
| |
Collapse
|
4
|
Sarmiento E, Cifrian J, Calahorra L, Bravo C, Lopez S, Laporta R, Ussetti P, Sole A, Morales C, de Pablos A, Jaramillo M, Ezzahouri I, García S, Navarro J, Lopez-Hoyos M, Carbone J. Monitoring of early humoral immunity to identify lung recipients at risk for development of serious infections: A multicenter prospective study. J Heart Lung Transplant 2018; 37:1001-1012. [DOI: 10.1016/j.healun.2018.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/12/2018] [Accepted: 04/03/2018] [Indexed: 12/13/2022] Open
|
5
|
Gupta E, Pamecha V, Verma Y, Kumar N, Rastogi A, Hasnian N, Bhadoria AS. Pre-Transplant Cytomegalovirus Immunoglobulin G Antibody Levels Could Prevent Severe Cytomegalovirus Infections Post-Transplant in Liver Transplant Recipients: Experience from a Tertiary Care Liver Centre. Indian J Med Microbiol 2017; 35:499-503. [DOI: 10.4103/ijmm.ijmm_17_201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
6
|
Toyoda M, Shin BH, Ge S, Mirocha J, Thomas D, Chu M, Rodriguez E, Chao C, Petrosyan A, Galera OA, Vo A, Choi J, Peng A, Kahwaji J, Jordan SC. Impact of Desensitization on Antiviral Immunity in HLA-Sensitized Kidney Transplant Recipients. J Immunol Res 2017; 2017:5672523. [PMID: 28265581 PMCID: PMC5317146 DOI: 10.1155/2017/5672523] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/15/2016] [Indexed: 12/15/2022] Open
Abstract
Viral infections represent significant morbidity and mortality factors in kidney transplant recipients, with CMV, EBV, and BKV infections being most common. Desensitization (DES) with IVIg and rituximab with/without plasma exchange followed by kidney transplantation with alemtuzumab induction increased successful transplant rates in HLA-sensitized patients but may represent an increased risk for viral infections due to severe lymphocyte depletion. Here, we report on the posttransplant viral infection status in 372 DES versus 538 non-DES patients. CMV and EBV viremia were significantly lower in DES patients, while BKV viremia was similar. This trend was observed primarily in CMV sero(-), EBV sero(+), and sero(-) patients. No patient developed PTLD. The incidence of BKAN, allograft, and patient survival was similar in both groups. These viral infections were not associated with subsequent allograft rejection which occurred within 6 months after the infection. Conclusions. The IVIg + rituximab desensitization combined with alemtuzumab induction with triple immunosuppression maintenance does not increase the risk for CMV, EBV, and BKV infections. Possible factors include, in addition to posttransplant antiviral prophylaxis and PCR monitoring, presence of memory T cells and antibodies specific to CMV and likely EBV, NK cell-mediated ADCC despite lymphocyte depletion, elimination of EBV and CMV reservoirs by rituximab and alemtuzumab, and use of IVIg with antiviral properties.
Collapse
Affiliation(s)
- Mieko Toyoda
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bong-Ha Shin
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shili Ge
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - James Mirocha
- Biostatistics Core, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Thomas
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Maggie Chu
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edgar Rodriguez
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christine Chao
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anna Petrosyan
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Odette A. Galera
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jua Choi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alice Peng
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Kahwaji
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stanley C. Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
7
|
Sarmiento E, Jaramillo M, Calahorra L, Fernandez-Yañez J, Gomez-Sanchez M, Crespo-Leiro MG, Paniagua M, Almenar L, Cebrian M, Rabago G, Levy B, Segovia J, Gomez-Bueno M, Lopez J, Mirabet S, Navarro J, Rodriguez-Molina JJ, Fernandez-Cruz E, Carbone J. Evaluation of humoral immunity profiles to identify heart recipients at risk for development of severe infections: A multicenter prospective study. J Heart Lung Transplant 2016; 36:529-539. [PMID: 27866926 DOI: 10.1016/j.healun.2016.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/17/2016] [Accepted: 10/12/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND New biomarkers are necessary to improve detection of the risk of infection in heart transplantation. We performed a multicenter study to evaluate humoral immunity profiles that could better enable us to identify heart recipients at risk of severe infections. METHODS We prospectively analyzed 170 adult heart recipients at 8 centers in Spain. Study points were before transplantation and 7 and 30 days after transplantation. Immune parameters included IgG, IgM, IgA and complement factors C3 and C4, and titers of specific antibody to pneumococcal polysaccharide antigens (anti-PPS) and to cytomegalovirus (CMV). To evaluate potential immunologic mechanisms leading to IgG hypogammaglobulinemia, before heart transplantation we assessed serum B-cell activating factor (BAFF) levels using enzyme-linked immunoassay. The clinical follow-up period lasted 6 months. Clinical outcome was need for intravenous anti-microbials for therapy of infection. RESULTS During follow-up, 53 patients (31.2%) developed at least 1 severe infection. We confirmed that IgG hypogammaglobulinemia at Day 7 (defined as IgG <600 mg/dl) is a risk factor for infection in general, bacterial infections in particular, and CMV disease. At Day 7 after transplantation, the combination of IgG <600 mg/dl + C3 <80 mg/dl was more strongly associated with the outcome (adjusted odds ratio 7.40; 95% confidence interval 1.48 to 37.03; p = 0.014). We found that quantification of anti-CMV antibody titers and lower anti-PPS antibody concentrations were independent predictors of CMV disease and bacterial infections, respectively. Higher pre-transplant BAFF levels were a risk factor of acute cellular rejection. CONCLUSION Early immunologic monitoring of humoral immunity profiles proved useful for the identification of heart recipients who are at risk of severe infection.
Collapse
Affiliation(s)
- Elizabeth Sarmiento
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Maria Jaramillo
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Leticia Calahorra
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Juan Fernandez-Yañez
- Cardiology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Maria G Crespo-Leiro
- Cardiology Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Maria Paniagua
- Cardiology Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Luis Almenar
- Heart Failure and Heart Transplant Unit, Cardiology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Monica Cebrian
- Heart Failure and Heart Transplant Unit, Cardiology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Gregorio Rabago
- Heart Surgery Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Beltran Levy
- Heart Surgery Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Javier Segovia
- Heart Failure and Cardiomyopathy Unit, Heart Failure and Heart Transplant Section, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Manuel Gomez-Bueno
- Heart Failure and Cardiomyopathy Unit, Heart Failure and Heart Transplant Section, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Javier Lopez
- Heart Failure and Heart Transplant Unit, Hospital Clínico Universitario, Valladolid, Spain
| | - Sonia Mirabet
- Cardiology Department, Sant Pau Hospital, Barcelona, Spain
| | - Joaquin Navarro
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Eduardo Fernandez-Cruz
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.
| |
Collapse
|
8
|
Torre-Cisneros J, Aguado J, Caston J, Almenar L, Alonso A, Cantisán S, Carratalá J, Cervera C, Cordero E, Fariñas M, Fernández-Ruiz M, Fortún J, Frauca E, Gavaldá J, Hernández D, Herrero I, Len O, Lopez-Medrano F, Manito N, Marcos M, Martín-Dávila P, Monforte V, Montejo M, Moreno A, Muñoz P, Navarro D, Pérez-Romero P, Rodriguez-Bernot A, Rumbao J, San Juan R, Vaquero J, Vidal E. Management of cytomegalovirus infection in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations. Transplant Rev (Orlando) 2016; 30:119-43. [DOI: 10.1016/j.trre.2016.04.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 04/02/2016] [Accepted: 04/04/2016] [Indexed: 02/06/2023]
|
9
|
Potena L, Solidoro P, Patrucco F, Borgese L. Treatment and prevention of cytomegalovirus infection in heart and lung transplantation: an update. Expert Opin Pharmacother 2016; 17:1611-22. [PMID: 27340928 DOI: 10.1080/14656566.2016.1199684] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Heart and lung transplantation are standard therapeutic strategies to improve survival and quality of life in selected patients with end-stage heart or lung diseases. Cytomegalovirus (CMV) is one the most clinically relevant and frequent post-transplant infectious agents, which may cause direct acute syndromes, and chronic indirect graft-related injury. Despite effective antiviral drugs being available to prevent and treat CMV infection, due to the immunosuppression burden and the specific characteristics of thoracic grafts, CMV infection remains a major clinical problem in heart and lung transplant recipients. AREAS COVERED We performed an extensive literature search focused on studies specifically including heart or lung transplantation, when available, or kidney transplant recipients when data on thoracic transplants were not available. We discuss the pros and cons supporting the use of currently available drugs and strategies for CMV prevention and treatment, highlighting current unmet needs. EXPERT OPINION While (Val)Ganciclovir remains the cornerstone of anti-CMV therapy, prolonged universal prophylaxis may expose a large number of patients to an excess of drug toxicity. Additional drugs with lower toxicity may be available in the context of anti-CMV prophylaxis, and effective CMV-risk stratification, by means of novel immune monitoring assays, which may help to customize the therapeutic approach.
Collapse
Affiliation(s)
- Luciano Potena
- a Heart and Lung Transplant Program, Academic Hospital S. Orsola-Malpighi , Bologna University , Bologna , Italy
| | - Paolo Solidoro
- b Lung Transplant Center, Cardiovascular Thoracic Department , A.O.U. Città della Salute e della Scienza di Torino , Turin , Italy
| | - Filippo Patrucco
- b Lung Transplant Center, Cardiovascular Thoracic Department , A.O.U. Città della Salute e della Scienza di Torino , Turin , Italy
| | - Laura Borgese
- a Heart and Lung Transplant Program, Academic Hospital S. Orsola-Malpighi , Bologna University , Bologna , Italy
| |
Collapse
|
10
|
Carbone J. The Immunology of Posttransplant CMV Infection: Potential Effect of CMV Immunoglobulins on Distinct Components of the Immune Response to CMV. Transplantation 2016; 100 Suppl 3:S11-8. [PMID: 26900990 PMCID: PMC4764014 DOI: 10.1097/tp.0000000000001095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 12/14/2022]
Abstract
The immune response to cytomegalovirus (CMV) infection is highly complex, including humoral, cellular, innate, and adaptive immune responses. Detection of CMV by the innate immune system triggers production of type I IFNs and inflammatory cytokines which initiate cellular and humoral responses that are critical during the early viremic phase of CMV infection. Sustained control of CMV infection is largely accounted for by cellular immunity, involving various T-cell and B-cell subsets. In solid organ transplant patients, global suppression of innate and adaptive immunities by immunosuppressive agents limits immunological defense, including inhibition of natural killer cell activity with ongoing lowering of Ig levels and CMV-specific antibody titers. This is coupled with a short-term suppression of CMV-specific T cells, the extent and duration of which can predict risk of progression to CMV viremia. CMV immunoglobulin (CMVIG) preparations have the potential to exert immunomodulatory effects as well as providing passive immunization. Specific CMVIG antibodies and virus neutralization might be enhanced by modulation of dendritic cell activity and by a decrease in T-cell activation, effects which are of importance during the initial phase of infection. In summary, the role of CMVIG in reconstituting specific anti-CMV antibodies may be enhanced by some degree of modulation of the innate and adaptive immune responses, which could help to control some of the direct and indirect effects of CMV infection.
Collapse
Affiliation(s)
- Javier Carbone
- Clinical Immunology Department, General University Hospital Gregorio Marañon, Complutense University, Madrid, Spain
| |
Collapse
|
11
|
Gracia-Ahufinger I, Ferrando-Martínez S, Montejo M, Muñoz-Villanueva M, Cantisán S, Rivero A, Solana R, Leal M, Torre-Cisneros J. Pre-transplant thymic function is associated with the risk of cytomegalovirus disease after solid organ transplantation. Clin Microbiol Infect 2015; 21:511.e1-7. [DOI: 10.1016/j.cmi.2014.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/20/2014] [Accepted: 12/24/2014] [Indexed: 11/28/2022]
|
12
|
Bruminhent J, Thongprayoon C, Dierkhising RA, Kremers WK, Theel ES, Razonable RR. Risk factors for cytomegalovirus reactivation after liver transplantation: can pre-transplant cytomegalovirus antibody titers predict outcome? Liver Transpl 2015; 21:539-46. [PMID: 25597303 DOI: 10.1002/lt.24078] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/25/2014] [Indexed: 01/15/2023]
Abstract
Despite preexisting cytomegalovirus (CMV) immunity, CMV-seropositive liver transplantation (LT) patients remain at risk of CMV infection. We hypothesized that the pre-transplant CMV antibody titer correlates with the risk of CMV reactivation. We conducted a retrospective study of CMV-seropositive LT recipients who did not receive anti-CMV prophylaxis from 2007 to 2013. The pre-transplant CMV immunoglobulin G (IgG) titer, which was measured with an enzyme-linked fluorescent immunoassay, was assessed as a risk factor for CMV reactivation with multivariate Cox proportional hazards models. The population consisted of 225 CMV-seropositive LT patients with a median age of 57 years (interquartile range, 47-62 years). The CMV titer distributions were as follows: <60 (40%) and ≥60 AU/mL (60%). The Kaplan-Meier estimates for CMV infection were 17% at 3 months, 18% at 6 months, and 19% at 12 months after transplantation. In a univariate analysis, a marginally significant increased risk of CMV infection was seen in LT recipients with a pre-transplant CMV IgG titer<60 AU/mL versus ≥60 AU/mL [hazard ratio (HR), 1.79; 95% confidence interval (CI), 0.98-3.28 (P=0.06)]. This risk was statistically significant in the subgroup of recipients who received allografts from CMV-seropositive donors [HR, 2.21; 95% CI, 1.15-4.26 (P=0.02)]. In a multivariate analysis, a pre-transplant CMV IgG titer<60 AU/mL was significantly associated with CMV infection [HR, 3.11; 95% CI, 1.60-6.03 (P<0.001)]. The other risk factors were high body mass index, donor CMV seropositivity, prolonged cold ischemic time, use of an interleukin-2 receptor antagonist for induction therapy, and high numbers of post-transplant infections. A lower pre-transplant CMV antibody titer is significantly associated with CMV infection after LT. Quantitative measurement of CMV-specific humoral immunity may have a potential role in improving the CMV prevention strategy in CMV-seropositive LT recipients.
Collapse
Affiliation(s)
- Jackrapong Bruminhent
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN; Somdech Phra Debaratana Medical Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | | | | | | | | |
Collapse
|
13
|
Kerr J, Quinti I, Eibl M, Chapel H, Späth PJ, Sewell WAC, Salama A, van Schaik IN, Kuijpers TW, Peter HH. Is dosing of therapeutic immunoglobulins optimal? A review of a three-decade long debate in europe. Front Immunol 2014; 5:629. [PMID: 25566244 PMCID: PMC4263903 DOI: 10.3389/fimmu.2014.00629] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/25/2014] [Indexed: 12/13/2022] Open
Abstract
The consumption of immunoglobulins (Ig) is increasing due to better recognition of antibody deficiencies, an aging population, and new indications. This review aims to examine the various dosing regimens and research developments in the established and in some of the relevant off-label indications in Europe. The background to the current regulatory settings in Europe is provided as a backdrop for the latest developments in primary and secondary immunodeficiencies and in immunomodulatory indications. In these heterogeneous areas, clinical trials encompassing different routes of administration, varying intervals, and infusion rates are paving the way toward more individualized therapy regimens. In primary antibody deficiencies, adjustments in dosing and intervals will depend on the clinical presentation, effective IgG trough levels and IgG metabolism. Ideally, individual pharmacokinetic profiles in conjunction with the clinical phenotype could lead to highly tailored treatment. In practice, incremental dosage increases are necessary to titrate the optimal dose for more severely ill patients. Higher intravenous doses in these patients also have beneficial immunomodulatory effects beyond mere IgG replacement. Better understanding of the pharmacokinetics of Ig therapy is leading to a move away from simplistic "per kg" dosing. Defective antibody production is common in many secondary immunodeficiencies irrespective of whether the causative factor was lymphoid malignancies (established indications), certain autoimmune disorders, immunosuppressive agents, or biologics. This antibody failure, as shown by test immunization, may be amenable to treatment with replacement Ig therapy. In certain immunomodulatory settings [e.g., idiopathic thrombocytopenic purpura (ITP)], selection of patients for Ig therapy may be enhanced by relevant biomarkers in order to exclude non-responders and thus obtain higher response rates. In this review, the developments in dosing of therapeutic immunoglobulins have been limited to high and some medium priority indications such as ITP, Kawasaki' disease, Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, myasthenia gravis, multifocal motor neuropathy, fetal alloimmune thrombocytopenia, fetal hemolytic anemia, and dermatological diseases.
Collapse
Affiliation(s)
- Jacqueline Kerr
- Section Poly- and Monoclonal Antibodies, Paul Ehrlich Institut, Langen, Germany
| | - Isabella Quinti
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Helen Chapel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Peter J. Späth
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | | | - Abdulgabar Salama
- Zentrum für Transfusionsmedizin u. Zelltherapie, Charité, Berlin, Germany
| | - Ivo N. van Schaik
- Department of Neurology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Taco W. Kuijpers
- Department of Pediatric Hematology, Immunology and Infectious disease, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Hans-Hartmut Peter
- Centrum für chronische Immunodeficienz (CCI), University Medical Centre, University of Freiburg, Freiburg im Breisgau, Germany
| |
Collapse
|
14
|
Yamazaki R, Tanaka Y, Nakasone H, Sato M, Terasako-Saito K, Sakamoto K, Akahoshi Y, Nakano H, Ugai T, Yamasaki R, Wada H, Ishihara Y, Kawamura K, Ashizawa M, Kimura SI, Kikuchi M, Kako S, Kanda J, Tanihara A, Nishida J, Kanda Y. Allotype analysis to determine the origin of cytomegalovirus immunoglobulin-G after allogeneic stem cell transplantation. Transpl Infect Dis 2014; 16:904-13. [DOI: 10.1111/tid.12304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/17/2014] [Accepted: 08/07/2014] [Indexed: 11/26/2022]
Affiliation(s)
- R. Yamazaki
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Y. Tanaka
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - H. Nakasone
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - M. Sato
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - K. Terasako-Saito
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - K. Sakamoto
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Y. Akahoshi
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - H. Nakano
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - T. Ugai
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - R. Yamasaki
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - H. Wada
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Y. Ishihara
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - K. Kawamura
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - M. Ashizawa
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - S.-I. Kimura
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - M. Kikuchi
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - S. Kako
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - J. Kanda
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - A. Tanihara
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - J. Nishida
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| | - Y. Kanda
- Division of Hematology; Department of Internal Medicine; Saitama Medical Center; Jichi Medical University; Saitama Japan
| |
Collapse
|
15
|
Dunn JP. An overview of current and future treatment options for patients with cytomegalovirus retinitis. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.945906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
16
|
Florescu DF, Kalil AC, Qiu F, Schmidt CM, Sandkovsky U. What is the impact of hypogammaglobulinemia on the rate of infections and survival in solid organ transplantation? A meta-analysis. Am J Transplant 2013; 13:2601-10. [PMID: 23919557 DOI: 10.1111/ajt.12401] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/28/2013] [Accepted: 05/31/2013] [Indexed: 01/25/2023]
Abstract
Hypogammaglobulinemia has been described after solid organ transplantation and has been associated with increased risk of infections. The aim of the study was to evaluate the rate of severe hypogammaglobulinemia and its relationship with the risk of infections during the first year posttransplantation. Eighteen studies (1756 patients) that evaluated hypogammaglobulinemia and posttransplant infections were included. The data were pooled using the DerSimonian and Laird random-effects model. Q statistic method was used to assess statistical heterogeneity. Within the first year posttransplantation, the rate of hypogammaglobulinemia (IgG < 700 mg/dL) was 45% (95% CI: 0.34-0.55; Q = 330.1, p < 0.0001), the rate of mild hypogammaglobulinemia (IgG = 400-700 mg/dL) was 39% (95% CI: 0.22-0.56; Q = 210.09, p < 0.0001) and the rate of severe hypogammaglobulinemia (IgG < 400 mg/dL) was 15% (95% CI: 0.08-0.22; Q = 50.15, p < 0.0001). The rate of hypogammaglobulinemia by allograft type: heart 49% (21%-78%; Q = 131.16, p < 0.0001); kidney 40% (30%-49%; Q = 24.55, p = 0.0002); liver 16% (0.001%-35%; Q = 14.31, p = 0.0002) and lung 63% (53%-74%; Q = 6.85, p = 0.08). The odds of respiratory infection (OR = 4.83; 95% CI: 1.66-14.05; p = 0.004; I(2) = 0%), CMV (OR = 2.40; 95% CI: 1.16-4.96; p = 0.02; I(2) = 26.66%), Aspergillus (OR = 8.19; 95% CI: 2.38-28.21; p = 0.0009; I(2) = 17.02%) and other fungal infections (OR = 3.69; 95% CI: 1.11-12.33; p = 0.03; I(2) = 0%) for patients with IgG < 400 mg/dL were higher than the odds for patients with IgG > 400 mg/dL. The odds for 1-year all-cause mortality for severe hypogammaglobulinemia group was 21.91 times higher than those for IgG > 400 mg/dL group (95% CI: 2.49-192.55; p = 0.005; I(2) = 0%). Severe hypogammaglobulinemia during the first year posttransplantation significantly increased the risk of CMV, fungal and respiratory infections, and was associated with higher 1-year all-cause mortality.
Collapse
Affiliation(s)
- D F Florescu
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE; Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | | |
Collapse
|
17
|
Muñoz P, Crespo Leiro MG. [Prophylaxis of cytomegalovirus infection in heart transplantation]. Enferm Infecc Microbiol Clin 2012; 29 Suppl 6:52-5. [PMID: 22541924 DOI: 10.1016/s0213-005x(11)70059-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cytomegalovirus (CMV) is a common complication after heart transplantation, affecting almost half of all recipients. The clinical spectrum of this infection includes, in order of greater to lesser severity, latent infection, asymptomatic viremia, CMV syndrome and CMV disease. CMV is associated with rejection and vascular graft disease and is a major cause of morbidity and mortality. The factors most frequently involved in susceptibility to this infection and its severity are donor and recipient CMV serological status, the intensity of immunosuppression and the type of immunosuppressive agents used. The management strategies of this infection include universal or targeted prophylaxis, preemptive therapy and treatment of established disease. The use of preventive measures significantly reduces the incidence of symtomatic infection or CMV disease, which has been reported to be less than 3% in some recent series.
Collapse
Affiliation(s)
- Patricia Muñoz
- Servicio de Microbiología-Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, CIBERES, GESITRA, REIPI, España.
| | | |
Collapse
|
18
|
Carbone J, Lanio N, Gallego A, Kern F, Navarro J, Muñoz P, Alonso R, Catalán P, Fernández-Yáñez J, Palomo J, Ruiz M, Fernández-Cruz E, Sarmiento E. Simultaneous Monitoring of Cytomegalovirus-Specific Antibody and T-cell levels in Seropositive Heart Transplant Recipients. J Clin Immunol 2012; 32:809-19. [DOI: 10.1007/s10875-012-9670-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
|
19
|
Carbone J, del Pozo N, Gallego A, Sarmiento E. Immunological risk factors for infection after immunosuppressive and biologic therapies. Expert Rev Anti Infect Ther 2011; 9:405-13. [PMID: 21504398 DOI: 10.1586/eri.10.178] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Immunosuppressive and biologic therapies are costly and can involve a considerable risk of infection. Noninvasive diagnostic tools for early prediction of infection before and after administration of these therapies are of major interest. Serial longitudinal immune monitoring would provide data on immunocompetence and complement clinical follow-up protocols. Biomarkers of immune response may be useful to identify patients at risk of developing infection and who could be candidates for immunosuppressant dose reduction. This article focuses on the potential use of biomarkers of immune response to predict development of infection after immunosuppressive and biologic therapies in selected settings of autoimmune disease (rituximab for treatment of rheumatoid arthritis) and solid organ transplantation.
Collapse
Affiliation(s)
- Javier Carbone
- Transplant Immunology Group, Clinical Immunology Department, University Hospital Gregorio Marañon, Doctor Esquerdo 46, 28007 Madrid, Spain.
| | | | | | | |
Collapse
|