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Pednekar P, Graf M, Tuly R, Batt K, Wang C. Gaining consensus around patient risk groups and prognostic profiles to guide CMV management among patients with solid organ transplant: Insights from a Delphi panel with SOT experts. Clin Transplant 2023; 37:e14905. [PMID: 36603193 DOI: 10.1111/ctr.14905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/29/2022] [Accepted: 01/01/2023] [Indexed: 01/07/2023]
Abstract
INTRODUCTION This study aimed to characterize patient risk groups and respective prognostic profiles to optimize clinical decision-making and guide appropriate medical cytomegalovirus (CMV) management among patients with solid organ transplant (SOT). METHODS Between September 2021 and February 2022, a three-round modified Delphi study was conducted to generate consensus among 14 international experts in virology and organ transplantation. Experts were asked about treatment and prognoses for patients in seven distinct clinical scenarios. Furthermore, experts were asked to risk-stratify patients by pre-/post-transplant characteristics. Consensus around opting for/against a treatment was observed if ≥75% or <25% of experts reported ≥50% likelihood to recommend or if treatments were ranked inside/outside the top two options and ≥75% of experts were within 1 standard deviation of the mean rank. RESULTS Experts agreed on several unmet needs in CMV disease management post-SOT, particularly avoidance of treatment-limiting toxicities with conventional CMV therapy and emergence of both primary refractory and drug resistant treatment failures. Experts considered CMV viral load, resistance profile, and route of administration as critical to treatment selection. For newer CMV therapeutic options, experts listed lack of long-term use data, concerns over potential resistance, high cost and limited availability as challenges restricting adoption, and successful patient management. CONCLUSION Experts achieved consensus around patient risk stratifications and factors influencing therapeutic options. Recommendations emerging from this Delphi study may support practicing physicians when confronted with challenging CMV scenarios in SOT patients, but additional experiences with newer anti-CMV agents are needed to re-validate expert consensus and update post-transplant CMV guidelines.
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Affiliation(s)
| | | | | | | | - Connie Wang
- Hennepin Healthcare, Minneapolis, Minnesota, USA
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Jarasvaraparn C, Choudhury S, Rusch C, Nadler M, Liss KH, Stoll J, Hmiel S, Khan A, Doyle M, Kulkarni S. Characteristics, risk factors, and outcomes of neutropenia after liver or kidney transplantation in children. Pediatr Transplant 2022; 26:e14131. [PMID: 34494348 PMCID: PMC10591294 DOI: 10.1111/petr.14131] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND While prior adult studies have shown that approximately 20%-38% of subjects undergoing solid-organ transplant develop neutropenia, similar analyses in pediatric subjects are scarce. METHODS We conducted a retrospective chart review of liver transplant (LT) and kidney transplant (KT) recipients at our center during the period 2008-2018. All of the KT and none of the LT subjects during this time period had induction with either anti-thymocyte globulin (ATG) or basiliximab at time of transplant. Neutropenia was defined as absolute neutrophil count (ANC) value ≤1000/mm3 . RESULTS One hundred subjects with LT and 82 subjects with KT were included. The incidence of neutropenia within the first year of transplant in KT was higher compared to LT (54.8% vs 39%, p = .01). The median number of hospitalizations (p = .001) and infectious complications (p = .04) was significantly higher only in the KT subjects who developed neutropenia (compared to those who did not). Multivariate analysis identified factors associated with severity of liver disease at transplant, namely h/o upper gastrointestinal bleeding (p = .02), weight deficit (p = .01), and pre-LT ANC (p = .01), along with high or moderate risk cytomegalovirus status (p = .05) as predictors of neutropenia in LT subjects. Female gender (p = .03) predicted neutropenia, while BK virus infection was protective for neutropenia (p = .04) in KT subjects. CONCLUSIONS The incidence of and morbidity associated with neutropenia within 1 year post-transplant is higher in KT subjects compared to LT subjects. The likely reason for this is the use of induction therapy (ATG, basiliximab) at the time of transplant in KT subjects.
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Affiliation(s)
- Chaowapong Jarasvaraparn
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Shelley Choudhury
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Courtney Rusch
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michelle Nadler
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kim H.H. Liss
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Janis Stoll
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stanley Hmiel
- Department of Pediatrics, Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Adeel Khan
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Maria Doyle
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sakil Kulkarni
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
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Gui RR, Li Z, Zu YL, Wang J, Liu YY, Zhang BL, Yu FK, Zhang Y, Zhao HF, Wang P, Song YP, Zhou J. [CMV-CTL for treatment of refractory CMV infection in 17 patients following alternative donor hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:865-868. [PMID: 34788929 PMCID: PMC8607013 DOI: 10.3760/cma.j.issn.0253-2727.2021.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- R R Gui
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - Z Li
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - Y L Zu
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - J Wang
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - Y Y Liu
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - B L Zhang
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - F K Yu
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - Yanli Zhang
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - H F Zhao
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - P Wang
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - Y P Song
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
| | - J Zhou
- Department of Hematology, Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Zhengzhou 450008, China
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4
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Páez-Vega A, Gutiérrez-Gutiérrez B, Agüera ML, Facundo C, Redondo-Pachón D, Suñer M, López-Oliva MO, Yuste JR, Montejo M, Galeano-Álvarez C, Ruiz-San Millan JC, Los-Arcos I, Hernández D, Fernández-Ruiz M, Muñoz P, Valle-Arroyo J, Cano A, Rodríguez-Benot A, Crespo M, Rodelo-Haad C, Lobo-Acosta MA, Garrido-Gracia JC, Vidal E, Guirado L, Cantisán S, Torre-Cisneros J. Immunoguided Discontinuation of Prophylaxis for Cytomegalovirus Disease in Kidney Transplant Recipients Treated with Antithymocyte Globulin: A Randomized Clinical Trial. Clin Infect Dis 2021; 74:757-765. [PMID: 34228099 DOI: 10.1093/cid/ciab574] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Antiviral prophylaxis is recommended in cytomegalovirus (CMV)-seropositive kidney transplant (KT) recipients receiving antithymocyte globulin (ATG) as induction. An alternative strategy of premature discontinuation of prophylaxis after CMV-specific cell-mediated immunity (CMV-CMI) recovery (immunoguided prevention) has not been studied. The aim of this study was to evaluate whether it is effective and safe to discontinue prophylaxis when CMV-CMI is detected and to continue with preemptive therapy. METHODS In this open-label, non-inferiority clinical trial, patients were randomized 1:1 to follow immunoguided strategy, receiving prophylaxis (valganciclovir 900 mg daily) until CMV-CMI recovery or to receive fixed-duration prophylaxis until day +90. After prophylaxis, preemptive therapy (valganciclovir 900 mg twice daily) was indicated in both arms until month 6. The primary and secondary outcomes were incidence of CMV disease and replication, respectively, within the first 12 months. Desirability of outcome ranking (DOOR) assessed two deleterious events (CMV disease/replication and neutropenia). RESULTS A total of 150 CMV-seropositive KT recipients were randomly assigned. There was no difference in the incidence of CMV disease (0% vs. 2.7%; P = 0.149) and replication (17.1% vs. 13.5%; log-rank test, P = 0.422) between both arms. Incidence of neutropenia was lower in the immunoguided arm (9.2% vs. 37.8%; OR, 6.0; P < 0.001). A total of 66.1% of patients in the immunoguided arm showed a better DOOR, indicating a greater likelihood of a better outcome. CONCLUSIONS Prophylaxis can be prematurely discontinued in CMV-seropositive KT patients receiving ATG when CMV-CMI is recovered since no significant increase in the incidence of CMV replication or disease is observed.
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Affiliation(s)
- Aurora Páez-Vega
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001, RD16/0016/0002, RD16/0016/0003, RD16/0016/0007, RD16/0016/0008, RD16/0016/0009 and RD16/0016/0012), Instituto de Salud Carlos III, Madrid, Spain
| | - Belén Gutiérrez-Gutiérrez
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine. Virgen Macarena University Hospital/ University of Seville. Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Maria L Agüera
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,Nephrology Service, Reina Sofia University Hospital, RedInRen (RD16/0009/0034), Cordoba, Spain
| | - Carme Facundo
- Renal Transplant Unit, Nephrology Service, Fundació Puigvert, Institut Investigació Biosanitaria Sant Pau, Autonomous University of Barcelona (UAB), RedInRen (RD16/0009/0019), Barcelona, Spain
| | - Dolores Redondo-Pachón
- Nephrology Service, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), RedInRen (RD16/0009/0013), Barcelona, Spain
| | - Marta Suñer
- Nephrology Service, Virgen del Rocío University Hospital, Seville, Spain
| | - Maria O López-Oliva
- Nephrology Service, La Paz University Hospital, RedInRen (RD16/0009/0008), Madrid, Spain
| | - Jose R Yuste
- Infectious Diseases Unit, Clinic University of Navarra, Pamplona, Spain
| | - Miguel Montejo
- Infectious Diseases Service, Cruces University Hospital, Bilbao, Spain
| | - Cristina Galeano-Álvarez
- Nephrology Service, Ramón y Cajal University Hospital, IRYCIS, RedInRen (RD16/0009/0014), Madrid, Spain
| | - Juan C Ruiz-San Millan
- Nephrology Service, Marqués de Valdecilla Hospital, University of Cantabria, IDIVAL, RedInRen (RD16/0009/0027), Santander, Spain
| | - Ibai Los-Arcos
- Infectious Diseases Service, Vall d' Hebron University Hospital, Barcelona, Spain
| | - Domingo Hernández
- Nephrology Service, Carlos Haya Regional University Hospital, Institute for Biomedical Research of Malaga (IBIMA), Universidad of Malaga, RedInRen (RD16/0009/0006), Malaga, Spain
| | - Mario Fernández-Ruiz
- Infectious Diseases Unit, 12 de Octubre University Hospital, Health Research Institute (imas12), Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Gregorio Marañon University Hospital, Madrid, Spain. Gregorio Marañón Biomedical Research Institute, Madrid, Spain. Department of Medicine, Complutense University of Madrid, Madrid, Spain. CIBERES (CB06/06/0058), Madrid, Spain
| | - Jorge Valle-Arroyo
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001, RD16/0016/0002, RD16/0016/0003, RD16/0016/0007, RD16/0016/0008, RD16/0016/0009 and RD16/0016/0012), Instituto de Salud Carlos III, Madrid, Spain
| | - Angela Cano
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001, RD16/0016/0002, RD16/0016/0003, RD16/0016/0007, RD16/0016/0008, RD16/0016/0009 and RD16/0016/0012), Instituto de Salud Carlos III, Madrid, Spain
| | - Alberto Rodríguez-Benot
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,Nephrology Service, Reina Sofia University Hospital, RedInRen (RD16/0009/0034), Cordoba, Spain
| | - Marta Crespo
- Nephrology Service, Hospital del Mar, Hospital del Mar Medical Research Institute (IMIM), RedInRen (RD16/0009/0013), Barcelona, Spain
| | - Cristian Rodelo-Haad
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,Nephrology Service, Reina Sofia University Hospital, RedInRen (RD16/0009/0034), Cordoba, Spain
| | - María A Lobo-Acosta
- Clinical Trials Unit, Virgen del Rocio University Hospital (CTU-HUVR), (SCReNPT13/0002/0010-PT17/0017/0012). Seville, Spain
| | - Jose C Garrido-Gracia
- Clinical Trials Unit, Maimonides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofia University Hospital/University of Cordoba (SCReN PT13/0002/0014, PT17/0017/0032), Cordoba, Spain
| | - Elisa Vidal
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001, RD16/0016/0002, RD16/0016/0003, RD16/0016/0007, RD16/0016/0008, RD16/0016/0009 and RD16/0016/0012), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Service, Reina Sofia University Hospital, Cordoba, Spain
| | - Luis Guirado
- Renal Transplant Unit, Nephrology Service, Fundació Puigvert, Institut Investigació Biosanitaria Sant Pau, Autonomous University of Barcelona (UAB), RedInRen (RD16/0009/0019), Barcelona, Spain
| | - Sara Cantisán
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001, RD16/0016/0002, RD16/0016/0003, RD16/0016/0007, RD16/0016/0008, RD16/0016/0009 and RD16/0016/0012), Instituto de Salud Carlos III, Madrid, Spain
| | - Julián Torre-Cisneros
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001, RD16/0016/0002, RD16/0016/0003, RD16/0016/0007, RD16/0016/0008, RD16/0016/0009 and RD16/0016/0012), Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Service, Reina Sofia University Hospital, Cordoba, Spain
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5
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Persistent Neutropenia after ABOi Kidney Transplantation: A Case Report. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2020017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Post-transplant neutropenia (PTN) is frequently reported in the first-year after transplantation. Although prevalence and clinical consequences are widely described, there are no guidelines to manage diagnosis and treatment. We report here a case of persistent PTN occurred in a patient undergoing a kidney transplant from an AB0-incompatible living donor. The desensitization protocol consisted of Rituximab administration and immunoadsorption while the pre-transplant protocol, which was initiated 14 days before the transplant, included Tacrolimus, Mofetil Mycophenolate (MMF), antimicrobial and antiviral prophylaxis. Induction therapy consisted of anti-thymocyte globulins and steroids, while maintenance after transplantation consisted of steroid, tacrolimus and MMF. When the first occurrence of leukopenia was observed six weeks after the transplant, firstly antimicrobial/antiviral prophylaxis was stopped and later also MMF treatment was interrupted but severe neutropenia relapsed after MMF resuming treatment. Immunological and virological causes were excluded. The patient was treated with Filgrastim. Bone marrow biopsy, which was performed to exclude a hematological cause of severe persistent neutropenia, revealed a bone marrow hypoplasia with neutrophils maturation interrupted at the early stages. This case highlights the need to establish diagnostic and therapeutic guidelines for PTN which take in consideration all the therapeutic steps including the pre-transplant phase in particular in the context of AB0i where immunosuppression is more consistent.
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6
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Chow JKL, Ruthazer R, Boucher HW, Vest AR, DeNofrio DM, Snydman DR. Factors associated with neutropenia post heart transplantation. Transpl Infect Dis 2021; 23:e13634. [PMID: 33982834 DOI: 10.1111/tid.13634] [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: 01/26/2021] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neutropenia is a serious complication following heart transplantation (OHT); however, risk factors for its development and its association with outcomes is not well described. We sought to study the prevalence of neutropenia, risk factors associated with its development, and its impact on infection, rejection, and survival. METHODS A retrospective single-center analysis of adult OHT recipients from July 2004 to December 2017 was performed. Demographic, laboratory, medication, infection, rejection, and survival data were collected for 1 year post-OHT. Baseline laboratory measurements were collected within the 24 hours before OHT. Neutropenia was defined as absolute neutrophil count ≤1000 cells/mm3. Cox proportional hazards models explored associations with time to first neutropenia. Associations between neutropenia, analyzed as a time-dependent covariate, with secondary outcomes of time to infection, rejection, or death were also examined. RESULTS Of 278 OHT recipients, 84 (30%) developed neutropenia at a median of 142 days (range 81-228) after transplant. Factors independently associated with increased risk of neutropenia included lower baseline WBC (HR 1.12; 95% CI 1.11-1.24), pre-OHT ventricular assist device (1.63; 1.00-2.66), high-risk CMV serostatus [donor positive, recipient negative] (1.86; 1.19-2.88), and having a previous CMV infection (4.07; 3.92-13.7). CONCLUSIONS Neutropenia is a fairly common occurrence after adult OHT. CMV infection was associated with subsequent neutropenia, however, no statistically significant differences in outcomes were found between neutropenic and non-neutropenic patients in this small study. It remains to be determined in future studies if medication changes in response to neutropenia would impact patient outcomes.
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Affiliation(s)
- Jennifer K L Chow
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, USA
| | - Robin Ruthazer
- Tufts Clinical and Translational Science Institute, Biostatistics, Epidemiology, and Research Design Center, Tufts Medical Center, Boston, MA, USA
| | - Helen W Boucher
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, USA
| | - Amanda R Vest
- Division of Cardiology, Tufts University School of Medicine, Tufts Medical Center, Boston, MA, USA
| | - David M DeNofrio
- Division of Cardiology, Tufts University School of Medicine, Tufts Medical Center, Boston, MA, USA
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, USA
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7
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Zhao XY, Pei XY, Chang YJ, Yu XX, Xu LP, Wang Y, Zhang XH, Liu KY, Huang XJ. First-line Therapy With Donor-derived Human Cytomegalovirus (HCMV)-specific T Cells Reduces Persistent HCMV Infection by Promoting Antiviral Immunity After Allogenic Stem Cell Transplantation. Clin Infect Dis 2021; 70:1429-1437. [PMID: 31067570 DOI: 10.1093/cid/ciz368] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 05/02/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Human cytomegalovirus (HCMV) infection, especially persistent HCMV infection, is an important cause of morbidity and mortality after allogenic stem cell transplantation (allo-SCT). Antiviral agents remain the first-line therapy but are limited by side effects and acquired resistance. METHODS We evaluated the safety and efficacy of donor-derived HCMV-specific cytotoxic T cells (CTLs) as a first-line therapy for HCMV infection after allo-SCT and investigated the underlying mechanisms. RESULTS In humanized HCMV-infected mice, first-line therapy with CTLs effectively combated systemic HCMV infection by promoting the restoration of graft-derived endogenous HCMV-specific immunity in vivo. In a clinical trial, compared with the pair-matched, high-risk control cohort, first-line therapy with CTLs significantly reduced the rate of persistent (2.9% vs 20.0%, P = .018) and late (5.7% vs 20.0%, P = .01) HCMV infection and cumulative incidence of persistent HCMV infection (hazard ratio [HR], 0.13; 95% confidence interval [CI], 0.10-0.82; P = .02), lowered 1-year treatment-related mortality (HR, 0.15. 95% CI, 0.11-0.90. P = .03), and improved 1-year overall survival (HR, 6.35; 95% CI, 1.05-9.00; P = .04). Moreover, first-line therapy with CTLs promoted the quantitative and functional recovery of CTLs in patients, which was associated with HCMV clearance. CONCLUSIONS We provide robust support for the benefits of CTLs combined with antiviral drugs as a first-line therapy for treating HCMV infection and suggest that adoptively infused CTLs may stimulate the recovery of endogenous HCMV-specific immunity. CLINICAL TRIALS REGISTRATION NCT02985775.
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Affiliation(s)
- Xiang-Yu Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease.,Beijing Engineering Lab for Cell Therapy, Beijing, China
| | - Xu-Ying Pei
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease
| | - Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease
| | - Xing-Xing Yu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease.,Beijing Engineering Lab for Cell Therapy, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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8
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Lum J, Echenique I, Athans V, Koval CE. Alternative pneumocystis prophylaxis in solid organ transplant recipients at two large transplant centers. Transpl Infect Dis 2020; 23:e13461. [PMID: 32894607 DOI: 10.1111/tid.13461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/03/2020] [Accepted: 08/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for Pneumocystis jirovecii pneumonia (PJP) prophylaxis and has activity against other opportunistic infections (OIs) after solid organ transplant (SOT). We aimed to describe the incidence, reasons for and outcomes of use of alternative prophylactic agents (APAs) across SOT programs in our high volume centers. METHODS Solid organ transplant recipients (SOTRs) at our centers from 1/2015-12/2016 were identified. Pharmacy records identified APA (pentamidine, atovaquone, or dapsone) use within 1 year. Records were reviewed for allergies, laboratory values at APA initiation, diagnostic tests for TMP-SMX-preventable OIs, and APA side effects. RESULTS An APA was initiated in 105/1173 (8.9%) SOTRs. Of these, 51 (48.6%) were because of sulfonamide allergy recorded pre-SOT, mostly rash/hives (58.8%). The remaining 54 (51.4%) had TMP-SMX discontinued post-SOT, mostly for neutropenia (48%) and renal effects (34%). Differences occurred across programs, with kidney transplant never stopping TMP-SMX for renal issues. Of those changed to APAs post-transplant, 19 (35%) were later successfully re-challenged with TMP-SMX. With thresholds in mind, 67 (64%) received an APA unnecessarily, accounting for up to $100 000/y excess cost. Potential TMP-SMX-preventable OIs occurred in 7 (5 Nocardia; 2 PJP). APA side effects occurred in 14/105 (13.3%). CONCLUSIONS Use of APAs for PJP prophylaxis after SOT is less than previously reported but often unwarranted. Such decisions require scrutiny to avoid TMP-SMX-preventable OIs, cost and important APA side effects. Use of reasonable thresholds for cessation of TMP-SMX and data-driven approaches to re-challenge would substantially reduce APA use.
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Affiliation(s)
- Jessica Lum
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Ignacio Echenique
- Department of Infectious Diseases, Cleveland Clinic Florida, Weston, FL, USA.,Teva Pharmaceuticals, Miramar, FL, USA
| | - Vasilios Athans
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA, USA
| | - Christine E Koval
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
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9
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Papanicolaou GA, Silveira FP, Langston AA, Pereira MR, Avery RK, Uknis M, Wijatyk A, Wu J, Boeckh M, Marty FM, Villano S. Maribavir for Refractory or Resistant Cytomegalovirus Infections in Hematopoietic-cell or Solid-organ Transplant Recipients: A Randomized, Dose-ranging, Double-blind, Phase 2 Study. Clin Infect Dis 2020; 68:1255-1264. [PMID: 30329038 PMCID: PMC6451997 DOI: 10.1093/cid/ciy706] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 10/03/2018] [Indexed: 12/27/2022] Open
Abstract
Background Cytomegalovirus (CMV) infections that are refractory or resistant (RR) to available antivirals ([val]ganciclovir, foscarnet, cidofovir) are associated with higher mortality in transplant patients. Maribavir is active against RR CMV strains. Methods Hematopoietic-cell or solid-organ transplant recipients ≥12 years old with RR CMV infections and plasma CMV deoxyribonucleic acid (DNA) ≥1000 copies/mL were randomized (1:1:1) to twice-daily dose-blinded maribavir 400, 800, or 1200 mg for up to 24 weeks. The primary efficacy endpoint was the proportion of patients with confirmed undetectable plasma CMV DNA within 6 weeks of treatment. Safety analyses included the frequency and severity of treatment-emergent adverse events (TEAEs). Results From July 2012 to December 2014, 120 patients were randomized and treated (40 per dose group): 80/120 (67%) patients achieved undetectable CMV DNA within 6 weeks of treatment (95% confidence interval, 57–75%), with rates of 70%, 63%, and 68%, respectively, for maribavir 400, 800, and 1200 mg twice daily. Recurrent on-treatment CMV infections occurred in 25 patients; 13 developed mutations conferring maribavir resistance. Maribavir was discontinued due to adverse events in 41/120 (34%) patients, and 17/41 discontinued due to CMV infections. During the study, 32 (27%) patients died, 4 due to CMV disease. Dysgeusia was the most common TEAE (78/120; 65%) and led to maribavir discontinuation in 1 patient. Absolute neutrophil counts <1000/µL were noted in 12/106 (11%) evaluable patients, with rates similar across doses. Conclusions Maribavir ≥400 mg twice daily was active against RR CMV infections in transplant recipients; no new safety signals were identified. Clinical Trials Registration NCT01611974.
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Affiliation(s)
| | - Fernanda P Silveira
- The Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Marcus R Pereira
- Department of Medicine, Columbia University Medical Center, New York, New York
| | | | - Marc Uknis
- Shire Pharmaceuticals, Wayne, Pennsylvania
| | | | - Jingyang Wu
- Shire Pharmaceuticals, Lexington, Massachusetts
| | - Michael Boeckh
- The Fred Hutchinson Cancer Research Center, Seattle, Washington
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10
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Ilic K, Song I, Wu J, Martin P. Evaluation of the Effect of Maribavir on Cardiac Repolarization in Healthy Participants: Thorough QT/QTc Study. Clin Transl Sci 2020; 13:1260-1270. [PMID: 32506738 PMCID: PMC7719377 DOI: 10.1111/cts.12814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/29/2020] [Indexed: 12/27/2022] Open
Abstract
Maribavir is an orally bioavailable benzimidazole riboside in clinical development for treatment of cytomegalovirus infection in patients who undergo transplantation. Maribavir was evaluated in a thorough QT (TQT) study to determine any effects on cardiac repolarization. The effect of maribavir 100 and 1,200 mg oral doses on the baseline-adjusted and placebo-adjusted corrected QT (QTc) interval (delta delta QTc (ddQTc)) and other electrocardiogram (ECG) parameters was assessed in a randomized, phase I, placebo-controlled, four-period crossover study in healthy participants (men and women ages 18-50 years). Additionally, maribavir pharmacokinetics, safety, and tolerability were investigated. Moxifloxacin (400 mg) was used as a positive control to demonstrate the study's ability to detect QT prolongation. Digital 12-lead Holter ECG monitoring was performed over 22 hours following study drug administration. Individual, Fridericia's, and Bazett's QTc intervals were calculated. Of 52 randomized participants (29 ± 8.1 years old; 31 men (60%)), 50 (96%) completed the study. For both 100-mg and 1200-mg doses of maribavir, analysis of ddQTc demonstrated that the upper bound of the two-sided 90% confidence interval was below the 10-ms threshold at all time points. The concentration-effect analysis demonstrated no relationship between ddQTc and plasma concentrations of maribavir (and its metabolite). There were no clinically meaningful changes in heart rate and systolic blood pressure. The most common adverse event was dysgeusia; no serious adverse events were reported. This TQT study demonstrated that maribavir did not have impact on cardiac repolarization.
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Affiliation(s)
- Katarina Ilic
- Shire, a Takeda Company, Lexington, Massachusetts, USA
| | - Ivy Song
- Shire, a Takeda Company, Lexington, Massachusetts, USA
| | - Jingyang Wu
- Shire, a Takeda Company, Lexington, Massachusetts, USA
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11
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Maertens J, Cordonnier C, Jaksch P, Poiré X, Uknis M, Wu J, Wijatyk A, Saliba F, Witzke O, Villano S. Maribavir for Preemptive Treatment of Cytomegalovirus Reactivation. N Engl J Med 2019; 381:1136-1147. [PMID: 31532960 DOI: 10.1056/nejmoa1714656] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Maribavir is a benzimidazole riboside with activity against cytomegalovirus (CMV). The safety and efficacy of maribavir for preemptive treatment of CMV infection in transplant recipients is not known. METHODS In a phase 2, open-label, maribavir dose-blinded trial, recipients of hematopoietic-cell or solid-organ transplants (≥18 years of age, with CMV reactivation [1000 to 100,000 DNA copies per milliliter]) were randomly assigned to receive maribavir at a dose of 400, 800, or 1200 mg twice daily or the standard dose of valganciclovir for no more than 12 weeks. The primary efficacy end point was the percentage of patients with a response to treatment, defined as confirmed undetectable CMV DNA in plasma, within 3 weeks and 6 weeks after the start of treatment. The primary safety end point was the incidence of adverse events that occurred or worsened during treatment. RESULTS Of the 161 patients who underwent randomization, 159 received treatment, and 156 had postbaseline data available - 117 in the maribavir group and 39 in the valganciclovir group. The percentage of patients with postbaseline data available who had a response to treatment within 3 weeks was 62% among those who received maribavir and 56% among those who received valganciclovir. Within 6 weeks, 79% and 67% of patients, respectively, had a response (risk ratio, 1.20; 95% confidence interval, 0.95 to 1.51). The percentages of patients with a response to treatment were similar among the maribavir dose groups. Two patients who had a response to treatment had a recurrence of CMV infection within 6 weeks after starting maribavir at a dose of 800 mg twice daily; T409M resistance mutations in CMV UL97 protein kinase developed in both patients. The incidence of serious adverse events that occurred or worsened during treatment was higher in the maribavir group than in the valganciclovir group (52 of 119 patients [44%] vs. 13 of 40 [32%]). A greater percentage of patients in the maribavir group discontinued the trial medication because of an adverse event (27 of 119 [23%] vs. 5 of 40 [12%]). A higher incidence of gastrointestinal adverse events was reported with maribavir, and a higher incidence of neutropenia was reported with valganciclovir. CONCLUSIONS Maribavir at a dose of at least 400 mg twice daily had efficacy similar to that of valganciclovir for clearing CMV viremia among recipients of hematopoietic-cell or solid-organ transplants. A higher incidence of gastrointestinal adverse events - notably dysgeusia - and a lower incidence of neutropenia were found in the maribavir group. (Funded by ViroPharma/Shire Development; EudraCT number, 2010-024247-32.).
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Affiliation(s)
- Johan Maertens
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
| | - Catherine Cordonnier
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
| | - Peter Jaksch
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
| | - Xavier Poiré
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
| | - Marc Uknis
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
| | - Jingyang Wu
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
| | - Anna Wijatyk
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
| | - Faouzi Saliba
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
| | - Oliver Witzke
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
| | - Stephen Villano
- From the Hematology Department, University Hospitals Leuven, KU Leuven, Leuven (J.M.), and the Section of Hematology, Cliniques Universitaires Saint-Luc, Brussels (X.P.) - both in Belgium; the Hematology Department, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP) and University Paris-Est-Créteil, Créteil (C.C.), and AP-HP Hôpital Paul Brousse, Villejuif (F.S.) - all in France; the Medical University of Vienna, General Hospital, Vienna (P.J.); Shire, Wayne, PA (M.U., S.V.); Shire, Lexington, MA (J.W., A.W.); and the Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany (O.W.)
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12
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Pérez-Flores I, Santiago JL, Fernández-Pérez C, Urcelay E, Moreno de la Higuera MÁ, Romero NC, Cubillo BR, Sánchez-Fructuoso AI. Impacts of Interleukin-18 Polymorphisms on the Incidence of Delayed-Onset Cytomegalovirus Infection in a Cohort of Kidney Transplant Recipients. Open Forum Infect Dis 2019; 6:ofz325. [PMID: 31660404 PMCID: PMC6798256 DOI: 10.1093/ofid/ofz325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/16/2019] [Indexed: 12/26/2022] Open
Abstract
Background The incidence of cytomegalovirus (CMV) infection in solid organ transplant recipients may be reduced by antiviral prophylaxis, but this strategy may lead to delayed-onset CMV infection. The proinflammatory cytokine interleukin (IL)-18 plays a major role in viral host defense responses. This study examines the impacts of 2 single-nucleotide polymorphisms (SNPs) in the promoter region of the IL-18 gene, -607C/A (rs1946518) and -137G/C (rs187238), on the incidence of delayed-onset CMV infection in patients undergoing kidney transplant. Methods This retrospective study analyzed 2 IL-18 SNPs in consecutive adult kidney transplant recipients using real-time polymerase chain reaction with TaqMan probes. Participants were enrolled over the period 2005–2013 and stratified according to their IL-18 SNP genotype. The concordance index (Harrell’s c-index) was used as a measure of the discriminatory power of the predictive models constructed with bootstrapping to correct for optimistic bias. Results Seven hundred nine patients received transplants in the study period, and 498 met selection criteria. Cytomegalovirus infection and disease incidence were 38% and 7.5%, respectively. In multivariate competing risk regression models, carriers of the -607C/-137G haplotype who received prophylaxis showed a higher incidence of CMV replication after antiviral agent discontinuation (hazard ratio = 2.42 [95% confidence interval, 1.11–5.26]; P = .026), whereas CMV disease was not observed in those given prophylaxis who were noncarriers of this polymorphism (P = .009). Conclusions Our findings suggest that the -607C/-137G IL-18 haplotype is associated with a higher incidence of postprophylaxis CMV replication. The prior identification of this polymorphism could help select alternative measures to prevent delayed-onset CMV infection in these patients.
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Affiliation(s)
- Isabel Pérez-Flores
- Nephrology Department, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Cristina Fernández-Pérez
- Clinical Research and Methodology Unit, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Madrid, Spain
| | - Elena Urcelay
- Kidney Transplant Group Hospital Clínico San Carlos, Madrid, Spain
| | | | - Natividad Calvo Romero
- Nephrology Department, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Beatriz Rodríguez Cubillo
- Nephrology Department, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
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13
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Kim SJ, Huang YT, Foldi J, Lee YJ, Maloy M, Giralt SA, Jakubowski AA, Papanicolaou GA. Cytomegalovirus resistance in CD34 + -selected hematopoietic cell transplant recipients. Transpl Infect Dis 2018; 20:e12881. [PMID: 29570237 PMCID: PMC5988949 DOI: 10.1111/tid.12881] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/02/2018] [Accepted: 02/18/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) viremia after CD34+ -selected hematopoietic stem cell transplant (HCT) often requires prolonged antiviral therapy. We report rates and outcomes of resistant CMV in a contemporary cohort of CD34+ -selected HCT recipients managed preemptively. METHODS We retrospectively reviewed 220 consecutive, CMV-seropositive recipients (R+), who received CD34+ -selected HCT at Memorial Sloan Kettering Cancer Center between June 2010 and December 2014. Patients were monitored by quantitative CMV PCR and were treated preemptively. CMV resistance was tested by a genotypic assay. RESULTS One hundred and sixty-one (73%) patients developed CMV viremia and 47 (29% of viremic and 21% of total patients) had CMV resistance testing by one-year from HCT. CMV resistance was confirmed in 19 (12% of viremic and 9% of total) patients and was identified >3 months from HCT in 90% of patients. Twelve patients had mutations in UL97 only; the remaining 7 patients had mutations in UL54 only or UL54 and UL97. By 1 year from HCT, 11 of 19 (58%) patients with mutations had CMV end-organ disease. CMV-related mortality in patients with resistance was 42%. CONCLUSIONS Nine percent of CMV R+, CD34+ -selected HCT recipients had resistant CMV by 1 year from HCT. Of 19 patients with resistant CMV, 58% had CMV end-organ disease and 42% died of CMV. Effective strategies for CMV prevention and restoration of CMV immunity are needed for CD34+ -selected HCT.
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Affiliation(s)
- Seong Jin Kim
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julia Foldi
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yeon Joo Lee
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Medical College, Cornell University, New York, NY, USA
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio A Giralt
- Weill Medical College, Cornell University, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ann A Jakubowski
- Weill Medical College, Cornell University, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Medical College, Cornell University, New York, NY, USA
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14
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Rose-Felker K, Mukhtar A, Kelleman MS, Deshpande SR, Mahle WT. Neutropenia in pediatric heart transplant recipients. Pediatr Transplant 2018; 22:e13130. [PMID: 29473271 DOI: 10.1111/petr.13130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2017] [Indexed: 01/19/2023]
Abstract
Neutropenia has been reported in pediatric heart transplant recipients, but its association with infectious morbidity and mortality is unknown. We sought to determine neutropenia's prevalence and impact on infection, rejection, and survival. A retrospective analysis of pediatric heart transplant recipients from March 2005 to August 2015 was performed. Demographics, medications, infection, and rejection data were collected. Of 142 pediatric heart transplant recipients, 77 (54.2%) developed neutropenia within 4.7 months [3.3-12.1 months] of transplant. In all patients, the adjusted 5-year cumulative incidence of neutropenia was 30.2%. Fifty-one patients (66.2%) had recurrent neutropenia. Six of 14 tested had positive antineutrophil antibodies. Medications associated with neutropenia were decreased in 15 (19.5%) and discontinued in 42 (54.4%) patients with no change in 1-year rejection rates compared to published data. Fifteen patients developed infection within 30 days of neutropenia and two from 30 days to 1 year, with an infection rate similar to the non-neutropenic group. There was no significant difference in survival, ANC, rate of rejection or PTLD in neutropenic patients with and without infection at median follow-up (5.5 years). Neutropenia is common in pediatric heart transplant recipients. Neutropenia had <20% risk of associated infection, similar to non-neutropenic patients. Infection in neutropenic patients did not increase mortality.
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Affiliation(s)
- Kirsten Rose-Felker
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Ayesha Mukhtar
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Michael S Kelleman
- Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Shriprasad R Deshpande
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - William T Mahle
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, GA, USA
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15
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Liang X, Famure O, Li Y, Kim SJ. Incidence and Risk Factors for Leukopenia in Kidney Transplant Recipients Receiving Valganciclovir for Cytomegalovirus Prophylaxis. Prog Transplant 2018; 28:124-133. [DOI: 10.1177/1526924818765798] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Context: Valganciclovir is used not only for cytomegalovirus prophylaxis after kidney transplantation but can also induce leukopenia, thereby making patients more susceptible to other infections. The epidemiology of leukopenia in patients on valganciclovir remains poorly understood. Objective: To determine the incidence and risk factors for leukopenia in patients receiving valganciclovir for cytomegalovirus prophylaxis after kidney transplantation. Methods: In this single-center, retrospective, cohort study, we included kidney recipients transplanted from January 1, 2003, to December 31, 2010, to determine the incidence and risk factors for leukopenia in patients who received valganciclovir for cytomegalovirus prophylaxis. The Kaplan-Meier product limit method was used to graphically assess time to leukopenia, and risk factors were assessed using Cox proportional hazards models. Results: A total of 542 kidney transplant recipients were included in the study cohort. The cumulative incidence of leukopenia at 6 months posttransplant was 39.3% (11.0% for neutropenia). Low baseline white blood cell count (hazard ratio [HR] 2.34 [95% confidence interval [CI], 1.37-4.00]) and high baseline body mass index (HR 1.05 [95% CI, 1.02-1.09]) were independently associated with an increased risk of leukopenia, while higher Cockcroft-Gault creatinine clearance (HR 0.87 [95% CI, 0.78-0.97]) was significantly associated with a decreased risk of leukopenia. Conclusions: These data suggest that recipient baseline white blood cell count, baseline body mass index, and kidney function are clinical predictors of new-onset leukopenia after kidney transplantation. Our results may inform the approach to cytomegalovirus prophylaxis to reduce the risk of valganciclovir-induced leukopenia in kidney transplant recipients.
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Affiliation(s)
- Xinyun Liang
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Olusegun Famure
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Yanhong Li
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - S. Joseph Kim
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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16
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Abstract
PURPOSE OF REVIEW Immune monitoring to determine when and how the recovery of cytomegalovirus (CMV)-specific T-cells occurs post-transplantation may help clinicians to risk stratify individuals at risk of complications from CMV. We aimed to review all recent clinical studies using CMV immune monitoring in the pre- and post-transplant setting including the use of recently developed standardized assays (Quantiferon-CMV and the CMV ELISPOT) to better understand in whom, when, and how immune monitoring is best used. RECENT FINDINGS Pre-transplant assessment of CMV immunity in solid-organ transplant recipients where CMV seropositive recipients had undetectable cell-mediated responses despite past immunity has shown that they are at a much higher risk of developing CMV reactivation. Post-transplant CMV immune monitoring can guide (shorten or prolong) the duration of antiviral prophylaxis, identify recipients at risk of post-prophylaxis CMV disease, and predict recurrent CMV reactivation. Thus, CMV immune monitoring, in addition to current clinical and DNA-based monitoring for CMV, has the potential to be incorporated into routine clinical care to better improve CMV management in both the stem and solid-organ transplant population.
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Affiliation(s)
- Michelle K Yong
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, 792 Elizabeth Street, Melbourne, VIC, 3000, Australia. .,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia.
| | - Sharon R Lewin
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, 792 Elizabeth Street, Melbourne, VIC, 3000, Australia
| | - Oriol Manuel
- Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland.,Transplantation Center, Department of Anesthesiology and Surgery, University Hospital and University of Lausanne, Lausanne, Switzerland
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Mavrakanas TA, Fournier MA, Clairoux S, Amiel JA, Tremblay ME, Vinh DC, Coursol C, Thirion DJG, Cantarovich M. Neutropenia in kidney and liver transplant recipients: Risk factors and outcomes. Clin Transplant 2017; 31. [PMID: 28736953 DOI: 10.1111/ctr.13058] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2017] [Indexed: 12/17/2022]
Abstract
No studies have directly compared the key characteristics and outcomes of kidney (KTx) and liver transplantation (LTx) recipients with neutropenia. In this single-center, retrospective, cohort study, we enrolled all adult patients who received a KTx or LTx between 2000 and 2011. Neutropenia was defined as 2 consecutive absolute neutrophil count (ANC) values <1500/mm3 in patients without preexisting neutropenia. The first neutropenia episode occurring during the first year post-transplantation was analyzed. A total of 663 patients with KTx and 354 patients with LTx met the inclusion criteria. Incidence of neutropenia was 20% in KTx and 38% in LTx, respectively. High-risk CMV status and valganciclovir (VGCV) use were significant predictors of neutropenia for KTx recipients, but only VGCV use vs nonuse in LTx recipients. Neutropenia was associated with worse survival in KTx recipients (adjusted HR 1.95, 95% CI 1.18-3.22, P<.01), but not in LTx recipients (adjusted HR 0.75, 95% CI 0.52-1.10, P=.15). Sixteen acute rejection episodes were associated with preceding neutropenia in KTx recipients (HR 1.77, 95% CI 1.16-2.68, P=.007) and 24 acute rejection episodes in LTx recipients (HR 1.41, 95% CI 0.97-2.04, P=.07). Incidence of infection was similar in patients with and without neutropenia among KTx and LTx recipients.
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Affiliation(s)
- Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, Multi-Organ Transplant Program, McGill University Health Center, Montreal, QC, Canada
| | - Marie-Andrée Fournier
- Department of Pharmacy, University of Montreal Hospital Centre, Montreal, QC, Canada.,Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada
| | - Sarah Clairoux
- Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada.,Department of Pharmacy, McGill University Health Center, Montreal, QC, Canada.,Department of Pharmacy, Sacré-Coeur Hospital, Montreal, QC, Canada
| | - Jacques-Alexandre Amiel
- Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada.,Department of Pharmacy, McGill University Health Center, Montreal, QC, Canada
| | | | - Donald C Vinh
- Division of Infectious Diseases, McGill University Health Center, Montreal, QC, Canada
| | - Christian Coursol
- Department of Pharmacy, McGill University Health Center, Montreal, QC, Canada
| | - Daniel J G Thirion
- Faculty of Pharmacy, University of Montreal, Montreal, QC, Canada.,Department of Pharmacy, McGill University Health Center, Montreal, QC, Canada
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, Multi-Organ Transplant Program, McGill University Health Center, Montreal, QC, Canada
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18
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Recurrence of CMV Infection and the Effect of Prolonged Antivirals in Organ Transplant Recipients. Transplantation 2017; 101:1449-1454. [DOI: 10.1097/tp.0000000000001338] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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19
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Mengarelli A, Annibali O, Pimpinelli F, Riva E, Gumenyuk S, Renzi D, Cerchiara E, Piccioni L, Palombi F, Pisani F, Romano A, Spadea A, Papa E, Cordone I, Canfora M, Arcese W, Ensoli F, Marchesi F. Prospective surveillance vs clinically driven approach for CMV reactivation after autologous stem cell transplant. J Infect 2015; 72:265-8. [PMID: 26687516 DOI: 10.1016/j.jinf.2015.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 11/23/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
Affiliation(s)
- A Mengarelli
- Hematology and Stem Cell Transplant Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - O Annibali
- Unit of Hematology, Stem Cell Transplant, Transfusion Medicine and Cellular Therapy, University Campus Bio-Medico, Rome, Italy
| | - F Pimpinelli
- Molecular Virology, Pathology and Microbiology Laboratory, San Gallicano Dermatological Institute, Rome, Italy
| | - E Riva
- Virology Unit, Laboratory of Pathology and Microbiology, Campus Bio-Medico University, Rome, Italy
| | - S Gumenyuk
- Hematology and Stem Cell Transplant Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - D Renzi
- Hematology and Stem Cell Transplant Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - E Cerchiara
- Unit of Hematology, Stem Cell Transplant, Transfusion Medicine and Cellular Therapy, University Campus Bio-Medico, Rome, Italy
| | - L Piccioni
- Virology Unit, Laboratory of Pathology and Microbiology, Campus Bio-Medico University, Rome, Italy
| | - F Palombi
- Hematology and Stem Cell Transplant Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - F Pisani
- Hematology and Stem Cell Transplant Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - A Romano
- Hematology and Stem Cell Transplant Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - A Spadea
- Hematology and Stem Cell Transplant Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - E Papa
- Hematology and Stem Cell Transplant Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - I Cordone
- Clinical Pathology, Regina Elena National Cancer Institute, Rome, Italy
| | - M Canfora
- Scientific Direction, Regina Elena National Cancer Institute, Rome, Italy
| | - W Arcese
- Rome Transplant Network, Rome, Italy
| | - F Ensoli
- Molecular Virology, Pathology and Microbiology Laboratory, San Gallicano Dermatological Institute, Rome, Italy
| | - F Marchesi
- Hematology and Stem Cell Transplant Unit, Regina Elena National Cancer Institute, Rome, Italy.
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20
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Sood S, Haifer C, Yu L, Pavlovic J, Gow PJ, Jones RM, Visvanathan K, Angus PW, Testro AG. Targeted individual prophylaxis offers superior risk stratification for cytomegalovirus reactivation after liver transplantation. Liver Transpl 2015; 21:1478-85. [PMID: 26194446 DOI: 10.1002/lt.24216] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/15/2015] [Accepted: 06/20/2015] [Indexed: 02/07/2023]
Abstract
Cytomegalovirus (CMV) can reactivate following liver transplantation. Management of patients currently considered low risk based on pretransplant serology remains contentious, with universal prophylaxis and preemptive strategies suffering from significant deficiencies. We hypothesized that a CMV-specific T cell assay performed early after transplant as part of a preemptive strategy could better stratify "low-risk" (recipient seropositive) patients. We conducted a prospective, blinded, observational study in 75 adult recipients. QuantiFERON-cytomegalovirus was performed both before and at multiple times after transplant. Low-risk patients (n = 58) were monitored as per unit protocol and treatment was commenced if CMV > 1000 copies/mL (DNAemia). Twenty patients needed antiviral treatment for other reasons and were censored (mainly for rejection or herpes simplex virus infection); 19/38 (50%) of the remaining low-risk patients developed DNAemia at mean 34.6 days after transplant. A week 2 result of <0.1 IU/mL was significantly associated with risk of subsequent DNAemia (hazard ratio [HR], 6.9; P = 0.002). The positive predictive value of 80% suggests these patients are inappropriately labeled low risk and are actually at high likelihood of CMV reactivation. A secondary cutoff of <0.2 IU/mL was associated with moderate risk (HR, 2.8; P = 0.01). In conclusion, a protocol based on a single early CMV-specific T cell based assay would offer improved risk stratification and individualization of patient management after transplant. This could offer improved drug and service utilization and potentially result in significant improvements over both currently used protocols to manage supposedly low-risk patients.
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Affiliation(s)
- Siddharth Sood
- Liver Transplant Unit Victoria, Austin Health, Melbourne, Australia
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Australia
- Innate Immune Laboratory, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Craig Haifer
- Liver Transplant Unit Victoria, Austin Health, Melbourne, Australia
| | - Lijia Yu
- Innate Immune Laboratory, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Julie Pavlovic
- Liver Transplant Unit Victoria, Austin Health, Melbourne, Australia
| | - Paul J Gow
- Liver Transplant Unit Victoria, Austin Health, Melbourne, Australia
| | - Robert M Jones
- Liver Transplant Unit Victoria, Austin Health, Melbourne, Australia
| | - Kumar Visvanathan
- Innate Immune Laboratory, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Peter W Angus
- Liver Transplant Unit Victoria, Austin Health, Melbourne, Australia
| | - Adam G Testro
- Liver Transplant Unit Victoria, Austin Health, Melbourne, Australia
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21
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Severe neutropenia in children after renal transplantation: incidence, course, and treatment with granulocyte colony-stimulating factor. Pediatr Nephrol 2015; 30:2029-36. [PMID: 25994524 DOI: 10.1007/s00467-015-3113-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/02/2015] [Accepted: 04/06/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Infections are an important cause of morbidity and mortality in solid organ transplant recipients. Neutrophils play a crucial role in the initial host defense against bacterial pathogens. Neutropenia is not uncommon after renal transplantation in adults; however, there are scarce published data in children. We conducted a historical cohort study to evaluate the incidence, clinical course, and management of severe neutropenia after renal transplantation in children. METHODS In a single-center study, we collected clinical and laboratory data on all children (<20 years) who underwent renal transplantation from January 2005 to March 2014. All post-transplantation blood counts were reviewed; the lowest absolute neutrophil count was recorded and correlated with clinical information and other laboratory findings. RESULTS Of the 72 patients studied, 46 (64%) had at least one episode of neutropenia [absolute neutrophil count (ANC) <1500/μl] during the study period, 16 of whom (22%) had severe neutropenia (ANC < 500/μl), 2-11 months (median, 3.5) after renal transplantation. Work-up for viral infection or malignancy was performed. Initial management included dose decrease and subsequent discontinuation of antimetabolite, stopping co-trimoxazole and valganciclovir. Bone marrow aspiration in four children revealed normal marrow cellularity in all cases, with myelocyte maturational arrest in two. Eight children (11%) were treated with granulocyte colony-stimulating factor (G-CSF) (5 mcg/kg/day) 1-4 doses (median, 2), with excellent response in all and no adverse effects. Eight children presented with fever during severe neutropenia, and were treated with empiric antibiotics. Mycophenolate/azathioprine were resumed in all patients unless contraindicated (pre-existing BK viremia -1, PTLD -1). Recurrence of neutropenia was seen in five patients, only one of whom required further treatment with G-CSF. Graft function was preserved during and after resolution of neutropenia. Post-transplant neutropenia in children is common, and mostly occurs in the first few months. Its etiology is probably primarily a result of the combination of immunosuppressive agents and prophylactic treatment of infections in the early post-transplant period. CONCLUSIONS Decreasing immunosuppressive or antimicrobial medications carries the risk of acute rejection or infection. Off-label treatment with G-CSF may present a safe and effective alternative.
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