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Raval AD, Kistler KD, Tang Y, Murata Y, Snydman DR. Epidemiology, risk factors, and outcomes associated with cytomegalovirus in adult kidney transplant recipients: A systematic literature review of real-world evidence. Transpl Infect Dis 2020; 23:e13483. [PMID: 33012092 DOI: 10.1111/tid.13483] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/21/2022]
Abstract
Kidney transplant recipients (KTRs) have increased risk for cytomegalovirus (CMV) infection/disease given the necessity of drug-induced immunosuppression. A comprehensive review of published literature reporting real-world data on prevention strategies utilized and associated CMV burden outcomes is limited. Such data could help inform future clinical practice and identify unmet needs in CMV management. We conducted a systematic review of observational studies published in Medline or EMBASE from January 2008 to November 2018 to identify current real-world CMV management approaches, CMV infection/disease risk factors, and outcomes associated with CMV infection. Descriptive statistics and pooled quantitative analyses were conducted. From 1608 records screened, 86 citations, including 69 803 adult KTR, were included. Prophylaxis and preemptive therapy (PET) were predominant approaches among D+/R- and R + CMV serostatus transplants, respectively. Valganciclovir and ganciclovir were frequently utilized across CMV risk strata. Despite prevention approaches, approximately one-fourth of KTR developed CMV infection. Age and D+/R- CMV serostatus were consistent risk factors for CMV infection/disease. CMV infection/disease was associated with increased mortality and graft loss. CMV was similarly associated with acute rejection (AR) risk, but with high heterogeneity among studies. Limited data were available on CMV and opportunistic infections (OIs) risk. CMV remains a significant issue. New strategies may be needed to optimize CMV management.
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Outcome Comparison between Low-Dose Rabbit Anti-Thymocyte Globulin and Basiliximab in Low-Risk Living Donor Kidney Transplantation. J Clin Med 2020; 9:jcm9051320. [PMID: 32370265 PMCID: PMC7290680 DOI: 10.3390/jcm9051320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 01/09/2023] Open
Abstract
The objective of this study was to compare outcomes between basiliximab and low-dose r-ATG in living donor kidney transplantation recipients with low immunological risk. Patients in the low-dose r-ATG group received 1.5 mg/kg of r-ATG for 3 days (total 4.5 mg/kg). Graft survival, patient survival, acute rejection, de novo donor specific antibody (DSA), estimated glomerular filtration rate (e-GFR) changes, and infection status were compared. Among 268 patients, 37 received r-ATG, and 231 received basiliximab. There was no noticeable difference in the graft failure rate (r-ATG vs. basiliximab: 2.7% vs. 4.8%) or rejection (51.4% vs. 45.9%). de novo DSA was more frequent in the r-ATG group (11.4% vs. 2.4%, p = 0.017). e-GFR changes did not differ noticeably between groups. Although most infections showed no noticeable differences between groups, more patients in the r-ATG group had cytomegalovirus (CMV) antigenemia and serum polyomavirus (BK virus) (73.0% vs. 51.9%, p = 0.032 in CMV; 37.8% vs. 15.6%, p = 0.002 in BK), which did not aggravate graft failure. Living donor kidney transplantation patients who received low-dose r-ATG and patients who received basiliximab showed comparable outcomes in terms of graft survival, function, and overall infections. Although CMV antigenemia, BK viremia were more frequent in the r-ATG group, those factors didn’t change the graft outcomes.
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Cytomegalovirus infection in patients with lupus nephritis: clinical and laboratory features and therapeutic considerations. Clin Exp Med 2017; 17:467-475. [DOI: 10.1007/s10238-017-0456-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 02/06/2017] [Indexed: 12/13/2022]
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de Matos SB, Meyer R, Lima FWDM. Cytomegalovirus Infection after Renal Transplantation: Occurrence, Clinical Features, and the Cutoff for Antigenemia in a University Hospital in Brazil. Infect Chemother 2017; 49:255-261. [PMID: 29299892 PMCID: PMC5754335 DOI: 10.3947/ic.2017.49.4.255] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 11/14/2017] [Indexed: 12/22/2022] Open
Abstract
Background Cytomegalovirus (CMV) is the main infectious agent causative of morbidity and mortality in transplant recipients. This study aimed to describe the occurrence and clinical features of CMV infection, and the optimum antigenemia assay cutoff associated with symptomatic infection. Materials and Methods This was a cohort study that investigated 87 patients undergoing renal transplantation. The patients were monitored with the CMV antigenemia assay performed weekly for the first 3 months post-transplantation and subsequently, when CMV infection was suspected clinically. Results CMV infection was observed in 63.2% (55/87) of the recipients during the follow-up. Of the 65 episodes observed, 75% (49/65) occurred until 100 days after transplantation (D+100) and 25% (16/65) after D+100 with a median of 60 days. CMV infection was associated with age of the transplant recipients (P = 0.001) and use of deceased donor organ (P = 0.009). There were asymptomatic (34%) and symptomatic (66%) episodes of CMV infection, in which diarrhea was the most common symptom (22.6%), followed by elevated creatinine levels (14.5%), fever (12.9%) and leukopenia (10.5%). The optimum cutoff point associated with symptomatic infection was 5 positive cells/200,000 leukocytes (area under the curve = 0.87, positive predictive value = 88% and negative predictive value= 71%). Conclusions The high occurrence and the risk factors for CMV infection such as the age of recipients, the number of positive cells in the antigenemia assay, and use of a deceased donor organ should be considered for appropriate monitoring and management of kidney recipients during the post-transplant period.
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Affiliation(s)
- Sócrates Bezerra de Matos
- Immunology Service for Infectious Diseases, Faculty of Pharmacy, Federal University of Bahia, Salvador, BA, Brazil.
| | - Roberto Meyer
- Health Sciences Institute, Federal University of Bahia, Salvador, BA, Brazil
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Carvalho FR, Cosendey RIJ, Souza CF, Medeiros T, Menezes PA, Silva AA, Almeida JR, Lugon JR. Clinical correlates of pp65 antigenemia monitoring in the first months of post kidney transplant in patients undergoing universal prophylaxis or preemptive therapy. Braz J Infect Dis 2016; 21:51-56. [PMID: 27888673 PMCID: PMC9425529 DOI: 10.1016/j.bjid.2016.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/09/2016] [Accepted: 09/19/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction Human cytomegalovirus is a major cause of morbidity in kidney transplant patients. Objectives We aimed to study viral replication and serological response in the first months post kidney transplant in patients undergoing universal prophylaxis or preemptive therapy and correlate the findings with the clinical course of Human cytomegalovirus infection. Patients and methods Independent from the clinical strategy adopted for managing Human cytomegalovirus infection, prophylaxis versus preemptive therapy, the pp65 antigenemia assay and serological response were assessed on the day of transplantation, and then weekly during the first three months of post-transplant. Results From the 32 transplant recipients, 16 were positive for pp65 antigenemia, with a similar incidence rate in each group. There were no positive results in the first three weeks of monitoring; the positivity rate peaked at week eight. There was a trend for a higher and earlier frequency of positivity in the universal prophylaxis group in which the course of the Human cytomegalovirus infection was also more severe. Despite the differences in clinical picture and in the initial immunosuppressant schedule, the serological response was similar in both groups. Conclusion Routine monitoring during the first three post-transplant months has a positive impact on the early detection of Human cytomegalovirus viral replication allowing for timely treatment in order to reduce morbidity of the disease. The strategy of universal therapy employing intravenous ganciclovir was associated to a worse clinical course of the Human cytomegalovirus infection suggesting that the use of >10 cells/2 × 105 leukocytes as a cut-off in this setting may be inappropriate.
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Affiliation(s)
- Fabiana Rabe Carvalho
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Laboratório Multiusuário de Apoio a Pesquisa em Nefrologia e Ciências Médicas, Niterói, RJ, Brazil
| | - Rachel Ingrid Juliboni Cosendey
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Laboratório Multiusuário de Apoio a Pesquisa em Nefrologia e Ciências Médicas, Niterói, RJ, Brazil
| | - Cintia Fernandes Souza
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Laboratório Multiusuário de Apoio a Pesquisa em Nefrologia e Ciências Médicas, Niterói, RJ, Brazil
| | - Thalia Medeiros
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Laboratório Multiusuário de Apoio a Pesquisa em Nefrologia e Ciências Médicas, Niterói, RJ, Brazil
| | - Paulo Alexandre Menezes
- Universidade Federal Fluminense, Departamento de Medicina Interna, Nefrologia, Niterói, RJ, Brazil
| | - Andrea Alice Silva
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Laboratório Multiusuário de Apoio a Pesquisa em Nefrologia e Ciências Médicas, Niterói, RJ, Brazil; Universidade Federal Fluminense, Faculdade de Medicina, Departamento de Patologia, Niterói, RJ, Brazil
| | - Jorge Reis Almeida
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Laboratório Multiusuário de Apoio a Pesquisa em Nefrologia e Ciências Médicas, Niterói, RJ, Brazil; Universidade Federal Fluminense, Departamento de Medicina Interna, Nefrologia, Niterói, RJ, Brazil.
| | - Jocemir Ronaldo Lugon
- Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Laboratório Multiusuário de Apoio a Pesquisa em Nefrologia e Ciências Médicas, Niterói, RJ, Brazil; Universidade Federal Fluminense, Departamento de Medicina Interna, Nefrologia, Niterói, RJ, Brazil
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Kim T, Lee YM, Lee SO, Choi SH, Kim YS, Woo JH, Sung H, Jung JH, Shin S, Kim YH, Kang YA, Lee YS, Lee JH, Lee JH, Lee KH, Park SK, Han DJ, Kim SH. Differences of cytomegalovirus diseases between kidney and hematopoietic stem cell transplant recipients during preemptive therapy. Korean J Intern Med 2016; 31:961-70. [PMID: 27055664 PMCID: PMC5016278 DOI: 10.3904/kjim.2015.079] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/22/2015] [Accepted: 06/30/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND/AIMS Cytomegalovirus (CMV) surveillance and preemptive therapy is a widely-used strategy for preventing CMV disease in transplant recipients. However, there are limited data on the incidence and patterns of CMV disease during the preemptive period. Thus, we investigated the incidence and pattern of tissue-invasive CMV disease in CMV seropositive kidney transplantation (KT) and hematopoietic stem cell transplantation (HCT) recipients during preemptive therapy. METHODS We prospectively identified patients with tissue-invasive CMV disease among 664 KT (90%) and 496 HCT (96%) recipients who were D+/R+ (both donor and recipient seropositive) during a 4-year period. RESULTS The incidence rates of CMV disease were 4.1/100 person-years (4%, 27/664) in KT recipients and 5.0/100 person-years (4%, 21/496) in HCT recipients. Twenty-six (96%) of the KT recipients with CMV disease had gastrointestinal CMV, whereas 17 (81%) of the HCT recipients had gastrointestinal CMV and 4 (19%) had CMV retinitis. Thus, CMV retinitis was more common among HCT recipients (p = 0.03). All 27 KT recipients with CMV disease suffered abrupt onset of CMV disease before or during preemptive therapy; 10 (48%) of the 21 HCT recipients with CMV disease were also classified in this way but the other 11 (52%) were classified as CMV disease following successful ganciclovir preemptive therapy (p < 0.001). CONCLUSIONS The incidence of CMV disease was about 4% in both KT and HCT recipients during preemptive therapy. However, CMV retinitis and CMV disease as a relapsed infection were more frequently found among HCT recipients.
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Affiliation(s)
- Tark Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yu-Mi Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Infectious Diseases, Inje University Busan Paik Hospital, Busan, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Hee Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Ah Kang
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Shin Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Hee Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoo-Hyung Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su-Kil Park
- Department of Nephrology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Chun J, Lee C, Kwon JE, Hwang SW, Kim SG, Kim JS, Jung HC, Im JP. Usefulness of the cytomegalovirus antigenemia assay in patients with ulcerative colitis. Intest Res 2015; 13:50-9. [PMID: 25691843 PMCID: PMC4316222 DOI: 10.5217/ir.2015.13.1.50] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/28/2014] [Accepted: 06/30/2014] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Patients with ulcerative colitis (UC) are at high risk for cytomegalovirus (CMV) reactivation. The usefulness of the CMV antigenemia assay in active UC patients has rarely been studied. We assessed whether the assay detects CMV colitis and predicts clinical outcomes in patients with UC. Methods We retrospectively reviewed the medical records of patients hospitalized for moderate-to-severe UC from 2003 to 2012. Positive CMV antigenemia was defined as ≥1 pp65-positive cell per 2×105 polymorphonuclear neutrophils. CMV colitis was defined as the presence of inclusion bodies and/or positive immunohistochemistry in the colonic mucosa. The primary outcome was steroid refractoriness, defined as the absence of clinical improvement after intravenous high-dose steroid administration. Results A total of 43 patients were enrolled. CMV antigenemia was detected in 12 (27.9%) patients. Positive CMV antigenemia was significantly associated with CMV colitis (P =0.001). The sensitivity and specificity of positive CMV antigenemia for diagnosing CMV colitis were 66.7% and 87.1%, respectively. Steroid refractoriness was found in 11 of 12 (91.7%) and 12 of 31 (38.7%) patients with positive and negative CMV antigenemia, respectively (P =0.002). The independent predictors for steroid refractoriness were positive CMV antigenemia (adjusted odds ratio [OR], 7.73; 95% confidence interval [CI], 1.22-49.19; P =0.030) and a shorter duration from the diagnosis of UC (adjusted OR, 0.99; 95% CI, 0.98-0.99; P =0.025). Conclusions The CMV antigenemia assay shows low sensitivity but high specificity for detecting CMV colitis and may predict steroid-refractory UC. Early rescue therapy might be considered in UC patients positive for CMV antigenemia.
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Affiliation(s)
- Jaeyoung Chun
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Changhyun Lee
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Ji-Eun Kwon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Wook Hwang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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The effects of preemptive therapy using a very low threshold of pp65 antigenemia to prevent cytomegalovirus disease in kidney transplant recipients: a single-center experience. Transplant Proc 2013; 45:182-4. [PMID: 23375295 DOI: 10.1016/j.transproceed.2012.07.144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 07/27/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND Preemptive therapy is a valid option for cytomegalovirus (CMV) disease prevention in kidney transplant recipients. However, there are controversies regarding the appropriate threshold value to be reached before starting antiviral drugs. The aim of this study was to evaluate the benefit of a low threshold of the CMV pp65 antigenemia test as a guide to initiate the therapy. METHODS We performed a prospective study on 47 consecutive kidney recipients. The CMV pp65 antigenemia test was performed over 6 months posttransplantation; patients who displayed ≥ 2/200,000 CMV antigen-positive leukocytes were treated for 2 months with valgancyclovir (450 mg twice a day). RESULTS Twenty-five patients developed CMV infections, which were initially diagnosed at 55 ± 25 days posttransplantation. The number of CMV antigen-positive cells/200,000 leukocytes on the first positive test was 17 ± 22. The test first became negative at 17 ± 8 days after the diagnosis. A positive correlation was observed between the number of CMV antigen-positive cells and the time to obtain the first negative test (P = .01). At the end of follow-up (35.3 ± 16.4 months), none of the patients had developed CMV syndrome. Among the CMV-positive recipients, the creatinine levels showed no differences from the values before the CMV infection. No difference in creatinine levels was noted between CMV infection positive versus negative patients. CONCLUSION Our data suggested that a CMV antigenemia titer ≥ 2/200.000 leucocytes can be considered to be an appropriate threshold to start anti-CMV preemptive therapy.
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