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Prakash K, Aslam S. New updates in the world of hepatitis C virus infected organ transplantation. Curr Opin Organ Transplant 2021; 25:364-370. [PMID: 32520787 DOI: 10.1097/mot.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW With the advent of direct acting antiviral (DAA) therapy, the use of organs from hepatitis C virus infected (HCV+) donors is gaining more traction. In this review, we aim to: provide an overview of recent literature that supports the use of HCV+ organs, outline ongoing challenges to the use of these organs, and highlight the areas within this field where active investigation is ongoing. RECENT FINDINGS The present review describes clinical outcomes related to the transplantation of both HCV+ nonviremic and viremic organs and the distinction between hepatic and nonhepatic transplants. It also discusses the current debate pertaining to the ideal treatment strategy for donor-derived HCV infection, that is pre-emptive therapy versus prophylaxis therapy. SUMMARY Data suggest that the use of HCV+ organs is an effective and relatively well tolerated strategy to combat the organ scarcity. However, clinicians must be vigilant to a signal of increased inflammation as HCV+ organ transplantation becomes more universal. Recent studies suggest that shorter courses of DAA may sufficiently treat donor-derived HCV infection, however the best treatment approach to minimize risk, cost, and toxicity is still under investigation.
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Affiliation(s)
- Katya Prakash
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
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Winston A, Wurcel AG, Gordon C, Goyal N. Viral hepatitis in patients on hemodialysis. Semin Dial 2020; 33:254-262. [PMID: 32394502 DOI: 10.1111/sdi.12882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hepatitis B and hepatitis C (HCV) prevalence are higher in people on hemodialysis (HD) than the general population. Through implementation of prevention interventions including vaccines, serologic screening, and post-exposure management, transmissions linked to HD have decreased dramatically. In this manuscript, we review epidemiology of viral hepatitis, summarize current screening and vaccine recommendations, and appraise the available data about efforts to decrease incidence within HD facilities, including isolation of people with viral hepatitis within HD units. Also included is a discussion of the highly effective all-oral HCV treatment options and treatment for HCV in people awaiting kidney transplant.
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Affiliation(s)
- Anna Winston
- Tufts University School of Medicine, Boston, Massachusetts
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Craig Gordon
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Nitender Goyal
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Potluri VS, Goldberg DS, Mohan S, Bloom RD, Sawinski D, Abt PL, Blumberg EA, Parikh CR, Sharpe J, Reddy KR, Molnar MZ, Sise M, Reese PP. National Trends in Utilization and 1-Year Outcomes with Transplantation of HCV-Viremic Kidneys. J Am Soc Nephrol 2019; 30:1939-1951. [PMID: 31515244 DOI: 10.1681/asn.2019050462] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/16/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Recent pilot trials have demonstrated the safety of transplanting HCV-viremic kidneys into HCV-seronegative recipients. However, it remains unclear if allograft function is impacted by donor HCV-viremia or recipient HCV-serostatus. METHODS We used national United States registry data to examine trends in HCV-viremic kidney use between 4/1/2015 and 3/31/2019. We applied advanced matching methods to compare eGFR for similar kidneys transplanted into highly similar recipients of kidney transplants. RESULTS Over time, HCV-seronegative recipients received a rising proportion of HCV-viremic kidneys. During the first quarter of 2019, 200 HCV-viremic kidneys were transplanted into HCV-seronegative recipients, versus 69 into HCV-seropositive recipients, while 105 HCV-viremic kidneys were discarded. The probability of HCV-viremic kidney discard has declined over time. Kidney transplant candidates willing to accept a HCV-seropositive kidney increased from 2936 to 16,809 from during this time period. When transplanted into HCV-seronegative recipients, HCV-viremic kidneys matched to HCV-non-viremic kidneys on predictors of organ quality, except HCV, had similar 1-year eGFR (66.3 versus 67.1 ml/min per 1.73 m2, P=0.86). This was despite the much worse kidney donor profile index scores assigned to the HCV-viremic kidneys. Recipient HCV-serostatus was not associated with a clinically meaningful difference in 1-year eGFR (66.5 versus 71.1 ml/min per 1.73 m2, P=0.056) after transplantation of HCV-viremic kidneys. CONCLUSIONS By 2019, HCV-seronegative patients received the majority of kidneys transplanted from HCV-viremic donors. Widely used organ quality scores underestimated the quality of HCV-viremic kidneys based on 1-year allograft function. Recipient HCV-serostatus was also not associated with worse short-term allograft function using HCV-viremic kidneys.
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Affiliation(s)
- Vishnu S Potluri
- Renal-Electrolyte and Hypertension Division, Department of Medicine
| | - David S Goldberg
- Departments of Biostatistics, Epidemiology and Bioinformatics and.,Division of Gastroenterology and Hepatology, Department of Medicine, and
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons and.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Roy D Bloom
- Renal-Electrolyte and Hypertension Division, Department of Medicine
| | - Deirdre Sawinski
- Renal-Electrolyte and Hypertension Division, Department of Medicine
| | | | - Emily A Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chirag R Parikh
- Renal Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James Sharpe
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, and
| | - Miklos Z Molnar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee.,Department of Surgery and Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee; and
| | - Meghan Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, .,Departments of Biostatistics, Epidemiology and Bioinformatics and
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McLean RC, Reese PP, Acker M, Atluri P, Bermudez C, Goldberg LR, Abt PL, Blumberg EA, Van Deerlin VM, Reddy KR, Bloom RD, Hasz R, Suplee L, Sicilia A, Woodards A, Zahid MN, Bar KJ, Porrett P, Levine MH, Hornsby N, Gentile C, Smith J, Goldberg DS. Transplanting hepatitis C virus-infected hearts into uninfected recipients: A single-arm trial. Am J Transplant 2019; 19:2533-2542. [PMID: 30768838 DOI: 10.1111/ajt.15311] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 02/06/2023]
Abstract
The advent of direct-acting antiviral therapy for hepatitis C virus (HCV) has generated tremendous interest in transplanting organs from HCV-infected donors. We conducted a single-arm trial of orthotopic heart transplantation (OHT) from HCV-infected donors into uninfected recipients, followed by elbasvir/grazoprevir treatment after recipient HCV was first detected (NCT03146741; sponsor: Merck). We enrolled OHT candidates aged 40-65 years; left ventricular assist device (LVAD) support and liver disease were exclusions. We accepted hearts from HCV-genotype 1 donors. From May 16, 2017 to May 10, 2018, 20 patients consented for screening and enrolled, and 10 (median age 52.5 years; 80% male) underwent OHT. The median wait from UNOS opt-in for HCV nucleic-acid-test (NAT)+ donor offers to OHT was 39 days (interquartile range [IQR] 17-57). The median donor age was 34 years (IQR 31-37). Initial recipient HCV RNA levels ranged from 25 IU/mL to 40 million IU/mL, but all 10 patients had rapid decline in HCV NAT after elbasvir/grazoprevir treatment. Nine recipients achieved sustained virologic response at 12 weeks (SVR-12). The 10th recipient had a positive cross-match, experienced antibody-mediated rejection and multi-organ failure, and died on day 79. No serious adverse events occurred from HCV transmission or treatment. These short-term results suggest that HCV-negative candidates transplanted with HCV-infected hearts have acceptable outcomes.
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Affiliation(s)
- Rhondalyn C McLean
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Acker
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee R Goldberg
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter L Abt
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily A Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vivianna M Van Deerlin
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - K Rajender Reddy
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roy D Bloom
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Hasz
- Gift of Life Donor Program, Philadelphia, Pennsylvania
| | | | - Anna Sicilia
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Ashley Woodards
- Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Muhammad Nauman Zahid
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katharine J Bar
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paige Porrett
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew H Levine
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicole Hornsby
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caren Gentile
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Jennifer Smith
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - David S Goldberg
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Mogahed EA, Abdelaziz H, Helmy H, Ghita H, Abdel Mawla MA, Hassanin F, Fadel FI, El-Karaksy H. Safety and Efficacy of Pegylated Interferon Alpha-2b Monotherapy in Hepatitis C Virus-Infected Children with End-Stage Renal Disease on Hemodialysis. J Interferon Cytokine Res 2016; 36:681-688. [PMID: 27656950 DOI: 10.1089/jir.2016.0019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Treatment of hepatitis C virus (HCV) in end-stage renal disease (ESRD) patients is an important issue before kidney transplantation (KT). The aim of the study is to assess the efficacy and tolerability of HCV treatment with pegylated interferon (PEG IFN)-α 2b in children with ESRD. The study included 17 children, aged 3-18 years with ESRD on hemodialysis (HD), with chronic HCV. They received 40 μg/m2 of PEG IFN-α 2b once-weekly subcutaneous injections for 48 weeks. Early virological response (EVR) was achieved in 76.5%. At week 24, 8 patients had negative HCV RNA. Six patients received KT during therapy. Treatment was discontinued in 2 patients: one for anemia and another for retinopathy. Two patients completed 48 weeks of therapy and both achieved end-of-treatment response and sustained virological response (SVR). Constitutional symptoms were the most frequently reported side effects. Neutropenia occurred in 10 patients (58.8%), drop in hemoglobin in 10, and thrombocytopenia in 9. HCV-infected children with ESRD on HD have high EVR (76.5%) on IFN monotherapy. SVR could not be assessed due to the high dropout rate related mainly to early transplantation. Constitutional symptoms and hematological side effects were the most frequently reported side effects.
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Affiliation(s)
- Engy A Mogahed
- 1 Department of Pediatrics, Kasr Alainy Medical School, Cairo University , Cairo, Egypt
| | - Hanan Abdelaziz
- 1 Department of Pediatrics, Kasr Alainy Medical School, Cairo University , Cairo, Egypt
| | - Heba Helmy
- 1 Department of Pediatrics, Kasr Alainy Medical School, Cairo University , Cairo, Egypt
| | - Haytham Ghita
- 1 Department of Pediatrics, Kasr Alainy Medical School, Cairo University , Cairo, Egypt
| | | | - Fetouh Hassanin
- 3 Faculty of Pharmacy, Misr International University , Cairo, Egypt
| | - Fatina I Fadel
- 1 Department of Pediatrics, Kasr Alainy Medical School, Cairo University , Cairo, Egypt
| | - Hanaa El-Karaksy
- 1 Department of Pediatrics, Kasr Alainy Medical School, Cairo University , Cairo, Egypt
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Hepatitis C virus infection in nonliver solid organ transplant candidates and recipients. Curr Opin Organ Transplant 2015; 20:259-66. [PMID: 25944237 DOI: 10.1097/mot.0000000000000195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Transplantation is the best treatment for many patients with end-stage organ failure. Hepatitis C infection is prevalent among solid organ candidates and recipients and continues to represent a major source of morbidity and mortality. Prior interferon (IFN)-based therapies have been associated with limited efficacy and high rates of adverse events. Furthermore, prior IFN-based regimens are associated with high rates of allograft rejection limiting their use post-transplant. This review will outline the limited experience with current treatment regimens and how to incorporate the new hepatitis C virus (HCV) treatment regimens. RECENT FINDINGS The introduction of new direct-acting antiviral (DAA) agents against HCV has dramatically altered the landscape of treatment for HCV. Different all-oral regimens are currently available and are rapidly becoming the standard for treating patients with chronic hepatitis C. Excluding patients with liver disease or those who received liver transplant, those regimens have not been studied in patients awaiting solid organ transplant, or those transplanted. SUMMARY The safety and efficacy of DAAs in patients awaiting liver transplant and liver transplant recipients provide us with some insight and guidance on how to use those all-oral IFN-free regimens to allow effective treatment for patients who received or are awaiting nonliver solid organ transplants.
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EXP CLIN TRANSPLANTExp Clin Transplant 2015; 13. [DOI: 10.6002/ect.mesot2014.o160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Li LF, Shi KQ, Lin YQ, Wang LR, He JP, Braddock M, Chen YP, Zheng MH. Factors associated with efficacy of pegylated interferon-α plus ribavirin for chronic hepatitis C after renal transplantation. Gene 2014; 544:101-6. [DOI: 10.1016/j.gene.2014.04.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 03/20/2014] [Accepted: 04/29/2014] [Indexed: 02/08/2023]
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Wei F, Liu J, Liu F, Hu H, Ren H, Hu P. Interferon-based anti-viral therapy for hepatitis C virus infection after renal transplantation: an updated meta-analysis. PLoS One 2014; 9:e90611. [PMID: 24699257 PMCID: PMC3974660 DOI: 10.1371/journal.pone.0090611] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 01/31/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is highly prevalent in renal transplant (RT) recipients. Currently, interferon-based (IFN-based) antiviral therapies are the standard approach to control HCV infection. In a post-transplantation setting, however, IFN-based therapies appear to have limited efficacy and their use remains controversial. The present study aimed to evaluate the efficacy and safety of IFN-based therapies for HCV infection post RT. METHODS We searched Pubmed, Embase, Web of Knowledge, and The Cochrane Library (1997-2013) for clinical trials in which transplant patients were given Interferon (IFN), pegylated interferon (PEG), interferon plus ribavirin (IFN-RIB), or pegylated interferon plus ribavirin (PEG-RIB). The Sustained Virological Response (SVR) and/or drop-out rates were the primary outcomes. Summary estimates were calculated using the random-effects model of DerSimonian and Laird, with heterogeneity and sensitivity analysis. RESULTS We identified 12 clinical trials (140 patients in total). The summary estimate for SVR rate, drop-out rate and graft rejection rate was 26.6% (95%CI, 15.0-38.1%), 21.1% (95% CI, 10.9-31.2%) and 4% (95%CI: 0.8%-7.1%), respectively. The overall SVR rate in PEG-based and standard IFN-based therapy was 40.6% (24/59) and 20.9% (17/81), respectively. The most frequent side-effect requiring discontinuation of treatment was graft dysfunction (14 cases, 45.1%). Meta-regression analysis showed the covariates included contribute to the heterogeneity in the SVR logit rate, but not in the drop-out logit rate. The sensitivity analyses by the random model yielded very similar results to the fixed-effects model. CONCLUSIONS IFN-based therapy for HCV infection post RT has poor efficacy and limited safety. PEG-based therapy is a more effective approach for treating HCV infection post-RT than standard IFN-based therapy. Future research is required to develop novel strategies to improve therapeutic efficacy and tolerability, and reduce the liver-related morbidity and mortality in this important patient population.
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Affiliation(s)
- Fang Wei
- Department of infectious Disease, Institute for Viral hepatitis, Key Laboratory of Molecular Biology for infectious disease, The second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Junying Liu
- Department of Gastroenterology, The Central hospital of Zhoukou, Henan Province, China
| | - Fen Liu
- Department of infectious Disease, Institute for Viral hepatitis, Key Laboratory of Molecular Biology for infectious disease, The second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Huaidong Hu
- Department of infectious Disease, Institute for Viral hepatitis, Key Laboratory of Molecular Biology for infectious disease, The second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Hong Ren
- Department of infectious Disease, Institute for Viral hepatitis, Key Laboratory of Molecular Biology for infectious disease, The second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Peng Hu
- Department of infectious Disease, Institute for Viral hepatitis, Key Laboratory of Molecular Biology for infectious disease, The second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe the new insights of hepatitis C virus (HCV) infection and renal transplantation. RECENT FINDINGS HCV is its most frequent cause of liver disease after transplantation. In the long run, HCV infection can lead to cirrhosis, hepatocarcinoma and death in some patients. As interferon is generally contraindicated after transplantation, the best way to treat patients is before transplantation. Long-term patient and graft survival rates are lower in HCV-positive patients than in HCV-negative graft recipients. HCV infection is an independent risk factor for death and graft loss. Mortality is higher, mainly as a result of cardiovascular complications, liver disease and infections but is lower than in HCV-positive patients on the transplant waiting list. New-onset diabetes after transplantation (NODAT), and HCV-related glomerulonephritis, together with chronic rejection and notably transplant glomerulopathy can contribute to graft failure. Despite this factor, transplantation is the best option for the HCV-positive patient on dialysis. Renal transplantation with kidneys from donors with positive anti-HCV antibodies into HCV RNA-positive recipients seems to be safe in the long term. SUMMARY Renal transplantation is the therapy of choice for dialysis patients with HCV infection. To improve the results, a careful follow-up in the outpatient clinic for early detection of HCV-related complications is mandatory.
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Brennan DC, Aguado JM, Potena L, Jardine AG, Legendre C, Säemann MD, Mueller NJ, Merville P, Emery V, Nashan B. Effect of maintenance immunosuppressive drugs on virus pathobiology: evidence and potential mechanisms. Rev Med Virol 2012; 23:97-125. [PMID: 23165654 DOI: 10.1002/rmv.1733] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 09/07/2012] [Accepted: 09/20/2012] [Indexed: 12/11/2022]
Abstract
Recent evidence suggesting a potential anti-CMV effect of mTORis is of great interest to the transplant community. However, the concept of an immunosuppressant with antiviral properties is not new, with many accounts of the antiviral properties of several agents over the years. Despite these reports, to date, there has been little effort to collate the evidence into a fuller picture. This manuscript was developed to gather the evidence of antiviral activity of the agents that comprise a typical immunosuppressive regimen against viruses that commonly reactivate following transplant (HHV1 and 2, VZV, EBV, CMV and HHV6, 7, and 8, HCV, HBV, BKV, HIV, HPV, and parvovirus). Appropriate immunosuppressive regimens posttransplant that avoid acute rejection while reducing risk of viral reactivation are also reviewed. The existing literature was disparate in nature, although indicating a possible stimulatory effect of tacrolimus on BKV, potentiation of viral reactivation by steroids, and a potential advantage of mammalian target of rapamycin (mTOR) inhibition in several viral infections, including BKV, HPV, and several herpesviruses.
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Abstract
BACKGROUND Kidney transplantation (KTx) alone in patients with cirrhosis and renal failure (end-stage renal disease [ESRD]) infected with hepatitis C virus (HCV) is controversial. The aim of this study was to compare outcomes of HCV+ patients with ESRD and cirrhosis (C group) versus HCV+ patients with ESRD but with no cirrhosis (NC group) listed for KTx. METHODS Ninety HCV+ patients with ESRD were evaluated for KTx between 2003 and 2010. Listed patients underwent transjugular liver biopsy with hepatic portal venous gradient (HPVG) measurements. Only patients with HPVG less than 10 mm Hg were considered for KTx alone. We analyzed patient demographics, waitlist/liver disease characteristics, and posttransplant outcomes between groups. RESULTS Sixty-four patients listed for KTx alone were studied. Twelve patients (18.75%) showed biopsy-proven cirrhosis. Thirty-seven patients underwent KTx alone (9 from C and 28 from NC). No patients developed decompensation of their liver disease, although one patient for NC group developed metastatic hepatocellular carcinoma 16 months after transplantation. One- and three-year graft survival rates were 75% and 75% versus 92.1% and 75.1% for groups C and NC, respectively (P=0.72). One- and three-year patient survival rates were 88.9% and 88.9% versus 96.3% and 77.9% for groups C and NC, respectively (P=0.76). Only increasing recipient age and decreasing albumin levels were significantly associated with worse graft and patient survival. CONCLUSIONS Our study suggests that KTx alone may be safe in patients with compensated HCV, cirrhosis, and ESRD with HPVG less than 10 mm Hg. A simultaneous liver-kidney transplantation may be an unnecessary use of a liver allograft in these patients.
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Abstract
Infections are a major cause of morbidity and mortality in kidney transplant recipients. To some extent, these may be preventable. Careful pretransplant screening, immunization, and post-transplant prophylactic antimicrobials may all reduce the risk for post-transplant infection. However, because transplant recipients may not manifest typical signs and symptoms of infection, diagnoses may be confounded. Furthermore, treatment regimens may be complicated by drug interactions and the need to maintain immunosuppression to avoid allograft rejection. This article reviews common post-transplant infections, including prophylactic, diagnostic, and treatment strategies, providing guidance regarding care of kidney transplant patients with infection.
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Affiliation(s)
- Shamila Karuthu
- Division of Nephrology, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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