1
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Bobrowski AE, Muller WJ. Varicella infection following vaccination in a pediatric kidney transplant recipient. Pediatr Transplant 2020; 24:e13667. [PMID: 32068320 DOI: 10.1111/petr.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/19/2019] [Accepted: 01/07/2020] [Indexed: 12/22/2022]
Abstract
Live viral vaccines have historically been avoided in children after solid organ transplantation. Multiple reports of safety and immunogenicity, largely in the pediatric liver transplant population, have led to a reconsideration of this recommendation. Here, we report the case of a 4-year-old boy who inadvertently received the live attenuated MMR-varicella vaccine (MMRV) at a routine well-child visit 16 months after receiving a living donor kidney transplant. This was not known until after he was admitted with rash and documented disseminated varicella infection 5 weeks later. He was treated with intravenous acyclovir followed by oral therapy and recovered fully. This case and its discussion illustrate what is still unknown about the risk-to-benefit ratio of live viral vaccination in any individual transplant recipient. Criteria to determine which patients should receive these vaccines should be evaluated before their use after transplant becomes routine, and all recipients and their families should be counseled to have a low threshold to seek medical care for any febrile illness or rash after live viral vaccination.
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Affiliation(s)
- Amy E Bobrowski
- Division of Pediatric Kidney Diseases, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
| | - William J Muller
- Division of Infectious Diseases, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
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2
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Suresh S, Upton J, Green M, Pham-Huy A, Posfay-Barbe KM, Michaels MG, Top KA, Avitzur Y, Burton C, Chong PP, Danziger-Isakov L, Dipchand AI, Hébert D, Kumar D, Morris SK, Nalli N, Ng VL, Nicholas SK, Robinson JL, Solomon M, Tapiero B, Verma A, Walter JE, Allen UD. Live vaccines after pediatric solid organ transplant: Proceedings of a consensus meeting, 2018. Pediatr Transplant 2019; 23:e13571. [PMID: 31497926 DOI: 10.1111/petr.13571] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/12/2019] [Accepted: 07/26/2019] [Indexed: 12/11/2022]
Abstract
Growing evidence suggests receipt of live-attenuated viral vaccines after solid organ transplant (SOT) has occurred and is safe and needed due to lapses in herd immunity. A 2-day consortium of experts in infectious diseases, transplantation, vaccinology, and immunology was held with the objective to review evidence and create expert recommendations for clinicians when considering live viral vaccines post-SOT. For consideration of VV and MMR post-transplant, evidence exists only for kidney and liver transplant recipients. For MMR vaccine post-SOT, consider vaccination during outbreak or travel to endemic risk areas. Patients who have received antiproliferative agents (eg. mycophenolate mofetil), T cell-depleting agents, or rituximab; or have persistently elevated EBV viral loads, or are in a state of functional tolerance, should be vaccinated with caution and have a more in-depth evaluation to define benefit of vaccination and net state of immune suppression prior to considering vaccination. MMR and/or VV (not combined MMRV) is considered to be safe in patients who are clinically well, are greater than 1 year after liver or kidney transplant and 2 months after acute rejection episode, can be closely monitored, and meet specific criteria of "low-level" immune suppression as defined in the document.
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Affiliation(s)
- Sneha Suresh
- Division of Infectious Disease and IHOPE, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Julia Upton
- Division of Immunology and Allergy, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Michael Green
- Division of Infectious Diseases, Department of Pediatrics, Pediatric Transplant Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Department of Paediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Klara M Posfay-Barbe
- Division of Pediatric Infectious Diseases, Department of Paediatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Marian G Michaels
- Division of Infectious Diseases, Department of Pediatrics, Pediatric Transplant Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Karina A Top
- Division of Infectious Diseases, Department of Pediatrics, Dalhousie University, Canadian Center for Vaccinology IWK Health Centre, Halifax, NS, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Catherine Burton
- Division of Infectious Diseases, Department of Paediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Pearlie P Chong
- Division of Infectious Diseases, Department of Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Lara Danziger-Isakov
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Anne I Dipchand
- Department of Paediatrics, Labatt Family Heart Centre, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Diane Hébert
- Division of Nephrology, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Deepali Kumar
- Department of Medicine, Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Shaun K Morris
- Division of Infectious Diseases, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Nadya Nalli
- Department of Pharmacy, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, ON, Canada
| | - Vicky Lee Ng
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Sarah Kogan Nicholas
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Joan L Robinson
- Division of Infectious Diseases and Immunology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Bruce Tapiero
- Division of Infectious Diseases, Department of Paediatrics, CHU Sainte Justine, University of Montreal, Montreal, QC, Canada
| | - Anita Verma
- Department of Infection Science, Kings College Hospital, London, UK
| | - Jolan E Walter
- Division of Pediatric Allergy/Immunology, Department of Pediatrics, University of South Florida, John's Hopkins All Children's Hospital, St. Petersburg, Florida.,Division of Pediatric Allergy/Immunology, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Upton D Allen
- Division of Infectious Diseases, Department of Paediatrics, Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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3
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Pergam SA, Limaye AP. Varicella zoster virus in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13622. [PMID: 31162727 DOI: 10.1111/ctr.13622] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/19/2019] [Accepted: 05/29/2019] [Indexed: 12/21/2022]
Abstract
These updated guidelines from the American Society of Transplantation Infectious Diseases Community of Practice review the diagnosis, prevention, and management of varicella zoster virus (VZV) in the pre- and post-transplant period. Primary varicella is an uncommon complication post-solid-organ transplant (SOT), except among pediatric transplant patients and those seronegative for VZV. As the majority of SOT recipients are seropositive for VZV, herpes zoster (HZ) occurs frequently following SOT, particularly among recipients who are older (≥65 years of age) and those receiving more intensive immunosuppression. Transplant providers should aware of the increased risk for HZ-related complications such as dissemination, organ-specific involvement, and post-herpetic neuralgia. Treatment for localized zoster is primarily given as oral regimens, but those with more complicated presentations or those at risk for dissemination should be treated initially with IV therapy. Available antiviral prophylaxis regimens and vaccination strategies for varicella and HZ among these immunosuppressed patients remain a mainstay for prevention in the pre-and post-transplant periods. Finally, we discuss important approaches to addressing post-exposure prophylaxis and infection control practices for those SOT patients with documented VZV infections.
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Affiliation(s)
- Steven A Pergam
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Ajit P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
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4
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Helou E, Grant M, Landry M, Wu X, Morrow JS, Malinis MF. Fatal case of cutaneous-sparing orolaryngeal zoster in a renal transplant recipient. Transpl Infect Dis 2017; 19. [PMID: 28401625 DOI: 10.1111/tid.12704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/08/2016] [Accepted: 01/09/2017] [Indexed: 01/04/2023]
Abstract
Herpesvirus infections in solid organ transplant (SOT) recipients are a significant cause of morbidity and mortality. We report a case of herpes zoster (HZ) in a kidney transplant recipient while receiving belatacept, a CTLA-4 inhibitor that prevents acute rejection. The patient presented with oropharyngolaryngeal mucosal lesions that subsequently disseminated resulting in pneumonitis and meningo-encephalitis. Very late-onset HZ can occur and can present atypically in SOT recipients. Delayed recognition and treatment may result in poor outcomes, as illustrated by this case.
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Affiliation(s)
- Elie Helou
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew Grant
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Marie Landry
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Xinyu Wu
- Department of Surgical Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Jon S Morrow
- Department of Surgical Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Maricar F Malinis
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT, USA.,Department of Surgery (Transplant), Yale University School of Medicine, New Haven, CT, USA
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5
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Clinical Presentation of Herpes Zoster in Immunocompetent and Immunocompromised Hospitalized Children Treated With Acyclovir. J Pediatr Hematol Oncol 2016; 38:394-7. [PMID: 27347778 DOI: 10.1097/mph.0000000000000567] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Herpes zoster, defined as the reactivation of a latent varicella-zoster virus (VZV) infection, used to be a serious disease in immunocompromised children until recently. The aim of this study was to describe the clinical presentation of herpes zoster in hospitalized immunocompromised children compared with hospitalized immunocompetent counterparts. We reviewed the hospital charts of 72 children aged 6 months to 18 years diagnosed with herpes zoster and treated with acyclovir in our department covering a 19-year period. Forty-six of the children were immunocompromised which was mainly due to hematologic diseases. There were no differences in the age at which herpes zoster occurred, length of hospitalization, and the location or extent of the skin eruption. General symptoms were observed more frequently in the hospitalized immunocompetent patients compared with the hospitalized immunocompromised children (80% vs. 56%). The average age at which primary VZV infection occurred was higher among the immunocompromised children than the immunocompetent children with the latter group suffering from significantly more primary VZV infections during infancy. The presentation of herpes zoster in immunocompromised children is similar to that of herpes zoster in hospitalized immunocompetent children.
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6
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Demir Z, Frange P, Lacaille F. Vaccinations, response, and controls before and after intestinal transplantation in children. Pediatr Transplant 2016; 20:449-55. [PMID: 26847771 DOI: 10.1111/petr.12669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2015] [Indexed: 11/25/2022]
Abstract
Vaccination is an effective strategy to decrease infections in transplant recipients. Children after intestinal transplantation carry a high risk of infection due to increased immunosuppression. In a series of 22 children after intestinal transplantation, we studied the vaccination schedules and the antibodies against vaccine-preventable diseases before transplantation, and at one and five yr after transplantation. We reviewed whether the vaccination schedules were complete, and we analysed the factors that may influence serological immunity and the incidence of disease in patients with deficient immunity. All patients completed the recommended vaccination schedules for DTaP-IPV and HBV. After transplantation, the negative antibodies against vaccine-preventable diseases were mostly related to an antirejection therapy: for DTaP-IPV: four of four patients with no antibody had been treated for rejection, for HBV: two of five, HAV: three of four, MMR: three of seven, and VZV: three of four. A post-transplantation varicella infection was followed by acute rejection, with probability for a relationship between both events. We observed 50% of varicella cases in unvaccinated children, highlighting the importance of pretransplant vaccination. Waning immunogenicity mediated by antibodies against vaccine-preventable disease after transplantation indicated a need for boosters. The recommendations should be regularly enforced, as the reliance on routine immunizations schedules is not adequate in immunocompromised patients.
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Affiliation(s)
- Z Demir
- Pediatric Hepato-Gastro-Enterology-Nutrition Unit, Necker-Enfants Malades Hospital, Paris, France
| | - P Frange
- Microbiology Department, Necker-Enfants Malades Hospital, Paris, France.,Pediatric Immunology and Hematology Unit, Necker Hospital, Paris, France.,EA 7327, Paris Descartes University, Sorbonne Paris Cite, Paris, France
| | - F Lacaille
- Pediatric Hepato-Gastro-Enterology-Nutrition Unit, Necker-Enfants Malades Hospital, Paris, France
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7
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Ljungman P, Snydman D, Boeckh M. Infection Prevention and Control Issues After Solid Organ Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7123530 DOI: 10.1007/978-3-319-28797-3_46] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Infections are an important cause of morbidity and mortality in solid organ transplant recipients. Consequently, infection prevention is an essential component of any organ transplant program. Given their frequent and often prolonged contact with the healthcare system, solid organ transplant recipients are at high risk for healthcare-associated infections, including those caused by antibiotic-resistant organisms. In this chapter we review several different healthcare-associated infections of importance to transplant recipients, including those caused by bacterial, viral, and fungal organisms. We also describe infection prevention and control strategies applicable to this patient population. These practices focus on clinical interventions and environmental controls designed to prevent the spread of potentially pathogenic organisms in the healthcare setting. We also describe post-exposure interventions applicable to solid organ transplant recipients exposed to potential pathogens in order to reduce their risk of subsequent infection.
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Affiliation(s)
- Per Ljungman
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - David Snydman
- Tufts University School of Medicine Tufts Medical Center, Boston, Massachusetts USA
| | - Michael Boeckh
- University of Washington Fred Hutchinson Cancer Research Center, Seattle, Washington USA
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8
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Funaki T, Shoji K, Miyata I, Sakamoto S, Kasahara M, Yoshii H, Miyairi I, Saitoh A. Serostatus following live attenuated vaccination administered before pediatric liver transplantation. Liver Transpl 2015; 21:774-83. [PMID: 25762489 DOI: 10.1002/lt.24104] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/20/2015] [Accepted: 02/26/2015] [Indexed: 02/07/2023]
Abstract
After liver transplantation (LT), live attenuated vaccines (LAVs) are generally contraindicated. LAVs are recommended before LT for patients ≥ 6 months of age. However, the evidence supporting this practice is limited. Patients were enrolled before and after LT. Clinical data for patients were obtained from medical records. Serum antibody titers were evaluated at the time of enrollment and prospectively. Serum antibody titers were measured with a hemagglutination inhibition test for measles and rubella and with an enzyme-linked immunosorbent assay for varicella and mumps. Univariate and multivariate analyses were performed to investigate the factors that affect the serostatus. Serological analyses of 49 patients immunized before LT (median age, 45 months; male, 35%) were performed. Underlying diseases were biliary atresia (n = 27; 55%), metabolic diseases (n = 13; 27%), fulminant hepatic failure (n = 5; 10%), and others (n = 4; 8%). The seropositivity rate after each vaccine was 46.9% (measles), 89.4% (rubella), 67.5% (varicella), and 48.8% (mumps). Factors independently associated with seronegativity were a vaccination age < 12 months for measles (P = .002), a lower body weight for varicella (P = 0.01), and underlying diseases other than biliary atresia for mumps (P = .004). No serious adverse event was observed during the study period. The immunogenicity of LAVs before LT was high for rubella but low for the others. Before LT, further vaccination strategies are needed for patients. In addition, serological follow-up may be indicated for patients with factors associated with seronegativity.
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Affiliation(s)
- Takanori Funaki
- Division of Infectious Diseases, Department of Medical Subspecialties, Center for Transplant Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Kensuke Shoji
- Division of Infectious Diseases, Department of Medical Subspecialties, Center for Transplant Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Ippei Miyata
- Division of Infectious Diseases, Department of Medical Subspecialties, Center for Transplant Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Division of Transplant Surgery, Center for Transplant Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Division of Transplant Surgery, Center for Transplant Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Hironori Yoshii
- Research Foundation for Microbial Diseases of Osaka University, Kagawa, Japan
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, Center for Transplant Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Akihiko Saitoh
- Division of Infectious Diseases, Department of Medical Subspecialties, Center for Transplant Surgery, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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9
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Abstract
Pediatric heart transplantation (HTx) remains an important treatment option in the care of children with end-stage heart disease, whether it is secondary to cardiomyopathy or congenital heart disease (CHD). As surgical outcomes for CHD have improved, the indications for pediatric HTx have had to be dynamic, not only for children with CHD but also for the growing population of adults with CHD. As the field of pediatric HTx has evolved, the outcomes for children undergoing HTx have improved. This is undoubtedly due to the continued research efforts of both single-center studies, as well as research collaboratives such as the International Society for Heart and Lung Transplantation (ISHLT) and the Pediatric Heart Transplant Study (PHTS) group. Research collaboratives are increasingly important in pediatric HTx as single center studies for a limited patient population may not elicit strong enough evidence for practice evolution. Similarly, complications that limit the long term graft survival may occur in a minority of patients thus pooled experience is essential. This review focuses on the indications and outcomes for pediatric HTx, with a special emphasis on studies generated by these research collaboratives.
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Affiliation(s)
- Philip T Thrush
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Timothy M Hoffman
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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10
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Thrush PT, Hoffman TM. Pediatric heart transplantation-indications and outcomes in the current era. J Thorac Dis 2014; 6:1080-96. [PMID: 25132975 DOI: 10.3978/j.issn.2072-1439.2014.06.16] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/04/2014] [Indexed: 12/20/2022]
Abstract
Pediatric heart transplantation (HTx) remains an important treatment option in the care of children with end-stage heart disease, whether it is secondary to cardiomyopathy or congenital heart disease (CHD). As surgical outcomes for CHD have improved, the indications for pediatric HTx have had to be dynamic, not only for children with CHD but also for the growing population of adults with CHD. As the field of pediatric HTx has evolved, the outcomes for children undergoing HTx have improved. This is undoubtedly due to the continued research efforts of both single-center studies, as well as research collaboratives such as the International Society for Heart and Lung Transplantation (ISHLT) and the Pediatric Heart Transplant Study (PHTS) group. Research collaboratives are increasingly important in pediatric HTx as single center studies for a limited patient population may not elicit strong enough evidence for practice evolution. Similarly, complications that limit the long term graft survival may occur in a minority of patients thus pooled experience is essential. This review focuses on the indications and outcomes for pediatric HTx, with a special emphasis on studies generated by these research collaboratives.
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Affiliation(s)
- Philip T Thrush
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Timothy M Hoffman
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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11
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Pergam SA, Limaye AP. Varicella zoster virus in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:138-46. [PMID: 23465007 PMCID: PMC5331930 DOI: 10.1111/ajt.12107] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Steven A. Pergam
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ajit P. Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
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12
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Lin SY, Liu JH, Lin CL, Tsai IJ, Chen PC, Chung CJ, Liu YL, Wang IK, Lin HH, Huang CC. A comparison of herpes zoster incidence across the spectrum of chronic kidney disease, dialysis and transplantation. Am J Nephrol 2012; 36:27-33. [PMID: 22699521 DOI: 10.1159/000339004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/17/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The effect of different renal replacement therapies on the risk of developing herpes zoster in renal failure patients is unknown. We aimed to investigate the incidence of herpes zoster attack among renal failure patients who were receiving different dialysis modalities, renal transplantation (RT), or not receiving any of the above mentioned therapies yet. METHODS A retrospective cohort study of the national health insurance register database was conducted. This observational cohort study involved 79,581 study controls, 15,802 chronic kidney disease patients, 3,694 hemodialysis (HD) patients, 317 peritoneal dialysis (PD) patients, and 159 RT patients. RESULTS The RT group had the worst risk of herpes zoster (hazard ratio, HR, 8.46; 95% CI 5.85-12.2), followed by PD (HR 3.61; 95% CI 2.49-4.83) and HD (HR 1.35; 95% CI 1.18-1.55), compared with the comparison group (p < 0.0001). The RT group had also the highest risk of developing herpes zoster with complications among all groups (adjusted HR 15.3). The HRs of the PD group were higher than the HRs of the HD group in terms of herpes zoster or its complications (p < 0.0001 and p = 0.0002, respectively). CONCLUSIONS This study suggests that different treatment modalities are associated with different risks of herpes zoster attacks in renal failure patients. PD patients had higher risks than the HD group in terms of herpes zoster or its complications.
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Affiliation(s)
- Shih-Yi Lin
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan, ROC
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13
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Abuali MM, Arnon R, Posada R. An update on immunizations before and after transplantation in the pediatric solid organ transplant recipient. Pediatr Transplant 2011; 15:770-7. [PMID: 22111996 DOI: 10.1111/j.1399-3046.2011.01593.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Vaccination offers a unique opportunity to decrease the burden of infectious complications following solid organ transplantation. In this paper we review the current guidelines for routine immunizations before and after solid organ transplantation, including the recent updates and changes to recommendations for certain vaccines. We also address the issue of waning immunity in solid organ transplant recipients and discuss the current data on vaccinating this patient population with live vaccines after transplantation.
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Affiliation(s)
- Mayssa M Abuali
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY 10029, USA
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14
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Varma PP, Hooda AK, Sinha T, Chopra GS, Karan SC, Sethi GS, Badwal S, Kotwal A. Renal Transplantation - An Experience of 500 Patients. Med J Armed Forces India 2011; 63:107-11. [PMID: 27407961 DOI: 10.1016/s0377-1237(07)80049-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2006] [Accepted: 03/03/2007] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Renal transplantation is the treatment modality of choice for patients with end stage kidney failure. We present our experience of graft and patient survival of initial 500 renal transplants performed between May 1991 and July 2006, at Army Hospital (R&R). MATERIAL AND METHODS All patients received triple drug immunosuppression with cyclosporine/tacrolimus, azathioprine/ mycophenolate mofetil and steroids. Patients in high risk group received induction therapy with IL-2 receptor blockers/anti-thymocyte globulin. RESULTS Majority of the recipients (79%) were males, whereas majority of the donors (59.4%) were females. In the donor profile, 385 (77%) transplants were live related, 108 (21.6 %) were spousal and 7 (1.4%) were cadaveric transplants. Mean age of the donors and recipients was 42.11 ± 11.53 years (range 19-72 years) and 33 ± 9.39 years (range 5-60 years) respectively. Eighty two patients (16.4%) were lost to follow up and the present data on rejections, patients and graft survival pertains to 418 patients. These patients have been followed up for a mean period of 2.63 years (SE, 0.122; median 1.8 years; range 0-13.36 years). Acute rejection episodes occurred in 115 (27.3%) patients and 95% of these could be reversed with steroids/ATG. Sixty eight patients (16%) have died on follow-up. Our one-year, 5 year and 10 year estimated graft survival is 95.4% (SE, 0.01), 80.5% (SE, 0.03) and 53.1% (SE, 0.09) respectively and patient survival at one year is 93.2% (SE, 0.01). The estimated graft and patient survival in our series is 9.83 (95% CI, 8.92-10.73) and 9.80 (8.93-10.67) years respectively. CONCLUSION This centre's short-term graft survival of 95.4% is comparable to the best centres of the world.
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Affiliation(s)
- P P Varma
- Senior Advisor (Medicine & Nephrology), Army Hospital (Research & Referral), Delhi Cantt
| | - A K Hooda
- Senior Advisor (Medicine & Nephrology), Army Hospital (Research & Referral), Delhi Cantt
| | - T Sinha
- Senior Advisor (Surgery & Urology), Army Hospital (Research & Referral), Delhi Cantt
| | - G S Chopra
- Senior Advisor (Pathology & Immunopathology), Army Hospital (Research & Referral), Delhi Cantt
| | - S C Karan
- Senior Advisor (Surgery & Urology), Army Hospital (Research & Referral), Delhi Cantt
| | - G S Sethi
- Classified Specialist (Surgery) & Urologist, Army Hospital (Research & Referral), Delhi Cantt
| | - S Badwal
- Classified Specialist (Pathology & Nephropathologist), Army Hospital (Research & Referral), Delhi Cantt
| | - A Kotwal
- Classified Specialist (PSM & Epidemiology), Army Hospital (Research & Referral), Delhi Cantt
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15
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Pestre V, Mouthon L. Manifestations pulmonaires associées aux immunosuppresseurs utilisés dans les transplantations et les maladies auto-immunes. Presse Med 2010; 39:878-86. [DOI: 10.1016/j.lpm.2010.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Accepted: 04/09/2010] [Indexed: 10/19/2022] Open
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16
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Allen U, Green M. Prevention and treatment of infectious complications after solid organ transplantation in children. Pediatr Clin North Am 2010; 57:459-79, table of contents. [PMID: 20371047 PMCID: PMC7111630 DOI: 10.1016/j.pcl.2010.01.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Effective prevention, diagnosis, and treatment of infectious diseases after transplantation are key factors contributing to the success of organ transplantation. Most transplant patients experience different kinds of infections during the first year after transplantation. Children are at particular risk of developing some types of infections by virtue of lack of immunity although they may be at risk for other types due the effect of immunosuppressive regimens necessary to prevent rejection. Direct consequences of infections result in syndromes such as mononucleosis, pneumonia, gastroenteritis, hepatitis, among other entities. Indirect consequences are mediated through cytokines, chemokines, and growth factors elaborated by the transplant recipient in response to microbial replication and invasion, which contribute to the net state of immunosuppression among other effects. This review summarizes the major infections that occur after pediatric organ transplantation, highlighting the current treatment and prevention strategies, based on the available data and/or consensus.
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Affiliation(s)
- Upton Allen
- Department of Paediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada.
| | - Michael Green
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Division of Infectious Diseases, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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17
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Affiliation(s)
- S A Pergam
- Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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18
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Abstract
BACKGROUND Exposure of immunocompromised children to varicella often requires postexposure prophylaxis. Exposures requiring this management are often not recognized. Varicella can be a severe disease when it occurs in immunocompromised children, in spite of antiviral therapy. Varicella exposure and varicella in these children can also disrupt scheduled therapy for their underlying illness. Both postexposure prophylaxis and treatment of varicella are likely to be expensive and use significant medical resources. Numerous trials have been undertaken to vaccinate children who are immunocompromised by a variety of conditions and therapies that depress their immune function. METHODS Clinical trials of varicella vaccine administration to immunocompromised children that were reported since 1975 were identified in the Ovid medical database. Reports were selected for analysis and discussion on the basis of their completeness and the utility of their conclusions. RESULTS Vaccination before immune compromise is discussed as a strategy for some settings. The obstacles, potential opportunities, and success in varicella vaccination for immunocompromised children are separately analyzed for (1) children with leukemia and other malignancies, (2) human immunodeficiency virus-infected children, and (3) children with hematopoietic stem cell or solid-organ transplantation. CONCLUSIONS Vaccination before immune compromise is often successful, and the vaccine-induced response is usually partially or fully protective. In many treatment settings, it is possible to safely vaccinate once the level of immune suppression has been reduced. Targets for future research are outlined. A consensus conference should be undertaken to develop guidelines for the use of varicella vaccine in immunocompromised children.
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Affiliation(s)
- Myron J Levin
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado School of Medicine, Denver, USA.
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19
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Incidence and Clinical Characteristics of Herpes Zoster After Lung Transplantation. J Heart Lung Transplant 2008; 27:11-6. [DOI: 10.1016/j.healun.2007.09.028] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Revised: 07/17/2007] [Accepted: 09/24/2007] [Indexed: 01/27/2023] Open
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20
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Jean-Philippe P, Freedman A, Chang MW, Steinberg SP, Gershon AA, LaRussa PS, Borkowsky W. Severe varicella caused by varicella-vaccine strain in a child with significant T-cell dysfunction. Pediatrics 2007; 120:e1345-9. [PMID: 17974726 DOI: 10.1542/peds.2004-1681] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In March 1995, the US Food and Drug Administration approved a live attenuated varicella vaccine for use in healthy children 12 months to 12 years old. We report here an 18-month-old girl with cell-mediated immunodeficiency who developed a severe vaccine-associated rash and clinical evidence of vaccine-associated pneumonia 1 month after inadvertent receipt of varicella vaccine.
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Affiliation(s)
- Patrick Jean-Philippe
- Department of Pediatrics, New York University School of Medicine, New York, New York, USA.
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21
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Lee PPW, Lee TL, Ho MHK, Wong WHS, Lau YL. Herpes zoster in juvenile-onset systemic lupus erythematosus: incidence, clinical characteristics and risk factors. Pediatr Infect Dis J 2006; 25:728-32. [PMID: 16874173 DOI: 10.1097/01.inf.0000226841.03751.1f] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Herpes zoster (HZ) is common in systemic lupus erythematosus (SLE) patients, but its clinical features and risk factors in juvenile-onset SLE have not been well described before. METHODS A retrospective review of the clinical course and infections in pediatric SLE patients managed in our institution from 1988-2004 was performed. Clinical characteristics and potential risk factors for HZ were analyzed. RESULTS Forty-nine children with SLE were identified. Nineteen episodes of HZ were recorded in 15 patients, and 2 of them had recurrent HZ. The incidence rate was 58.7 episodes/1000 patient-years. No patient had disseminated HZ, postherpetic neuralgia, or cutaneous scarring, and no death was attributed to HZ. Most (63.2%) HZ occurred within 6 months from onset of SLE or disease flare-up. There was no significant difference in age of onset of SLE, gender, disease duration, use of high dose steroid, or other immunosuppressive agents in patients with and without HZ. Patients with HZ were more likely to have prior or concurrent lupus nephritis (86.7%) than those without HZ (58.5%) (P = 0.096). Occurrence of other major infections was also significantly more common in those who had HZ (80.0%) than those without (32.3%) (P = 0.006). CONCLUSIONS Herpes zoster was common in juvenile-onset SLE patients. Most were benign, without systemic dissemination and postherpetic neuralgia. SLE patients with renal involvement and heightened lupus activity were at greater risk of having HZ. Those with HZ were also more likely to have other major infections during their disease course.
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Affiliation(s)
- Pamela P W Lee
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong, China
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22
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Abstract
Viral infection is a recognized and potentially serious complication in children following solid organ transplantation. The risks of viral infection are particularly important for infants who may not have completed standard childhood immunizations at the time of transplantation and are therefore at risk for otherwise preventable infections. The general practice of withholding live virus immunization from transplant recipients has been questioned and several small studies have looked at MMR and/or Varivax administration in children following transplantation. This retrospective study analyzes the response to primary MMR and varicella immunization in selected pediatric liver transplant recipients in the largest such study to date. Nineteen of 26 children (73%) developed serologic immunity for measles following MMR (although 18 required multiple doses). Similarly, varicella immunization resulted in seroconversion in 20 of 31 children (64.5%; seven required multiple doses). Only minor adverse effects reported in the general population were observed. Live virus immunization with MMR and Varivax was safe and immunogenic in this selected population of liver transplant recipients.
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Affiliation(s)
- Saba Khan
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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23
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Malfroot A, Adam G, Ciofu O, Döring G, Knoop C, Lang AB, Van Damme P, Dab I, Bush A. Immunisation in the current management of cystic fibrosis patients. J Cyst Fibros 2005; 4:77-87. [PMID: 15978534 DOI: 10.1016/j.jcf.2004.10.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2004] [Accepted: 10/29/2004] [Indexed: 11/29/2022]
Abstract
Although no special recommendations exist, clearly patients with cystic fibrosis (CF) can benefit from immunisation. We reviewed the literature regarding vaccination in CF and other chronic diseases. CF subjects should follow national immunisation programmes without delay to obtain optimal vaccination coverage. Indeed they may escape normal programmes due to frequent hospital admissions and school absenteeism and may be more at risk to get "vaccine-controlled" diseases at any age. There is no uniform European immunisation schedule for basic infant and childhood vaccines or for vaccines against hepatitis A (HAV) and B (HBV), varicella (VZ) and booster vaccinations. HAV and HBV vaccination is appropriate in CF as recommended in general for patients with chronic liver disease (CLD). Varicella (VZ) vaccination is not recommended in all European countries. There are no recent data about possible worsening of pulmonary status following VZ in CF, but it is known to cause pulmonary damage in non-CF adults and to be potentially fatal post transplantation and during steroid treatment. Therefore it is recommended at least for seronegative adolescents and transplant candidates. Influenza vaccine is recommended annually for CF patients aged > or =6 months. Pneumococcal vaccine is generally indicated for CF patients. RSV infection might play a role in the initial Pseudomonas colonization and the decline in pulmonary function. However no RSV vaccine is available at present. There are no recommendations for palivizumab in CF as an alternative but expensive prophylaxis. Anti-bacterial vaccinations protecting directly against Pseudomonas aeruginosa colonisation are promising for the future, potential candidates are currently being assessed in phase III clinical trials. More studies are needed to complete recommendations especially for CF adults and transplant candidates.
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Affiliation(s)
- Anne Malfroot
- Department of Paediatrics, Paediatric Respiratory Medicine, Infectious Diseases and Cystic Fibrosis Clinic, Academisch Ziekenhuis-Vrije Universiteit Brussel (AZ-VUB), Laarbeeklaan 101, B-1090 Brussels, Belgium.
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24
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Sartori AMC. A review of the varicella vaccine in immunocompromised individuals. Int J Infect Dis 2004; 8:259-70. [PMID: 15325594 DOI: 10.1016/j.ijid.2003.09.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2003] [Accepted: 09/18/2003] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Individuals with underlying cell-mediated immunodeficiency disorders are at high risk of developing severe, life-threatening illness associated with varicella-zoster virus infection. A live-attenuated varicella vaccine is recommended for routine childhood immunisation in some countries. In healthy children, the vaccine is efficacious and safe but because immunocompromised individuals may be unable to limit replication of live-attenuated vaccine viruses, the varicella vaccine is not recommended for them and there are few exceptions. OBJECTIVES The purpose of this paper is to review the published studies addressing the use of the varicella vaccine in people with cell-mediated immunodeficiency disorders. METHODS A computerised search on the PubMed database was used to collect the relevant papers published up to March 2003. RESULTS The varicella vaccine has been extensively studied in susceptible children with acute lymphoblastic leukaemia in remission, but studies involving individuals with other immunodeficiency disorders are scarce. Some of the current recommendations are based on very few and small studies with short follow-up. Immunocompromised individuals should be given the varicella vaccine only with complete knowledge of their clinical and immunological conditions and after considering the risks of natural infection and vaccination.
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Affiliation(s)
- Ana Marli Christovam Sartori
- Clinic of Infectious and Parasitic Diseases, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, SP, Brazil.
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25
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Avitzur Y, De Luca E, Cantos M, Jimenez-Rivera C, Jones N, Fecteau A, Grant D, Ng VL. Health Status Ten Years After Pediatric Liver Transplantation—Looking Beyond The Graft. Transplantation 2004; 78:566-73. [PMID: 15446316 DOI: 10.1097/01.tp.0000131663.87106.1a] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little is known about long-term health after pediatric orthotopic liver transplantation (OLT). This study aimed to characterize the health status of recipients 10 years after OLT, with an emphasis on transplant-related morbidity and quality of life. METHODS We performed a retrospective database review of 32 children who underwent OLT before October 1992 at one center and were alive after 10 years. Outcome measures were assessed 10 years after OLT. Cantril's self-anchoring scale was used for global quality of life assessment. RESULTS Synthetic liver function at 10 years was preserved in all patients. The annual rate of episodes of acute rejection dropped markedly after the first year (1.4 at year 1 to 0.19 rejections/patient/year at year 10). Histologically confirmed chronic rejection developed in eight (25%) patients. At 10 years, long-term complications included mild to severe chronic renal failure (77%), mild chronic anemia (59%), and hypertension (25%). Significant growth retardation (z-score < -2), hyperlipidemia, and diabetes were uncommon. Infection requiring hospitalization occurred in 81% of the patients, with varicella zoster virus as the most common pathogen. Epstein-Barr virus-related malignancies affected 22% of patients. Ten-year survivors perceived quality of life as very good. Self-reporting of drug nonadherence by seven (22%) adolescents may have contributed to development of late onset rejection in this subgroup. Conclusions. Children who are 10-year survivors of OLT have excellent graft function and, despite chronic extrahepatic morbidities, a self-reported high quality of life.
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Affiliation(s)
- Yaron Avitzur
- Paediatric Academic Multi-Organ Transplantation (PAMOT) Program, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Iglesias Berengue J, López Espinosa J, Campins Martí M, Ortega López J, Moraga Llop F. [Vaccinations and solid-organ transplantation: review and recommendations]. An Pediatr (Barc) 2003; 58:364-75. [PMID: 12681186 DOI: 10.1016/s1695-4033(03)78071-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Pediatric solid-organ transplant recipients are at high risk for various infectious diseases. Many children are not fully vaccinated before transplantation. To reduce the risk of morbidity and mortality from vaccine-preventable disease, physicians treating pediatric solid-organ transplant recipients should monitor the immunization status of these patients. Consensus on the most appropriate immunization schedule for solid-organ transplant recipients is lacking. Therefore, we provide a review of the currently available data on immunization safety and efficacy and describe strategies to avoid vaccine-preventable diseases in pediatric solid-organ transplant recipients.
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Affiliation(s)
- J Iglesias Berengue
- Equipo de Trasplante Hepático Pediátrico. Hospital Universitario Vall d'Hebron. Barcelona. España.
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27
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Phillips SKJ. Pediatric Liver Transplantation. Prog Transplant 2002. [DOI: 10.1177/152692480201200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pediatric liver transplantation is a fast-growing and challenging field. Healthcare providers must stay informed of advancements in the management of liver transplant candidates and recipients. The goal of this paper is to provide nurses who care for pediatric liver transplant candidates and recipients with a review of the basic medical management of these patients, from the preoperative evaluation to postoperative care.
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