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Heald-Sargent T, Michaels MG, Ardura MI. Pre-Transplantation Strategies for Infectious Disease Mitigation and Prevention. J Pediatric Infect Dis Soc 2024; 13:S3-S13. [PMID: 38417081 DOI: 10.1093/jpids/piad075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/22/2023] [Indexed: 03/01/2024]
Abstract
Pediatric Infectious Disease (ID) clinicians play a critical role in helping prevent and mitigate infectious risks in children peri- and post-transplantation. Prevention starts during the pre-transplant evaluation and persists throughout the solid organ transplant and hematopoietic cell transplant continuum. The pre-transplant evaluation is an opportunity to screen for latent infections, plan preventative strategies, optimize immunizations, and discuss risk mitigation practices. An ideal pre-transplant evaluation establishes a relationship with the family that further promotes post-transplant infectious risk reduction. This manuscript builds on shared pediatric ID prevention strategies, introduces updated ID testing recommendations for transplant donors/candidates, highlights emerging data, and identifies ongoing knowledge gaps that are potential areas of research.
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Affiliation(s)
- Taylor Heald-Sargent
- Department of Pediatrics, Division of Infectious Diseases, Northwestern University, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Marian G Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Monica I Ardura
- Division of Pediatric Infectious Diseases & Host Defense Program, Nationwide Children's Hospital and Department of Pediatrics, The Ohio University College of Medicine, Columbus, Ohio, USA
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2
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Kilduff S, Steinman B, Hayde N. Changes in graft outcomes in recipients <10 kg over 25 years of pediatric kidney transplantation in the United States. Pediatr Transplant 2024; 28:e14679. [PMID: 38149338 PMCID: PMC10872313 DOI: 10.1111/petr.14679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/13/2023] [Accepted: 12/05/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Kidney transplant (KT) was initially associated with poor outcomes, especially in smaller recipients. However, pediatric transplantation has evolved considerably over time. We investigated the impact of weight at the time of transplant and whether outcomes changed over 25 years for <10 kg recipients. METHODS Using the UNOS database, pediatric recipient outcomes were analyzed between 1/1/99 and 12/31/14. KT weight was stratified: <8.6 kg (mean weight of recipients <10 kg), 8.6-9.9 kg, 10-14.9 kg, 15-29.9 kg, and ≥30 kg. Outcomes in recipients <10 kg were then compared between 1990-1999 and 2000-2014. RESULTS 17 314 pediatric KT recipients were included; 518 (3%) had a transplant weight <10 kg. The highest rates of allograft loss and death were in recipients <8.6 kg and ≥30 kg. Recipients <8.6 kg also had higher rates of delayed graft function, rejection, and longer hospital length of stay. In the multivariable Cox regression model, transplant weight was not a predictor of allograft loss. When compared with recipients <8.6 kg, patient survival hazard ratios associated with recipient weight of 10-14.9 kg, 15-29.9 kg, and ≥30 kg were 0.61 (95%CI: 0.4, 1), 0.42 (95%CI: 0.3, 0.7) and 0.32 (95%CI: 0.2, 0.6), respectively. In the later era of transplant, recipients <10 kg had improved outcomes on univariate analysis; however, the era of transplantation was not an independent predictor of allograft loss or patient survival in Cox regression models. CONCLUSIONS Outcomes in children weighing 8.6-9.9 kg at the time of KT were similar to higher weight groups and improved over time; however, special precautions should be taken for recipients <8.6 kg at the time of transplant.
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Affiliation(s)
- Stella Kilduff
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Benjamin Steinman
- Robert Wood Johnson Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Nicole Hayde
- The Children's Hospital at Montefiore/Einstein, Bronx, New York, USA
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3
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Squires JE, Raghu VK, Mazariegos GV. Optimizing the pediatric transplant candidate. Curr Opin Organ Transplant 2024; 29:43-49. [PMID: 37823752 DOI: 10.1097/mot.0000000000001115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW Advances in pediatric transplant parallel those in adult populations; however, there remain critical unique considerations and differences that require specialized knowledge and a specific skill set to optimize care afforded to the pediatric transplant candidate. We introduce general themes regarding optimization of the transplant candidate that are unique to children. RECENT FINDINGS The pathologies leading to pediatric organ transplant candidacy differ from adults and a precise understanding of the physiologies and natural histories of such diseases is critical for optimized care. Regardless of etiology, comorbidities including malnutrition, sarcopenia, and developmental delay are seen and often require disease and organ specific approaches to management. Additionally, an understanding of the concepts of developmental immunology and their relevance to transplant is critical. SUMMARY When looking to optimize pretransplant care, awareness of the pediatric-specific challenges by the transplant community in addition to organ- and age-specific management strategies enable the best outcomes for children awaiting solid organ transplantation.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh
| | - Vikram K Raghu
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh
| | - George V Mazariegos
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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4
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Donà D, Bravo-Gallego LY, Remacha EF, Cananzi M, Gastaldi A, Canizalez JT, Stephenne X, Lacaille F, Lindemans C, Calore E, Galea N, Benetti E, Nachbaur E, Sandes AR, Teixeira A, Ferreira S, Klaudel-Dreszler M, Ackermann O, Boyer O, Espinosa L, Guereta LG, Sciveres M, Fischler B, Schwerk N, Neland M, Nicastro E, Dello Strologo L, Toporski J, Vainumae I, Rascon J, Urbonas V, Del Rosal T, López-Granados E, Perilongo G, Baker A, Vega PJ. Vaccination practices in pediatric transplantation: A survey among member centers of the European reference network TransplantChild. Pediatr Transplant 2023; 27:e14589. [PMID: 37543721 DOI: 10.1111/petr.14589] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/24/2023] [Accepted: 07/16/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND There is considerable variation in vaccination practices between pediatric transplant centers. This study aims to evaluate active immunization attitudes and practices among ERN-TransplantChild centers and identify potential areas of improvement that could be addressed by shared evidence-based protocols. METHODS A cross-sectional questionnaire of attitudes and practices toward immunization of pediatric SOT and HSCT candidates and recipients was sent to a representative member of multidisciplinary teams from 27 European centers belonging to the ERN-TransplantChild. RESULTS A total of 28/62 SOT programs and 6/12 HSCT programs across 21 European centers participated. A quarter of centers did not have an on-site protocol for the immunizations. At the time of transplantation, pediatric candidates were fully immunized (80%-100%) in 57% and 33% of the SOT and HSCT programs. Variations in the time between vaccine administration and admission to the waiting list were reported between the centers, with 2 weeks for inactivated vaccines and variable time (2-4 weeks) for live-attenuated vaccines (LAVs). Almost all sites recommended immunization in the post-transplant period, with a time window of 4-8 months for the inactivated vaccines and 16-24 months for MMR and Varicella vaccines. Only five sites administer LAVs after transplantation, with seroconversion evaluated in 80% of cases. CONCLUSIONS The immunization coverage of European pediatric transplant recipients is still inconsistent and far from adequate. This survey is a starting point for developing shared evidence-based immunization protocols for safe vaccination among pediatric transplant centers and generating new research studies.
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Affiliation(s)
- Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Luz Yadira Bravo-Gallego
- Lymphocyte Pathophysiology in Immunodeficiencies Group, La Paz Institute of Biomedical Research (IdiPAZ), Center for Biomedical Network Research on Rare Diseases (CIBERER U767), Madrid, Spain
| | - Esteban Frauca Remacha
- Pediatric Hepatology Department, La Paz University Hospital, Molecular Hepatology Group, La Paz Institute of Biomedical Research (IdiPAZ), Madrid, Spain
| | - Mara Cananzi
- Unit of Paediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Andrea Gastaldi
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
- Department of Pediatrics, Woman and Child Hospital, University of Verona, Verona, Italy
| | - Juan Torres Canizalez
- Lymphocyte Pathophysiology in Immunodeficiencies Group, La Paz Institute of Biomedical Research (IdiPAZ), Center for Biomedical Network Research on Rare Diseases (CIBERER U767), Madrid, Spain
| | - Xavier Stephenne
- Laboratoire d'Hépatologie Pédiatrique et Thérapie Cellulaire, Unité PEDI, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Florence Lacaille
- Service de Gastroentérologie-Hépatologie-Nutrition Pédiatriques, Hôpital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | - Caroline Lindemans
- Princess Maxima Center for Pediatric Oncology, Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elisabetta Calore
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Nathalie Galea
- Paediatric Department of Mater Dei Hospital, Msida, Malta
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, Azienda Ospedaliera di Padova, Padua, Italy
| | - Edith Nachbaur
- Division of Pediatric Pulmonology, Allergology and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ana Rita Sandes
- Unidade de Nefrologia e Transplantação Renal, Serviço de Pediatria Médica, Departamento de Pediatria, Hospital de Santa Maria, Centro Académico de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Teixeira
- Department of Pediatric Nephrology, Pediatric Service, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Porto, Portugal
| | - Sandra Ferreira
- Hepatology and Pediatric Liver Transplantation Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Maja Klaudel-Dreszler
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Oanez Ackermann
- Hepatologie et Transplantation Hepatique Pediatriques, Centre de reference de l'atresie des voies biliaires et des cholestases genetiques, FSMR FILFOIE, ERN RARE LIVER, Hôpital Bicêtre, AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Olivia Boyer
- Service de Néphrologie Pédiatrique, AP-HP, Centre de Référence de maladies rénales rares de l'enfant et de l'adulte (MARHEA), Hôpital Necker-Enfants Malades, Paris, France
- Institut Imagine, Laboratoire des maladies rénales héréditaires, INSERM UMR 1163, Université de Paris, Paris, France
| | - Laura Espinosa
- Pediatric Nephrology Department, La Paz University Hospital, Diagnosis and Treatment of Diseases Associated with Abnormalities of the Complement System Group, La Paz Institute of Biomedical Research (IdiPAZ), Madrid, Spain
| | | | - Marco Sciveres
- Pediatric Hepatology and Liver Transplantation, ISMETT-University of Pittsburgh Medical Center Italy, Palermo, Italy
| | - Björn Fischler
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Nicolaus Schwerk
- Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Mette Neland
- Department of Paediatrics and Adolescence Medicine, Odense University Hospital, Odense, Denmark
| | - Emanuele Nicastro
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Dello Strologo
- Nephrology Unit, Bambino Gesù Children's Research Hospital, IRCCS, Rome, Italy
| | - Jacek Toporski
- Department of Pediatrics, Section of Pediatric Oncology, Hematology, Immunology and Nephrology, Skåne University Hospital, Lund, Sweden
- Center of Allogenic Stem Cell Transplantation and Cellular Therapy, Karolinska University Hospital, Stockholm, Sweden
| | - Inga Vainumae
- Department of Pediatrics, Tartu University Hospital, Tartu, Estonia
| | - Jelena Rascon
- Centre for Paediatric Oncology and Haematology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Vaidotas Urbonas
- Department of Paediatric Gastroenterology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Teresa Del Rosal
- Paediatric Infectious and Tropical Diseases Department, La Paz University Hospital, Translational Research Network in Paediatric Infectious Diseases (RITIP), La Paz Institute of Biomedical Research (IdiPAZ), and Center for Biomedical Network Research on Rare Diseases (CIBERER U767), Madrid, Spain
| | - Eduardo López-Granados
- Lymphocyte Pathophysiology in Immunodeficiencies Group, La Paz Institute of Biomedical Research (IdiPAZ), Center for Biomedical Network Research on Rare Diseases (CIBERER U767), Madrid, Spain
- Clinical Immunology Department, La Paz University Hospital, Madrid, Spain
| | - Giorgio Perilongo
- Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Alastair Baker
- Paediatric Liver, Gastrointestinal and Nutrition Centre, King's College London School of Medicine at King's College Hospital, London, UK
| | - Paloma Jara Vega
- Pediatric Hepatology Department, La Paz University Hospital, Molecular Hepatology Group, La Paz Institute of Biomedical Research (IdiPAZ), ERN TransplantChild Coordinator, Madrid, Spain
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5
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Velagala VR, Velagala NR, Singh A, Kumar T, Thakre S, Lamture Y. Immunological Nuances and Complications of Pediatric Organ Transplant: A Narrative Review. Cureus 2023; 15:e46309. [PMID: 37916238 PMCID: PMC10616683 DOI: 10.7759/cureus.46309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/01/2023] [Indexed: 11/03/2023] Open
Abstract
Organ transplantation is considered an exaggerated immune state in which the body reacts in an elaborate cascade of reactions against the lifesaving graft transplanted. Unrepairable organ damage is the main indication for a pediatric patient to undergo a transplant. The host and the donor must fulfill the criteria for a successful transplant to have as few side effects as possible. There has been much-needed research in the domain of surgery of organ transplantation, thereby extending into the pediatric age group. This article elaborates on the post-transplant management, the immuno-biochemistry aspect, and its post-surgery treatment. The post-surgery period requires great emphasis as morbidity and mortality are highest. There is much to understand about managing transplant patients to avoid complications such as infections, hypertension, or side effects of immunosuppressive drugs. The treating clinician faces the challenges of managing the dose and frequency of immuno-suppressive medicines to prevent complications in the patients. If the dose is inadequate, there are chances of graft rejection. If the immuno-suppression is prolonged, there may be chances of infections in the patient. This article aims to summarize the mechanism of graft rejection and put forth the need for further research about creating a universal protocol for managing a patient's immune system post-transplant. The authors hope this protocol will help the clinician better understand the patient's current state and help in appropriately using immuno-suppressive drugs. It calls upon the need for a reliable and easily repeatable battery of investigations that will help solve this dilemma.
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Affiliation(s)
- Vivek R Velagala
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Namrata R Velagala
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Arihant Singh
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tanishq Kumar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swedaj Thakre
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Yashwant Lamture
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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6
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Liman AYJ, Wozniak LJ, de St Maurice A, Dunkel GL, Wanlass EM, Venick RS, McDiarmid SV. Low post-transplant measles and varicella titers among pediatric liver transplant recipients: A 10-year single-center study. Pediatr Transplant 2022; 26:e14322. [PMID: 35582739 DOI: 10.1111/petr.14322] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/17/2022] [Accepted: 04/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vaccine preventable illnesses are important sources of morbidity, mortality, and increased healthcare costs in pediatric LT recipients. Our aim was to measure the seroprevalence of antibodies to measles and VZV in this population. METHODS We conducted a retrospective chart review of 44 patients who received LT before age 18 at UCLA Mattel Children's Hospital from January 2008 to December 2017. RESULTS Median age at transplantation was 2.5 years (IQR 1.2-7.7). Post-transplant measles antibodies were present in 17 of 37 patients (46%); risk factors for seronegativity included younger age at transplant (p = .02) and greater time from transplant to testing (p = .04). Post-transplant VZV antibodies were present in 17 of 39 patients (44%); risk factors for seronegativity included greater time from transplant to testing (p = .04). 6 of 16 patients (38%) who tested positive for pre-transplant VZV antibodies tested negative after transplantation. Fourteen of 20 patients (70%) with at least 1 documented dose of the MMR vaccine tested positive for post-transplant measles antibodies. Ten of 20 of patients (50%) with at least 1 documented dose of the VZV vaccine tested positive for post-transplant VZV antibodies. We also describe 10 patients who received post-transplant measles and VZV vaccines without documented complications. CONCLUSIONS Our study suggests that pediatric LT patients are at greater risk of contracting measles and VZV despite vaccination status, and that prevalence of measles and VZV antibodies decreases as time from transplantation increases. This should weigh into the institutional risk-benefit assessment when deciding whether or not to administer LAVs to these patients.
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Affiliation(s)
- Andrew Y J Liman
- Department of Pediatrics, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, California, USA
| | - Laura J Wozniak
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, California, USA
| | - Annabelle de St Maurice
- Division of Pediatric Infectious Diseases, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, California, USA
| | - Gregory L Dunkel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, California, USA
| | - Emy M Wanlass
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, California, USA
| | - Robert S Venick
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, California, USA
| | - Sue V McDiarmid
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Mattel Children's Hospital at UCLA Medical Center, Los Angeles, California, USA
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Daly KP, Sharma TS. Experience with Live Attenuated Varicella Vaccination in Pediatric Heart Transplant Recipients: Considering a New Path Forward. J Heart Lung Transplant 2022; 41:1027-1028. [DOI: 10.1016/j.healun.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 10/18/2022] Open
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8
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Newman AM, Posch LC, Gianchetti L, Rand EB, Mohammad S, Downes KJ, Muller WJ. Live virus vaccination following pediatric liver transplantation: Outcomes from two academic children's hospitals. Am J Transplant 2022; 22:1201-1212. [PMID: 34967134 DOI: 10.1111/ajt.16937] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 12/17/2021] [Accepted: 12/23/2021] [Indexed: 01/25/2023]
Abstract
Pediatric liver transplant (LT) recipients are often transplanted at a young age, precluding them from receiving live virus vaccinations (LVV) such as varicella (VZV) vaccine and measles, mumps and rubella. This places them at profound risk for vaccine preventable illness. We sought to detail safety of vaccination. This was a retrospective cohort study of pediatric LT recipients at two children's hospitals. Among 204 LT recipients included in the study, 97 received at least one LVV after LT. Six patients who did not receive LVV after transplant had evidence of vaccine-preventable infection following vaccination (one disseminated VZV disease, five VZV-related rash), while one patient who received LVV after transplant developed a diffuse VZV-related rash. Rejection rates were the same between those that did and did not receive a live virus vaccine post-transplant. There were no serious adverse events caused by vaccination post-transplant. LVV following LT was safe at our two institutions, although there exist limitations in our study due to its retrospective study design. Larger scale studies should be performed to evaluate the effectiveness of LVV in relation to immunosuppression.
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Affiliation(s)
- Alexander M Newman
- Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Leila C Posch
- Division of Infectious Diseases, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Lauren Gianchetti
- Center for Pediatric Clinical Effectiveness (CPCE), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth B Rand
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology, and Nutrition, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kevin J Downes
- Center for Pediatric Clinical Effectiveness (CPCE), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - William J Muller
- Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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9
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Chen JK, Cheng J, Liverman R, Serluco A, Corbo H, Yildirim I. Vaccination in pediatric solid organ transplant: A primer for the immunizing clinician. Clin Transplant 2022; 36:e14577. [PMID: 34997642 DOI: 10.1111/ctr.14577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022]
Abstract
Pediatric solid organ transplant (SOT) recipients are at a uniquely elevated risk for vaccine preventable illness (VPI) secondary to a multitude of factors including incomplete immunization at the time of transplant, inadequate response to vaccines with immunosuppression, waning antibody titers observed post-SOT, and uncertainty among providers on the correct immunization schedule to utilize post-SOT. Multiple guidelines are in existence from the Infectious Diseases Society of America and the American Society of Transplantation, which require use in adjunct with additional published references. We summarize the present state of SOT vaccine recommendations from relevant resources in tandem with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices guidance utilizing both routine and rapid catch-up schedules. The purpose of this all-inclusive review is to provide improved clarity on the most optimal pre- and post-transplant vaccine management within a one-stop-shop for the immunizing clinician. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Justin K Chen
- Department of Pharmacy, NewYork-Presbyterian, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer Cheng
- Department of Pharmacy, NewYork-Presbyterian, Columbia University Irving Medical Center, New York, New York, USA
| | - Rochelle Liverman
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Anastacia Serluco
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Heather Corbo
- Department of Pharmacy, NewYork-Presbyterian, Columbia University Irving Medical Center, New York, New York, USA
| | - Inci Yildirim
- Section of Infectious Diseases and Global Health, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA.,Yale Institute of Global Health, Yale University, New Haven, Connecticut, USA
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10
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Alukal JJ, Naqvi HA, Thuluvath PJ. Vaccination in Chronic Liver Disease: An Update. J Clin Exp Hepatol 2022; 12:937-947. [PMID: 34975241 PMCID: PMC8710401 DOI: 10.1016/j.jceh.2021.12.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/04/2021] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic liver disease (CLD) with or without cirrhosis remain at risk of developing hepatic decompensation when infected with viral or bacterial pathogens. The Advisory Committee on Immunization Practices (ACIP) currently recommends vaccination in CLD against hepatitis A virus (HAV), hepatitis B virus (HBV), influenza, pneumococcus, herpes zoster, tetanus, diphtheria, pertussis, and SARS-CoV-2. Inactivated vaccines are preferred over live attenuated ones, especially in transplant recipients where live vaccines are contraindicated. As the severity of the liver disease progresses, vaccine efficacy declines, and therefore, vaccines should be ideally administered early in the disease course for optimal immune response. Despite the strong recommendations, overall vaccination coverage in CLD remains poor; however, it is encouraging to note that in recent years coverage against influenza and pneumococcus has shown some improvement. Inadequate access to healthcare, lack of information on vaccine safety, poor financial reimbursement for healthcare providers, and vaccine misinformation are often responsible for low immunization rates. This review summarizes the impact of vaccine-preventable illness in those with CLD, updated vaccine guidelines, seroconversion rates in the vaccinated, and barriers faced by healthcare professionals in immunizing those with liver disease.
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Key Words
- ACIP, Advisory Committee on Immunization Practices
- ACLF, acute on chronic liver failure
- ALD, alcohol-related liver disease
- CLD, Chronic liver disease
- CLIF-C, Chronic Liver Failure Consortium
- DAA, direct-acting antiviral drugs
- HAV, hepatitis A virus
- HBV, hepatitis B virus
- HCV, hepatitis C virus
- LT, liver transplant
- NAFLD, nonalcoholic fatty liver disease
- SARS-CoV-2
- SOFA, sequential organ failure assessment
- chronic liver disease
- immunization
- vaccines
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Affiliation(s)
- Joseph J. Alukal
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore MD, USA
| | | | - Paul J. Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore MD, USA
- Address for correspondence: Paul J. Thuluvath, MD., FRCP, Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore MD, USA.
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Gumm AJ, Lerret S, Zeman M, Rueter J, Huppler AR, Khan Z, Telega G, Vitola B. Quality improvement project to improve vaccinations in the pediatric liver transplant population. Pediatr Transplant 2021; 25:e14076. [PMID: 34185930 DOI: 10.1111/petr.14076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 04/07/2021] [Accepted: 06/12/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES A quality improvement approach was used to increase pediatric liver transplant recipient live and inactive vaccination rates by assessing titers and recommending vaccinations. METHODS A new screening and immunization process for both live and inactive vaccines was discussed with families at their annual visit. Antibody titers for varicella, measles, mumps, rubella, Haemophilus influenzae type B, hepatitis A, and hepatitis B were obtained. Specific criteria were developed for live virus vaccination candidacy. Vaccines were recommended based on patient titers and vaccination candidacy criteria. Surveillance for adverse effects to live vaccines was performed. Repeat titers were obtained approximately 1-month post-vaccine administration. RESULTS After PDSA cycle 1, 99% (71/72) of pediatric liver transplant patients had titers obtained. Live vaccines were recommended for 32 patients and 16 (50%) were vaccinated. Inactive vaccines were recommended to 64 patients, and 31 (48%) were vaccinated. Eight of 13 (62%) patients with follow-up titers achieved immunity for inactive vaccines. Zero patients had an adverse reaction to any live vaccine. Ten of 12 (83%) patients with follow-up titers achieved immunity from live vaccines. The most common barriers to receive live vaccines included not scheduling appointment with primary care provider (n = 3) and "non-vaccinators" (n = 3). CONCLUSIONS Administering live and inactive vaccines to select pediatric liver transplant patients appears to be safe and effective in our studied population. For PDSA cycle 2, we will continue our current practice and consider offering vaccines in transplant clinic, since this was a barrier to vaccination identified during PDSA cycle 1.
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Affiliation(s)
- Alexis J Gumm
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Stacee Lerret
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew Zeman
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Janelle Rueter
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anna R Huppler
- Divisions of Pediatric Infectious Disease, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zahida Khan
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Grzegorz Telega
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bernadette Vitola
- Divisions of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
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Hayes EA, Hart SA, Gowda C, Nandi D. Hospitalizations for Respiratory Syncytial Virus and Vaccine Preventable Infections following Pediatric Heart Transplantation. J Pediatr 2021; 236:101-107.e3. [PMID: 34000283 DOI: 10.1016/j.jpeds.2021.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/03/2021] [Accepted: 05/10/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the risk factors for acquiring a respiratory syncytial virus (RSV) and vaccine-preventable infections (R/VPI) in pediatric heart transplant recipients and the associated morbidity and hospital resource use. STUDY DESIGN Patients <18 years who underwent heart transplantation from September 2003 to December 2018 at hospitals using the Pediatric Health Information System database were identified. Their transplant hospitalization and subsequent hospitalizations for R/VPI through December 2018 were analyzed. Risk factors for R/VPI hospitalizations were evaluated using negative regression binomial models adjusted for demographic and clinical confounders. Total hospital costs were adjusted for 2018 US$. RESULTS Of 3815 transplant recipients, 681 (17.9%) had an R/VPI hospitalization during 23 746 available person-years of follow-up. There were 984 R/VPIs diagnosed during 951 hospitalizations, and 440 (44.7%) occurred the first year after transplantation. The most common causes were RSV (n = 380; 38.6%), influenza (n = 265; 26.9%), and pneumococcus (n = 105; 10.7%). In adjusted analyses, there was an increased risk of R/VPI hospitalization in patients requiring mechanical circulatory support before transplantation, patients receiving induction with ≥2 immunosuppressive agents, and patients <2 years in the first year after transplantation. The median length of stay for an R/VPI hospitalization was 4 days (IQR, 2-8 days) with a median total cost of $11 081 (IQR, $6215-$24 322). CONCLUSIONS Hospitalization for R/VPIs occurred frequently after heart transplantation and were associated with significant costs. Potential strategies to minimize R/VPI include expanding vaccine use through accelerated immunization schedules, further studies of use of palivizumab beyond 2 years of age, and immunogenicity monitoring after vaccination with re-immunization based on guidelines.
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Affiliation(s)
- Emily A Hayes
- The Heart Center, Nationwide Children's Hospital, Columbus, OH.
| | - Stephen A Hart
- The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Charitha Gowda
- Department of Infectious Diseases, Nationwide Children's Hospital, Columbus, OH
| | - Deipanjan Nandi
- The Heart Center, Nationwide Children's Hospital, Columbus, OH
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Rosenthal A, Madigan T, Chen SF, Gans H, Nadimpalli S. Live virus vaccination of pediatric solid organ transplant candidates within 1 month prior to transplantation: A multicenter experience. Transpl Infect Dis 2021; 23:e13667. [PMID: 34145665 DOI: 10.1111/tid.13667] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/20/2021] [Accepted: 05/27/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients are at increased risk of vaccine-preventable illness due to the high degree of immunosuppression required following transplantation. The current recommendation is to vaccinate with live attenuated vaccines, including Measles, Mumps, and Rubella (MMR) and Varicella (VAR) vaccines, at least 4 weeks prior to transplant. However, data to support the time interval between vaccine and transplant are limited. METHODS We conduct a literature review of the natural history of the viruses and length of viremia following live-attenuated viral vaccines, and we describe a series of 5 cases from 2 pediatric transplant centers in which live attenuated viral vaccines were administered within 21 days prior to SOT. RESULTS None of the 5 children who received MMR or VAR 8-21 days prior to liver (2) and heart (3) transplant suffered from vaccine-related viral illness after transplant, even in the presence of significant immunosuppression with T-cell-depleting agents. CONCLUSION These cases support that shorter intervals of live vaccine administration prior to transplant may be safe, allowing the vaccination of a larger cohort of SOT candidates. Increasing pretransplant vaccinations is crucial since, in most cases, live viral vaccines are contraindicated posttransplantation, and the most effective vaccine approaches utilize prime-boost strategies, priming before and boosting after transplant.
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Affiliation(s)
- Ayelet Rosenthal
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Theresa Madigan
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sharon F Chen
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Hayley Gans
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Sruti Nadimpalli
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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Vaccination of immune compromised children-an overview for physicians. Eur J Pediatr 2021; 180:2035-2047. [PMID: 33665677 PMCID: PMC8195953 DOI: 10.1007/s00431-021-03997-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 01/19/2023]
Abstract
Immune compromised children are threatened by a higher risk of infections; some of these are preventable by vaccination. Primary care physicians play a fundamental role in optimising vaccination status. In this narrative review, we present the evidence on vaccine safety and immunogenicity in immune compromised children and discuss in which conditions live-attenuated vaccines can possibly be used. Vaccination schedules differ in some of these conditions, including the use of vaccines with higher antigenic contents (e.g. high-dose hepatitis B vaccine), additional vaccine doses (e.g. 2-dose schedule meningococcal vaccine), more frequent booster doses (e.g. life-long pneumococcal vaccine booster), supplementary vaccines (e.g. meningococcal B vaccine) and use of vaccines beyond the age of usual recommendation (e.g. Haemophilus influenza type b vaccine after 5 years of age). Serological monitoring is a useful tool for customizing vaccination schedule in immune compromised children, confirming adequate vaccine response and documenting seroprotection (especially against measles and varicella). Finally, verification of vaccination status of all household members can prevent them being vector of transmission of an infection to the immune compromised children. Conclusion: Intensified information strategies are needed to improve trust, rectify perceived risks and improve vaccine acceptability; primary physicians can play a critical role in the latter. What is Known: • Physician's awareness is key to success, since it repeatedly correlates with higher vaccination rates What is New: • The vaccination status of immunocompromised children is rarely up-to-date • Knowing the latest vaccine recommendations is challenging, as they differ for each medical condition and change periodically • This review summarises the vaccine recommendations for children with compromised immune systems and highlights how paediatricians play a key role in coordinating their application.
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