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Srivastava A, Bodnar J, Osman F, Jorgenson MR, Astor BC, Mandelbrot DA, Parajuli S. Serum Albumin Level Before Kidney Transplant Predicts Post-transplant BK and Possibly Cytomegalovirus Infection. Kidney Int Rep 2020; 5:2228-2237. [PMID: 33305116 PMCID: PMC7710825 DOI: 10.1016/j.ekir.2020.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Opportunistic viral infections cause extensive morbidity and mortality in kidney transplant recipients (KTRs). Low serum albumin levels before and after transplant have been associated with negative outcomes. However, it is uncertain whether serum albumin levels before transplantation are associated with the risk for post-transplantation opportunistic BK polyomavirus (BKV) or cytomegalovirus (CMV). Methods We reviewed all KTRs transplanted at our institution between 1 January 2005 and 31 December 2015 with serum albumin measured within 45 days before transplantation in a retrospective observational cohort study. Selected patients were stratified into 3 groups: normal albuminemia (≥3.5 g/dl), moderate hypoalbuminemia (3.49–2.5 g/dl), and severe hypoalbuminemia (<2.5 g/dl). Patients were observed for post-transplantation BKV or CMV according to standard of care. Results We included 1717 patients in this study; 72.3% had normal serum albumin, 26.3% had moderate hypoalbuminemia, and 1.5% had severe hypoalbuminemia. Moderate and severe hypoalbuminemia incurred a higher risk for BKV compared with normal serum albumin levels in univariable analysis (moderate hypoalbuminemia: hazard ratio [HR] = 1.5; 95% confidence interval [CI], 1.14–1.90; P = .003); severe hypoalbuminemia: HR = 2.15; 95% CI, 1.01–4.56; P = 0.05). Although not significant after multivariable adjustment, there was still 18% increased risk in moderate hypoalbuminemia and 64% in severe hypoalbuminemia for BKV compared with the normal albumin group. Moderate hypoalbuminemia was associated with a higher risk for CMV infection than normal serum albumin levels in multivariable analysis, although it was not statistically significant (HR = 1.15; 95% CI, 0.36–3.64; P = 0.81). Conclusions These findings suggest that pretransplantation hypoalbuminemia is associated with a higher risk for post-transplantation BKV and possibly CMV. More intense screening is warranted for these viruses in recipients with pretransplant hypoalbuminemia.
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Affiliation(s)
- Aniruddha Srivastava
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Joshua Bodnar
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Fauzia Osman
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Department of Population Health Sciences Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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de Campos Dieamant D, Bonon SHA, Prates LC, Belangelo VMS, Pontes ER, Costa SCB. Active human cytomegalovirus infection and glycoprotein b genotypes in brazilian pediatric renal or hematopoietic stem cell transplantation patients. Braz J Microbiol 2010; 41:50-8. [PMID: 24031463 PMCID: PMC3768614 DOI: 10.1590/s1517-838220100001000010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Accepted: 04/09/2009] [Indexed: 11/21/2022] Open
Abstract
A prospective analysis of active Human Cytomegalovirus infection (HCMV) was conducted on 33 pediatric renal or hematopoietic stem cell post-transplant patients. The HCMV-DNA positive samples were evaluated for the prevalence of different gB subtypes and their subsequent correlation with clinical signs. The surveillance of HCMV active infection was based on the monitoring of antigenemia (AGM) and on a nested polymerase chain reaction (N-PCR) for the detection of HCMV in the patients studied. Using restriction analysis of the gB gene sequence by PCR-RFLP (Restriction Fragment Length Polymorphism), different HCMV strains could be detected and classified in at least four HCMV genotypes. Thirty-three pediatric recipients of renal or bone marrow transplantation were monitored. Twenty out of thirty-three (60.6%) patients demonstrated active HCMV infection. gB1 and gB2 genotypes were more frequent in this population. In this study, we observed that gB2 had correlation with reactivation of HCMV infection and that patients with mixture of genotypes did not show any symptoms of HCMV disease. Future studies has been made to confirm this.
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Affiliation(s)
- Débora de Campos Dieamant
- Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas , Campinas, SP , Brasil
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Management of CMV, HHV-6, HHV-7 and Kaposi-sarcoma herpesvirus (HHV-8) infections in patients with hematological malignancies and after SCT. Bone Marrow Transplant 2008; 42:227-40. [PMID: 18587440 DOI: 10.1038/bmt.2008.162] [Citation(s) in RCA: 238] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
These recommendations were prepared by the European Conference on Infections in Leukaemia following a predefined methodology. Literature searches were made to identify studies pertinent to management of CMV, HHV-6, -7 and -8 infections. For CMV, 76 studies were reviewed: 72 published and 4 presented as abstracts. Twenty-nine of these studies were prospective randomized trials. For the other herpesviruses, HHV-6, -7 and -8, no randomized controlled trial has been performed, although data from some studies with other primary endpoints have been used to assess the management of HHV-6 infection. Works presented only as abstracts were used to a very limited extent. The quality of evidence and level of recommendation were graded according to the Center for Disease Control (CDC) criteria.
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Ayala E, Greene J, Sandin R, Perkins J, Field T, Tate C, Fields KK, Goldstein S. Valganciclovir is safe and effective as pre-emptive therapy for CMV infection in allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2006; 37:851-6. [PMID: 16532016 DOI: 10.1038/sj.bmt.1705341] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Despite significant advances in prevention and therapy, cytomegalovirus (CMV) infection continues to be an important cause of morbidity and mortality in the hematopoietic stem cell transplant (HSCT) recipient. The standard drug for pre-emptive therapy is intravenous ganciclovir (GCV). Valganciclovir (VGC), the oral pro-drug of GCV, has excellent bioavailability and is ideal for oral therapy. Since March 2002, VGC was adopted in our center for outpatient pre-emptive therapy in all patients undergoing allogeneic HSCT. Fifty-two allogeneic HSCT recipients were followed weekly via Digene hybrid capture assay. Patients with a positive assay were treated with VGC 900 mg p.o. b.i.d. x 14 days followed by 900 mg p.o. QD until at least 7 days after a negative test. Eighteen patients (14 sib, four MUD) had 30 episodes of CMV DNA detection treated with oral VGC. Median duration of therapy was 21 days (range 10-21 days). The rate of response was 93% (28/30) as confirmed by a negative assay within 14 days. No significant toxicity was encountered. Two patients failed oral VGC. One case of CMV enteritis was diagnosed in a patient with acute GVHD. Pre-emptive therapy of CMV infection with oral VGC is safe and effective in allogeneic HSCT recipients.
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Affiliation(s)
- E Ayala
- H Lee Moffitt Cancer Center, Tampa, FL, USA.
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Lengerke C, Ljubicic T, Meisner C, Loeffler J, Sinzger C, Einsele H, Hebart H. Evaluation of the COBAS Amplicor HCMV Monitor for early detection and monitoring of human cytomegalovirus infection after allogeneic stem cell transplantation. Bone Marrow Transplant 2006; 38:53-60. [PMID: 16788683 DOI: 10.1038/sj.bmt.1705408] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Early diagnosis of human cytomegalovirus (HCMV) infection and the introduction of preemptive antiviral therapy have reduced HCMV-related mortality after allogeneic stem cell transplantation. A critical goal remains stratifying risk profiles and minimizing potential harm owing to antiviral overtreatment. We compared the commercially available standardized COBAS Amplicor CMV Monitor (CACM) to an in-house PCR assay, for the monitoring of HCMV infection. Seventy-two patients were surveyed by an in-house PCR of whole blood, quantitative viral load assessment by CACM and virus culture assays in a prospective and a retrospective study. A high concordance between CACM and PCR was documented. The viral load at onset correlated with the peak viral load (Spearman rank correlation R=0.634, P=0.0004). In patients developing HCMV disease, both viral loads were in trend higher (P=0.823, respectively P=0.053), and the viremic episodes longer (P=0.015), as compared to asymptomatically HCMV-infected patients. The serological pre-transplant status was the major risk factor for the development of HCMV disease, showing highest risk for seropositive patients receiving a seronegative graft, whereas donor type (related or unrelated) and graft type (bone marrow or peripheral blood mobilized stem cells) did not have an influence. HCMV infection proved to be a risk factor for the development of non-viral opportunistic infections (P=0.002).
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Affiliation(s)
- C Lengerke
- Department of Hematology/Oncology, University of Tübingen Medical Center, Tübingen, Germany
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Zaucha-Prazmo A, Wójcik B, Drabko K, Choma M, Kowalczyk JR. Cytomegalovirus (CMV) infections in children undergoing hematopoetic stem cell transplantation. Pediatr Hematol Oncol 2005; 22:271-6. [PMID: 16020113 DOI: 10.1080/08880010590935158] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cytomegalovirus (CMV) is one of the major causes of morbidity and mortality after hematopoetic stem cell transplantations (HSCT). The purpose of the study was to analyze risk factors of CMV disease in children undergoing HSCT. A total of 110 children who undergone hematopoetic stem cells transplantation were analyzed. In 16 patients (14.5%) CMV antigenemia in white blood cells was diagnosed. Most patients with CMV infection had undergone alloHSCT; one patient had undergone autologous transplantation. Second CMV reactivation in 4 of 16 patients was observed. Acute GvHD occurred in 11/15 patients. Early onset of CMV infection in 13/16 patients and late onset in 3/16 patients were diagnosed. CMV serological status of the donor and recipient before transplantation in children with CMV antigenemia was analyzed. The risk factors of CMV infection in analyzed group of children were type of transplant, recipient seropositivity before transplantation, and presence and intensity of GvHD. In most cases reactivation of CMV infection was diagnosed. CMV infection can also occur in the late post-transplantation period. CMV reactivation can occur in patients after autologous HSCT.
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Bonon SHA, Menoni SMF, Rossi CL, De Souza CA, Vigorito AC, Costa DB, Costa SCB. Surveillance of cytomegalovirus infection in haematopoietic stem cell transplantation patients. J Infect 2005; 50:130-7. [PMID: 15667914 DOI: 10.1016/j.jinf.2003.11.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2003] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to describe our experience in the control of active CMV infection following HSCT using two strategies of CMV infection treatment: ganciclovir universal prophylaxis at low doses and pre-emptive therapy with ganciclovir. METHODS The surveillance was based on the monitoring of antigenaemia (AGM) and on a nested polymerase chain reaction (N-PCR) for the detection of CMV in both strategies. Forty-five recipients with malignant diseases and with a risk for CMV disease received universal prophylaxis (Group A). The non-treated group consisted of 24 patients, most of them with non-malignant diseases who did not receive universal prophylaxis (Group B). RESULTS In Group A, the incidence of positive AGM was 51%, with a positive PCR of 68.9%. In Group B, the AGM positivity was 66.7% and that of N-PCR was 66.7%. CMV disease occurred in 6/55 patients (10.9%), with 2/36 (5.5%) from Group A and 4/19 (21%) from Group B. Two of these six patients (33.3%) died of CMV disease. CONCLUSIONS Our result suggests that AGM and N-PCR can be used as markers for assessing the monitoring and the introduction pre-emptive therapy. This approach could prove to be more cost-effective than ganciclovir universal prophylaxis for treating CMV infection.
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Affiliation(s)
- Sandra H A Bonon
- Department of Internal Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP), CP 6111, CEP 13081-970, Campinas, São Paulo, Brazil
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Fraser GAM, Walker II. Cytomegalovirus prophylaxis and treatment after hematopoietic stem cell transplantation in Canada: a description of current practices and comparison with Centers for Disease Control/Infectious Diseases Society of America/American Society for Blood and Marrow Transplantation guideline recommendations. Biol Blood Marrow Transplant 2005; 10:287-97. [PMID: 15111928 DOI: 10.1016/j.bbmt.2003.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Prevention and management of cytomegalovirus (CMV) disease after hematopoietic stem cell transplantation (HSCT) is critically important, but clinical practices have historically been heterogeneous. The Centers for Disease Control (CDC), as part of a larger clinical practice guideline initiative, has published evidence-based recommendations, but their effect on clinical practice has not been assessed. A survey was sent to all Canadian HSCT program directors to describe current practices. Current practices were subsequently compared with CDC guideline recommendations and with a Canadian survey published before the CDC guidelines. When current practices did not conform to guideline recommendations, a literature review was performed to determine whether current practices were supported by evidence published after the CDC guidelines. The survey response rate was 100%. Variability in practices was observed in several aspects of patient care, including (1) indications for CMV-negative blood products, (2) surveillance tests used to detect CMV infection, (3) duration of surveillance testing, (4) duration of maintenance treatment after preemptive therapy was initiated, and (5) treatment of CMV disease. Overall adherence to guideline recommendations was good, especially when they were supported by high-quality data. However, deviations from guideline recommendations were observed: (1) most Canadian allogeneic programs used shorter courses of preemptive therapy; (2) prevention measures aimed at late CMV disease were not systematically applied at most allogeneic programs; and (3) most autologous HSCT programs did not administer preemptive therapy even in high-risk recipients. When deviations occurred, recent evidence supported current practices in some instances (shorter courses of preemptive therapy) but not in others (absence of strategies to prevent late CMV disease). Compared with practices in Canada before publication of the CDC guidelines, a higher proportion of programs used CDC-recommended surveillance tests and treatment for CMV infection. Current practices in Canada remain heterogeneous. Discrepancies between current practices and CDC guideline recommendations occurred in situations either in which practices had changed in response to recently published data or in which evidence supporting a recommendation was poor. These results suggest an urgent need for the development of well-designed clinical trials. Incorporation of recent data into updated guidelines may be appropriate.
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Affiliation(s)
- Graeme A m Fraser
- Mc Master University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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Ljungman P, Reusser P, de la Camara R, Einsele H, Engelhard D, Ribaud P, Ward K. Management of CMV infections: recommendations from the infectious diseases working party of the EBMT. Bone Marrow Transplant 2004; 33:1075-81. [PMID: 15077131 DOI: 10.1038/sj.bmt.1704505] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- P Ljungman
- Department of Haematology, Huddinge University Hospital, Stockholm, Sweden.
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Zaia JA. Prevention of cytomegalovirus disease in hematopoietic stem cell transplantation. Clin Infect Dis 2002; 35:999-1004. [PMID: 12355388 DOI: 10.1086/342883] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2002] [Revised: 05/22/2002] [Indexed: 11/03/2022] Open
Abstract
Prevention of cytomegalovirus (CMV) infection after hematopoietic stem cell transplantation (HSCT) generally involves preemptive treatment of recognized infection before the onset of overt CMV-associated disease. The success of this method depends on efficient recognition of infection and intervention before the disease progresses. Reliable tests for such diagnosis include blood culture, antigenemia assays, polymerase chain reaction assays, and other DNA sequence- or RNA sequence-based assays. For selected high-risk patients, such as patients receiving T cell-depleted hematopoietic stem cell transplants, prophylactic use of antiviral agents before the onset of CMV infection is recommended. The ability to monitor the immunological status of the patient relative to CMV-specific immunity is increasing in importance. Ultimately, the solution to the problem of efficient prevention of CMV infection in this population will require combined antiviral chemotherapy and improved reconstitution of CMV immunity.
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Affiliation(s)
- John A Zaia
- Division of Virology, Beckman Research Institute of the City of Hope, Duarte, CA 91010, USA.
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Affiliation(s)
- Per Ljungman
- Department of Haematology, Huddinge University Hospital, Karolinska Institutet, Stockholm, Sweden.
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Zaia JA. Prevention and management of CMV-related problems after hematopoietic stem cell transplantation. Bone Marrow Transplant 2002; 29:633-8. [PMID: 12180106 DOI: 10.1038/sj.bmt.1703407] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prevention and management of human cytomegalovirus (CMV) infection after hematopoietic stem cell transplantation has improved substantially in the past decade. However, with this improvement, there is increased complexity in deciding which diagnostic tests, treatment strategies and immunologic assessments are optimal for different patient populations. The purpose of this review is to address certain practical problems that commonly arise and suggest a suitable approach to management that should have wide applicability.
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Affiliation(s)
- J A Zaia
- Division of Virology, Beckman Research Institute of City of Hope, 1500 Duarte Road, Duarte, CA 91010, USA
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