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Hammer N, Hoessly L, Haidar F, Hirzel C, de Seigneux S, van Delden C, Vogt B, Sidler D, Neofytos D. Pitfalls in Valganciclovir Prophylaxis Dose Adjustment Based on Renal Function in Kidney Transplant Recipients. Transpl Int 2024; 37:12712. [PMID: 38784442 PMCID: PMC11112565 DOI: 10.3389/ti.2024.12712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/09/2024] [Indexed: 05/25/2024]
Abstract
Valganciclovir (VGC) is administered as prophylaxis to kidney transplant recipients (KTR) CMV donor (D)+/recipient (R)- and CMV R+ after thymoglobulin-induction (R+/TG). Although VGC dose adjustments based on renal function are recommended, there is paucity of real-life data on VGC dosing and associations with clinical outcomes. This is a retrospective Swiss Transplant Cohort Study-embedded observational study, including all adult D+/R- and R+/TG KTR between 2010 and 2020, who received prophylaxis with VGC. The primary objective was to describe the proportion of inappropriately (under- or over-) dosed VGC week-entries. Secondary objectives included breakthrough clinically significant CMV infection (csCMVi) and potential associations between breakthrough-csCMVi and cytopenias with VGC dosing. Among 178 KTR, 131 (73.6%) patients had ≥2 week-entries for the longitudinal data of interest and were included in the outcome analysis, with 1,032 VGC dose week-entries. Overall, 460/1,032 (44.6%) were appropriately dosed, while 234/1,032 (22.7%) and 338/1,032 (32.8%) were under- and over-dosed, respectively. Nineteen (14.5%) patients had a breakthrough-csCMVi, without any associations identified with VCG dosing (p = 0.44). Unlike other cytopenias, a significant association between VGC overdosing and lymphopenia (OR 5.27, 95% CI 1.71-16.22, p = 0.004) was shown. VGC prophylaxis in KTR is frequently inappropriately dosed, albeit without meaningful clinical associations, neither in terms of efficacy nor safety.
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Affiliation(s)
- Nathalie Hammer
- Service of Nephrology and Hypertension, Inselspital, Bern, Switzerland
| | - Linard Hoessly
- Swiss Transplant Cohort Study (STCS), University Hospital Basel, Basel, Switzerland
| | - Fadi Haidar
- Service of Nephrology, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Cédric Hirzel
- Service of Infectious Diseases, Inselspital, Bern, Switzerland
| | - Sophie de Seigneux
- Service of Nephrology, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Christian van Delden
- Transplant Infectious Diseases Unit, Service of Infectious Diseases, HUG, Geneva, Switzerland
| | - Bruno Vogt
- Service of Nephrology and Hypertension, Inselspital, Bern, Switzerland
| | - Daniel Sidler
- Service of Nephrology and Hypertension, Inselspital, Bern, Switzerland
| | - Dionysios Neofytos
- Transplant Infectious Diseases Unit, Service of Infectious Diseases, HUG, Geneva, Switzerland
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Kotton CN, Torre-Cisneros J, Yakoub-Agha I. Slaying the "Troll of Transplantation"-new frontiers in cytomegalovirus management: A report from the CMV International Symposium 2023. Transpl Infect Dis 2024; 26:e14183. [PMID: 37942955 DOI: 10.1111/tid.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023]
Abstract
The 2023 International CMV Symposium took place in Barcelona in May 2023. During the 2-day meeting, delegates and faculty discussed the ongoing challenge of managing the risk of cytomegalovirus infection (the Troll of Transplantation) after solid organ or hematopoietic cell transplantation. Opportunities to improve outcomes of transplant recipients by applying advances in antiviral prophylaxis or pre-emptive therapy, immunotherapy, and monitoring of cell-mediated immunity to routine clinical practice were debated and relevant educational clinical cases presented. This review summarizes the presentations, cases, and discussions from the meeting and describes how further advances are needed before the Troll of Transplantation is slain.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Torre-Cisneros
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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Farkas K, Varga M, Dinnyes I, Rem L, Telkes G, Wagner L, Remport A, Piros L, Szijarto A, Huszty G. Low-Dose vs Standard-Dose Valganciclovir for Cytomegalovirus Prophylaxis After Kidney Transplantation: A Single-Center Retrospective Analysis. Transplant Proc 2024; 56:105-110. [PMID: 38199858 DOI: 10.1016/j.transproceed.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Prophylactic administration of valganciclovir (VG) is an accepted method for the prevention of cytomegalovirus (CMV) infection after kidney transplantation (KTx). The standard dosage of oral VG is 900 mg/day, adjusted to renal function. There is growing evidence that low-dose 450 mg/day VG might be safe and effective. We compared low-dose vs standard-dose prophylaxis after KTx in a single-center follow-up study. METHODS Data from 603 renal transplantations at a single center were retrospectively analyzed (2011-2014, 12-month follow-up). Recipients with donor IgG positive-recipient IgG positive (D+/R+), (D+/R-), and (D-/R+) CMV serostatus were routinely treated with 450 mg/day VG for 3 months. Based on the same prophylactic dose, patients could be categorized into two groups according to their postoperative renal function: those receiving standard-dose VG due to a lower estimated glomerular filtration rate (eGFR) (average eGFR<60 mL/min/1.73 m2) and those receiving low-dose VG due to higher eGFR (average eGFR>60 mL/min/1.73 m2). RESULTS Estimated glomerular filtration rate-based VG serum alterations significantly affected the risk of CMV infection with a higher incidence in higher VG levels (standard-dose: 357 patients, CMV: 33 cases (9.2 %); low-dose: 246 patients, CMV: 10 cases (4.1%). The occurrence of known risk factors: serologic risk distribution and rate of induction therapy were not statistically different between the 2 groups. Treatment of an acute rejection episode influenced the infection rate significantly in the standard-dose group. As a side effect of prophylaxis, leucopenia (<3G/L) was 2.46 times higher in standard-dose vs low-dose group. CONCLUSION Low-dose VG administration is safe and non-inferior to the standard dose in the prophylaxis of CMV infection after KTx.
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Affiliation(s)
- Katalin Farkas
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Marina Varga
- Department of Laboratory Medicine, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Izabella Dinnyes
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Lili Rem
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Gabor Telkes
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Laszlo Wagner
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Adam Remport
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Laszlo Piros
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Attila Szijarto
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Gergely Huszty
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary.
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von Hoerschelmann E, Münch J, Gao L, Lücht C, Naik MG, Schmidt D, Pitzinger P, Michel D, Avaniadi P, Schrezenmeier E, Choi M, Halleck F, Budde K. Letermovir Rescue Therapy in Kidney Transplant Recipients with Refractory/Resistant CMV Disease. J Clin Med 2023; 13:100. [PMID: 38202107 PMCID: PMC10780128 DOI: 10.3390/jcm13010100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/12/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
(1) Background: CMV infections remain a problem after kidney transplantation, particularly if patients are refractory or resistant (r/r) to treatment with valganciclovir (VGCV) or ganciclovir (GCV). (2) Methods: In a single-center retrospective study, kidney transplant recipients (KTR) receiving letermovir (LTV) as rescue therapy for VGCV-/GCV-r/r CMV disease were analyzed regarding CMV history, immunosuppression, and outcomes. (3) Results: Of 201 KTR treated for CMV between 2017 and 2022, 8 patients received LTV following treatment failure with VGCV/GCV. All patients received CMV prophylaxis with VGCV according to the center's protocol, and 7/8 patients had a high-risk (D+/R-) CMV constellation. In seven of eight cases, rising CMV levels occurred during prophylaxis. In seven of eight patients, a mutation in UL97 associated with a decreased response to VGCV/GCV was detected. In four of eight patients, LTV resulted in CMV clearance after 24 ± 10 weeks (16-39 weeks), two of eight patients stabilized at viral loads <2000 cop/mL (6-20 weeks), and two of eight patients developed LTV resistance (range 8-10 weeks). (4) Conclusion: LTV, which is currently evaluated for CMV prophylaxis in kidney transplantation, also shows promising results for the treatment of patients with VGCV/GCV resistance despite the risk of developing LTV resistance. Additional studies are needed to further define its role in the treatment of patients with CMV resistance.
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Affiliation(s)
- Ellen von Hoerschelmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Johannes Münch
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Linde Gao
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Christian Lücht
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Marcel G. Naik
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Paul Pitzinger
- Institute of Virology, Charité Universitätsmedizin Berlin, Labor Berlin-Charité-Vivantes GmbH, 10117 Berlin, Germany
| | - Detlef Michel
- Institute of Virology, Universitätsklinikum Ulm, 89081 Ulm, Germany
| | - Parthenopi Avaniadi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
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Limaye AP, Budde K, Humar A, Vincenti F, Kuypers DRJ, Carroll RP, Stauffer N, Murata Y, Strizki JM, Teal VL, Gilbert CL, Haber BA. Letermovir vs Valganciclovir for Prophylaxis of Cytomegalovirus in High-Risk Kidney Transplant Recipients: A Randomized Clinical Trial. JAMA 2023; 330:33-42. [PMID: 37279999 PMCID: PMC10245286 DOI: 10.1001/jama.2023.9106] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/19/2023] [Indexed: 06/08/2023]
Abstract
Importance Valganciclovir for 200 days is standard care for cytomegalovirus (CMV) prophylaxis in high-risk CMV-seronegative kidney transplant recipients who receive an organ from a CMV-seropositive donor, but its use is limited by myelosuppression. Objective To compare the efficacy and safety of letermovir with valganciclovir for prevention of CMV disease in CMV-seronegative kidney transplant recipients who receive an organ from a CMV-seropositive donor. Design, Setting, and Participants Randomized, double-masked, double-dummy, noninferiority, phase 3 trial in adult CMV-seronegative kidney transplant recipients who received an organ from a CMV-seropositive donor at 94 participating sites between May 2018 and April 2021 (final follow-up in April 2022). Interventions Participants were randomized in a 1:1 ratio (stratified by receipt of lymphocyte-depleting induction immunosuppression) to receive letermovir, 480 mg, orally daily (with acyclovir) or valganciclovir, 900 mg, orally daily (adjusted for kidney function) for up to 200 days after transplant, with matching placebos. Main Outcomes and Measures The primary outcome was CMV disease, confirmed by an independent masked adjudication committee, through posttransplant week 52 (prespecified noninferiority margin, 10%). CMV disease through week 28 and time to onset of CMV disease through week 52 were secondary outcomes. Exploratory outcomes included quantifiable CMV DNAemia and resistance. The rate of leukopenia or neutropenia through week 28 was a prespecified safety outcome. Results Among 601 participants randomized, 589 received at least 1 dose of the study drug (mean age, 49.6 years; 422 [71.6%] men). Letermovir (n = 289) was noninferior to valganciclovir (n = 297) for prevention of CMV disease through week 52 (10.4% vs 11.8% of participants with committee-confirmed CMV disease; stratum-adjusted difference -1.4% [95% CI, -6.5% to 3.8%]). No participants who received letermovir vs 5 participants (1.7%) who received valganciclovir developed CMV disease through week 28. Time to onset of CMV disease was comparable between the groups (hazard ratio, 0.90 [95% CI, 0.56-1.47]). Quantifiable CMV DNAemia was detected in 2.1% of participants in the letermovir group vs 8.8% in the valganciclovir group by week 28. Of participants evaluated for suspected CMV disease or CMV DNAemia, none (0/52) who received letermovir and 12.1% (8/66) who received valganciclovir had resistance-associated substitutions. The rate of leukopenia or neutropenia through week 28 was lower with letermovir vs valganciclovir (26% vs 64%; difference, -37.9% [95% CI, -45.1% to -30.3%]; P < .001). Fewer participants in the letermovir group than the valganciclovir group discontinued prophylaxis due to adverse events (4.1% vs 13.5%) or drug-related adverse events (2.7% vs 8.8%). Conclusion and Relevance Among adult CMV-seronegative kidney transplant recipients who received an organ from a CMV-seropositive donor, letermovir was noninferior to valganciclovir for prophylaxis of CMV disease over 52 weeks, with lower rates of leukopenia or neutropenia, supporting its use for this indication. Trial Registration ClinicalTrials.gov Identifier: NCT03443869; EudraCT: 2017-001055-30.
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Affiliation(s)
- Ajit P. Limaye
- Division of Allergy & Infectious Diseases, Departments of Medicine & Laboratory Medicine and Pathology, University of Washington Medicine, Seattle
| | | | - Atul Humar
- Ajmera Transplant Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Flavio Vincenti
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco
| | - Dirk R. J. Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, UZ Leuven, Leuven, Belgium
| | - Robert P. Carroll
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Raval AD, Kistler KD, Tang Y, Vincenti F. Burden of neutropenia and leukopenia among adult kidney transplant recipients: A systematic literature review of observational studies. Transpl Infect Dis 2023; 25:e14000. [PMID: 36508475 DOI: 10.1111/tid.14000] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/17/2022] [Accepted: 11/19/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Leukopenia and neutropenia (L/N) may affect treatment decisions, potentially resulting in poor clinical and economic outcomes among kidney transplant recipients (KTRs). The burden of L/N is poorly quantified systematically. This systematic literature review aimed to summarize the incidence of, risk factors for, and clinical and economic outcomes associated with L/N post-KT. METHODS We systematically searched MEDLINE, Embase, and the Cochrane Library (from database inception-June 14, 2021) and conferences (past 3 years) to identify observational studies examining epidemiology, risk factors, or outcomes associated with L/N among adult KTRs. RESULTS Of 2081 records, 82 studies met inclusion criteria. Seventy-three studies reported the epidemiology of L/N post-KT. Pooled incidence of neutropenia, defined as absolute neutrophil counts (ANC) <1000/μl, ranged from 13% to 48% within 1-year post-transplant; ANC <500/μl ranged from 15% to 20%. Leukopenia, defined as white blood cell counts <3500/μl, was 19% to 83%. Eleven studies reported independent risk factors associated with L/N post-KT. D+/R- cytomegalovirus status, mycophenolic acid (MPA), and tacrolimus use were the most consistent risk factors across studies. Fourteen studies reported L/N-associated clinical outcomes. We noted a trend toward a positive association between neutropenia and acute rejection/opportunistic infections. Mixed findings were noted on the association between L/N and graft failure or mortality. Dosage modifications of valganciclovir, MPA, cotrimoxazole, and anti-thymoglobulin and the need for granulocyte colony-stimulating factor (G-CSF) use were common with L/N. CONCLUSION Findings suggest post-transplant L/N were common and associated with frequent modifications of immunosuppressive agents, requiring G-CSF use, and rejection or opportunistic infections. Findings highlight the need for interventions to reduce risk of L/N post-KT.
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Azhar A, Tsujita M, Talwar M, Balaraman V, Bhalla A, Eason JD, Nouer SS, Sumida K, Remport A, Hall IE, Griffin R, Rofaiel G, Molnar MZ. CMV specific T cell immune response in hepatitis C negative kidney transplant recipients receiving transplant from hepatitis C viremic donors and hepatitis C aviremic donors. Ren Fail 2022; 44:831-841. [PMID: 35546431 PMCID: PMC9103398 DOI: 10.1080/0886022x.2022.2072744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/12/2022] [Accepted: 04/22/2022] [Indexed: 12/03/2022] Open
Abstract
Kidney transplants (KT) from hepatitis C (HCV) viremic donors to HCV negative recipients has shown promising renal outcomes, however, high incidence of cytomegalovirus (CMV) viremia were reported. We performed a prospective cohort study of 52 HCV negative KT recipients from Methodist University Hospital including 41 receiving transplants from HCV aviremic donors and 11 from HCV viremic donors. CMV specific CD4+ and CD8 + T cell immunity was measured by intracellular flow cytometry assay. Primary outcome was the development of positive CMV specific CD4+ and CD8 + T cell immune response in the entire cohort and each subgroup. The association between donor HCV status and CMV specific CD4+ and CD8 + T cell immune response was analyzed by Cox proportional hazard models. Mean recipient age was 48 ± 13 years, with 73% male and 82% African American. Positive CMV specific CD4+ and CD8 + T cell immune response was found in 53% and 47% of the cohort at 1 month, 65% and 70% at 2 months, 80% and 75% at 4 months, 89% and 87% at 6 months, and 94% and 94% at 9 months post-transplant, respectively. There was no significant difference in the incidence of positive CMV specific T cell immune response between recipients of transplants from HCV aviremic donors compared to HCV viremic donors in unadjusted (for CD8+: HR = 1.169, 95%CI: 0.521-2.623; for CD4+: HR = 1.208, 95%CI: 0.543-2.689) and adjusted (for CD8+: HR = 1.072, 95%CI: 0.458-2.507; for CD4+: HR = 1.210, 95%CI: 0.526-2.784) Cox regression analyses. HCV viremia in donors was not associated with impaired development of CMV specific T cell immunity in this cohort.
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Affiliation(s)
- Ambreen Azhar
- Department of Medicine, Division of Nephrology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Makoto Tsujita
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James D. Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
- Department of Surgery, Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Simonne S. Nouer
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Keiichi Sumida
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adam Remport
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Isaac E. Hall
- Department of Medicine, Division of Nephrology & Hypertension, University of Utah, Salt Lake City, UT, USA
| | - Randi Griffin
- Office of Clinical Research, University of Tennessee Health Science Center, Memphis, TN, USA
| | - George Rofaiel
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Salt Lake City, UT, USA
| | - Miklos Z. Molnar
- Department of Medicine, Division of Nephrology & Hypertension, University of Utah, Salt Lake City, UT, USA
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Brar S, Berry R, Raval AD, Tang Y, Vincenti F, Skartsis N. Outcomes among CMV-mismatched and highly sensitized kidney transplants recipients who develop neutropenia. Clin Transplant 2022; 36:e14583. [PMID: 34984735 DOI: 10.1111/ctr.14583] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/23/2021] [Accepted: 12/30/2021] [Indexed: 12/21/2022]
Abstract
Limited data exist on the incidence and clinical outcomes of neutropenia among kidney transplant recipients. Our study included 572 adults who received a kidney transplant at the University of California, San Francisco Medical Center between 2012 and 2018, and were CMV-mismatched or had a PRA ≥ 80%. Recipients with HIV, Hepatitis B and C, and primary non-function were excluded. Participants were followed for at least one year after transplantation. Neutropenia was defined as absolute neutrophil count < 1000 cells/μL. Cox proportional hazards regression models using neutropenia as a time-varying predictor were used to determine the risk of mycophenolic acid and valganciclovir changes, rejection, hospitalizations and use of granulocyte colony stimulating factor. Models were adjusted for demographics and transplant characteristics. Mean follow-up was 3.7 (SD, 1.8) years. The mean age of the cohort was 50.4 (13.1) years, and 57.5% were female. A total of 208 (36.3%) participants had neutropenia. Neutropenia was associated with an increased risk of valganciclovir or MPA dose reductions or discontinuations [adjusted hazard ratio, aHR: 7.78, 95% CI: 4.73- 12.81], rejection [aHR 2.00, 95% CI: 1.10-3.64] and hospitalizations [aHR 3.32, 95% CI: 2.12-5.19]. Neutropenia occurs frequently after kidney transplantation and leads to more medication changes and adverse clinical outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sandeep Brar
- Department of Epidemiology and Biostatistics, University of California, San Francisco.,Division of Nephrology, Department of Medicine, University of Alberta, Edmonton
| | - Reyoot Berry
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco
| | | | | | - Flavio Vincenti
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco
| | - Nikolaos Skartsis
- Division of Nephrology, University of California, San Francisco School of Medicine, San Francisco
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Shi Y, Lerner AH, Rogers R, Vieira K, Merhi B, Mecadon K, Osband AJ, Bayliss G, Gohh R, Morrissey P, Farmakiotis D. Low-Dose Valganciclovir Prophylaxis Is Safe and Cost-Saving in CMV-Seropositive Kidney Transplant Recipients. Prog Transplant 2021; 31:368-376. [PMID: 34839729 DOI: 10.1177/15269248211046037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Observational studies suggest that low-dose valganciclovir prophylaxis (450 mg daily for normal renal function) is as effective as and perhaps safer than standard-dose valganciclovir (900 mg daily) in preventing CMV infection among kidney transplant recipients. However, this practice is not supported by current guidelines due to concerns for breakthrough infection from resistant CMV, mainly in high-risk CMV donor-seropositive/recipient-seronegative kidney transplant recipients. Standard-dose valganciclovir is costly and possibly associated with higher incidence of neutropenia and BKV DNAemia. Our institution adopted low-dose valganciclovir prophylaxis for intermediate-risk (seropositive) kidney transplant recipients in January 2018. Research Question: To analyze the efficacy (CMV DNAemia), safety (BK virus DNAemia, neutropenia, graft loss, and death), and cost savings associated with this change. Design: We retrospectively compared the above outcomes between CMV-seropositive kidney transplant recipients who received low-dose and standard-dose valganciclovir, transplanted within our institution, between 1/19/2014 and 7/15/2019, using propensity score-adjusted competing risk analyses. We also compared cost estimates between the two dosing regimens, for 3 months of prophylaxis, and for different percentage of patient-weeks with normal renal function, using the current average wholesale price of valganciclovir. Results: We studied 179 CMV-seropositive kidney transplant recipients, of whom 55 received low-dose and 124 standard-dose valganciclovir. The majority received nonlymphocyte depleting induction (basiliximab). Low-dose valganciclovir was at least as effective and safe as, and more cost-saving than standard-dose valganciclovir. Conclusion: This single-center study contributes to mounting evidence for future guidelines to be adjusted in favor of low-dose valganciclovir prophylaxis in CMV-seropositive kidney transplant recipients.
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Affiliation(s)
- Yiyun Shi
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alexis Hope Lerner
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ralph Rogers
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Kendra Vieira
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Basma Merhi
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Adena J Osband
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - George Bayliss
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Reginald Gohh
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Paul Morrissey
- 12321Warren Alpert Medical School of Brown University, Providence, RI, USA
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10
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van den Hoogen MWF, Seghers L, Manintveld OC, Roest S, Bekkers JA, den Hoed CM, Minnee RC, de Geus HRH, van Thiel RJ, Hesselink DA. Care for the organ transplant recipient on the intensive care unit. J Crit Care 2021; 64:37-44. [PMID: 33784577 DOI: 10.1016/j.jcrc.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 11/25/2022]
Abstract
All transplant recipients receive tacrolimus, mycophenolate and glucocorticoids and these drugs have many side-effects and drug-drug interactions. Common complications include surgical complications, infections, rejection and acute kidney injury. Infections as CMV and PJP can be prevented with prophylactic treatment. Given the complexity of organ transplant recipients a multi-disciplinary team of intensivists, surgeons, pharmacists and transplant specialists is essential. After heart transplantation a temporary pacemaker is required until the conduction system recovers. Stiffening of the heart and increased cardiac markers indicate rejection. An endomyocardial biopsy is performed via the right jugular vein, necessitating its preservation. For lung transplant patients, early intervention for aspiration is warranted to prevent chronic rejection. Risk of any infection is high, requiring active surveillance and intensive treatment, mainly of fungal infections. The liver is immunotolerant requiring lower immunosuppression. Transplantation surgery is often accompanied by massive blood loss and coagulopathy. Other complications include portal vein or hepatic artery thrombosis and biliary leakage or stenosis. Kidney transplant recipients have a high risk of cardiovascular disease and posttransplant anemia should be treated liberally. After postmortal transplantation, delayed graft function is common and dialysis is continued. Ureteral anastomosis complications can be diagnosed with ultrasound.
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Affiliation(s)
- M W F van den Hoogen
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - L Seghers
- Department of Pulmonology, Thorax Center, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - O C Manintveld
- Department of Cardiology, Thorax Center, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - S Roest
- Department of Cardiology, Thorax Center, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J A Bekkers
- Department of Thorax Surgery, Thorax Center, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - C M den Hoed
- Department of Gastroenterology, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - R C Minnee
- Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - H R H de Geus
- Department of Intensive Care, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - R J van Thiel
- Department of Intensive Care, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - D A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
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11
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Blazquez-Navarro A, Dang-Heine C, Bauer C, Wittenbrink N, Wolk K, Sabat R, Witzke O, Westhoff TH, Sawitzki B, Reinke P, Thomusch O, Hugo C, Babel N, Or-Guil M. Sex-Associated Differences in Cytomegalovirus Prevention: Prophylactic Strategy is Potentially Associated With a Strong Kidney Function Impairment in Female Renal Transplant Patients. Front Pharmacol 2020; 11:534681. [PMID: 33519427 PMCID: PMC7845412 DOI: 10.3389/fphar.2020.534681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022] Open
Abstract
Post-transplantation cytomegalovirus (CMV) syndrome can be prevented using the antiviral drug (val)ganciclovir. (Val)ganciclovir is typically administered following a prophylactic or a pre-emptive strategy. The prophylactic strategy entails early universal administration, the pre-emptive strategy, early treatment in case of infection. However, it is not clear which strategy is superior with respect to transplantation outcome; sex-specific effects of these prevention strategies are not known. We have retrospectively analyzed 540 patients from the multi-centre Harmony study along eight pre-defined visits: 308 were treated according to a prophylactic, 232 according to a pre-emptive strategy. As expected, we observed an association of prophylactic strategy with lower incidence of CMV syndrome, delayed onset and lower viral loads compared to the pre-emptive strategy. However, in female patients, the prophylactic strategy was associated with a strong impairment of glomerular filtration rate one year post-transplant (difference: -11.8 ± 4.3 ml min-1·1.73 m-2, p = 0.006). Additionally, we observed a tendency of higher incidence of acute rejection and severe BK virus reactivation in the prophylactic strategy group. While the prophylactic strategy was more effective for preventing CMV syndrome, our results suggest for the first time that the prophylactic strategy might lead to inferior transplantation outcomes in female patients, providing evidence for a strong association with sex. Further randomized controlled studies are necessary to confirm this potential negative effect.
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Affiliation(s)
- Arturo Blazquez-Navarro
- Department of Biology, Systems Immunology Lab, Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin-Brandenburger Centrum für Regenerative Therapien, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Center for Translational Medicine, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Chantip Dang-Heine
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin-Brandenburger Centrum für Regenerative Therapien, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Clinical Study Center (CSC), Berlin Institute of Health, and Charitét - Universitättsmedizin Berlin, Corporate Member of Freie Universitätt Berlin, Humboldt-Universitätt Zu Berlin, Campus Charitét Mitte Berlin, Germany
| | | | - Nicole Wittenbrink
- Department of Biology, Systems Immunology Lab, Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin-Brandenburger Centrum für Regenerative Therapien, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Kerstin Wolk
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin-Brandenburger Centrum für Regenerative Therapien, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Department of Dermatology and Allergy, Psoriasis Research and Treatment Center, Institute of Medical Immunology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Sabat
- Department of Dermatology and Allergy, Psoriasis Research and Treatment Center, Institute of Medical Immunology, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Department of Dermatology and Allergy, Interdisciplinary Group of Molecular Immunopathology, Institute of Medical Immunology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Witzke
- Klinik für Infektiologie, Universitätsklinikum Essen, Essen, Germany
| | - Timm H. Westhoff
- Center for Translational Medicine, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Birgit Sawitzki
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin-Brandenburger Centrum für Regenerative Therapien, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Petra Reinke
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin-Brandenburger Centrum für Regenerative Therapien, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Berlin Center for Advanced Therapies (BeCAT), Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Thomusch
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Christian Hugo
- Medizinische Klinik III - Bereich Nephrologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Nina Babel
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin-Brandenburger Centrum für Regenerative Therapien, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Center for Translational Medicine, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Michal Or-Guil
- Department of Biology, Systems Immunology Lab, Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Medical Immunology, Charité–Universitätsmedizin Berlin, Berlin, Germany
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12
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Heliövaara E, Husain S, Martinu T, Singer LG, Cypel M, Humar A, Keshavjee S, Tikkanen J. Drug-resistant cytomegalovirus infection after lung transplantation: Incidence, characteristics, and clinical outcomes. J Heart Lung Transplant 2019; 38:1268-1274. [PMID: 31570289 DOI: 10.1016/j.healun.2019.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/28/2019] [Accepted: 09/03/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection and development of CMV drug resistance can cause significant morbidity and mortality in patients with lung transplantation (LTX). We investigated the incidence of CMV drug resistance in adult patients with LTX and characterized this patient group and its outcomes. METHODS We analyzed a single-center retrospective cohort of 735 patients who received LTX between January 2012 and October 2017. We assessed the incidences of CMV UL97 and UL54 genotyping for clinically suspected drug resistance and confirmed drug resistance. Case-matched controls (3 control patients for each resistant patient) were identified by matching for CMV serological status, development of CMV disease or significant viremia (≥3,000 IU/ml), and transplantation date. RESULTS The incidence of drug-resistant CMV was 1.98% (11/556) in donor and/or recipient CMV-positive patients and 4.7% (7/150) in donor-positive/recipient-negative patients. Altogether, 27 patients were tested for drug resistance, and 11 strains were resistant, 8 sensitive, and 8 inconclusive. No differences in immunosuppression, acute rejection, or pre-transplant sensitization were seen between case-matched groups. The peak CMV viral load and mean duration of viremia were significantly higher in the resistant group (324,000 vs. 117,000 mean IU/ml, p = 0.048 and 140 vs. 55 days, p < 0.001, respectively). The resistant group had increased overall mortality after onset of viremia compared with controls (3-year mortality 70% vs. 30%; p = 0.01). CONCLUSIONS Drug-resistant CMV infection is rare, but patients who develop it have decreased overall survival. Peak CMV viral load and duration of CMV viremia were associated with development of resistant CMV infection.
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Affiliation(s)
- Elina Heliövaara
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Atul Humar
- Division of Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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