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Hardinger KL, Brennan DC. Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches. Ann Pharmacother 2024:10600280241237534. [PMID: 38501850 DOI: 10.1177/10600280241237534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
OBJECTIVE The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation. DATA SOURCES A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation. STUDY SELECTION AND DATA EXTRACTION Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded. DATA SYNTHESIS After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV. CONCLUSIONS Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.
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Affiliation(s)
- Karen L Hardinger
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel C Brennan
- Johns Hopkins Comprehensive Transplant Center, Baltimore, MD, USA
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2
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Fifteen-Year Surveillance of LTR Receiving Pre-Emptive Therapy for CMV Infection: Prevention of CMV Disease and Incidence of CLAD. Microorganisms 2022; 10:microorganisms10122339. [PMID: 36557592 PMCID: PMC9788487 DOI: 10.3390/microorganisms10122339] [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: 10/11/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/29/2022] Open
Abstract
The efficacy of pre-emptive therapy in the prevention of cytomegalovirus (CMV) disease and the potential association of CMV infection with the occurrence of chronic lung allograft dysfunction (CLAD) was evaluated in 129 lung transplant recipients receiving pre-emptive therapy based on pp65-antigenemia or CMV-DNA in the blood and in the bronchoalveolar lavage. Seventy-one (55%) patients received pre-emptive ganciclovir/valganciclovir (GCV/VGCV) for CMV infection for a median of 28 (9-191) days. Possible CMV disease occurred in six (5%) patients and was healed after the GCV/VGCV therapy. The cumulative incidence of CLAD was 38% and 54% at 5 and 10 years. Acute rejection and CMV load in the blood (but not in the lung) were independent predictors of the occurrence of CLAD. Pre-emptive therapy is highly effective in preventing CMV disease in lung recipients and does not induce a superior incidence of CLAD compared to what reported for other cohorts of patients who received an extended antiviral prophylaxis.
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3
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Kwak SH, Lee SH, Park MS, Jeong SJ, Lee JG, Paik HC, Kim YS, Chang J, Kim SY. Risk Factors for Cytomegalovirus Reactivation in Lung Transplant Recipients. Lung 2020; 198:829-838. [PMID: 32696252 DOI: 10.1007/s00408-020-00380-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/10/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE We examined risk factors that may have contributed to Cytomegalovirus (CMV) reactivation among patients who underwent lung transplantation (LTx). METHODS We reviewed medical records of patients who underwent LTx at a tertiary healthcare hospital in South Korea between January 2013 and May 2017. We excluded patients who died within the first year after LTx and those lost to follow-up. CMV reactivation was defined as the detection of CMV titers above 3000 copies/ml regardless of specific symptoms after prophylaxis cessation. RESULTS Of 89 patients included, 39 (43.8%) developed CMV reactivation. Of those 39 patients, 16 (41.0%) experienced additional CMV reactivation. Multivariate analysis identified lymphocyte counts below 1.0 × 103/μl (hazard ratio [HR] 49.33, p < 0.001) and use of steroids at more than twice the standard dose (HR 8.07, p < 0.001) as risk factors for CMV reactivation. The multivariate model also identified chronic kidney disease (CKD; HR 5.19, p = 0.016) and pneumonia (HR 17.22, p = 0.013) as risk factors for repetitive CMV reactivation. CONCLUSION This study suggests that lymphopenia and high doses of steroids may be important risk factors for CMV reactivation in LTx patients. Our results also suggest that repetitive CMV reactivation may be associated with CKD and pneumonia.
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Affiliation(s)
- Se Hyun Kwak
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Su Hwan Lee
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Chae Paik
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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4
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Forte E, Zhang Z, Thorp EB, Hummel M. Cytomegalovirus Latency and Reactivation: An Intricate Interplay With the Host Immune Response. Front Cell Infect Microbiol 2020; 10:130. [PMID: 32296651 PMCID: PMC7136410 DOI: 10.3389/fcimb.2020.00130] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/10/2020] [Indexed: 12/16/2022] Open
Abstract
CMV is an ancient herpesvirus that has co-evolved with its host over millions of years. The 236 kbp genome encodes at least 165 genes, four non-coding RNAs and 14 miRNAs. Of the protein-coding genes, 43-44 are core replication genes common to all herpesviruses, while ~30 are unique to betaherpesviruses. Many CMV genes are involved in evading detection by the host immune response, and others have roles in cell tropism. CMV replicates systemically, and thus, has adapted to various biological niches within the host. Different biological niches may place competing demands on the virus, such that genes that are favorable in some contexts are unfavorable in others. The outcome of infection is dependent on the cell type. In fibroblasts, the virus replicates lytically to produce infectious virus. In other cell types, such as myeloid progenitor cells, there is an initial burst of lytic gene expression, which is subsequently silenced through epigenetic repression, leading to establishment of latency. Latently infected monocytes disseminate the virus to various organs. Latency is established through cell type specific mechanisms of transcriptional silencing. In contrast, reactivation is triggered through pathways activated by inflammation, infection, and injury that are common to many cell types, as well as differentiation of myeloid cells to dendritic cells. Thus, CMV has evolved a complex relationship with the host immune response, in which it exploits cell type specific mechanisms of gene regulation to establish latency and to disseminate infection systemically, and also uses the inflammatory response to infection as an early warning system which allows the virus to escape from situations in which its survival is threatened, either by cellular damage or infection of the host with another pathogen. Spontaneous reactivation induced by cellular aging/damage may explain why extensive expression of lytic genes has been observed in recent studies using highly sensitive transcriptome analyses of cells from latently infected individuals. Recent studies with animal models highlight the potential for harnessing the host immune response to blunt cellular injury induced by organ transplantation, and thus, prevent reactivation of CMV and its sequelae.
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Affiliation(s)
- Eleonora Forte
- Department of Surgery, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Zheng Zhang
- Department of Surgery, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Edward B. Thorp
- Department of Pathology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Mary Hummel
- Department of Surgery, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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5
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Bak S, Tischer S, Dragon A, Ravens S, Pape L, Koenecke C, Oelke M, Blasczyk R, Maecker-Kolhoff B, Eiz-Vesper B. Selective Effects of mTOR Inhibitor Sirolimus on Naïve and CMV-Specific T Cells Extending Its Applicable Range Beyond Immunosuppression. Front Immunol 2018; 9:2953. [PMID: 30619313 PMCID: PMC6304429 DOI: 10.3389/fimmu.2018.02953] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 11/30/2018] [Indexed: 12/13/2022] Open
Abstract
Cytomegalovirus (CMV) infection/reactivation remains among the most important complications of immunosuppression after transplantation. However, recent clinical observations indicate that mammalian target of rapamycin (mTOR) inhibition with sirolimus may improve the outcome of CMV complications. Underlying mechanisms of this observation, particularly the effect of sirolimus on naïve- and CMV-specific cytotoxic CD8+ T-cell (CMV-CTL) functionality is still undiscovered. Here, the influence of sirolimus on naïve and memory CMV-CTLs was determined by CD3/CD28 crosslinking and alloreactivity assays. After stimulating CMV-CTL with HLA-A*02:01-restricted CMVpp65-peptide loaded artificial antigen-presenting cells (aAPCs), we measured the effect of sirolimus on T-cell proliferation, phenotype, and functionality. Sirolimus significantly improved CMV-specific effector memory T-cell function and negatively influenced naïve T cells. This unique mechanism of action was further characterized by increased secretion of interferon-gamma (IFN-γ), granzyme B (GzB) and enhanced target-cell-dependent cytotoxic capacity of activated CMV-CTLs. Next-generation-sequencing (NGS) was applied to monitor T-cell receptor (TCR)-repertoire dynamics and to verify, that the increased functionality was not related to sirolimus-resistant CTL-clones. Instead, modulation of environmental cues during CMV-CTL development via IL-2 receptor (IL-2R)-driven signal transducer and activator of transcription-5 (STAT-5) signaling under mTOR inhibition allowed fine-tuning of T-cell programming for enhanced antiviral response with stable TCR-repertoire dynamics. We show for the first time that sirolimus acts selectively on human naïve and memory T cells and improves CMV-specific T-cell function via modulation of the environmental milieu. The data emphasize the importance to extend immune monitoring including cytokine levels and T-cell functionality which will help to identify patients who may benefit from individually tailored immunosuppression.
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Affiliation(s)
- Szilvia Bak
- Hannover Medical School, Institute for Transfusion Medicine, Hannover, Germany
| | - Sabine Tischer
- Hannover Medical School, Institute for Transfusion Medicine, Hannover, Germany
| | - Anna Dragon
- Hannover Medical School, Institute for Transfusion Medicine, Hannover, Germany
| | - Sarina Ravens
- Hannover Medical School, Institute of Immunology, Hannover, Germany
| | - Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Christian Koenecke
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Mathias Oelke
- Department of Pathology, John Hopkins School of Medicine, Baltimore, MD, United States.,NexImmune Inc., Gaithersburg, MD, United States
| | - Rainer Blasczyk
- Hannover Medical School, Institute for Transfusion Medicine, Hannover, Germany
| | - Britta Maecker-Kolhoff
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Britta Eiz-Vesper
- Hannover Medical School, Institute for Transfusion Medicine, Hannover, Germany
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6
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Reusing JO, Feitosa EB, Agena F, Pierrotti LC, Azevedo LSF, Kotton CN, David-Neto E. Cytomegalovirus prophylaxis in seropositive renal transplant recipients receiving thymoglobulin induction therapy: Outcome and risk factors for late CMV disease. Transpl Infect Dis 2018; 20:e12929. [PMID: 29809309 DOI: 10.1111/tid.12929] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/29/2018] [Accepted: 04/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-thymocyte globulin (ATG) therapy is a risk factor for cytomegalovirus (CMV) disease in renal transplant (RTx) recipients and therefore antiviral prophylaxis is commonly used. We evaluated the outcome of our current policy of 90 days of CMV prophylaxis in seropositive recipients given ATG and the risk factors for the occurrence of CMV disease after prophylaxis. METHODS We studied a retrospective cohort of 423 RTx (2010-2014) CMV-seropositive adults given ATG induction therapy. RESULTS 54 (13%) patients developed CMV disease at a median of 163 days after transplant, of which 29 (54%) had viral syndrome and 25 (46%) had invasive disease. Median prophylaxis time (94 days) and immunosuppressive drugs were similar between groups (CMV vs no-CMV). Those with CMV disease had more deceased donors and higher donor age, lower lymphocyte count, and lower median eGFR at day 90. Multivariable logistic regression analysis at day 90 and 180 found that eGFR ≤40 ml/min/1.73 m2 (but not acute rejection) was associated with late CMV disease. In a separate validation cohort of 124 patients with 8% late CMV disease, eGFR ≤45 and lymphocyte count ≤800 cells/mm3 at the end of prophylaxis remained predictive of late CMV disease occurrence. CONCLUSIONS These data indicate that antiviral prophylaxis adequately prevented CMV in seropositive recipients given ATG, but late disease still occurred. Low eGFR and low lymphocyte count at the end of prophylaxis may help identify patients at higher risk of CMV disease.
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Affiliation(s)
- Jose O Reusing
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Emanoela B Feitosa
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Fabiana Agena
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Lígia C Pierrotti
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Luiz S F Azevedo
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Harvard Medical School, Infectious Diseases Division, Massachusetts General Hospital, Boston, MA, USA
| | - Elias David-Neto
- Renal Transplantation Service, Hospital das Clínicas, University of Sao Paulo Medical School, São Paulo, Brazil
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7
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Effect of Low-Dose Vs Standard-Dose Valganciclovir in the Prevention of Cytomegalovirus Disease in Kidney Transplantation Recipients: A Systemic Review and Meta-Analysis. Transplant Proc 2018; 50:2473-2478. [PMID: 29871773 DOI: 10.1016/j.transproceed.2018.01.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/23/2017] [Accepted: 01/23/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Valganciclovir is widely used to prevent post-transplant cytomegalovirus (CMV) infection in kidney transplant patients. However, the currently used dose remains controversial because the continuous use of this drug decreases kidney function and can induce leukopenia. OBJECTIVE The purpose of this study was to measure the appropriate dose of valganciclovir required to prevent CMV infection. METHODS A systematic review and meta-analysis were performed by using a random effects model. The Cochrane Central Register, MEDLINE, EMBASE, and PubMed databases were searched up to April 15, 2017. We conducted analysis on low-dose (450 mg) and standard-dose (900 mg) valganciclovir groups. RESULTS After completion of the research, the analysis revealed that the glomerular filtration rate, graft loss, tacrolimus level, antibody-mediated rejection, and fungal and Candida infection rates did not differ between the 2 groups. However, the incidence of CMV tended to decrease in the low-dose group (0.584 [95% confidence interval [CI], 0.352-0.967]; P = .036). The biopsy-proven rejection rate decreased by 0.427 times in the low-dose group compared with the standard-dose group (95% CI, 0.274-0.667; P = .002). Furthermore, the incidence of leukopenia decreased by 0.371 times in the low-dose group compared with the standard-dose group (95% CI, 0.264-0.523; P = .001). CONCLUSIONS The 450-mg dose of valganciclovir effectively prevented post-transplantation CMV infection and decreased drug-induced side effects such as leukopenia. In the future, the lower dose of valganciclovir should be considered to prevent CMV infection and enhance cost-effectiveness.
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8
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Monforte V, Sintes H, López-Gallo C, Delgado M, Santos F, Zurbano F, Solé A, Gavaldá J, Borro JM, Redel-Montero J, Cifrian JM, Pastor A, Román A, Ussetti P. Risk factors, survival, and impact of prophylaxis length in cytomegalovirus-seropositive lung transplant recipients: A prospective, observational, multicenter study. Transpl Infect Dis 2017; 19. [PMID: 28294487 DOI: 10.1111/tid.12694] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/15/2016] [Accepted: 12/24/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal length of cytomegalovirus (CMV) prophylaxis in lung transplantation according to CMV serostatus is not well established. METHODS We have performed a prospective, observational, multicenter study to determine the incidence of CMV infection and disease in 92 CMV-seropositive lung transplant recipients (LTR), their related outcomes and risk factors, and the impact of prophylaxis length. RESULTS At 18 months post transplantation, 37 patients (40%) developed CMV infection (23 [25%]) or disease (14 [15.2%]). Overall mortality was higher in patients with CMV disease (64.3% vs 10.2%; P<.001), but only one patient died from CMV disease. In the multivariate analysis, CMV disease was an independent death risk factor (odds ratio [OR] 18.214, 95% confidence interval [CI] 4.120-80.527; P<.001). CMV disease incidence was higher in patients with 90-day prophylaxis than in those with 180-day prophylaxis (31.3% vs 11.8%; P=.049). Prophylaxis length was an independent risk factor for CMV disease (OR 4.974, 95% CI 1.231-20.094; P=.024). Sixteen patients withdrew from prophylaxis because of adverse events. CONCLUSION CMV infection and disease in CMV-seropositive LTR remain frequent despite current prophylaxis. CMV disease increases mortality, whereas 180-day prophylaxis reduces the incidence of CMV disease.
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Affiliation(s)
- Victor Monforte
- Respiratory Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Helena Sintes
- Respiratory Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Maria Delgado
- Thoracic Surgery Department, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | - Felipe Zurbano
- Respiratory Department, Hospital Marqués de Valdecilla, Santander, Spain
| | - Amparo Solé
- Respiratory Department, Hospital La Fe, Valencia, Spain
| | - Joan Gavaldá
- Infectious Disease Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Jose Maria Borro
- Thoracic Surgery Department, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | | | - Amparo Pastor
- Respiratory Department, Hospital La Fe, Valencia, Spain
| | - Antonio Román
- Respiratory Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Piedad Ussetti
- Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Respiratory Department, Hospital Puerta de Hierro, Madrid, Spain
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9
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Dropulic LK, Lederman HM. Overview of Infections in the Immunocompromised Host. Microbiol Spectr 2016; 4:10.1128/microbiolspec.DMIH2-0026-2016. [PMID: 27726779 PMCID: PMC8428766 DOI: 10.1128/microbiolspec.dmih2-0026-2016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 12/12/2022] Open
Abstract
Understanding the components of the immune system that contribute to host defense against infection is key to recognizing infections that are more likely to occur in an immunocompromised patient. In this review, we discuss the integrated system of physical barriers and of innate and adaptive immunity that contributes to host defense. Specific defects in the components of this system that predispose to particular infections are presented. This is followed by a review of primary immunodeficiency diseases and secondary immunodeficiencies, the latter of which develop because of a specific illness or condition or are treatment-related. The effects of treatment for neoplasia, autoimmune diseases, solid organ and stem cell transplants on host defenses are reviewed and associated with susceptibility to particular infections. In conclusion, an approach to laboratory screening for a suspected immunodeficiency is presented. Knowledge of which host defects predispose to specific infections allows clinicians to prevent, diagnose, and manage infections in their immunocompromised patients most effectively.
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Affiliation(s)
- Lesia K Dropulic
- The National Institutes of Health, National Institute of Allergy and Infectious Diseases, Division of Intramural Research, Bethesda, MD 20892
| | - Howard M Lederman
- Departments of Pediatrics, Medicine, and Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287
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10
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Torre-Cisneros J, Aguado J, Caston J, Almenar L, Alonso A, Cantisán S, Carratalá J, Cervera C, Cordero E, Fariñas M, Fernández-Ruiz M, Fortún J, Frauca E, Gavaldá J, Hernández D, Herrero I, Len O, Lopez-Medrano F, Manito N, Marcos M, Martín-Dávila P, Monforte V, Montejo M, Moreno A, Muñoz P, Navarro D, Pérez-Romero P, Rodriguez-Bernot A, Rumbao J, San Juan R, Vaquero J, Vidal E. Management of cytomegalovirus infection in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations. Transplant Rev (Orlando) 2016; 30:119-43. [DOI: 10.1016/j.trre.2016.04.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 04/02/2016] [Accepted: 04/04/2016] [Indexed: 02/06/2023]
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11
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Liu XF, Jie C, Zhang Z, Yan S, Wang JJ, Wang X, Kurian S, Salomon DR, Abecassis M, Hummel M. Transplant-induced reactivation of murine cytomegalovirus immediate early gene expression is associated with recruitment of NF-κB and AP-1 to the major immediate early promoter. J Gen Virol 2016; 97:941-954. [PMID: 26795571 DOI: 10.1099/jgv.0.000407] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Reactivation of latent human cytomegalovirus is a significant infectious complication of organ transplantation and current therapies target viral replication once reactivation of latent virus has already occurred. The specific molecular pathways that activate viral gene expression in response to transplantation are not well understood. Our studies aim to identify these factors, with the goal of developing novel therapies that prevent transcriptional reactivation in transplant recipients. Murine cytomegalovirus (MCMV) is a valuable model for studying latency and reactivation of CMV in vivo. We previously demonstrated that transplantation of MCMV-latently infected kidneys into allogeneic recipients induces reactivation of immediate early (IE) gene expression and epigenetic reprogramming of the major immediate early promoter (MIEP) within 48 h. We hypothesize that these events are mediated by activation of signalling pathways that lead to binding of transcription factors to the MIEP, including AP-1 and NF-κB. Here we show that transplantation induces rapid activation of several members of the AP-1 and NF-κB transcription factor family and we demonstrate that canonical NF-κB (p65/p50), the junD component of AP-1, and nucleosome remodelling complexes are recruited to the MIEP following transplantation. Proteomic analysis of recipient plasma and transcriptome analysis of kidney RNA identified five extracellular ligands, including TNF, IL-1β, IL-18, CD40L and IL-6, and three intracellular signalling pathways associated with reactivation of IE gene expression. Identification of the factors that mediate activation of these signalling pathways may eventually lead to new therapies to prevent reactivation of CMV and its sequelae.
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Affiliation(s)
- Xue-Feng Liu
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chunfa Jie
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Zheng Zhang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shixian Yan
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jiao-Jing Wang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Xueqiong Wang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sunil Kurian
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, LaJolla, CA, USA
| | - Daniel R Salomon
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, LaJolla, CA, USA
| | - Michael Abecassis
- Department of Microbiology and Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mary Hummel
- Department of Microbiology and Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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12
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Vu D, Shah T, Ansari J, Sakharkar P, Yasir Q, Naraghi R, Hutchinson I, Min D. Interferon-gamma gene polymorphism +874 A/T is associated with an increased risk of cytomegalovirus infection among Hispanic renal transplant recipients. Transpl Infect Dis 2014; 16:724-32. [DOI: 10.1111/tid.12285] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 04/25/2014] [Accepted: 06/21/2014] [Indexed: 11/30/2022]
Affiliation(s)
- D. Vu
- Mendez National Institute of Transplantation; Los Angeles California USA
- Western University of Health Sciences; Pomona California USA
- Transplant Research Institute; Los Angeles California USA
- St. Vincent Medical Center; Los Angeles California USA
| | - T. Shah
- Western University of Health Sciences; Pomona California USA
- Transplant Research Institute; Los Angeles California USA
- St. Vincent Medical Center; Los Angeles California USA
- University of Southern California; Los Angeles California USA
| | - J. Ansari
- Western University of Health Sciences; Pomona California USA
| | - P. Sakharkar
- Roosevelt University College of Pharmacy; Schaumburg Illinois USA
| | - Q. Yasir
- Roosevelt University College of Pharmacy; Schaumburg Illinois USA
| | - R. Naraghi
- Transplant Research Institute; Los Angeles California USA
- St. Vincent Medical Center; Los Angeles California USA
| | - I. Hutchinson
- Mendez National Institute of Transplantation; Los Angeles California USA
- University of Southern California; Los Angeles California USA
| | - D. Min
- Western University of Health Sciences; Pomona California USA
- St. Vincent Medical Center; Los Angeles California USA
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13
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Bowman LJ, Edwards A, Brennan DC. The role of rabbit antithymocyte globulin in renal transplantation. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.946902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Lee YM, Kim Y, Han D, Park SK, Park J, Sung H, Hong HL, Kim T, Kim SH, Choi SH, Kim Y, Woo J, Lee SO. Cytomegalovirus infection after acute rejection therapy in seropositive kidney transplant recipients. Transpl Infect Dis 2014; 16:397-402. [DOI: 10.1111/tid.12227] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 12/17/2013] [Accepted: 01/20/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Y.-M. Lee
- Department of Infectious Diseases; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
- Department of Infectious Diseases; Busan Paik Hospital; Inje University College of Medicine; Busan Korea
| | - Y.H. Kim
- Department of Surgery; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - D.J. Han
- Department of Surgery; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - S.-K. Park
- Department of Nephrology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - J.S. Park
- Department of Nephrology; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - H. Sung
- Department of Laboratory Medicine; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - H.-L. Hong
- Department of Infectious Diseases; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - T. Kim
- Department of Infectious Diseases; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - S.-H. Kim
- Department of Infectious Diseases; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - S.-H. Choi
- Department of Infectious Diseases; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - Y.S. Kim
- Department of Infectious Diseases; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - J.H. Woo
- Department of Infectious Diseases; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | - S.-O. Lee
- Department of Infectious Diseases; Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
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CMV Viremia is associated with a decreased incidence of BKV reactivation after kidney and kidney-pancreas transplantation. Transplantation 2014; 96:1097-103. [PMID: 24056621 DOI: 10.1097/tp.0b013e3182a6890d] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) and BK virus (BKV) infections can cause significant morbidity after kidney and kidney-pancreas transplant. There are limited data on the epidemiology and interactions between these two viral pathogens. METHODS We prospectively screened 609 kidney or kidney-pancreas transplant recipients from January 2007 to June 2011 for BKV and/or CMV viremia. This included 7453 quantitative BKV polymerase chain reaction and 15,496 quantitative CMV polymerase chain reaction tests. We evaluated risk factors and timing of these infections and the impact of treatment of one infection on the other. RESULTS Among 609 recipients, 108 (17.7%) developed CMV viremia, of which 95 (88%) were asymptomatic, 5 (5%) had CMV syndrome, and 8 (7%) developed CMV tissue invasive disease at a median of 5.6 months after transplantation. Risk factors for CMV infection using multivariable analysis were D+R- serogroup (P≤0.0001), donor age >50 years (P=0.013), and higher mean tacrolimus (P=0.0009) and mycophenolate mofetil (P=0.01) blood levels. The incidence of BKV infection in the total population was 163 of 609 (26.7%), of which 150 (92%) occurred in patents without antecedent CMV viremia. Such patients demonstrated a higher rate of subsequent BKV viremia than patients with antecedent CMV viremia (P=0.003; hazard ratio, 2.05; 95% confidence interval, 1.2-3.4). Moreover, we found that only symptomatic CMV viremia had a significant negative impact on graft survival when compared with asymptomatic CMV viremia and those without CMV viremia (relative risk, 3.5; 95% confidence interval, 1.06-8.9; P=0.04). CONCLUSION CMV viremia may indirectly protect against subsequent BK viremia possibly due to a reduction of intensity of immunosuppression after diagnosis of CMV viremia.
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Díaz J, Henao J, Rodelo J, García Á, Arbeláez M, Jaimes F. Incidence and Risk Factors for Cytomegalovirus Disease in a Colombian Cohort of Kidney Transplant Recipients. Transplant Proc 2014; 46:160-6. [DOI: 10.1016/j.transproceed.2013.07.070] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/24/2013] [Indexed: 10/25/2022]
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17
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Bedino G, Esposito P, Bosio F, Corradetti V, Valsania T, Rocca C, Pattonieri EF, Gregorini M, Rampino T, Dal Canton A. The role of therapeutic drug monitoring in the treatment of cytomegalovirus disease in kidney transplantation. Int Urol Nephrol 2013; 45:1809-13. [PMID: 23054314 DOI: 10.1007/s11255-012-0293-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 09/08/2012] [Indexed: 02/07/2023]
Abstract
Cytomegalovirus (CMV) infection is a common complication following solid organ transplantation that may severely affect the outcome of transplantation. Ganciclovir (GCV) and its prodrug valganciclovir are successfully used to prevent and treat CMV infection; however, in a small percentage of patients, CMV gene mutations may lead to drug resistance. GCV resistance is defined as increasing CMV viremia or progressive clinical disease during prolonged antiviral therapy, due to CMV gene mutation. This has emerged as a new challenge, especially because alternative drugs such as cidofovir and foscarnet have a number of important side effects. Here we report the case of a kidney transplanted patient who experienced life-threatening CMV disease, which initially appeared to be GCV-resistant, but was instead found to be associated with inadequate antiviral drug levels. The patient was then successfully treated by monitoring plasma GCV levels. We suggest using plasma GCV monitoring in the management of all cases of critical CMV disease, in which GCV resistance is suspected.
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Affiliation(s)
- Giulia Bedino
- Unit of Nephrology, Dialysis and Transplantation, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy,
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18
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Page E, Kwun J, Oh B, Knechtle S. Lymphodepletional strategies in transplantation. Cold Spring Harb Perspect Med 2013; 3:3/7/a015511. [PMID: 23818516 DOI: 10.1101/cshperspect.a015511] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Because lymphocytes were shown to mediate transplant rejection, their depletion has been studied as a mechanism of preventing rejection and perhaps inducing immunologic tolerance. Agents that profoundly deplete lymphocytes have included monoclonal antibodies, cytotoxic drugs, and radiation. We have studied several such agents but focused on antibodies that deplete not only peripheral blood lymphocytes, but also lymph node lymphocytes. Depletion of lymph node T lymphocytes appears to permit peripheral tolerance at least for T cells in animal models. Nevertheless, B-cell responses may be resistant to such approaches, and T memory cells are likewise relatively resistant to depleting antibodies. We review the experimental and clinical approaches to depletion strategies and outline some of the pitfalls of depletion, such as limitations of currently available agents, duration of tolerance, infection, and malignancy. It is notable that most tolerogenic strategies that have been attempted experimentally and clinically include depleting agents even when they are not named as the underlying strategy. Thus, there is an implicitly acknowledged role for reducing the precursor frequency of donor antigen-specific lymphocytes when approaching the daunting goal of transplant tolerance.
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Affiliation(s)
- Eugenia Page
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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19
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McGee J, Mave V, Yau CL, Killackey M, Paramesh A, Buell J, Slakey DP, Hamm LL, Zhang R. Cytomegalovirus disease in African-American kidney transplant patients. Transpl Infect Dis 2013; 14:604-10. [PMID: 23228184 DOI: 10.1111/j.1399-3062.2012.00759.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 01/27/2012] [Accepted: 02/14/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) disease is a serious infection after kidney transplantation. The risk factors and the impact of CMV disease in African-American (AA) kidney transplant patients have not been well characterized. METHODS We performed a retrospective analysis on 448 AA patients transplanted between 1996 and 2005. A 3-month universal chemoprophylaxis with ganciclovir or valganciclovir was administered to CMV donor-positive/recipient-negative (D+/R-) patients and to those treated with anti-thymocyte globulin for rejection, but not routinely to those with other D/R serostatus. RESULTS A total of 31 AA patients (7%) developed clinical CMV disease. Compared with other D/R serostatus groups, the D+/R- group had the highest 3-year cumulative incidence of CMV disease (16.9% vs. 6.3% in D+/R+, 4.9% in D-/R+, and 2.4% in D-/R-). The D+/R- group also had the worst 3-year death-censored allograft survival (75% vs. 92% in D+/R+, 94% in D-/R+, and 96% in D-/R-, log-rank P = 0.01). Multivariate analysis found that D+/R- serostatus (odds ratio [OR] 5.4, 95% confidence interval [CI] 0.6-48.2, P = 0.003) and donor age > 60 years (OR 9.1, 95% CI 1.3-65, P = 0.03) were independent risk factors for CMV disease. CONCLUSION The D+/R- group has the highest incidence of CMV disease and the worst 3-year renal allograft survival despite 3-month universal prophylaxis. Prolonged chemoprophylaxis may be needed to prevent the late development of CMV disease and to improve allograft survival in the high-risk group of AA kidney transplant recipients.
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Affiliation(s)
- J McGee
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
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20
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21
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Patel R, Wiesner RH, Paya CV. Prophylaxis and Treatment of Cytomegalovirus Infection after Solid Organ Transplantation. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/bf03259312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Bugelski PJ, Martin PL. Concordance of preclinical and clinical pharmacology and toxicology of therapeutic monoclonal antibodies and fusion proteins: cell surface targets. Br J Pharmacol 2012; 166:823-46. [PMID: 22168282 PMCID: PMC3417412 DOI: 10.1111/j.1476-5381.2011.01811.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 10/14/2011] [Accepted: 11/28/2011] [Indexed: 12/20/2022] Open
Abstract
Monoclonal antibodies (mAbs) and fusion proteins directed towards cell surface targets make an important contribution to the treatment of disease. The purpose of this review was to correlate the clinical and preclinical data on the 15 currently approved mAbs and fusion proteins targeted to the cell surface. The principal sources used to gather data were: the peer reviewed Literature; European Medicines Agency 'Scientific Discussions'; and the US Food and Drug Administration 'Pharmacology/Toxicology Reviews' and package inserts (United States Prescribing Information). Data on the 15 approved biopharmaceuticals were included: abatacept; abciximab; alefacept; alemtuzumab; basiliximab; cetuximab; daclizumab; efalizumab; ipilimumab; muromonab; natalizumab; panitumumab; rituximab; tocilizumab; and trastuzumab. For statistical analysis of concordance, data from these 15 were combined with data on the approved mAbs and fusion proteins directed towards soluble targets. Good concordance with human pharmacodynamics was found for mice receiving surrogates or non-human primates (NHPs) receiving the human pharmaceutical. In contrast, there was poor concordance for human pharmacodynamics in genetically deficient mice and for human adverse effects in all three test systems. No evidence that NHPs have superior predictive value was found.
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Affiliation(s)
- Peter J Bugelski
- Biologics Toxicology, Janssen Research & Development, division of Johnson & Johnson Pharmaceutical Research & Development, LLC, Radnor, PA 19087, USA
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23
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Chouhan KK, Zhang R. Antibody induction therapy in adult kidney transplantation: A controversy continues. World J Transplant 2012; 2:19-26. [PMID: 24175192 PMCID: PMC3782231 DOI: 10.5500/wjt.v2.i2.19] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 03/14/2012] [Accepted: 03/20/2012] [Indexed: 02/05/2023] Open
Abstract
Antibody induction therapy is frequently used as an adjunct to the maintenance immunosuppression in adult kidney transplant recipients. Published data support antibody induction in patients with immunologic risk to reduce the incidence of acute rejection (AR) and graft loss from rejection. However, the choice of antibody remains controversial as the clinical studies were carried out on patients of different immunologic risk and in the context of varying maintenance regimens. Antibody selection should be guided by a comprehensive assessment of immunologic risk, patient comorbidities, financial burden as well as the maintenance immunosuppressives. Lymphocyte-depleting antibody (thymoglobulin, ATGAM or alemtuzumab) is usually recommended for those with high risk of rejection, although it increases the risk of infection and malignancy. For low risk patients, interleukin-2 receptor antibody (basiliximab or daclizumab) reduces the incidence of AR without much adverse effects, making its balance favorable in most patients. It should also be used in the high risk patients with other medical comorbidities that preclude usage of lymphocyte-depleting antibody safely. There are many patients with very low risk, who may be induced with intravenous steroids without any antibody, as long as combined potent immunosuppressives are kept as maintenance. In these patients, benefits with antibody induction may be too small to outweigh its adverse effects and financial cost. Rituximab can be used in desensitization protocols for ABO and/or HLA incompatible transplants. There are emerging data suggesting that alemtuzumab induction be more successful than other antibody for promoting less intensive maintenance protocols, such as steroid withdrawal, tacrolimus monotherapy or lower doses of tacrolimus and mycophenolic acid. However, the long-term efficacy and safety of these unconventional strategies remains unknown.
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Affiliation(s)
- Kanwaljit K Chouhan
- Kanwaljit K Chouhan, Rubin Zhang, Section of Nephrology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, United States
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24
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Bansal N, Arora A, Kumaran V, Mehta N, Varma V, Sharma P, Tyagi P, Sachdeva M, Kumar A. Atypical presentation of cytomegalovirus infection in a liver transplant patient. J Clin Exp Hepatol 2011; 1:207-9. [PMID: 25755388 PMCID: PMC3940243 DOI: 10.1016/s0973-6883(11)60236-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 11/29/2011] [Indexed: 12/12/2022] Open
Abstract
Cytomegalovirus (CMV) is the most common viral infection in solid organ transplant recipients. Symptomatic infection usually presents with fever, pneumonia, colitis, or cytopenia. We describe a case of symptomatic CMV infection in a liver transplant recipient presenting with atypical symptoms of only persistent nausea and vomiting, in the absence of classical symptoms and signs; thus, highlighting the importance of high index of suspicion of CMV in immunocompromised patients, keeping in mind the high morbidity and mortality associated with this disease.
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Key Words
- ALT, alanine aminotransferase
- ANA, anti-nuclear antibody
- ASMA, antibody smooth muscle antigen
- AST, aspartate aminotransferase
- Atypical presentation
- CMV, cytomegalovirus
- EBV, Epstein-Barr virus
- HBsAg, hepatitis B surface antigen
- HEV, hepatitis E virus
- INR, international normalized ratio
- anti-HBc, antibody-hepatitis B core
- anti-HCV, antibody-hepatitis C virus
- anti-LKM, antibody-liver–kidney-microsomal antigen
- cytomegalovirus
- i.v., intravenous
- immunosuppressed
- liver transplant
- transplantation
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Affiliation(s)
- Naresh Bansal
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Vinay Kumaran
- Department of Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Naimish Mehta
- Department of Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Vibha Varma
- Department of Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Praveen Sharma
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Pankaj Tyagi
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Munish Sachdeva
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi, India
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Torre-Cisneros J, Fariñas MC, Castón JJ, Aguado JM, Cantisán S, Carratalá J, Cervera C, Cisneros JM, Cordero E, Crespo-Leiro MG, Fortún J, Frauca E, Gavaldá J, Gil-Vernet S, Gurguí M, Len O, Lumbreras C, Marcos MÁ, Martín-Dávila P, Monforte V, Montejo M, Moreno A, Muñoz P, Navarro D, Pahissa A, Pérez JL, Rodriguez-Bernot A, Rumbao J, San Juan R, Santos F, Varo E, Zurbano F. GESITRA-SEIMC/REIPI recommendations for the management of cytomegalovirus infection in solid-organ transplant patients. Enferm Infecc Microbiol Clin 2011; 29:735-58. [DOI: 10.1016/j.eimc.2011.05.022] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 05/30/2011] [Indexed: 12/31/2022]
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26
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Focosi D, Maggi F, Pistello M, Boggi U, Scatena F. Immunosuppressive monoclonal antibodies: current and next generation. Clin Microbiol Infect 2011; 17:1759-68. [PMID: 21995285 DOI: 10.1111/j.1469-0691.2011.03677.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Monoclonal antibodies (mAbs) are well-established therapeutics, as evidenced by the large number of Food and Drug Administration-approved mAbs for the treatment of cancers, and inflammatory or autoimmune diseases, and for the prevention and treatment of solid organ transplant rejection. Although, in many cases, mAbs have improved patient survival, they are also associated with an increased incidence of opportunistic infections. We review here the current and next generation of mAbs and the risks that infectious disease specialists should be aware of.
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Affiliation(s)
- D Focosi
- U.O. Immuoematologia SSN, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
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27
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Ulrich F, Niedzwiecki S, Pascher A, Kohler S, Weiss S, Fikatas P, Schumacher G, May G, Reinke P, Neuhaus P, Tullius SG, Pratschke J. Long-term outcome of ATG vs. Basiliximab induction. Eur J Clin Invest 2011; 41:971-8. [PMID: 21382021 DOI: 10.1111/j.1365-2362.2011.02490.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND An evaluation of the long-term efficacy and incidence of adverse events after induction therapy with antithymocyte globulin (ATG) vs. Basiliximab in renal transplant patients. METHODS Sixty recipients receiving ATG induction and a dual immunosuppression with Tacrolimus and steroids were compared retrospectively with 60 patients treated with Basiliximab. The following characteristics were evaluated: concomitant immunosuppression, recipient age, donor age, time on dialysis, cold ischemia time, year of transplantation and HLA mismatches. RESULTS The 6-year patient survival in the ATG group was 91·7% compared to 85% in the Basiliximab group (not significant, n.s.). Graft survival at 6 years was 89·7% and. 83·6% in the ATG and the Basiliximab group (n.s.), respectively. Incidence of biopsy proven acute rejection episodes (33·3% vs. 26·7%) and delayed graft function (30% vs. 33·3%) were similar in both groups. Kidney function was not significantly different at 1 and 6 years. CMV infections were more prevalent in the ATG arm (22% vs. 5%; P = 0·05), and a significantly higher rate of haematological complications was observed following ATG induction. CONCLUSIONS ATG induction was associated with an improved (but n.s.) trend in patient and graft survival. Patients induced with ATG had a higher rate of CMV infections and haematological complications.
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Affiliation(s)
- Frank Ulrich
- Department of Visceral, General and Transplantation Surgery, Charité Universitätsmedizin Berlin, Germany.
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28
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De Keyzer K, Van Laecke S, Peeters P, Vanholder R. Human cytomegalovirus and kidney transplantation: a clinician's update. Am J Kidney Dis 2011; 58:118-26. [PMID: 21684438 DOI: 10.1053/j.ajkd.2011.04.010] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 04/13/2011] [Indexed: 01/15/2023]
Abstract
Infection with human cytomegalovirus (CMV) is an important cause of morbidity and mortality in kidney transplant recipients. CMV disease is diagnosed based on the detection of viral replication by phosphoprotein 65 antigenemia or CMV DNA polymerase chain reaction in combination with typical signs and symptoms. Risk factors include CMV-seronegative recipients receiving a CMV-seropositive transplant, older donor age, exposure to cyclosporine and/or antilymphocyte antibody, rejection episodes, and impaired transplant function. Current preventive strategies in kidney transplant recipients include pre-emptive therapy with valganciclovir or intravenous ganciclovir and universal prophylaxis with valacyclovir, valganciclovir, or ganciclovir for 3-6 months after kidney transplantation and for 1-3 months after treatment with antilymphocyte antibody. Established disease should be treated using either intravenous ganciclovir or oral valganciclovir until CMV replication can no longer be detected. In addition to direct effects, CMV infection also induces a wide range of indirect effects, such as decreased transplant and recipient survival and susceptibility to rejection and opportunistic infections. In this review, we highlight the most relevant topics on CMV and kidney transplantation based on current evidence and guidelines.
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29
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Mahmud N, Klipa D, Ahsan N. Antibody immunosuppressive therapy in solid-organ transplant: Part I. MAbs 2011; 2:148-56. [PMID: 20150766 DOI: 10.4161/mabs.2.2.11159] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Currently, a wide variety of both polyclonal and monoclonal antibodies are being routinely utilized to prevent and treat solid organ rejection. More commonly, these agents are also administered in order to delay introduction of calcineurin inhibitors, especially in patients with already compromised renal function. While these antibody therapies dramatically reduced the incidence of acute rejection episodes and improved both short and long-term graft survival, they are also associated with an increased incidence of opportunistic infections and neoplastic complications. Therefore, effective patient management must necessarily balance these risks against the potential benefits of the therapy.
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30
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Tayebi-Khosroshahi H, Makhdami N, Heris HK, Habibzadeh A, Zadimani A, Badrogli N. Universal prophylaxis with gancyclovir preparation is not necessary in our kidney allograft recipients. Transplant Proc 2011; 43:547-50. [PMID: 21440757 DOI: 10.1016/j.transproceed.2011.01.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is a common cause of morbidity, graft loss, and mortality among kidney recipients due to its direct and indirect influences on organs and systems. In this study, we evaluated CMV infection in transplant recipients in Iran. MATERIALS AND METHODS We performed a retrospective study of 104 renal allograft recipients and their donors transplanted between January 2005 and January 2010. We included all patients (recipients and donors) with least one valid laboratory result for CMV immunoglobulin (Ig)G and CMV IgM. We evaluated the occurrence of CMV disease in allograft recipients in at least the first 3 years after renal transplantation. RESULTS Fifty-seven renal allograft recipients (54.8%) were males and 47 (45.2%) were females. The overall mean (±standard error) age was 40.32±13.30 years. CMV IgG was positive in 95 cases (91.3%), negative in 9 (8.7%). Serologically, 76.9% patients were D+/R+ 14.4% D-/R+, and 8.7% D+R-. Due to the proccurrence of rejection rendering them high-risk patients for CMV infection about 15% of subjects were treated with anti thymocyte globulin (ATG) followed by prophylactic intravenous gancyclovir for 2 weeks, at doses based on allograft function. Confirmed CMV infection and CMV disease occurred in less than 5% of recipients in the first year after transplantation. About 6% of renal allograft recipients died due to infections during the first 3 years posttransplantation but CMV disease was not confirmed in these patients. CONCLUSION Due to the living donor-based renal transplantation program, the selection of low-risk patients (panel-reactive antibodies 30%), the low percent of D+/R- patients (8.7%) and the low use of ATG for induction therapy in the Iranian model, universal prophylaxis with gancyclovir is not routinely recommended for our cases.
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Affiliation(s)
- H Tayebi-Khosroshahi
- Kidney Transplant Center, Department of Internal Medicine, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
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31
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Teschner S, Burst V. Leflunomide: a drug with a potential beyond rheumatology. Immunotherapy 2011; 2:637-50. [PMID: 20874647 DOI: 10.2217/imt.10.52] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Leflunomide, an inhibitor of the dihydroorotase dehydrogenase and thereby pyrimidine synthesis, was introduced and licensed for the treatment of rheumatoid arthritis in 1998. In the following years, its antiviral properties were discovered and the drug was used in solid organ transplantation for polyomavirus type BK or cytomegalovirus infection. Owing to its long half-life and weak interaction with the cytochrome system, special considerations apply in the use of this drug. This article summarizes the clinical experience with leflunomide in rheumatology and in the evolving field of transplantation.
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Affiliation(s)
- Sven Teschner
- Transplant Center Cologne, University of Cologne, 50924 Cologne, Germany.
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Impact of prophylactic versus preemptive valganciclovir on long-term renal allograft outcomes. Transplantation 2010; 90:412-8. [PMID: 20555305 DOI: 10.1097/tp.0b013e3181e81afc] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Both prophylactic and preemptive oral valganciclovir therapy are effective for the management of cytomegalovirus (CMV) postrenal transplantation in the short term. The long-term effect of either strategy is less well defined. METHODS We analyzed the data on 115 adult recipients previously enrolled in a prospective randomized controlled trial of prophylaxis versus preemptive therapy for CMV. The primary outcome was a composite of freedom from acute rejection, graft loss, or death. Secondary outcomes included individual primary outcomes, posttransplant cardiovascular events, new-onset diabetes mellitus after transplantation, achievement of goal blood pressure, change in body mass index, interstitial fibrosis/tubular atrophy, and change in renal function. The analysis period was a minimum of 48-month posttransplant or a date of death or graft loss, whichever was earlier. RESULTS The primary outcome was similar between groups (83% prophylactic vs. 81% preemptive, P=0.754). The secondary outcomes showed similarities between the prophylactic and preemptive groups. Four patients in the prophylactic group (8%) compared with none in the preemptive group (0%) died with a functioning graft, P=0.043. CONCLUSIONS Within the limitations of sample size, our data suggest that either strategy for the management of CMV immediately after transplantation seems effective for patient and graft survival in the long term. CMV management is one of the many therapeutic strategies incorporated into a renal transplantation protocol, which often differs among institutions, and the decision as to which approach to use remains center- and resource-specific. The increased incidence of death in the prophylactic group requires further investigation.
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33
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Fishman JA, Issa NC. Infection in Organ Transplantation: Risk Factors and Evolving Patterns of Infection. Infect Dis Clin North Am 2010; 24:273-83. [DOI: 10.1016/j.idc.2010.01.005] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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34
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Preemptive Versus Sequential Prophylactic-Preemptive Treatment Regimens for Cytomegalovirus in Renal Transplantation: Comparison of Treatment Failure and Antiviral Resistance. Transplantation 2010; 89:320-6. [DOI: 10.1097/tp.0b013e3181bc0301] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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35
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Abstract
The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.
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36
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TNF-alpha signaling is not required for in vivo transcriptional reactivation of latent murine cytomegalovirus. Transplantation 2009; 88:640-5. [PMID: 19741460 DOI: 10.1097/tp.0b013e3181b242a7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Reactivation of cytomegalovirus (CMV) is frequently observed in recipients of solid organs and bone marrow transplants and is associated with increased risk of acute and chronic allograft rejection, opportunistic infection, graft failure, and patient mortality. The molecular mechanisms by which reactivation occurs are not well understood. Previous studies have suggested that tumor necrosis factor (TNF)-alpha, which is induced by allogeneic transplantation, may have a role in reactivation of CMV through activation of nuclear factor kappa-light-chain-enhancer of activated B cells and subsequent transcriptional reactivation of immediate early (ie) gene expression. METHODS AND RESULTS We have tested the role of TNF-alpha in the reactivation of CMV directly by testing whether TNF-alpha is required to initiate transcription of ie gene expression in a murine model of allogeneic transplantation of kidneys latently infected with mouse CMV. CONCLUSIONS Our studies show that although TNF-alpha seems to be sufficient, it is not required for initiating transcription of ie gene expression in this model, suggesting that both TNF-alpha-dependent and -independent pathways play an important role in the reactivation of latent CMV infection.
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37
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A Hybrid Strategy for the Prevention of Cytomegalovirus-Related Complications in Pediatric Liver Transplantation Recipients. Transplantation 2009; 87:1318-24. [DOI: 10.1097/tp.0b013e3181a19cda] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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38
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39
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Nogueira E, Ozaki KS, Tomiyama H, Câmara NOS, Granato CFH. Clinical correlations of human cytomegalovirus strains and viral load in kidney transplant recipients. Int Immunopharmacol 2009; 9:26-31. [DOI: 10.1016/j.intimp.2008.08.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Revised: 07/04/2008] [Accepted: 08/26/2008] [Indexed: 11/29/2022]
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40
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41
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Snydman D. Editorial Commentary:Persistent Clinical Impact of Cytomegalovirus in Organ Transplantation. Clin Infect Dis 2008; 47:883-4. [DOI: 10.1086/591533] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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42
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San Juan R, Aguado J, Lumbreras C, Fortun J, Muñoz P, Gavalda J, Lopez‐Medrano F, Montejo M, Bou G, Blanes M, Ramos A, Moreno A, Torre‐Cisneros J, Carratalá J. Impact of Current Transplantation Management on the Development of Cytomegalovirus Disease after Renal Transplantation. Clin Infect Dis 2008; 47:875-82. [DOI: 10.1086/591532] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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43
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Haustein SV, Kolterman AJ, Sundblad JJ, Fechner JH, Knechtle SJ. Nonhuman primate infections after organ transplantation. ILAR J 2008; 49:209-19. [PMID: 18323582 DOI: 10.1093/ilar.49.2.209] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Nonhuman primates, primarily rhesus macaques (Macaca mulatta), cynomolgus macaques (Macaca fascicularis), and baboons (Papio spp.), have been used extensively in research models of solid organ transplantation, mainly because the nonhuman primate (NHP) immune system closely resembles that of the human. Nonhuman primates are also frequently the model of choice for preclinical testing of new immunosuppressive strategies. But the management of post-transplant nonhuman primates is complex, because it often involves multiple immunosuppressive agents, many of which are new and have unknown effects. Additionally, the resulting immunosuppression carries a risk of infectious complications, which are challenging to diagnose. Last, because of the natural tendency of animals to hide signs of weakness, infectious complications may not be obvious until the animal becomes severely ill. For these reasons the diagnosis of infectious complications is difficult among post-transplant NHPs. Because most nonhuman primate studies in organ transplantation are quite small, there are only a few published reports concerning infections after transplantation in nonhuman primates. Based on our survey of these reports, the incidence of infection in NHP transplant models is 14%. The majority of reports suggest that many of these infections are due to reactivation of viruses endemic to the primate species, such as cytomegalovirus (CMV), polyomavirus, and Epstein-Barr virus (EBV)-related infections. In this review, we address the epidemiology, pathogenesis, role of prophylaxis, clinical presentation, and treatment of infectious complications after solid organ transplantation in nonhuman primates.
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Affiliation(s)
- Silke V Haustein
- Division of Organ Transplantation, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53792, USA
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44
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TNF Receptor Independent Activation of the Cytomegalovirus Major Immediate Early Enhancer in Response to Transplantation. Transplantation 2008; 85:1039-45. [DOI: 10.1097/tp.0b013e318168449c] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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45
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Arthurs SK, Eid AJ, Pedersen RA, Kremers WK, Cosio FG, Patel R, Razonable RR. Delayed-onset primary cytomegalovirus disease and the risk of allograft failure and mortality after kidney transplantation. Clin Infect Dis 2008; 46:840-6. [PMID: 18260785 DOI: 10.1086/528718] [Citation(s) in RCA: 201] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND During the contemporary era of antiviral prophylaxis, the impact of delayed-onset primary cytomegalovirus (CMV) disease on the outcome of kidney transplantation is not known. We evaluated the incidence, clinical features, risk factors, and outcomes of CMV disease among high-risk kidney transplant recipients. METHODS The medical records of CMV-seronegative recipients of kidney transplants from CMV-seropositive donors were reviewed. Cox proportional hazards regression was used to identify factors associated with CMV disease and to assess its impact on allograft loss and mortality. RESULTS None of the 176 CMV-seronegative recipients of kidney transplants from CMV-seropositive donors developed breakthrough CMV disease during a median of 92 days (interquartile range, 90-92 days) of oral ganciclovir or valganciclovir prophylaxis. Thereafter, 51 patients (29%) developed CMV disease at a median of 61 days (interquartile range, 40-143 days) after stopping antiviral prophylaxis. Early-onset bacterial and fungal infection (hazard ratio, 3.61; 95% confidence interval, 1.78-7.33; p < .001) and a Charlson comorbidity index > or =3 (hazard ratio, 2.21; 95% confidence interval, 1.15-4.22; p = .011) were associated with a higher risk of delayed-onset primary CMV disease, and postrejection antiviral prophylaxis (hazard ratio, 0.29; 95% confidence interval, 0.09-0.94; P = .039) was associated with a lower risk of such CMV disease. A time-dependent Cox regression analysis revealed a statistically significant association between tissue-invasive CMV disease and allograft loss or mortality (hazard ratio, 2.85; 95% confidence interval, 1.22-6.67; P = .016). CONCLUSION This study of a large cohort of CMV-seronegative recipients of kidney transplants from CMV-seropositive donors illustrates the ongoing challenge of delayed-onset primary CMV disease and its impact on transplantation outcomes despite antiviral prophylaxis. Better strategies for CMV disease prevention after kidney transplantation are warranted.
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Affiliation(s)
- Supha K Arthurs
- Divisions of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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46
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Rubin RH. The pathogenesis and clinical management of cytomegalovirus infection in the organ transplant recipient: the end of the 'silo hypothesis'. Curr Opin Infect Dis 2007; 20:399-407. [PMID: 17609600 DOI: 10.1097/qco.0b013e328285a358] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Cytomegalovirus infection is initiated when tumor necrosis factor binds to the cytomegalovirus receptors of latently infected cells, resulting in the reactivation of the virus and the production of clinical disease of two types: direct infection causing pneumonia, mononucleosis, colitis and other viral-related syndromes, and indirect infection in which an array of cytokines are released by the host that produce much the same effect as does the rejection process. RECENT FINDINGS These effects fall into three categories: allograft injury, an increase in superinfection with opportunistic pathogens and an increase in the incidence of B cell lymphoproliferative disease. Other factors that modulate the clinical impact of reactivated cytomegalovirus in the transplant patient include the past experience of the host with the virus (primary infection, donor seropositive and recipient seronegative), the degree of major histocompatibility complex mismatch, the viral burden and the amount of calcineurin inhibitor the patient receives. SUMMARY Optimal therapy for diagnosing, treating and preventing these indirect effects still remains to be defined; the direct effects, in contrast, are well managed with valganciclovir.
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Affiliation(s)
- Robert H Rubin
- Harvard Medical School, Center for Experimental Pharmacology and Therapeutics, Harvard-MIT Division of Health Sciences and Technology, Division of Infectious Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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47
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Avery RK. Management of late, recurrent, and resistant cytomegalovirus in transplant patients. Transplant Rev (Orlando) 2007. [DOI: 10.1016/j.trre.2007.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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48
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Scheinberg P, Fischer SH, Li L, Nunez O, Wu CO, Sloand EM, Cohen JI, Young NS, John Barrett A. Distinct EBV and CMV reactivation patterns following antibody-based immunosuppressive regimens in patients with severe aplastic anemia. Blood 2006; 109:3219-24. [PMID: 17148582 PMCID: PMC1852232 DOI: 10.1182/blood-2006-09-045625] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The natural history of EBV and CMV reactivation and the potential for serious complications following antibody-based immunosuppressive treatment for bone marrow failure syndromes in the absence of transplantation is not known. We monitored blood for EBV and CMV reactivation by polymerase chain reaction (PCR) weekly in 78 consecutive patients (total of 99 immunosuppressive courses) with aplastic anemia. Four regimens were studied: (1) HC, horse ATG/cyclosporine; (2) HCS, horse ATG/CsA/sirolimus; (3) RC, rabbit ATG/CsA; and (4) CP, alemtuzumab. There were no cases of EBV or CMV disease, but EBV reactivation occurred in 82 (87%) of 94 and CMV reactivation in 19 (33%) of 57 seropositive patients after starting immunosuppression. The median peak EBV copies were higher in the RC group when compared with HC, HCS, and alemtuzumab (P < .001). The median duration of PCR positivity for EBV was higher in the RC group compared with HC, HCS, and alemtuzumab (P = .001). Subclinical reactivation of both EBV and CMV is common and nearly always self-limited in patients with bone marrow failure receiving immunosuppression; different regimens are associated with different intensity of immunosuppression as measured by viral load and lymphocyte count; and viral reactivation patterns differ according to immunosuppressive regimens.
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MESH Headings
- Adolescent
- Adult
- Aged
- Alemtuzumab
- Anemia, Aplastic/blood
- Anemia, Aplastic/complications
- Anemia, Aplastic/drug therapy
- Anemia, Aplastic/virology
- Animals
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/administration & dosage
- Antibodies, Neoplasm/adverse effects
- Antilymphocyte Serum/administration & dosage
- Antilymphocyte Serum/adverse effects
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Child
- Child, Preschool
- Cyclosporine/administration & dosage
- Cyclosporine/adverse effects
- Cytomegalovirus
- Cytomegalovirus Infections/blood
- Cytomegalovirus Infections/chemically induced
- DNA, Viral/blood
- Epstein-Barr Virus Infections/blood
- Epstein-Barr Virus Infections/chemically induced
- Female
- Herpesvirus 4, Human
- Horses
- Humans
- Immunosuppression Therapy/adverse effects
- Immunosuppressive Agents/administration & dosage
- Immunosuppressive Agents/adverse effects
- Male
- Middle Aged
- Monitoring, Physiologic
- Polymerase Chain Reaction
- Rabbits
- Sirolimus/administration & dosage
- Sirolimus/adverse effects
- Time Factors
- Virus Activation/drug effects
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Affiliation(s)
- Phillip Scheinberg
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA.
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49
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Khoury JA, Storch GA, Bohl DL, Schuessler RM, Torrence SM, Lockwood M, Gaudreault-Keener M, Koch MJ, Miller BW, Hardinger KL, Schnitzler MA, Brennan DC. Prophylactic versus preemptive oral valganciclovir for the management of cytomegalovirus infection in adult renal transplant recipients. Am J Transplant 2006; 6:2134-43. [PMID: 16780548 DOI: 10.1111/j.1600-6143.2006.01413.x] [Citation(s) in RCA: 245] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Prophylaxis reduces cytomegalovirus (CMV) disease, but is associated with increased costs and risks for side effects, viral resistance and late onset CMV disease. Preemptive therapy avoids drug costs but requires frequent monitoring and may not prevent complications of asymptomatic CMV replication. Kidney transplant recipients at risk for CMV (D+/R-, D+/R+, D-/R+) were randomized to prophylaxis (valganciclovir 900 mg q.d. for 100 days, n=49) or preemptive therapy (900 mg b.i.d. for 21 days, n=49) for CMV DNAemia (CMV DNA level>2000 copies/mL in >or=1 whole blood specimens by quantitative PCR) assessed weekly for 16 weeks and at 5, 6, 9 and 12 months. More patients in the preemptive group, 29 (59%) than in the prophylaxis group, 14 (29%) developed CMV DNAemia, p=0.004. Late onset of CMV DNAemia (>100 days after transplant) occurred in 11 (24%) randomized to prophylaxis, and none randomized to preemptive therapy. Symptomatic infection occurred in five patients, four (3 D+/R- and 1 D+/R+) in the prophylactic group and one (D+/R-) in the preemptive group. Peak CMV levels were highest in the D+/R- patients. Both strategies were effective in preventing symptomatic CMV. Overall costs were similar and insensitive to wide fluctuations in costs of either monitoring or drug.
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Affiliation(s)
- J A Khoury
- Department of Internal Medicine, Washington University School of Medicine, and Transplant Office, Barnes-Jewish Hospital, St. Louis, Missouri, USA
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50
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Strippoli GF, Hodson EM, Jones CJ, Craig JC. Pre-emptive treatment for cytomegalovirus viraemia to prevent cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2006:CD005133. [PMID: 16437521 DOI: 10.1002/14651858.cd005133.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a significant cause of morbidity and mortality in solid organ transplant recipients. Pre-emptive treatment with antiviral agents of patients with CMV viraemia has been widely adopted as an alternative to routine prophylaxis to prevent CMV disease. OBJECTIVES This review was conducted to evaluate the efficacy of pre-emptive treatment in preventing symptomatic CMV disease. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library Issue 2, 2005), MEDLINE (1966 to February 2005), EMBASE (1980 to February 2005) and reference lists and conference proceedings were searched. SELECTION CRITERIA We included randomised controlled trials (RCTs) of pre-emptive treatment versus placebo, no treatment or antiviral prophylaxis in solid organ transplant recipients. DATA COLLECTION AND ANALYSIS Two authors assessed the quality and extracted all data. Analysis was with a random-effects model and results expressed as relative risk (RR) and 95% confidence intervals (CI). MAIN RESULTS Ten eligible trials (476 patients) were identified, six of pre-emptive treatment versus placebo or treatment of CMV when disease occurred (standard care), three of pre-emptive treatment versus antiviral prophylaxis and one of oral versus intravenous pre-emptive treatment. Compared with placebo or standard care, pre-emptive treatment significantly reduced the risk of CMV disease (six trials, 288 patients: RR 0.29, 95% CI 0.11 to 0.80) but not acute rejection (three trials, 185 patient: RR 1.06, 95% CI 0.64 to 1.76) or all-cause mortality (two trials, 176 patients: RR 1.23, 95% CI 0.35 to 4.30). Comparative trials of pre-emptive therapy versus prophylaxis showed no significant difference in the risks of CMV disease, acute rejection or all-cause mortality. AUTHORS' CONCLUSIONS Few RCTs have evaluated the effects of pre-emptive therapy to prevent CMV disease. Pre-emptive therapy is effective compared with placebo or standard care, but additional head-to-head trials are required to determine the relative benefits and harms of pre-emptive therapy and prophylaxis to prevent CMV disease in solid organ transplant recipients.
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Affiliation(s)
- G F Strippoli
- NHMRC Centre for Clinical Research Excellence in Renal Medicine, Cochrane Renal Group, Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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