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Jung H, Dhatt R, Rassekh SR, Heran MKS. Intra-arterial methylprednisolone for pediatric gastrointestinal post-transplant lymphoproliferative disorder. Pediatr Hematol Oncol 2024; 41:240-245. [PMID: 37861406 DOI: 10.1080/08880018.2023.2267612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Hoyoung Jung
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ravjot Dhatt
- Department of Radiology, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - S Rod Rassekh
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manraj K S Heran
- Department of Radiology, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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2
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Pediatric post-transplant lymphoproliferative disorder identified on random gastrointestinal biopsies shows non-mass-forming PTLD with clonal plasma cells: report of 2 cases. J Hematop 2020. [DOI: 10.1007/s12308-020-00402-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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3
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The Morphologic Features of Primary Epstein-Barr Virus Infection in the Gastrointestinal Tract. Am J Surg Pathol 2019; 43:1253-1263. [DOI: 10.1097/pas.0000000000001319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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4
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Karakoyun M, Önen Ş, Baran M, Çakır M, Ecevit ÇÖ, Kılıç M, Kantar M, Aksoylar S, Özgenç F, Aydoğdu S. Post-transplant malignancies in pediatric liver transplant recipients: Experience of two centers in Turkey. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2018; 29:89-93. [PMID: 29391313 PMCID: PMC6322611 DOI: 10.5152/tjg.2017.17089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 08/15/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND/AIMS A liver transplant is the preferred treatment for patients with end-stage liver disease, as it usually results in longterm survival. However, due to the use of chronic immunosuppressive therapy, which is necessary to prevent rejection, de novo cancer is a major risk after transplantation. The aim of this study was to assess the incidence of post-transplant malignancies in children after liver transplantations. MATERIALS AND METHODS The study group consisted of 206 liver transplant recipients, with no history of cancer, including hepatocellular carcinoma, in two liver transplantation centers in Turkey between 1997 and 2015. Data were obtained from patient's data chart. RESULTS In the study group, de novo cancer was diagnosed in 13 of the 206 patients. Post-transplant lymphoproliferative disease (PTLD) occurred in seven (53.8%) patients and other malignancies in six of the 13 patients. The types of PTLD were as follows: B-cell origin (n=2), Epstein-Barr virus (EBV)-related (n=2), T-cell origin (n=1), and Hodgkin's lymphoma (n=2). EBV DNA was isolated from seven patients, three of whom developed PTLD. The others developed Kaposi's sarcomas, Burkitt's lymphomas, cutaneous large-cell lymphomas, Hodgkin's lymphomas, and liver sarcomas. CONCLUSION After transplantation, immunosuppressive treatment is unavoidable, increasing the risk of malignancies. However, a close follow-up and periodic screening can reduce cancer-related mortality and morbidity.
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Affiliation(s)
- Miray Karakoyun
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Şebnem Önen
- Department of Pediatrics, Ege University School of Medicine, İzmir, Turkey
| | - Maşallah Baran
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Katip Celebi University School of Medicine, İzmir, Turkey
| | - Murat Çakır
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Karadeniz Technical University School of Medicine, Trabzon Turkey
| | - Çiğdem Ömür Ecevit
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Prof. Dr. Behçet Uz Children’s Hospital, İzmir, Turkey
| | - Murat Kılıç
- Department of Transplantation and General Surgery, Kent Hospital, İzmir, Turkey
| | - Mehmet Kantar
- Department of Pediatric Oncology, Ege University School of Medicine, İzmir, Turkey
| | - Serap Aksoylar
- Department of Pediatric Oncology, Ege University School of Medicine, İzmir, Turkey
| | - Funda Özgenç
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ege University School of Medicine, İzmir, Turkey
| | - Sema Aydoğdu
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ege University School of Medicine, İzmir, Turkey
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Huang JG, Tan MYQ, Quak SH, Aw MM. Risk factors and clinical outcomes of pediatric liver transplant recipients with post-transplant lymphoproliferative disease in a multi-ethnic Asian cohort. Transpl Infect Dis 2017; 20. [PMID: 29071779 DOI: 10.1111/tid.12798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 06/20/2017] [Accepted: 07/09/2017] [Indexed: 11/30/2022]
Affiliation(s)
- James Guoxian Huang
- Khoo Teck Puat - National University Children's Medical Institute; National University Health System; Singapore
- Department of Paediatrics; Yong Loo Lin School of Medicine; National University of Singapore; Singapore
| | - Mervin Ye Qing Tan
- Yong Loo Lin School of Medicine; National University of Singapore; Singapore
| | - Seng-Hock Quak
- Khoo Teck Puat - National University Children's Medical Institute; National University Health System; Singapore
- Department of Paediatrics; Yong Loo Lin School of Medicine; National University of Singapore; Singapore
| | - Marion Margaret Aw
- Khoo Teck Puat - National University Children's Medical Institute; National University Health System; Singapore
- Department of Paediatrics; Yong Loo Lin School of Medicine; National University of Singapore; Singapore
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Malignancies in pediatric solid organ transplant recipients: epidemiology, risk factors, and prophylactic approaches. Curr Opin Organ Transplant 2010; 15:621-7. [DOI: 10.1097/mot.0b013e32833e1673] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
PURPOSE OF REVIEW To provide a general understanding of Clostridium difficile infection with a focus on recent publications that evaluate the disease in solid organ transplant recipients. RECENT FINDINGS The incidence of C. difficile infection is increasing worldwide. Epidemics due to a hypervirulent C. difficile strain are associated with an escalating severity of disease. New evidence further supports basing initial treatment choice on disease severity. SUMMARY C. difficile is a significant pathogen in solid organ transplant recipients. Multiple risk factors are found in this population that may result in more severe disease. A high index of suspicion is necessary for the early diagnosis and treatment of C. difficile infection in transplant recipients. Metronidazole and vancomycin show equivalent efficacy in the treatment for mild-to-moderate disease, but vancomycin has demonstrated superiority in the treatment of severe disease. Surgical intervention is also an important consideration in the treatment of solid organ transplant recipients with severe colitis. Rigorous infection control practices are essential for preventing the spread of C. difficile within the hospital environment.
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8
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Ju MK, Joo DJ, Kim SJ, Huh KH, Kim MS, Jeon KO, Kim HJ, Kim SI, Kim YS. Chronologically different incidences of post-transplant malignancies in renal transplant recipients: single center experience. Transpl Int 2009; 22:644-53. [PMID: 19220824 DOI: 10.1111/j.1432-2277.2009.00846.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The incidence of malignancy in transplant recipients is known to be higher than the same in the general population. However, the types of malignancies vary geographically, and the relative risks (RR) for malignancy in transplant recipients, compared with that of the general population, also differ country-by-country. In this study, we investigated the incidence and characteristics of malignancies after renal transplantation in a single center. A total of 2630 renal recipients who underwent surgery between April 1979 and June 2007 were enrolled in this study. The cumulative and interval incidences of malignancies were calculated for every 3 years post-transplantation. One-hundred ninety cases of postrenal transplant malignancies among 177 recipients (6.73%) were reported until 2007. The post-transplant malignancies were detected from 6 to 290 months after transplantation, with a mean duration of 112.6 +/- 66.0 months. Skin cancer [35 (18.4%)] was the most common post-transplant malignancy, followed by thyroid [25 (13.2%)], stomach [22 (11.6%)], colorectal [22 (11.6%)], and urologic cancers [19 (10.0%)]. As the post-transplant period increased, the interval incidence of malignancy correspondingly increased. Virus-related malignancies, such as Kaposi's sarcoma and cervical cancer, developed earlier within the post-transplant period, while urologic cancer, colorectal cancer developed late in the post-transplant period. The recipient's age at the time of transplantation was the sole independent risk factor for post-transplant malignancy based on the multivariate analysis (RR = 2.723, P < 0.0001 in the >50-year-old age group). We should establish strategies for post-transplant malignancy-screening based on the recipient's age at the time of transplantation, the post-transplant interval, and the national trend of post-transplant malignancy.
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Affiliation(s)
- Man Ki Ju
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Schubert S, Abdul-Khaliq H, Lehmkuhl HB, Yegitbasi M, Reinke P, Kebelmann-Betzig C, Hauptmann K, Gross-Wieltsch U, Hetzer R, Berger F. Diagnosis and treatment of post-transplantation lymphoproliferative disorder in pediatric heart transplant patients. Pediatr Transplant 2009; 13:54-62. [PMID: 18518912 DOI: 10.1111/j.1399-3046.2008.00969.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PTLD is a severe complication in transplant recipients. Detection of increased EBV load in the peripheral blood acts as a surrogate marker for increased risk of PTLD development. We analyzed the time course of the disease, its severity, the organs involved, and mortality rates in our institutional experience of pediatric heart transplantation. This paper identifies risk factors for PTLD and describes the different ways of diagnosing and treating the disease. PTLD was screened for in 146 pediatric heart transplant patients using a retrospective analysis in patients who received transplantation before 1998. Prospective determination was performed in 72/146 patients transplanted after 1998 within the post-transplant follow-up. The occurrence of PTLD with all interventions, including tapering of immunosuppression, surgery, viral monitoring, and antiviral interventions, was recorded. PTLD was diagnosed in 12/147 (8.2%) children at a mean age of 7.2 +/- 3.3 yr after a mean post-transplant period of 3.2 +/- 2.2 yr. PTLD manifested in: lymph nodes (n = 4), intestine (n = 3), tonsils and adenoids (n = 2), eye (n = 2), and lung (n = 1). It was diagnosed in 7/12 as a monomorphic B-cell lymphoma and in four patients as a monomorphic Burkitt lymphoma, a polymorphic B-cell lymphoma, a T-cell rich or angiocentric lymphoma (Liebow) and as reactive plasmacytic hyperplasia (early lesion), respectively. Histology was not possible in one patient with ocular manifestation. EBV association was 83%. Risk factors in the comparison with patients without PTLD were age at time of Tx, primary EBV infection after Tx, use of Azathioprine and >or=3 doses of ATG. CMV mismatch and CMV infection, rejection episodes and steroids were not risk factors. Despite reduction of immunosuppression, treatment consisted of surgical procedures to remove tumor masses (n = 6), Rituximab (n = 5), polychemotherapy (n = 3), antiviral (n = 1) and autologous T-cell therapy (n = 1). All patients demonstrated full remission without death related to PTLD or treatment at 3.9 (1.3-6.2) yr median follow-up time. The manifestation of PTLD in pediatric heart transplant recipients is associated with EBV infection and is predominantly in the form of a B-cell lymphoma. A tight and specific follow-up including early assessment of immunity status and specific therapeutic intervention to improve cellular immunity is warranted and may contribute to a significant reduction of PTLD-related morbidity and mortality.
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Affiliation(s)
- S Schubert
- Department of Congenital Heart Defects/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany.
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11
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Transplantation et cancers. ONCOLOGIE 2008. [DOI: 10.1007/s10269-008-0909-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Schubert S, Renner C, Hammer M, Abdul-Khaliq H, Lehmkuhl HB, Berger F, Hetzer R, Reinke P. Relationship of immunosuppression to Epstein-Barr viral load and lymphoproliferative disease in pediatric heart transplant patients. J Heart Lung Transplant 2008; 27:100-5. [PMID: 18187094 DOI: 10.1016/j.healun.2007.09.027] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 09/24/2007] [Accepted: 09/24/2007] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disease (PTLD) is a severe complication in transplant recipients. Detection of increased Epstein-Barr viral (EBV) load in the peripheral blood acts as a surrogate marker for increased risk of PTLD development. We prospectively monitored EBV load, immunosuppression and PTLD in pediatric heart transplant (HTx) patients to determine risk factors for an increased EBV load and risk of PTLD. METHODS Forty-one pediatric heart transplant recipients were included and underwent prospective monitoring of their immunosuppression and ethylene-diamine tetraacetic acid (EDTA) blood sampling for EBV load (copies/microg DNA) measurement using quantitative real-time polymerase chain reaction (PCR; TaqMan) during January 2001 to December 2006. RESULTS EBV load was measurable in 70% and was significantly increased (>2,000 copies/microg DNA) in 35% of the patients, with a median EBV load of 5,100 (range 0 to 50,665 copies/microg DNA). Increased EBV load was detected in patients receiving CsA-azathioprine or more than two doses of anti-thymocyte globulin (ATG) and in those <10 years of age, without any significant differences in CsA blood levels. Lowest or negative EBV load was measured in patients receiving CsA-mycophenolate mofetil (MMF) or CsA only. CsA blood levels were not predictable for increased EBV load or PTLD. Six patients developed a EBV-associated B-cell lymphoma (PTLD), among whom 4 (67%) were receiving CsA-azathioprine. CONCLUSIONS Frequent EBV load monitoring identifies patients at high risk for PTLD development. Azathioprine and ATG are major risk factors for increased EBV load and PTLD and patients may benefit from a change of immunosuppression in addition to pre-emptive anti-viral or anti-tumor strategies.
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Affiliation(s)
- Stephan Schubert
- Department of Congenital Heart Defects/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Germany.
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Gökçe S, Süoğlu OD, Sökücü S, Gün F, Emiroğlu H, Celik A, Doğan O, Cevikbaş U. Primary nonresponse to anti-cd20 therapy in gastrointestinal posttransplant lymphoproliferative disorder. J Pediatr Gastroenterol Nutr 2006; 42:316-20. [PMID: 16540802 DOI: 10.1097/01.mpg.0000189333.85268.b9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Selim Gökçe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Istanbul University Istanbul School of Medicine, Istanbul, Turkey
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Kullberg-Lindh C, Ascher H, Saalman R, Olausson M, Lindh M. Epstein-Barr viremia levels after pediatric liver transplantation as measured by real-time polymerase chain reaction. Pediatr Transplant 2006; 10:83-9. [PMID: 16499593 DOI: 10.1111/j.1399-3046.2005.00404.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Effective immunosuppression has improved the results following liver transplantation, but also increased the risk for opportunistic infections. Epstein-Barr virus (EBV) infection in transplant patients can cause various symptoms including the life-threatening premalignant condition, post-transplantation lymphoproliferative disorder (PTLD). Serum specimens from 24 consecutive children (mean 7.6 specimens/patient), who had undergone liver transplantation in Göteborg from January 1995 to May 2002, were analyzed retrospectively for EBV DNA by real-time TaqMan polymerase chain reaction (PCR). The results were related to clinical picture, immunosuppression, graft rejection and infections with other agents. Eleven patients (46%) developed primary EBV infection at a mean time of 4.8 months after transplantation, and six (25%) reactivated EBV infection at a mean of 4.0 months after transplantation. Four of the 11 patients with primary infection had symptomatic EBV infection: two had PTLD and two hepatitis. One patient in the group with reactivated infection developed PTLD. EBV DNA levels were significantly higher in the group with primary symptomatic infection compared with the patients with primary asymptomatic infection (mean 65 500 copies/mL; range 14 200-194 300 vs. 3700 copies/mL; range 100-9780). In patients with symptomatic infection EBV DNA levels did not differ between PTLD and hepatitis patients. The data suggest that quantitative analysis of EBV DNA in serum by real-time PCR is useful for identification of EBV-related disease.
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Abstract
As newer immunosuppressive regimens have steadily reduced the incidence of acute rejection and have extended the life expectancy of allograft recipients, posttransplant malignancy has become an important cause of mortality. In fact, it is expected that cancer will surpass cardiovascular complications as the leading cause of death in transplant patients within the next 2 decades. An understanding of the underlying pathobiology and how to minimize cancer risks in transplant recipients are essential. The etiology of posttransplant malignancy is believed to be multifactorial and likely involves impaired immunosurveillance of neoplastic cells as well as depressed antiviral immune activity with a number of common posttransplant malignancies being viral-related. Although calcineurin inhibitors and azathioprine have been linked with posttransplant malignancies, newer agents such as mycophenolate mofetil and sirolimus have not and indeed may have antitumor properties. Long-term data are needed to determine if the use of these agents will ultimately lower the mortality due to malignancy for transplant recipients.
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Affiliation(s)
- Joseph F Buell
- Israel Penn International Transplant Tumor Registry, University of Cincinnati, Cincinnati, OH 45267-0558, USA.
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16
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Abstract
Diarrhea is common after liver transplantation (LT). The true incidence of diarrhea in liver transplant recipients is unknown but possibly ranges from 10% to 43% based on a few published studies in other solid organ and bone marrow transplantation. Infectious etiologies, including cytomegalovirus (CMV), Clostridium difficile, and occasional atypical intestinal infections, are the most common causes. Diarrhea is also a frequent side effect of immunosuppressive medications. To variable extents, mycophenolate mofetil (MMF), cyclosporine A (CSA), tacrolimus, and sirolimus are all known to be associated with diarrhea. Rarely, graft-versus-host disease (GVHD), lymphoproliferative disorder, de novo inflammatory bowel disease (IBD), or colon cancer may present as diarrhea. Flare-up of preexisting IBD is also not uncommon after LT. However, the cause of acute diarrhea remains unidentified in 1 of 3 patients. This review summarizes the literature and provides recommendations on the management of acute diarrhea after LT. Although our focus is on LT, the etiology and management recommendations apply to most transplant recipients.
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Affiliation(s)
- Philip M Ginsburg
- Division of Gastroenterology and Hepatology, The Johns Hopkins University School of Medicine, Baltimore, MD 21204, USA
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Hurwitz M, Desai DM, Cox KL, Berquist WE, Esquivel CO, Millan MT. Complete immunosuppressive withdrawal as a uniform approach to post-transplant lymphoproliferative disease in pediatric liver transplantation. Pediatr Transplant 2004; 8:267-72. [PMID: 15176965 DOI: 10.1111/j.1399-3046.2004.00129.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Epstein-Barr virus (EBV)-associated post-transplant lymphoproliferative disease (PTLD) in pediatric liver transplant recipients is associated with a high mortality (up to 60%) and the younger age groups, who are predominantly EBV-naïve, are at highest risk for development of this disease. The aim of this study is to assess, in this high-risk group, patient outcome and graft loss to rejection when complete withdrawal of immunosuppressive agents (IMS) is instituted as the mainstay of treatment in addition to the use of standard therapy. A retrospective analysis of 335 pediatric patients whose liver transplants were performed by our team between September 1988 and September 2002, was carried out through review of computer records, database and patient charts. Fifty patients developed either EBV or PTLD; 80% were < or =2 yr of age. Of these 50 patients, 19 had a positive tissue diagnosis for PTLD and 31 were diagnosed with EBV infection, 14 of whom had positive tissue for EBV. Fifty-eight percent of patients who developed PTLD and 51.6% of patients with EBV received antibody for induction or treatment of rejection prior to onset of disease. Forty-six patients (92%) received post-transplant antiviral prophylaxis with ganciclovir or acyclovir. Antiviral treatment included ganciclovir in 76%, acyclovir in 20% and Cytogam (in addition to one of the former agents) in 44%. In those with PTLD, treatment included chemotherapy (n = 1), Rituximab (n = 2), and ocular radiation (n = 1). IMS was stopped in all patients with PTLD and in 19 with EBV infection and was held as long as there was no allograft rejection. Eight patients have remained off IMS for a mean of 1535.5 +/- 623 days. Of the 21 patients who were restarted on IMS for acute rejection, 18 responded to steroids and/or reinstitution of low-dose calcineurin inhibitors. The mean time to rejection while off IMS in this group was 107.43 +/- 140 days (range: 7-476). Two patients were re-transplanted for chronic rejection; one had chronic rejection that existed prior to discontinuing IMS. The mortality rate in our series was 31.6% in those with PTLD and 6% in those with EBV disease. The cause of death was related to PTLD or sepsis in all cases; no deaths were due to graft loss from acute or chronic rejection. PTLD is associated with high mortality in the pediatric population. Based on this report, we advocate aggressive management of PTLD that is composed of early cessation of IMS, the use of antiviral therapy, and chemotherapy when indicated. Episodes of rejection that occur after stopping IMS can be successfully treated with standard therapy without graft loss to acute rejection.
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Affiliation(s)
- Melissa Hurwitz
- Department of Pediatrics, Stanford University, Palo Alto, CA 94304, USA.
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Affiliation(s)
- Véronique Leblond
- Département d'hématologie, Hôpital Pitié-Salpêtrière, 47 Bd de I'Hopital, Paris, France.
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Berengue JI, López-Espinosa JA, Ortega-López J, Sánchez-Sánchez L, Castilla-Valdes P, Asensio-Llorente M, Margarit-Creixell C. Two- to three-fold increase in blood tacrolimus (FK506) levels during diarrhea in liver-transplanted children. Clin Transplant 2003; 17:249-53. [PMID: 12780676 DOI: 10.1034/j.1399-0012.2003.00043.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The diagnosis and treatment of diarrhea in liver transplant recipients often pose a challenge owing to the variety of infectious and non-infectious causes. However, diagnosis is principally focused on ruling out an infectious etiology. Tacrolimus, an immunosuppressive agent generally used after liver transplantation, is absorbed mainly from the duodenum through the upper jejunum. It can be assumed that metabolism of the drug will be influenced by diarrhea. METHODS Four liver transplant recipients who developed an episode of acute gastroenteritis. Infectious etiology was confirmed; trough tacrolimus levels were measured before, during and after gastroenteritis. RESULTS All patients presented a two- to three-fold increase in blood tacrolimus levels after the onset of gastroenteritis. CONCLUSIONS Until the role played by the intestine in the metabolism of tacrolimus is fully understood, it is prudent to recommend early dose reduction of tacrolimus and careful monitoring of trough levels during diarrheal disorders of any nature in pediatric liver-transplanted patients.
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Phillips SKJ. Pediatric Liver Transplantation. Prog Transplant 2002. [DOI: 10.1177/152692480201200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pediatric liver transplantation is a fast-growing and challenging field. Healthcare providers must stay informed of advancements in the management of liver transplant candidates and recipients. The goal of this paper is to provide nurses who care for pediatric liver transplant candidates and recipients with a review of the basic medical management of these patients, from the preoperative evaluation to postoperative care.
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Wong NACS, Bathgate AJ, Bellamy COC. Colorectal disease in liver allograft recipients -- a clinicopathological study with follow-up. Eur J Gastroenterol Hepatol 2002; 14:231-6. [PMID: 11953686 DOI: 10.1097/00042737-200203000-00005] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To determine the spectrum and outcome of colorectal diseases occurring in adult liver allograft recipients. DESIGN A retrospective cohort analysis of clinical, microbiological and histopathological data regarding colorectal disease. PATIENTS Forty three out of 302 adult primary liver allograft recipients were transplanted and followed up (at median 42 months) at a tertiary referral centre/teaching hospital. RESULTS Out of 302 patients, 43 (14%) were investigated (by endoscopy and/or laparotomy) for symptoms of colorectal disease after orthotopic liver transplantation. The symptoms were: diarrhoea (n = 31); per-rectal bleeding (n = 5); and symptoms relating to pre-transplant ulcerative colitis (n = 7). Among the patients without known ulcerative colitis, per-rectal bleeding occurring early after orthotopic liver transplantation was most commonly caused by cytomegalovirus colitis and carried a poor prognosis. Excluding ulcerative colitis, the commonest causes of diarrhoea were Clostridium difficile, cytomegalovirus infection and medications, particularly during the first 2 months after orthotopic liver transplantation. No cases of colorectal graft-versus-host disease, cryptosporidiosis, amoebiasis, atypical mycobacterial infection or post-transplant lymphoproliferative disease were demonstrated. The activity of pre-transplant ulcerative colitis was unchanged or increased after orthotopic liver transplantation. Two further patients developed new-onset ulcerative colitis after orthotopic liver transplantation. CONCLUSIONS Ulcerative colitis, C. difficile, cytomegalovirus infection and medications are the commonest colorectal causes of morbidity after orthotopic liver transplantation. Adult liver allograft recipients are, however, unlikely to show certain large bowel diseases encountered in other immunosuppressed groups. Amongst non-ulcerative colitis patients, those presenting with diarrhoea show a good outcome with appropriate management, whereas those with per-rectal bleeding have a more guarded prognosis.
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Affiliation(s)
- Newton A C S Wong
- Department of Pathology, University of Edinburgh Medical School, Edinburgh, UK.
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Kollmar O, Becker S, Schilling MK, Maurer CA. Intestinal lymphoma perforations as a consequence of highly effective anti-CD20 antibody therapy. Transplantation 2002; 73:669-70. [PMID: 11889454 DOI: 10.1097/00007890-200202270-00038] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nyberg SL, Hay EJ, Ramin KD, Rosen CB. Successful pregnancy after porcine bioartificial liver treatment and liver transplantation for fulminant hepatic failure. Liver Transpl 2002; 8:169-70. [PMID: 11862596 DOI: 10.1053/jlts.2002.30593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Scott L Nyberg
- Division of Transplantation Surgery, Mayo Clinic, Rochester, MN 55095, USA.
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25
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McInnes EF, Jarrett RF, Langford G, Atkinson C, Horsley J, Goddard MJ, Cozzi E, Schuurman HJ. Posttransplant lymphoproliferative disorder associated with primate gamma-herpesvirus in cynomolgus monkeys used in pig-to-primate renal xenotransplantation and primate renal allotransplantation. Transplantation 2002; 73:44-52. [PMID: 11792976 DOI: 10.1097/00007890-200201150-00008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A series of immunosuppressed cynomolgus monkeys were used in porcine-to-primate and primate-to-primate renal transplantation. In a number of animals nodal and extranodal lymphomas as well as areas of lymphoid hyperplasia in multiple organs (posttransplant lymphoproliferative disorder, PTLD) were recorded. METHODS PTLD was characterized with respect to manifestation sites, histopathology, immunophenotype, and association with primate Epstein Barr-like Virus by in situ hybridization and quantitative polymerase chain reaction. RESULTS PTLD was observed in 10 of 245 xenotransplanted and 9 of 231 allotransplanted monkeys; its detection in xenotransplanted animals was significantly earlier after transplantation than that in allo-transplanted animals (median, 40 and 104 days, respectively; P<0.001). In the xenotransplanted animals, four cases showed a B-cell lymphoma and six cases were nonneoplastic (lymphoid hyperplasia). All nine PTLD cases from allotransplanted animals were diagnosed as lymphoma. There was no clear relationship between the use of a particular drug or drug combination in maintenance immunosuppression and the occurrence of PTLD. Fourteen of 19 animals (six of the cases from xenotransplants, eight from the allotransplant series) were positive by in situ hybridization with oligonucleotide probes detecting primate gamma-herpesvirus. CONCLUSION These data indicate that PTLD in the xeno- and allotransplanted cynomolgus monkeys are associated with primate gamma-herpesvirus-induced B-cell proliferation.
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26
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Helderman JH, Goral S. Gastrointestinal complications of transplant immunosuppression. J Am Soc Nephrol 2002; 13:277-287. [PMID: 11752050 DOI: 10.1681/asn.v131277] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- J Harold Helderman
- Department of Medicine, Division of Nephrology, and the Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Simin Goral
- Department of Medicine, Division of Nephrology, and the Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee
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Molmenti EP, Nagata DE, Roden JS, Squires RH, Molmenti H, Fasola CG, Winick N, Tomlinson G, Lopez MJ, D'Amico L, Dyer HL, Savino AC, Sanchez EQ, Levy MF, Goldstein RM, Andersen JA, Klintmalm GB. Post-transplant lymphoproliferative syndrome in the pediatric liver transplant population. Am J Transplant 2001; 1:356-9. [PMID: 12099380 DOI: 10.1034/j.1600-6143.2001.10411.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Post-transplant lymphoproliferative disease remains a complication with a high morbidity and mortality. The present study examined 291 pediatric liver transplants performed in 263 children from October 1984 to December 1999. Post-transplant lymphoproliferative disease has an overall incidence of 12%. Tacrolimus and cyclosporine had a similar incidence of post-transplant lymphoproliferative disease. Fifty-six per cent of patients who developed post-transplant lymphoproliferative disease were Epstein-Barr virus negative at the time of transplantation. Mean time of conversion to Epstein-Barr virus positivity was 1.1 years after liver transplantation. Ten per cent of those who developed post-transplant lymphoproliferative disease never had Epstein-Barr virus detected. Mean time from Epstein-Barr virus positivity to detection of post-transplant lymphoproliferative disease was 2.68 years, and 3.13 years from liver transplantation (OLTx) to post-transplant lymphoproliferative disease. There was a 35% incidence of mortality. Deaths occurred a mean of 0.76 years after diagnosis of post-transplant lymphoproliferative disease. Most cases of post-transplant lymphoproliferative disease had extranodal location. There was one recurrence in 10% of patients, and two in 3%. All recurrent cases were seen in recipients who became Epstein-Barr virus positive after transplantation. There has been a decrease in the incidence of post-transplant lymphoproliferative disease from 15% to 9% to 4%. Post-transplant lymphoproliferative disease should be diagnosed promptly and treated aggressively. The best treatment, however, seems to be prevention, starting in the immediate postoperative period. Survivors should be monitored for both recurrence of post-transplant lymphoproliferative disease and acute cellular rejection.
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Affiliation(s)
- E P Molmenti
- Baylor University Medical Center, Transplantation Services, Dallas, TX 75246, USA
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Abstract
Viruses are important causes of diarrhea. In healthy adults, the main clinical manifestation is acute, self-limited gastroenteritis. Advances in molecular diagnostics have shown that epidemics of acute gastroenteritis most frequently are due to caliciviruses spread through contaminated food or through person-to-person contact. Application of similar technology is needed to make a definitive statement about the role of such candidate viruses as rotavirus, astrovirus, and adenovirus as the cause of nonepidemic acute gastroenteritis in adults. Rarely a previously healthy adult gets acute CMV colitis. CMV and EBV mainly cause diarrhea in immunocompromised patients, however. Advances in prophylaxis and treatment have reduced the frequency and severity of these diseases. Acute infantile gastroenteritis is caused by rotavirus, calcivirus, astrovirus, and adenovirus. These viral diseases of the gut are seen by the physician as routine and rare clinical problems.
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Affiliation(s)
- R W Goodgame
- Division of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
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29
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Preiksaitis JK, Keay S. Diagnosis and management of posttransplant lymphoproliferative disorder in solid-organ transplant recipients. Clin Infect Dis 2001; 33 Suppl 1:S38-46. [PMID: 11389521 DOI: 10.1086/320903] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The Epstein-Barr virus (EBV) has a pivotal pathophysiologic role in the development of most lymphoproliferative disorders that occur after solid-organ transplantation. The term "EBV-associated posttransplant lymphoproliferative disorder" (PTLD) includes all clinical syndromes of EBV-associated lymphoproliferation, ranging from uncomplicated posttransplant infectious mononucleosis to true malignancies that contain clonal chromosomal abnormalities. PTLDs are historically associated with a high mortality rate in patients who have a monoclonal form of the disorder. Recently described approaches to pathology, diagnosis, treatment, and preventive strategies of PTLD, however, have the potential to improve outcome.
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Affiliation(s)
- J K Preiksaitis
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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30
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Abstract
Gastrointestinal disease is a significant cause of morbidity and mortality in the immunocompromised patient. This article focuses on the infectious gastrointestinal complications associated with the treatment of malignant disease and with solid organ transplantation but not HIV. Gastrointestinal defenses and the various mechanisms by which they are impaired are reviewed. The major pathogens and malignancies of this patient population and an approach to their diagnosis, treatment, and prevention are discussed.
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Affiliation(s)
- L R Baden
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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31
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Koh BY, Rosenthal P, Medeiros LJ, Osorio RW, Roberts JP, Ascher NL, Gelb AB. Posttransplantation lymphoproliferative disorders in pediatric patients undergoing liver transplantation. Arch Pathol Lab Med 2001; 125:337-43. [PMID: 11231479 DOI: 10.5858/2001-125-0337-pldipp] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To study the clinicopathologic and molecular genetic findings in posttransplantation lymphoproliferative disorders (PTLDs) following pediatric liver transplantation and to determine the applicability of a recently proposed consensus classification system. DESIGN The clinical, pathologic, and molecular genetic findings of 11 PTLDs that occurred in 10 patients are presented. These 10 patients were derived from a group of 121 pediatric patients who underwent liver transplantation at the University of California, San Francisco. The PTLDs were classified using the proposed Society for Hematopathology scheme. Clonality was determined by immunohistochemical detection of monotypic immunoglobulin or by using polymerase chain reaction-based methods to detect monoclonal immunoglobulin heavy-chain gene rearrangements. Epstein-Barr virus (EBV) was detected by immunohistochemistry, in situ hybridization, or polymerase chain reaction. Epstein-Barr virus typing and the presence of LMP1 gene deletions were also analyzed by polymerase chain reaction. RESULTS There were 3 early lesions, 4 polymorphic PTLDs, and 4 monomorphic PTLDs. Monoclonality was demonstrated in 8 of 9 cases assessed. Epstein-Barr virus was present in all cases; of 9 cases assessed by polymerase chain reaction, the virus was type A in 8 and type B in 1. No EBV LMP1 gene deletions were identified. The corresponding liver explants were negative for EBV in 8 cases and positive in 1 case. Greater than 3 foci of disease and monomorphic PTLD were associated with decreased actuarial survival (P <.05). CONCLUSIONS The prognosis of pediatric patients with PTLD is favorable for early lesions and polymorphous PTLD, particularly in patients with localized disease. Multifocal disease and monomorphic PTLD are associated with an unfavorable prognosis.
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Kasiske BL, Vazquez MA, Harmon WE, Brown RS, Danovitch GM, Gaston RS, Roth D, Scandling JD, Singer GG. Recommendations for the outpatient surveillance of renal transplant recipients. American Society of Transplantation. J Am Soc Nephrol 2001. [PMID: 11044969 DOI: 10.1681/asn.v11suppl_1s1] [Citation(s) in RCA: 394] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Many complications after renal transplantation can be prevented if they are detected early. Guidelines have been developed for the prevention of diseases in the general population, but there are no comprehensive guidelines for the prevention of diseases and complications after renal transplantation. Therefore, the Clinical Practice Guidelines Committee of the American Society of Transplantation developed these guidelines to help physicians and other health care workers provide optimal care for renal transplant recipients. The guidelines are also intended to indirectly help patients receive the access to care that they need to ensure long-term allograft survival, by attempting to systematically define what that care encompasses. The guidelines are applicable to all adult and pediatric renal transplant recipients, and they cover the outpatient screening for and prevention of diseases and complications that commonly occur after renal transplantation. They do not cover the diagnosis and treatment of diseases and complications after they become manifest, and they do not cover the pretransplant evaluation of renal transplant candidates. The guidelines are comprehensive, but they do not pretend to cover every aspect of care. As much as possible, the guidelines are evidence-based, and each recommendation has been given a subjective grade to indicate the strength of evidence that supports the recommendation. It is hoped that these guidelines will provide a framework for additional discussion and research that will improve the care of renal transplant recipients.
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Affiliation(s)
- B L Kasiske
- Division of Nephrology, Hennepin County Medical Center, University of Minnesota, Minneapolis 55415, USA.
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Affiliation(s)
- S So
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
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34
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Abstract
Immunosuppressed organ allograft recipients have a 3- to 4-fold increased risk of developing tumours, but the risk of developing certain cancers is increased several hundredfold. With the exception of skin and lip cancers, most of the common malignancies seen in the general population are not increased in incidence. Instead, there is a higher frequency of some relatively rare tumours, including post-transplant lymphomas and lymphoproliferative disorders (PTLD), Kaposi's sarcoma (KS), renal carcinomas, in situ carcinomas of the uterine cervix, hepatobiliary carcinomas, anogenital carcinomas and various sarcomas (excluding KS). Skin and lip cancers present some unusual features: a remarkable frequency of KS, reversal of the ratio of basal to squamous cell carcinomas seen in the general population, the young age of the patients, and the high incidence of multiple tumours (in 43% of the patients). Anogenital cancers occur at a much younger age than in the general population. Salient features of PTLD are the high frequency of Epstein-Barr virus-related lesions, frequent involvement of extranodal sites, a marked predilection for the brain and frequent allograft involvement. As the immunosuppressed state per se and various potentially oncogenic viruses play a major role in causing these cancers, preventative measures include reducing immunosuppression to the lowest level compatible with good allograft function and prophylactic measures against certain virus infections. Reduction of exposure to sunlight may also decrease the incidence of skin cancer. In addition to conventional treatments (resection, radiation therapy, chemotherapy) patients may receive antiviral drugs, interferon-alpha and various other manipulations of the immune system. A significant percentage of cases of PTLD and KS respond to reduction or cessation of immunosuppressive therapy.
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Affiliation(s)
- I Penn
- Department of Surgery, University of Cincinnati Medical Center, Ohio, USA
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35
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Abstract
This review and critical analysis of current trends of immunosuppression management in pediatric transplantation provides evidence and support for the continued role of Neoral as an indispensable part of immunosuppressive protocols. CyA formulation influences clinical outcomes such as acute rejection, as confirmed by two studies. The CyA microemulsion formulation provides more reliable and effective absorption. An advanced TDM strategy to determine CyA bioavailability can improve the effectiveness and safety of immunosuppression in de novo liver transplant patients. especially in the younger de novo patient. Neoral is an indispensable part of combination protocols in pediatric transplantation.
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Affiliation(s)
- S Dunn
- Transplantation and Surgery, St Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134, USA
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36
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Their M, Holmberg C, Lautenschlager I, Höckerstedt K, Jalanko H. Infections in pediatric kidney and liver transplant patients after perioperative hospitalization. Transplantation 2000; 69:1617-23. [PMID: 10836371 DOI: 10.1097/00007890-200004270-00016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infectious complications are a major cause of morbidity and mortality after organ transplantation. There are several reports on infections during the first months after transplantation, but there are very few data regarding infections in long-term survivors of pediatric organ transplantation. METHODS The incidence and type of infections were retrospectively analyzed in 56 children who underwent 59 liver or renal transplantations. Follow-up was begun when the patient was sent home after a successful operation. All of the children received triple immunosuppression. RESULTS During a mean follow-up of 4.8 years (total, 286 patient years), 1540 episodes of infection were recorded. The median incidence was 4.8 episodes/patient year. The greatest number was seen in the smallest children, 3 to 6 months after transplantation. Viral upper respiratory tract infections were the most common problem, accounting for half of the episodes (2.7 episodes/patient year). Gastroenteritis was the second most common viral infection. Only 45 episodes of infection with herpesviruses were recorded, and seven of those were caused by cytomegalovirus. Otitis media and sinusitis were the most common bacterial infections and complicated upper respiratory infection in 23% of episodes. Thirty-nine episodes of urinary tract infections were diagnosed, thirty-one in children with renal transplants. Other bacterial infections were rare, and only three episodes of verified bacterial sepsis were diagnosed. CONCLUSION The frequency and type of infections in children with liver and renal transplants who are on triple immunosuppression are quite similar to those in age-matched healthy children.
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Affiliation(s)
- M Their
- Hospital for Children and Adolescents, University of Helsinki, Finland
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37
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Meerbach A, Klöcking R, Meier C, Lomp A, Helbig B, Wutzler P. Inhibitory effect of cycloSaligenyl-nucleoside monophosphates (cycloSal-NMP) of acyclic nucleoside analogues on HSV-1 and EBV. Antiviral Res 2000; 45:69-77. [PMID: 10774591 DOI: 10.1016/s0166-3542(99)00076-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The in vitro antiviral activity of a new series of cycloSal-pro-nucleotides derived from the acyclic nucleoside analogues aciclovir and penciclovir against herpes simplex virus type 1 (HSV-1), thymidine kinase deficient (TK-) HSV-1, and Epstein-Barr virus (EBV) was evaluated. Using the XTT-based tetrazolium reduction assay EZ4U, the cycloSal derivatives were examined for their antiviral and cytotoxic effects in HSV-1 as well as HSV-1-TK--infected Vero cells. The anti-EBV activity was assessed by means of an EBV DNA hybridization assay using a digoxigenin-labeled probe specific for the Bam H1-W-fragment of the EBV genome and by measuring viral capsid antigen (VCA) expression in P3HR-1 cells by indirect immunofluorescence. Among the new cycloSal-phosphotriesters the three aciclovir monophosphates proved to be potent and selective inhibitors of HSV-1 replication, EBV DNA synthesis and EB-VCA expression. Of interest is the retention of activity of the aciclovir monophosphates in HSV-1-TK--infected cells. Particularly 3-methyl-cycloSal-aciclovir monophosphate retained the same effectiveness, as compared to the wild type virus strain. In contrast to the aciclovir pro-nucleotides the penciclovir cycloSal-phosphotriesters exhibited at best only a marginal antiviral effect on HSV and EBV replication.
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Affiliation(s)
- A Meerbach
- Institute for Antiviral Chemotherapy, Friedrich-Schiller-University Jena, Erfurt, Germany.
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38
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Smets F, Bodeus M, Goubau P, Reding R, Otte JB, Buts JP, Sokal EM. Characteristics of Epstein-Barr virus primary infection in pediatric liver transplant recipients. J Hepatol 2000; 32:100-4. [PMID: 10673073 DOI: 10.1016/s0168-8278(00)80195-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND/AIM Pediatric liver transplant recipients are at high risk of Epstein-Barr virus infection. However the incidence of clinical symptoms and the graft function at the time of acute infection remains poorly documented. The aim of this study was to monitor the clinical and biochemical events associated with primary Epstein-Barr virus infection. METHODS Clinical and biological patterns associated with Epstein-Barr virus infection were prospectively searched in 38 liver transplanted children. Polymerase chain reaction and anti-Epstein-Barr virus IgM antibodies were used at regular intervals to detect the timing of primary infection. RESULTS Five children (13%) had pretransplant immunity, 26 (68.5%) developed primary Epstein-Barr virus infection 15 to 90 days after transplantation and seven (18.5%) remained Epstein-Barr virus negative. The four patients with clinical symptoms at the time of infection subsequently developed post-transplant lymphoproliferative disease. A single post-transplant lymphoproliferative disease occurred in non-symptomatic patients (overall incidence 13%). No mortality was associated with post-transplant lymphoproliferative disease. Two asymptomatic patients had abnormal liver function tests possibly related to primary Epstein-Barr virus infection. CONCLUSION Epstein-Barr virus primary infection occurs in 80% of seronegative patients within 3 months after OLT. Clinical symptoms are rare and closely associated with post-transplant lymphoproliferative disease. Outside post-transplant lymphoproliferative disease, the consequences of infection are marginal.
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Affiliation(s)
- F Smets
- Department of Pediatrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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39
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Abstract
Acute gastroenteritis is common in adults. It can occur in institutional epidemics or epidemics of food-borne illness; in these cases, caliciviruses are the major cause of the condition. When acute gastroenteritis occurs in nonepidemic form, its causes are less clear. It may be due to caliciviruses or to the less common serotypes of childhood gastroenteritis viruses, such as rotavirus, astrovirus, and adenovirus. The pathogenesis of acute viral gastroenteritis is not completely understood. Old evidence suggests that mild villus damage is responsible, but new evidence indicates that active secretion and motility disturbance may be involved in the production of symptoms. Five common viruses can remain latent in gastrointestinal tissues and produce disease many years after initial infection. Two major herpesviruses, cytomegalovirus and herpes simplex virus, cause ulcerative disease of the gastrointestinal tract. This disease occurs in healthy persons but is more common and more severe in immunocompromised patients. Three other viruses--Epstein-Barr virus, human papilloma virus, and human herpesvirus-8--are implicated in benign and malignant proliferative diseases of the gastrointestinal tract. Epstein-Barr virus has been associated with immunoproliferative disease after transplantation and may also cause small-bowel and colonic lymphoma in healthy adults. It causes most AIDS-related lymphomas. Human papillomaviruses cause anorectal condyloma and anal cancer. Human herpesvirus-8 causes gastrointestinal Kaposi sarcoma.
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Affiliation(s)
- R W Goodgame
- Department of Gastroenterology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030-3411, USA
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40
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Cox KL, Berquist WE, Castillo RO. Paediatric liver transplantation: indications, timing and medical complications. J Gastroenterol Hepatol 1999; 14 Suppl:S61-6. [PMID: 10382641 DOI: 10.1046/j.1440-1746.1999.01904.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Newer surgical techniques and immunosuppressive therapies have resulted in paediatric liver transplantation being available for most children with end-stage liver disease and has resulted in a greater than 80% 5-year survival rate. The most common indications for paediatric liver transplantation are biliary atresia (43%), metabolic disease (13%) and acute hepatic necrosis (11%). For approximately 75% of children with acute hepatic failure, the cause is unknown. Timing of liver transplantation not only affects survival rate, but may influence neurodevelopmental outcome. Fortunately, numerous types of donors, such as reduced-sized, living related or unrelated and blood-type mismatched, have reduced the mortality of children who are waiting for liver transplantation. However, the mortality and morbidity before and after liver transplantation remain high for children who have fulminant hepatic failure or are less than 5 months of age at the time of transplantation. The principle medical complications after liver transplantation are rejection and infection. Although use of newer immunosuppressive regimens has reduced the rate of rejection, Epstein-Barr virus infection with associated lymphoproliferative disorder remains the principle cause for morbidity and mortality after the initial 3 months post-liver transplant.
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Affiliation(s)
- K L Cox
- Department of Pediatrics, Stanford University, California, USA.
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41
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Cao S, Cox KL, Berquist W, Hayashi M, Concepcion W, Hammes GB, Ojogho OK, So SK, Frerker M, Castillo RO, Monge H, Esquivel CO. Long-term outcomes in pediatric liver recipients: comparison between cyclosporin A and tacrolimus. Pediatr Transplant 1999; 3:22-6. [PMID: 10359027 DOI: 10.1034/j.1399-3046.1999.00002.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In recent years, tacrolimus (FK506, TAC) has been increasingly utilized in liver transplantation. However, long-term risks and benefits as compared with conventional cyclosporin A (CsA) have not been fully elucidated. This retrospective study examined the potential outcome differences between TAC- and CsA-based immunosuppressive therapy in pediatric liver transplant recipients. From March 1988 to December 1996, 218 children (aged 0.1-17 yr) underwent 238 orthotopic liver transplantations; 58.7% (128/218) were under 2 yr of age at time of transplant. Initially, the maintenance immunosuppressive regimen consisted of CsA and prednisone, with antilymphocytic preparations (MALG, ATGAM, and OKT3) as induction therapy. Subsequently, TAC was used first as rescue therapy for steroid refractory rejection in CsA patients and then as maintenance immunosuppression. Fifty-seven out of the 147 CsA patients were converted to TAC for various reasons while 71 patients were placed on TAC as primary maintenance immunosuppression. 62.6 per cent (92/147) of liver recipients on CsA experienced at least one biopsy-proven acute rejection episode as compared to 50.7% (36/71) for TAC patients (p = 0.09); likewise, 34% (50/147) of CsA patients had more than one episode of rejection vs. 18.3% (13/71) for patients on TAC (p < 0.02). Rejection was the reason for conversion from CsA to TAC in 29 of 57 patients. Conversely, 19.0% (28/147) of CsA patients had to be switched to TAC for reasons not related to rejection (i.e. side-effects). The overall incidence of histologically proven chronic rejection was 7.8% (17/218). 10.9 per cent (16/147) of the children who were on CsA initially developed chronic rejection, which was significantly higher compared with one of 71 TAC recipients (p < 0.02). Of these 16 CsA patients with chronic rejection, 50.0% (8/16) underwent retransplantation for graft failure (mean interval from time of diagnosis of chronic rejection to re-transplant, 4.0 months; range 1-8 months), whereas the TAC patient has remained clinically stable with normal liver function tests after 23 months of follow-up. One year after liver transplantation, 72.8% (107/147) of CsA patients were still on steroids (mean dosage 0.20 mg/kg/d), as compared to 42.3% (30/71) of the TAC patients (mean dosage 0.14 mg/kg/d). The incidence of post-transplant lymphoproliferative disorder (PTLD) in Epstein-Barr virus (EBV)-infected patients was 2.2% (2/90), 7.0% (5/71) and 12.3% (7/57) for CsA, primary and TAC-converted groups, respectively. The overall incidence of PTLD was 6.9% (15/218). In summary, pediatric liver transplant recipients treated with TAC as primary maintenance immunosuppressive medication experienced significantly fewer episodes of rejection; especially chronic rejection, which lead to graft loss. However, the trade-off is a potential increased incidence of EBV-related PTLD in these patients.
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Affiliation(s)
- S Cao
- Department of Surgery, Loma Linda University Medical Center, California 92354, USA.
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