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Arvanitis P, Davis MR, Farmakiotis D. Cytomegalovirus infection and cardiovascular outcomes in abdominal organ transplant recipients: A systematic review and meta-analysis. Transplant Rev (Orlando) 2024; 38:100860. [PMID: 38815340 DOI: 10.1016/j.trre.2024.100860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
INTRODUCTION Despite advancements in Cytomegalovirus (CMV) management, its impact on graft function, mortality, and cardiovascular (CV) health of organ transplant recipients (OTR) remains a significant concern. We investigated the association between CMV infection and CV events (CVE) in organ (other than heart) transplant recipients. METHODS We conducted a comprehensive literature search in PubMed and EMBASE, including studies that reported on CMV infection or disease and post-transplantation CVE. Studies of heart transplant recipients were excluded. RESULTS We screened 3875 abstracts and 12 clinical studies were included in the final analysis, mainly in kidney and liver transplant recipients. A significant association was observed between CMV infection and an increased risk of CVE, with a pooled unadjusted hazard ratio (HR) of 1.99 (95% Confidence Intervals [CI] 1.45-2.73) for CMV infection and 1.59 (95% CI 1.21-2.10) for CMV disease. Pooled adjusted HR were 2.17 (95% CI 1.47-3.20) and 1.77 (95% CI 0.83-3.76), respectively. Heterogeneity was low (I2 = 0%) for CMV infection, suggesting consistent association across studies, and moderate-to-high for CMVdisease (I2 = 50% for unadjusted, 53% for adjusted HR). DISCUSSION We found a significant association between CMV infection and CV risk in abdominal OTR, underscoring the importance of proactive CMV surveillance and early treatment. Future research should aim for more standardized methodologies to fully elucidate the relationship between CMV and CV outcomes, potentially informing novel preventive and therapeutic strategies that could benefit the CV health of OTR.
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Affiliation(s)
- Panos Arvanitis
- Division of Infectious Diseases, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Michel R Davis
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Dimitrios Farmakiotis
- Division of Infectious Diseases, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States.
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2
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Rodríguez-Goncer I, Corbella L, Lora D, Redondo N, López-Medrano F, Gutiérrez E, Sevillano Á, Hernández Vicente A, San-Juan R, Ruiz-Merlo T, Parra P, González E, Folgueira MD, Andrés A, Aguado JM, Fernández-Ruiz M. Role of cytomegalovirus infection after kidney transplantation on the subsequent risk of atherosclerotic and thrombotic events. ATHEROSCLEROSIS PLUS 2022; 48:37-46. [PMID: 36644565 PMCID: PMC9833220 DOI: 10.1016/j.athplu.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/02/2022] [Accepted: 03/21/2022] [Indexed: 01/18/2023]
Abstract
Background and aims Whether cytomegalovirus (CMV) infection increases the risk of cardiovascular complications after kidney transplantation (KT) through different indirect effects remains controversial. Methods We analyzed the incidence of post-transplant atherosclerotic (PAEs) and thrombotic events (PTEs) in 465 KT recipients according to the previous exposure to any level or high-level (≥1,000 IU/mL) CMV viremia (either asymptomatic or clinical disease) by means of landmark analysis beyond days 30, 180 and 360 after transplantation. Proportional hazards models were constructed with death and graft loss as competing risks. Results After a median of 722 days, the cumulative incidences of PAE and PTE were 6.0% each. Most PAEs (53.6%) occurred beyond post-transplant day 360, whereas most PTEs (60.7%) were diagnosed between days 30-180.The incidence of PAE beyond day 180 was higher among patients with previous CMV viremia compared to those without (two-year rates: 4.7% versus 0.4%; P-value = 0.035). This difference was more pronounced in recipients developing high-level viremia (6.3% versus 0.7%, respectively; P-value = 0.013). After multivariate adjustment for age, pre-transplant cardiovascular risk, antiplatelet and statin therapy and graft function, however, associations were not maintained either for any-level (hazard ratio [HR]: 1.84; 95% confidence interval [CI]: 0.48-7.05) or high-level CMV viremia (HR: 2.84; 95% CI: 0.78-10.36). No significant differences were found in the remaining landmark analyses (days 30 or 360) or for the outcome of PTE either. Conclusions Our study does not support that CMV infection independently contributes to the risk of PAE or PTE after KT.
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Affiliation(s)
- Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain,Corresponding author. Unit of Infectious Diseases. Hospital Universitario "12 de Octubre". Centro de Actividades Ambulatorias, 2a planta, bloque D. Avda. de Córdoba, s/n. Postal code, 28041, Madrid, Spain.
| | - Laura Corbella
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - David Lora
- Clinical Research Unit, Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Natalia Redondo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain,School of Medicine, Universidad Complutense, Madrid, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Ángel Sevillano
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Ana Hernández Vicente
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Rafael San-Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain,School of Medicine, Universidad Complutense, Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Patricia Parra
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Esther González
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Maria Dolores Folgueira
- School of Medicine, Universidad Complutense, Madrid, Spain,Department of Microbiology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Amado Andrés
- School of Medicine, Universidad Complutense, Madrid, Spain,Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain,School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain,School of Medicine, Universidad Complutense, Madrid, Spain
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3
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Belga S, MacDonald C, Chiang D, Kabbani D, Shojai S, Abraldes JG, Cervera C. Donor Graft Cytomegalovirus Serostatus and the Risk of Arterial and Venous Thrombotic Events in Seronegative Recipients After Non-Thoracic Solid Organ Transplantation. Clin Infect Dis 2021; 72:845-852. [PMID: 32025704 DOI: 10.1093/cid/ciaa125] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/04/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) is the most common opportunistic pathogen, following solid organ transplantation (SOT), that leads to direct and indirect effects. The aim of this study was to assess the impact of CMV exposure at transplantation on the rate of posttransplant thrombotic events (TEs). METHODS We conducted a retrospective cohort study of patients transplanted at the University of Alberta Hospital between July 2005 and January 2018. We included adult SOT CMV-seronegative recipients at transplantation who received an allograft from either a seropositive donor (D+/R-) or a seronegative donor (D-/R-). RESULTS A total of 392 SOT recipients were included: 151 (39%) liver, 188 (48%) kidney, 45 (11%) pancreas, and 8 (2%) other transplants. The mean age was 47 years, 297 (76%) were males, and 181 (46%) had a CMV D+/R- donor. Patients in the CMV D+/R- cohort were slightly older (51 years versus 48 years in the D-/R- cohort; P = .036), while other variables, including cardiovascular risk factors and pretransplant TEs, were not different between groups. Overall, TEs occurred in 35 (19%) patients in the CMV D+/R- group, versus 21 (10%) in the CMV D-/R- group, at 5 years of follow-up (P = .008); the incidence rates per 100 transplant months were 5.12 and 1.02 in the CMV D+/R- and CMV D-/R- groups, respectively (P = .003). After adjusting for potential confounders with a Cox regression model, a CMV D+/R- transplantation was independently associated with an increased risk of a TE over 5 years (adjusted hazard ratio, 3.027; 95% confidence interval, 1.669-5.488). CONCLUSIONS A CMV D+/R- transplantation is associated with an increased risk of a TE posttransplantation.
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Affiliation(s)
- Sara Belga
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Clayton MacDonald
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Diana Chiang
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Soroush Shojai
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Juan G Abraldes
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Carlos Cervera
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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4
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Rodríguez-Goncer I, Fernández-Ruiz M, Aguado JM. A critical review of the relationship between post-transplant atherosclerotic events and cytomegalovirus exposure in kidney transplant recipients. Expert Rev Anti Infect Ther 2019; 18:113-125. [PMID: 31852276 DOI: 10.1080/14787210.2020.1707079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Introduction: Cytomegalovirus (CMV) infection after kidney transplantation (KT) has been implicated in the so-called 'indirect effects' attributable to the viral ability to evade host's immunity and trigger sustained inflammation. Whether CMV exposure contributes to the development of post-transplant atherosclerotic events (AEs) remains controversial.Areas covered: This review (based on a PubMed/MEDLINE search from database inception to October 2019) summarizes the proposed mechanisms for the role of CMV in atherogenesis, including accelerated immunosenescence, endothelial injury and inflammatory milieu in the vessel wall. Sero-epidemiological evidence linking CMV exposure and cardiovascular disease in the general population is discussed. Finally, we performed a comprehensive review of observational studies investigating the impact of CMV infection on the occurrence of AE after KT, as well as the potential protective effect of antiviral prophylaxis.Expert opinion: Reviewed studies provide biological plausibility and preliminary clinical evidence pointing to the pathogenic role of CMV in post-transplant atherogenesis. However, no definitive recommendations can be made regarding the use of antiviral prophylaxis to prevent post-transplant AE, since existing evidence is mainly founded on inadequately powered post hoc analysis. Well-designed observational studies should clarify the differential impact of prophylactic or preemptive approaches on the occurrence of CMV-associated post-transplant AE among KT recipients.
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Affiliation(s)
- Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", School of Medicine, Universidad Complutense, Madrid, Spain.,Spanish Network for Research in Infectious Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", School of Medicine, Universidad Complutense, Madrid, Spain.,Spanish Network for Research in Infectious Diseases, Instituto de Salud Carlos III, Madrid, Spain
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5
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Komorowska-Jagielska K, Heleniak Z, Dębska-Ślizień A. Cytomegalovirus Status of Kidney Transplant Recipients and Cardiovascular Risk. Transplant Proc 2018; 50:1868-1873. [DOI: 10.1016/j.transproceed.2018.03.126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/07/2018] [Accepted: 03/23/2018] [Indexed: 12/11/2022]
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6
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Rezaee-Zavareh MS, Ajudani R, Khosravi MH, Ramezani-Binabaj M, Rostami Z, Einollahi B. Effect of Cytomegalovirus Exposure on the Atherosclerotic Events Among Kidney-Transplanted Patients, A Systematic Review and Meta-Analysis. Nephrourol Mon 2018; 10. [DOI: 10.5812/numonthly.63900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
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7
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Van Laecke S, Malfait T, Schepers E, Van Biesen W. Cardiovascular disease after transplantation: an emerging role of the immune system. Transpl Int 2018; 31:689-699. [PMID: 29611220 DOI: 10.1111/tri.13160] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/12/2018] [Accepted: 03/22/2018] [Indexed: 02/06/2023]
Abstract
Cardiovascular disease (CVD) after transplantation remains a major concern. Little is known about what drives the increased cardiovascular risk in transplant recipients apart from traditional risk factors. The immune system is involved in the pathogenesis of hypertension, atherosclerosis, and coronary artery disease in the general population. Recently, inhibition of interleukin 1 - β by canakinumab versus placebo decreased the incidence of cardiovascular events. Emerging evidence points to a role of adaptive cellular immunity in the development of CVD. Especially, expansion of pro-inflammatory and antiapoptotic cytotoxic CD4+ CD28null T cells is closely associated with incident CVD in various study populations including transplant recipients. The association of cytomegalovirus exposure with increased cardiovascular mortality might be explained by its capacity to upregulate these cytotoxic cells. Also, humoral immunity seems to be relevant for cardiovascular outcome in transplant recipients. Panel-reactive antibodies at baseline and donor-specific antibodies are independently associated with poor cardiovascular outcome after kidney transplantation. Cardiovascular effects of immunosuppressive drugs and statins do not only imply indirect positive or negative effects on traditional cardiovascular risk factors but also intrinsic immunological effects. How immunosuppressive drugs modify atherosclerosis largely remains elusive.
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Affiliation(s)
| | - Thomas Malfait
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Eva Schepers
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Wim Van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
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8
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Abstract
Solid organ transplantation is an effective treatment for patients with end-stage organ disease. The prevalence of cardiovascular diseases (CVD) has increased in recipients. CVD remains a leading cause of mortality among recipients with functioning grafts. The pathophysiology of CVD recipients is a complex interplay between preexisting risk factors, metabolic sequelae of immunosuppressive agents, infection, and rejection. Risk modification must be weighed against the risk of mortality owing to rejection or infection. Aggressive risk stratification and modification before and after transplantation and tailoring immunosuppressive regimens are essential to prevent complications and improve short-term and long-term mortality and graft survival.
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Affiliation(s)
- Mrudula R Munagala
- Department of Cardiology, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite # L4, Newark, NJ 07112, USA.
| | - Anita Phancao
- Integris Baptist Medical Center, 3400 Northwest Expressway, Building C, Suite 200, Oklahoma City, OK 73112, USA
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9
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Reduced rate of cardiovascular death after cytomegalovirus prophylaxis in renal transplant recipients. Transplantation 2015; 99:1197-202. [PMID: 25606797 DOI: 10.1097/tp.0000000000000522] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unknown how death with a functioning graft (DWFG) is affected in renal transplant recipients who receive prophylaxis for cytomegalovirus (CMV) infection. METHODS Data from 61,927 adult recipients of a deceased donor kidney transplant in 1990 to 2012 registered with the Collaborative Transplant Study were analyzed. RESULTS Cytomegalovirus prophylaxis was administered in 18%, 75%, 27% and 34% of R-/D- (recipient-negative, donor-negative), R-/D+, R+/D- and R+/D+ transplants, respectively. Only in R-/D+ transplants was CMV prophylaxis associated with significantly improved patient survival versus no prophylaxis (P<0.001). Unexpectedly, in the R-/D+ subgroup, DWFG because of infection was not significantly affected by use of CMV prophylaxis (P=0.16) but death from cardiovascular disease was significantly lower (P<0.001). Cox regression analysis confirmed that the primary impact of CMV prophylaxis on DWFG in R-/D+ transplants was because of reduced cardiovascular death (hazard ratio, 0.66; 95% confidence interval, 0.51-0.85; P=0.002), an effect restricted to patients aged 40 years or older (hazard ratio, 0.61; 95% confidence interval, 0.46-0.81; P<0.001). CONCLUSION We conclude that CMV prophylaxis is associated with a significant benefit for risk of cardiovascular DWFG among R-/D+ kidney transplant patients aged ≥ 40 years. Cytomegalovirus prophylaxis appears particularly critical in this patient subpopulation.
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10
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Kacer M, Kielberger L, Bouda M, Reischig T. Valganciclovir versus valacyclovir prophylaxis for prevention of cytomegalovirus: an economic perspective. Transpl Infect Dis 2015; 17:334-41. [DOI: 10.1111/tid.12383] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 01/30/2015] [Accepted: 02/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- M. Kacer
- Department of Internal Medicine I; Charles University Medical School and Teaching Hospital; Pilsen Czech Republic
- Biomedical Center; Faculty of Medicine in Pilsen; Charles University in Prague; Pilsen Czech Republic
| | - L. Kielberger
- Department of Internal Medicine I; Charles University Medical School and Teaching Hospital; Pilsen Czech Republic
- Biomedical Center; Faculty of Medicine in Pilsen; Charles University in Prague; Pilsen Czech Republic
| | - M. Bouda
- Department of Internal Medicine I; Charles University Medical School and Teaching Hospital; Pilsen Czech Republic
- Biomedical Center; Faculty of Medicine in Pilsen; Charles University in Prague; Pilsen Czech Republic
| | - T. Reischig
- Department of Internal Medicine I; Charles University Medical School and Teaching Hospital; Pilsen Czech Republic
- Biomedical Center; Faculty of Medicine in Pilsen; Charles University in Prague; Pilsen Czech Republic
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11
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Reischig T, Kacer M, Jindra P, Hes O, Lysak D, Bouda M. Randomized trial of valganciclovir versus valacyclovir prophylaxis for prevention of cytomegalovirus in renal transplantation. Clin J Am Soc Nephrol 2014; 10:294-304. [PMID: 25424991 DOI: 10.2215/cjn.07020714] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Both valganciclovir and high-dose valacyclovir are recommended for cytomegalovirus prophylaxis after renal transplantation. A head-to-head comparison of both regimens is lacking. The objective of the study was to compare valacyclovir prophylaxis with valganciclovir, which constituted the control group. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS In a randomized, open-label, single-center trial, recipients of renal transplants (recipient or donor cytomegalovirus-seropositive) were randomly allocated (1:1) to 3-month prophylaxis with valacyclovir (2 g four times daily) or valganciclovir (900 mg daily). Enrollment occurred from November of 2007 to April of 2012. The primary end points were cytomegalovirus DNAemia and biopsy-proven acute rejection at 12 months. Analysis was by intention to treat. RESULTS In total, 119 patients were assigned to valacyclovir (n=59) or valganciclovir prophylaxis (n=60). Cytomegalovirus DNAemia developed in 24 (43%) of 59 patients in the valacyclovir group and 18 (31%) of 60 patients in the valganciclovir group (adjusted hazard ratio, 1.35; 95% confidence interval, 0.71 to 2.54; P=0.36). The incidence of cytomegalovirus disease was 2% with valacyclovir and 5% with valganciclovir prophylaxis (adjusted hazard ratio, 0.21; 95% confidence interval, 0.01 to 5.90; P=0.36). Significantly more patients with valacyclovir prophylaxis developed biopsy-proven acute rejection (18 of 59 [31%] versus 10 of 60 [17%]; adjusted hazard ratio, 2.49; 95% confidence interval, 1.09 to 5.65; P=0.03). The incidence of polyomavirus viremia was higher in the valganciclovir group (18% versus 36%; adjusted hazard ratio, 0.43; 95% confidence interval, 0.19 to 0.96; P=0.04). CONCLUSIONS Valganciclovir shows no superior efficacy in cytomegalovirus DNAemia prevention compared with valacyclovir prophylaxis. However, the risk of biopsy-proven acute rejection is higher with valacyclovir.
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Affiliation(s)
- Tomas Reischig
- Departments of Internal Medicine I, Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Martin Kacer
- Departments of Internal Medicine I, Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Pavel Jindra
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic Hemato-oncology, and
| | - Ondrej Hes
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic Pathology, Charles University Medical School and Teaching Hospital, Pilsen, Czech Republic; and
| | - Daniel Lysak
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic Hemato-oncology, and
| | - Mirko Bouda
- Departments of Internal Medicine I, Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
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12
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Reischig T, Kacer M. The efficacy and cost-effectiveness of valacyclovir in cytomegalovirus prevention in solid organ transplantation. Expert Rev Pharmacoecon Outcomes Res 2014; 14:771-9. [PMID: 25252996 DOI: 10.1586/14737167.2014.965157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Prevention of cytomegalovirus infection using antiviral prophylaxis or the pre-emptive therapy approach is an integral part of management of patients after solid organ transplantation. Regarding renal transplantation, valacyclovir is currently the only antiviral agent recommended for prophylaxis as an alternative to valganciclovir. This review article discusses studies documenting the efficacy and safety of valacyclovir prophylaxis as well as those comparing valacyclovir with other prophylactic regimens or with pre-emptive therapy. Also addressed are the economic aspects supporting the cost-effectiveness of valacyclovir prophylaxis and demonstrating lower costs compared with other cytomegalovirus preventive strategies.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Alej Svobody 80, 304 60 Pilsen, Czech Republic
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Roman A, Manito N, Campistol JM, Cuervas-Mons V, Almenar L, Arias M, Casafont F, del Castillo D, Crespo-Leiro MG, Delgado JF, Herrero JI, Jara P, Morales JM, Navarro M, Oppenheimer F, Prieto M, Pulpón LA, Rimola A, Serón D, Ussetti P. The impact of the prevention strategies on the indirect effects of CMV infection in solid organ transplant recipients. Transplant Rev (Orlando) 2014; 28:84-91. [DOI: 10.1016/j.trre.2014.01.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/19/2014] [Indexed: 01/10/2023]
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14
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Shimamura M. The contribution of cytomegalovirus to atherosclerotic events after kidney transplantation. J Infect Dis 2013; 207:1487-90. [PMID: 23417660 DOI: 10.1093/infdis/jit065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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15
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Courivaud C, Bamoulid J, Chalopin JM, Gaiffe E, Tiberghien P, Saas P, Ducloux D. Cytomegalovirus exposure and cardiovascular disease in kidney transplant recipients. J Infect Dis 2013; 207:1569-75. [PMID: 23417659 DOI: 10.1093/infdis/jit064] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Some data suggest that cytomegalovirus (CMV) may be involved in atherogenesis. However, there are few data suggesting that CMV may contribute to posttransplantation atherosclerosis. We studied a cohort of 570 consecutive renal transplant recipients. The impact of CMV on atherosclerotic events was analyzed with respect to other known main cardiovascular risk factors. The mean follow-up duration (± SD) was 87 ± 31 months. A total of 357 patients were considered to be CMV exposed, and 213 were considered to be CMV naive. Cox regression analysis revealed that CMV exposure (hazard ratio [HR], 1.80 [95% confidence interval {CI}, 1.06-3.05]; P = .030) was an independent risk factor for atherosclerotic events. A total of 213 patients remained CMV negative during follow-up, 225 CMV-positive patients had no replication after transplantation, and 132 CMV-positive patients experienced CMV replication after transplantation. Atherosclerotic event rates were 8.5%, 13.3%, and 18.2%, respectively (P = .034). Cox regression analysis revealed that patients with posttransplantation CMV replication had an increased risk of atherosclerotic events (HR, 2.06 [95% CI, 1.03-4.15]; P = .042) and death (HR, 1.76 [95% CI, 1.08-2.89]; P = .024). There was also a trend toward an increased risk of atherosclerotic events in CMV-positive patients without posttransplantation replication (HR, 1.62 [95% CI, .91-3.05]; P = .098). Both pretransplantation CMV exposure and posttransplantation CMV replication contribute to the increased risk of cardiovascular disease in transplant recipients.
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16
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Chacko B, John GT. Leflunomide for cytomegalovirus: bench to bedside. Transpl Infect Dis 2011; 14:111-20. [PMID: 22093814 DOI: 10.1111/j.1399-3062.2011.00682.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 05/02/2011] [Accepted: 08/04/2011] [Indexed: 11/27/2022]
Abstract
Cytomegalovirus (CMV) remains a major cause of morbidity and mortality among transplant recipients, frequently engaging the clinician in a struggle to balance graft preservation with control of CMV disease. Leflunomide has been shown to have immunosuppressive activity in experimental allograft models together with antiviral activity inhibiting CMV both in vitro and in vivo. Data are emerging about its potential role in ganciclovir-sensitive and -resistant CMV, primarily by virtue of a unique mechanism inhibiting virion assembly, as opposed to inhibition of viral DNA synthesis by current agents. This review aims to put in perspective, the knowledge acquired in the last decade or so on leflunomide for CMV. Evidence suggests that it might have activity against human CMV with good oral bioavailability and, more importantly in the resource-poor setting, is economical. Although the data presented here are not from randomized trials, several relevant observations have been made that could influence future, more structured assessments of the drug. An immune suppressive compound with antiviral features and experimental activity in chronic rejection is an attractive combination for organ transplantation, and it appears that leflunomide may just fit that niche.
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Affiliation(s)
- B Chacko
- Department of Nephrology, St. Johns Medical College Hospital, Bangalore, India.
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17
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The Influence of Cytomegalovirus Infections on Patient and Renal Graft Outcome: A 3-year, Multicenter, Observational Study (Post-ECTAZ Study). Transplant Proc 2011; 43:2630-5. [DOI: 10.1016/j.transproceed.2011.05.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 03/28/2011] [Accepted: 05/11/2011] [Indexed: 11/18/2022]
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18
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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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Bataille S, Moal V, Gaudart J, Indreies M, Purgus R, Dussol B, Zandotti C, Berland Y, Vacher-Coponat H. Cytomegalovirus risk factors in renal transplantation with modern immunosuppression. Transpl Infect Dis 2011; 12:480-8. [PMID: 20629971 DOI: 10.1111/j.1399-3062.2010.00533.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Immunosuppressive regimens have lowered the rate of kidney rejection, but with increasing immunodeficiency-related complications. New cytomegalovirus (CMV) prophylaxis also has become available. The impact of these 2 developments on CMV diseases has not been well evaluated. We conducted a randomized trial comparing a drug regimen common in the 1980s, cyclosporin A (CsA) with azathioprine (Aza), with a drug combination used most today, tacrolimus (Tac) with mycophenolate mofetil (MMF), and we analyzed CMV risk factors in kidney transplant patients. METHODS The 300 patients included in the trial underwent the same universal prophylaxis and preemptive therapy. CMV events and risk factors were prospectively recorded. RESULTS With preventive and preemptive strategies combined for 3 months, CMV replication was detected in 32.6% and CMV disease in 18.1% of patients. Multivariate analysis on risk factors for CMV disease were CMV donor (D)/recipient (R) matching and first month renal function (risk ratio [95% confidence interval]: 1.02 [1.01; 1.04]; P=0.011), but not the immunosuppressive regimen (P=0.35). The D+/R- combination increased the risk of CMV disease by a factor of 9 (P<0.0001) when compared with D-/R- status, and a factor of 3.5 (P<0.0001) when compared with all CMV-positive recipients. Despite the 50% rate of CMV disease in the D+/R- group, no asymptomatic CMV replication was detected with the preemptive strategy. CONCLUSIONS With modern immunosuppression, a sequential quadritherapy with Tac/MMF, and a 3-month CMV prevention strategy, the risk for CMV disease remains close to that with CsA/Aza. A CMV-negative recipient transplanted from a CMV-positive donor (D+/R-) remains a major risk factor, calling for better CMV prophylaxis or matching in negative recipients. Preemptive strategy thus appeared inefficient for this high-risk group. Transplant recipients with altered renal function should also be considered at risk.
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Affiliation(s)
- S Bataille
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, AP-HM, Marseille, France
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20
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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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21
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Management of Cytomegalovirus Infection After Renal Transplantation. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2009. [DOI: 10.1097/ipc.0b013e31819b8d27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Haller H, Richter N, Bröcker V, Gwinner W, Gueler F, Schwarz A. [Current problems of kidney transplantation]. Internist (Berl) 2009; 50:523-35. [PMID: 19396413 DOI: 10.1007/s00108-008-2269-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The long-term problems after kidney transplantation have changed considerably in recent years. While formerly immunosuppression and prevention of acute rejection were of prime concern, now attention focuses on chronic alterations of the transplanted organ and long-term survival of the patients. The transplantation procedure itself has evolved into a standardized technique with a high level of surgical quality. Problems involving organ preservation and ischemia/reperfusion damage also play a role, especially in view of chronic aspects. Monitoring of long-term complications should follow a program for the transplanted organ as well as a program for the patient. Monitoring kidney function should address the organ more precisely than has previously been the case. Serum creatinine level and proteinuria alone provide insufficient information and only change long after cellular deterioration has begun. Hence it is imperative that new testing methods be developed. One possibility is offered by protocol biopsies that allow histological and molecular analysis of the kidney at regular intervals. The patient programs concentrate on diagnostics and treatment of the cardiovascular diseases. Furthermore, the patients must be screened for occurrence of neoplasia. There are no prospective studies covering all cardiovascular risk factors after kidney transplantation. This pertains particularly to the subject of hypertension.
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Affiliation(s)
- H Haller
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Hannover.
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23
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Sund F, Lidehäll AK, Claesson K, Foss A, Tötterman TH, Korsgren O, Eriksson BM. CMV-specific T-cell immunity, viral load, and clinical outcome in seropositive renal transplant recipients: a pilot study. Clin Transplant 2009; 24:401-9. [DOI: 10.1111/j.1399-0012.2009.00976.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Effect of Cytomegalovirus Viremia on Subclinical Rejection or Interstitial Fibrosis and Tubular Atrophy in Protocol Biopsy at 3 Months in Renal Allograft Recipients Managed by Preemptive Therapy or Antiviral Prophylaxis. Transplantation 2009; 87:436-44. [DOI: 10.1097/tp.0b013e318192ded5] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Reischig T, Jindra P, Hes O, Svecová M, Klaboch J, Treska V. Valacyclovir prophylaxis versus preemptive valganciclovir therapy to prevent cytomegalovirus disease after renal transplantation. Am J Transplant 2008; 8:69-77. [PMID: 17973956 DOI: 10.1111/j.1600-6143.2007.02031.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Both preemptive therapy and universal prophylaxis are used to prevent cytomegalovirus (CMV) disease after transplantation. Randomized trials comparing both strategies are sparse. Renal transplant recipients at risk for CMV (D+/R-, D+/R+, D-/R+) were randomized to 3-month prophylaxis with valacyclovir (2 g q.i.d., n = 34) or preemptive therapy with valganciclovir (900 mg b.i.d. for a minimum of 14 days, n = 36) for significant CMV DNAemia (>/=2000 copies/mL by quantitative PCR in whole blood) assessed weekly for 16 weeks and at 5, 6, 9 and 12 months. The 12-month incidence of CMV DNAemia was higher in the preemptive group (92% vs. 59%, p < 0.001) while the incidence of CMV disease was not different (6% vs. 9%, p = 0.567). The onset of CMV DNAemia was delayed in the valacyclovir group (37 +/- 22 vs. 187 +/- 110 days, p < 0.001). Significantly higher rate of biopsy-proven acute rejection during 12 months was observed in the preemptive group (36% vs. 15%, p = 0.034). The average CMV-associated costs per patient were $5525 and $2629 in preemptive therapy and valacyclovir, respectively (p < 0.001). However, assuming the cost of $60 per PCR test, there was no difference in overall costs. In conclusion, preemptive valganciclovir therapy and valacyclovir prophylaxis are equally effective in the prevention of CMV disease after renal transplantation.
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Affiliation(s)
- T Reischig
- Department of Internal Medicine I, Charles Medical School and Teaching Hospital, Pilsen, Czech Republic.
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26
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Abstract
Renal transplantation is currently the preferred treatment modality for virtually all suitable candidates with end-stage renal disease. Compared with dialysis, kidney transplantation improves both patient survival and quality of life. Nonetheless, posttransplant cardiac complications are associated with increased morbidity and mortality after renal transplantation. When compared with the general population, cardiovascular mortality in transplant recipients is increased by nearly 10-fold among patients within the age range of 35 and 44 and at least doubled among those between the ages of 55 and 64. Although renal transplantation ameliorates cardiovascular disease risk factors by restoring renal function, it introduces new cardiovascular risks derived, in part, from immunosuppressive medications. We provide an overview of the literature on conventional and unconventional cardiovascular disease risk factors after renal transplantation, and discuss an approach to their medical management.
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Affiliation(s)
- Phuong-Thu T Pham
- Division of Nephrology, Kidney and Pancreas Transplantation, Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA 90095, USA.
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27
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Abstract
Renal transplant recipients are susceptible to infection by a wide array of pathogens. Impaired inflammatory responses due to immunosuppressive therapies suppress clinical and radiologic findings engendered by microbial invasion. As a result, patients are often minimally symptomatic and evaluation and diagnosis are delayed. Specific microbiologic diagnosis is essential both for the optimization of antimicrobial therapy and to avoid unnecessary drug toxicities. Differential diagnosis is guided by knowledge of organisms commonly involved in infection in immunocompromised hosts and understanding of the limitations of prophylactic strategies. The risk of infection in the organ transplant recipient is determined by the interaction between the individual's epidemiologic exposures and net state of immunosuppression. Epidemiology includes environmental exposures in the community and hospital, organisms derived from donor tissues and latent infections activated in the host during immune suppression. The net state of immune suppression is determined by the interaction of all factors contributing to infectious risk. Routine antimicrobial prophylaxis is aimed at common infections and unique risk factors in individual patient groups. This includes trimethoprim-sulfamethoxazole (for Pneumocystis, Toxoplasma, most Nocardia and Listeria, common urinary pathogens), perioperative (eg, anti-fungal prophylaxis for pancreas transplants), or antiviral (for herpesviruses in high risk recipients).
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Affiliation(s)
- Jay A Fishman
- Harvard Medical School, MGH Transplant Center, Transplant Infectious Disease and Compromised Host Program, Infectious Disease Division, Massachusetts General Hospital, Boston, MA 02114, USA.
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28
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Walker S, Fazou C, Crough T, Holdsworth R, Kiely P, Veale M, Bell S, Gailbraith A, McNeil K, Jones S, Khanna R. Ex vivo monitoring of human cytomegalovirus-specific CD8+ T-cell responses using QuantiFERON�-CMV. Transpl Infect Dis 2007; 9:165-70. [PMID: 17462006 DOI: 10.1111/j.1399-3062.2006.00199.x] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We have developed a novel diagnostic technology to monitor the human cytomegalovirus (HCMV)-specific CD8+ T-cell responses that is based on the detection of secreted interferon-gamma (IFN-gamma) in the whole blood (referred to as QuantiFERON -CMV). Evaluation of QuantiFERON -CMV in healthy individuals revealed that this technology was at least as sensitive and with some HCMV epitopes more sensitive than the ELISPOT for detecting ex vivo IFN-gamma. Results from QuantiFERON -CMV assays showed 97% (36/37 individuals) agreement with the anti-HCMV serology test in healthy individuals. Furthermore, we also show that this technology can be used to assess HCMV-specific T-cell responses in transplant patients. This study shows that QuantiFERON -CMV is a simple, reproducible, and reliable test for the detection of IFN-gamma in response to HCMV CD8+ T-cell epitopes, and may be a valuable diagnostic test for the detection of HCMV infection and a useful clinical tool for monitoring the immune response in immunosuppressed patients during therapy.
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Affiliation(s)
- S Walker
- Tumour Immunology Laboratory and Co-Operative Centre for Vaccine Technology, Division of Infectious Diseases and Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia
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29
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Abstract
The benefits of cytomegalovirus (CMV) prophylaxis in preventing the direct effects of CMV infection and disease are well established; however, the impact of exposure to antiviral agents on preventing the indirect effects of CMV infection are poorly defined. This article reviews the results of current studies demonstrating the benefits of CMV prophylaxis in reducing the risks of indirect effects of CMV infection: acute and chronic allograft rejection, graft failure, patient mortality, cardiac complications and atherosclerosis, and posttransplant lymphoproliferative disorder, in solid organ transplant recipients.
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Affiliation(s)
- Mark D Pescovitz
- Department of Surgery , Indiana University School of Medicine, Indianapolis, IN 46202,
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30
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de Mattos AM, Prather J, Olyaei AJ, Shibagaki Y, Keith DS, Mori M, Norman DJ, Becker T. Cardiovascular events following renal transplantation: role of traditional and transplant-specific risk factors. Kidney Int 2006; 70:757-64. [PMID: 16788687 DOI: 10.1038/sj.ki.5001628] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiovascular mortality is increased in transplant recipients. However, studies including non-fatal events are critical to assess the burden of disease and to identify novel risk factors. We described the incidence of fatal and non-fatal events, and explored associations and interactions among traditional and transplant-specific risk factors and cardiovascular events (CVE) in a cohort of 922 patients transplanted between 1993 and 1998. One hundred and seventy-six patients experienced 201 CVE (111 cardiac, 48 cerebrovascular, 42 peripheral-vascular). Most CVE were non-fatal. Factors associated with cardiac events were (adjusted hazard ratios) tobacco (3.53; P<0.001), obesity (2.92; P<0.001), diabetes (2.63; P<0.001), multiple rejections (2.19; P=0.008), prior CVE (2.0; P=0.004), dialysis >1 year (1.91; P=0.007), and overweight status (1.68; P=0.04); with cerebrovascular events: diabetes and peritoneal dialysis (11.95; P<0.001), age >45 (6.77; P<0.001), diabetes (4.87; P<0.001), prior CVE (3.73; P<0.001), creatinine >141 micromol/l (3.16; P=0.001), peritoneal dialysis (3.06; P=0.027), and obesity (0.32; P=0.046); with peripheral-vascular events: diabetes (8.48; P<0.001), tobacco and cytomegalovirus (3.88; P<0.001), age >45 (2.31; P=0.019), and prior CVE (2.25; P=0.016); with mortality: tobacco and deceased-donor (3.52; P<0.001), age >45 (1.81; P=0.002), diabetes (1.76; P=0.002), pulse pressure (1.64; P=0.029), prior CVE (1.52; P=0.04), and dialysis >1 year (1.47; P=0.04). The majority of CVE post-transplant were non-fatal. Previous CVE was strongly associated with CVE post-transplant. Interactions among transplant-specific and traditional risks impacted significantly the incidence of CVE. Modifiable factors such as duration of dialysis, deceased-donor transplantation, and acute rejection should be viewed as cardiovascular risks.
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Affiliation(s)
- A M de Mattos
- Transplantation Medicine Program, Oregon Health and Science University, Portland, Oregon, USA.
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31
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Reischig T, Opatrný K, Treska V, Mares J, Jindra P, Svecová M. Prospective comparison of valacyclovir and oral ganciclovir for prevention of cytomegalovirus disease in high-risk renal transplant recipients. Kidney Blood Press Res 2005; 28:218-25. [PMID: 16043964 DOI: 10.1159/000087129] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2004] [Accepted: 05/20/2005] [Indexed: 11/19/2022] Open
Abstract
AIMS To compare the efficacy, costs and safety of oral ganciclovir and valacyclovir in the prophylaxis of cytomegalovirus (CMV) disease in renal transplant (RTx) recipients at high risk of CMV disease. METHODS A total of 83 patients were prospectively randomized to 3-month treatment with either oral ganciclovir (3 g/day) or oral valacyclovir (8 g/day). A 3rd group received no prophylaxis. Forty-nine patients were considered to be at high risk of CMV disease due to D+R- serologic status, OKT3/ATG treatment and/or acute rejection within 12 months after RTx. Twenty-three high-risk patients were treated with ganciclovir (GAN group), 17 patients with valacyclovir (VAL group), and 9 patients received no prophylaxis (C group). RESULTS No significant differences were found among the groups in their demographic characteristics, immunosuppressive protocols, D/R CMV serology, or CMV risk factors. The 12-month incidence of CMV disease was 89% in the C group compared with 9% in the GAN group and 6% in the VAL group (p < 0.001, GAN or VAL vs. C; p = 0.713, GAN vs. VAL). Treatment failure (death, graft loss, CMV disease or withdrawal from study) occurred in 17, 6, and 89% in the GAN, VAL, and C groups, respectively (p < 0.001, GAN or VAL vs. C; p = 0.285, GAN vs. VAL). The average CMV-associated costs per patient were EUR 3,161, 3,757, and 7,247 in the GAN, VAL, and C groups, respectively (p = 0.027). CONCLUSION Valacyclovir and oral ganciclovir are equally effective in the prophylaxis of CMV disease in high-risk RTx patients. Both regimens are cost-effective and help reduce CMV-associated costs by nearly 50% compared with patients without prophylaxis.
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Affiliation(s)
- Tomás Reischig
- Department of Internal Medicine I, Charles University School of Medicine and University Hospital, Pilsen, Czech Republic.
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32
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Satyan S, Rocher LL. Impact of kidney transplantation on the progression of cardiovascular disease. Adv Chronic Kidney Dis 2004; 11:274-93. [PMID: 15241742 DOI: 10.1053/j.arrt.2004.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Kidney transplantation, of all the treatment modalities for end-stage renal disease, affords the greatest potential for prolonged survival and improved quality of life. Great strides in immunosuppressant therapy have improved graft survival and forced clinicians to consider other health-care needs of kidney transplant recipients. Chief among these needs is the prevention and treatment of cardiovascular disease. Cardiovascular disease is the most common cause of death among patients with a working renal allograft. Because therapies for primary and secondary prevention are successful in the general population, transplant clinicians are increasingly focused on preventing or limiting the progression of cardiovascular disease. Initiation of aggressive management of conventional atherosclerotic risk factors and uremia-related risk factors, ideally during the early stages of chronic kidney disease (CKD) or after kidney transplantation, and efforts to delay the progression of kidney disease will hopefully reduce the cardiovascular burden in transplant recipients.
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Affiliation(s)
- Sangeetha Satyan
- Department of Medicine, Division of Nephrology, William Beaumont Hospital, Royal Oak, MI 48073, USA
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33
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Abstract
Transplantation has emerged as one of the remarkable achievements of the latter half of the twentieth century for treatment of many end-stage organ disorders. Survival in pediatric solid organ transplantation continues to improve as strategies for immunosuppression, prevention and treatment of infectious complications progress. This article presents the summaries of the common and opportunistic pathogens that cause infectious complications for the pediatric transplant recipient. In addition, an approach to the pediatric transplant patient who presents with specific symptoms suggestive of infection is provided.
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Affiliation(s)
- William L Keough
- Division of Allergy, Immunology and Infectious Diseases, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA
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34
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Abstract
CHF is highly prevalent in ESRD and is a leading cause of death in such patients. Hypertension, renal anemia, and comorbid conditions such as coronary artery disease are particularly important risk factors for CHF in ESRD. Dialysis hypotension may be a marker of poor prognosis in such persons. Recent studies suggest that lipid peroxidation and L-carnitine deficiency may contribute to CHF in some patients with ESRD. All forms of renal replacement therapy are capable of ameliorating symptoms of CHF, but their effect on cardiovascular mortality has not been firmly established. Drug therapy, particularly angiotensin-converting enzyme inhibitors and beta-adrenergic receptor blockers, is under-used in patients with ESRD and CHF. Heart/kidney transplantation may be a viable option for some patients with advanced CHF and ESRD.
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Affiliation(s)
- Brian D Schreiber
- Department of Medicine, Medical College of Wisconsin, Milwaukee, USA
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35
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Kalil RSN, Hudson SL, Gaston RS. Determinants of cardiovascular mortality after renal transplantation: a role for cytomegalovirus? Am J Transplant 2003; 3:79-81. [PMID: 12492715 DOI: 10.1034/j.1600-6143.2003.30114.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Death with a functioning graft (DWF) is now the most common cause of late renal transplant failure, with cardiovascular disease its most frequent etiology. In some populations, infection with cytomegalovirus (CMV) increases risk of coronary disease. Few data exist regarding CMV and cardiovascular mortality after renal transplantation. We reviewed charts of 158 adult patients who died more than 90 days after receiving renal allografts and a matched cohort of 143 (of 2398) surviving patients transplanted at the University of Alabama at Birmingham between 1990 and 1998. Only advancing donor and recipient age increased risk of DWF; CMV infection did not. However, of 50 patients who died of cardiovascular causes, 94% were seropositive for CMV, while only 74% of the other 108 deaths occurred in CMV-seropositive patients (p < 0.05). Risk of cardiovascular death was greatest (p < 0.05) in patients with diabetes, advancing age, and CMV seropositivity. In renal transplant recipients, infection with CMV increases risk of death as a result of cardiovascular causes.
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Affiliation(s)
- Roberto S N Kalil
- Departments of Medicine and Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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36
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37
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Bostom AD, Brown RS, Chavers BM, Coffman TM, Cosio FG, Culver K, Curtis JJ, Danovitch GM, Everson GT, First MR, Garvey C, Grimm R, Hertz MI, Hricik DE, Hunsicker LG, Ibrahim H, Kasiske BL, Kennedy M, Klag M, Knatterud ME, Kobashigawa J, Lake JR, Light JA, Matas AJ, McDiarmid SV, Miller LW, Payne WD, Rosenson R, Sutherland DER, Tejani A, Textor S, Valantine HA, Wiesner RH. Prevention of post-transplant cardiovascular disease--report and recommendations of an ad hoc group. Am J Transplant 2002; 2:491-500. [PMID: 12118892 DOI: 10.1034/j.1600-6143.2002.20602.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Andrew D Bostom
- Department of Surgery, University of Minnesota, MMC-328 Mayo, Minneapolis 55455, USA
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Becker BN, Becker YT, Leverson GE, Simmons WD, Sollinger HW, Pirsch JD. Reassessing the impact of cytomegalovirus infection in kidney and kidney-pancreas transplantation. Am J Kidney Dis 2002; 39:1088-95. [PMID: 11979354 DOI: 10.1053/ajkd.2002.32793] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
New antiviral agents and practice guidelines have been implemented to address cytomegalovirus (CMV) infection in organ transplantation. We hypothesized that such measures would reduce rates of symptomatic CMV infection, CMV disease, and CMV seroconversion and associated complications in renal transplant and simultaneous pancreas-kidney transplant recipients. We analyzed the impact of CMV in 1,424 renal transplant and simultaneous pancreas-kidney transplant recipients, transplanted at our center between January 1, 1994 and June 30, 1999. Most patients received quadruple sequential immunosuppression with high-dose acyclovir (800 mg four times daily) for 12 weeks as prophylaxis. High-risk patients (donor CMV-positive/recipient CMV-negative) received ganciclovir (500 to 1,000 mg three times daily) beginning in 1998, again for 12 weeks. One hundred and one renal transplant (9.0%) and 40 simultaneous pancreas-kidney transplant (13.4%) recipients experienced symptomatic CMV infection or CMV disease. Donor CMV-positive/recipient CMV-negative patients had the greatest rates of CMV infection or CMV disease (25.2%; P = 0.0001 versus all other categories). The impact of CMV on outcomes was evaluated in a proportional hazards model. Symptomatic CMV infection or CMV disease increased the risk for subsequent rejection (relative risk, 2.11; P = 0.003) and non-CMV infection (relative risk, 2.24; P = 0.001). To determine if the effects of ganciclovir were masked by pre-1998 data, CMV infection and CMV disease rates for ganciclovir-treated patients (n = 62) were censored at 1 year and compared with acyclovir-treated patients (n = 287). Ganciclovir was associated with trends toward lower rates of infection and disease. It also delayed the time to infection or disease. Serologic testing in high-risk patients also showed late seroconversion, with 20% of patients seroconverting by 6 months, 12 weeks after the prophylaxis period. These data suggest that despite better prophylaxis strategies, CMV remains an important pathogen in renal transplant and simultaneous pancreas-kidney transplant recipients. This finding may require reassessment of prophylaxis strategies and the development of alternative or novel anti-CMV regimens.
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Affiliation(s)
- Bryan N Becker
- Division of Nephrology, Department of Medicine, School of Pharmacy, University of Wisconsin, Madison, Madison, WI, USA.
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Hernández D, Hanson E, Kasiske MK, Danielson B, Roel J, Kasiske BL. Cytomegalovirus disease is not a major risk factor for ischemic heart disease after renal transplantation. Transplantation 2001; 72:1395-9. [PMID: 11685110 DOI: 10.1097/00007890-200110270-00011] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND It has been suggested that cytomegalovirus infection increases the risk of ischemic heart disease. Both cytomegalovirus and ischemic heart disease are common after renal transplantation, suggesting a possible causal association in this population. METHODS AND PATIENTS We studied 1004 consecutive renal transplants with no prior history of ischemic heart disease and grafts that functioned at least 12 months. We performed univariate and multivariate analyses to examine the effect of cytomegalovirus disease and other risk factors (measured during the first posttransplant year) on the development of primary ischemic heart disease events after the first posttransplant year. RESULTS More than 1 year after transplantation, 116 patients (11.6%) experienced their first ischemic event (75 myocardial infarction, 12 percutaneous angioplasty, 18 bypass grafting, and 11 deaths). Patients with ischemic heart disease were more likely to have known risk factors (age, diabetes, smoking, hypercholesterolemia, systolic blood pressure, low serum albumin, and acute rejections). However, the incidence of cytomegalovirus disease was not different for those with or without ischemic heart disease (36.2% vs. 31.1%). Moreover, a similar proportion of those with and without ischemic heart disease (19.8% vs. 15.5%) had a rise in cytomegalovirus antibodies during follow-up. By multivariate analysis, risk factors for ischemic heart disease (P<0.05) were age, diabetes, smoking, low serum albumin, and two or more acute rejections during the first year. Cytomegalovirus disease was not associated with ischemic heart disease events: unadjusted relative risk=1.14 (95% confidence interval 0.78-1.67, P=0.485). After adjusting for multiple risk factors, the relative risk was 0.91 (0.60-1.37, P=0.657). CONCLUSION These data suggest that cytomegalovirus disease is not a significant risk factor for the development of primary ischemic heart disease after renal transplantation.
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Affiliation(s)
- D Hernández
- Department of Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN 55415, USA
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Valantine-von Kaeppler HA. Role of cytomegalovirus infection in transplant arteriosclerosis and chronic rejection. Transplant Rev (Orlando) 2001. [DOI: 10.1016/s0955-470x(05)80004-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kletzmayr J, Kreuzwieser E, Klauser R. New developments in the management of cytomegalovirus infection and disease after renal transplantation. Curr Opin Urol 2001; 11:153-8. [PMID: 11224745 DOI: 10.1097/00042307-200103000-00005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The clinical management of cytomegalovirus infection and disease in renal transplant recipients has recently been significantly improved with the availability of data on prophylaxis with oral ganciclovir and valacyclovir. In addition, significant progress in early diagnosis and the quantitation of viral load has been achieved. The influence of novel immunosuppressants on the clinical course of cytomegalovirus infection has been clarified to some extent by recent clinical data. The identification of risk factors for cytomegalovirus disease beyond seroconstellation and immunosuppression is an ongoing process that might lead to a more targeted use of antiviral agents, given the risk of ganciclovir resistance. The understanding of the effects of cytomegalovirus on long-term graft outcome still needs to be deepened in order to design cytomegalovirus-specific interventions to improve graft survival.
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Affiliation(s)
- J Kletzmayr
- Department of Medicine, Division of Nephrology and Dialysis, University of Vienna, Austria.
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