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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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Mayerova L, Wohlfahrt P, Sonka M, Chen Z, Kautzner J, Melenovsky V, Karmazin V, Malek I, Bedanova H, Tomasek A, Ozabalova E, Krejci J, Kovarnik T, Pazdernik M. Acetylsalicylic acid use and development of cardiac allograft vasculopathy: A national prospective study using highly automated 3-D optical coherence tomography analysis. Clin Transplant 2024; 38:e15275. [PMID: 38477134 PMCID: PMC10939248 DOI: 10.1111/ctr.15275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/10/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND There is conflicting evidence on the role of acetylsalicylic acid (ASA) use in the development of cardiac allograft vasculopathy (CAV). METHODS A nationwide prospective two-center study investigated changes in the coronary artery vasculature by highly automated 3-D optical coherence tomography (OCT) analysis at 1 month and 12 months after heart transplant (HTx). The influence of ASA use on coronary artery microvascular changes was analyzed in the overall study cohort and after propensity score matching for selected clinical CAV risk factors. RESULTS In total, 175 patients (mean age 52 ± 12 years, 79% male) were recruited. During the 1-year follow-up, both intimal and media thickness progressed, with ASA having no effect on its progression. However, detailed OCT analysis revealed that ASA use was associated with a lower increase in lipid plaque (LP) burden (p = .013), while it did not affect the other observed pathologies. Propensity score matching of 120 patients (60 patient pairs) showed similar results, with ASA use associated with lower progression of LPs (p = .002), while having no impact on layered fibrotic plaque (p = .224), calcification (p = .231), macrophage infiltration (p = .197), or the absolute coronary artery risk score (p = .277). According to Kaplan-Meier analysis, ASA use was not associated with a significant difference in survival (p = .699) CONCLUSION: This study showed a benefit of early ASA use after HTx on LP progression. However, ASA use did not have any impact on the progression of other OCT-observed pathologies or long-term survival.
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Affiliation(s)
| | - Peter Wohlfahrt
- Department of Preventive Cardiology, IKEM, Prague, Czech Republic
| | - Milan Sonka
- Iowa Institute for Biomedical Imaging, The University of Iowa, Iowa City, IA, USA
| | - Zhi Chen
- Iowa Institute for Biomedical Imaging, The University of Iowa, Iowa City, IA, USA
| | | | | | | | - Ivan Malek
- Department of Cardiology, IKEM, Prague, Czech Republic
| | - Helena Bedanova
- Cardiovascular and Transplantation Surgery, Brno, Czech Republic
| | - Ales Tomasek
- Cardiovascular and Transplantation Surgery, Brno, Czech Republic
| | - Eva Ozabalova
- Department of Cardiovascular Diseases, St. Anne’s University Hospital and Masaryk University Brno, Czech Republic
| | - Jan Krejci
- Department of Cardiovascular Diseases, St. Anne’s University Hospital and Masaryk University Brno, Czech Republic
| | - Tomas Kovarnik
- 2nd Department of Internal Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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Kotton CN, Torre-Cisneros J, Yakoub-Agha I. Slaying the "Troll of Transplantation"-new frontiers in cytomegalovirus management: A report from the CMV International Symposium 2023. Transpl Infect Dis 2024; 26:e14183. [PMID: 37942955 DOI: 10.1111/tid.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023]
Abstract
The 2023 International CMV Symposium took place in Barcelona in May 2023. During the 2-day meeting, delegates and faculty discussed the ongoing challenge of managing the risk of cytomegalovirus infection (the Troll of Transplantation) after solid organ or hematopoietic cell transplantation. Opportunities to improve outcomes of transplant recipients by applying advances in antiviral prophylaxis or pre-emptive therapy, immunotherapy, and monitoring of cell-mediated immunity to routine clinical practice were debated and relevant educational clinical cases presented. This review summarizes the presentations, cases, and discussions from the meeting and describes how further advances are needed before the Troll of Transplantation is slain.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Torre-Cisneros
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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4
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Moore WJ, Boutin CA, Tanna S. A new direction for cytomegalovirus prophylaxis among transplant recipients: Benefits and nonviral outcomes of letermovir use as primary CMV prophylaxis. Curr Opin Infect Dis 2023; 36:514-521. [PMID: 37773928 DOI: 10.1097/qco.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
PURPOSE OF REVIEW Letermovir has changed the game of primary prophylaxis against cytomegalovirus (CMV) for hematopoietic stem cell transplant (HSCT) and more recently, solid organ transplant recipients. This is largely due to letermovir's similar efficacy in protecting against CMV reactivation and disease, along with its superior safety profile, notably reduced myelotoxicity, and lack of renal dose adjustment compared to standard agents like valganciclovir. This review will describe the potential benefits and clinical considerations of letermovir as prophylaxis among transplant recipients, with a focus on recent evidence describing nonviral outcomes of CMV. RECENT FINDINGS Recent evidence has demonstrated improved safety (e.g., less myelosuppression) and tolerability with no difference in rates of CMV infection or disease in kidney transplant recipients given letermovir compared to valganciclovir. Real-world studies and meta-analyses in HSCT populations have explored various nonviral outcomes with letermovir use. Letermovir prophylaxis was associated with reduced mortality, lower rates of graft versus host disease, delayed CMV immune reconstitution, improved tolerability with extended durations, and decreased healthcare utilization. SUMMARY Letermovir is an effective antiviral agent for CMV prevention and has demonstrated enhanced safety, which may allow for extended durations of primary prophylaxis among transplant recipients along with other improved clinical outcomes by mitigating the indirect effects of CMV.
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Affiliation(s)
- W Justin Moore
- Department of Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
| | - Catherine-Audrey Boutin
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Sajal Tanna
- Division of Infectious Disease, Department of Medicine, Inova Medical Group, Falls Church, Virginia, USA
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Lerman JB, Green CL, Molina MR, Maharaj V, Ortega-Legaspi JM, Sen S, Flattery M, Maziarz EK, Shah KB, Martin CM, Alexy T, Shah P, Morris AA, DeVore AD, Cole RT. Multicenter study of universal prophylaxis versus pre-emptive therapy for patients at intermediate risk (R+) for CMV following heart transplantation. Clin Transplant 2023; 37:e15065. [PMID: 37392192 PMCID: PMC10592402 DOI: 10.1111/ctr.15065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
INTRODUCTION Heart transplant (HT) recipients with prior exposure to cytomegalovirus (CMV R+) are considered intermediate risk for CMV-related complications. Consensus guidelines allow for either universal prophylaxis (UP) or preemptive therapy (PET) (serial CMV testing) approaches to CMV prevention in such patients. Whether an optimal approach to mitigate CMV related risks exists in this setting remains uncertain. We therefore assessed the utility of PET as compared to UP in CMV R+ HT recipients. METHODS Retrospective analysis of all CMV R+ HT recipients from 6 U.S. centers between 2010 and 2018 was performed. The primary outcome was the development of CMV DNAemia or end-organ disease resulting in the initiation/escalation of anti-CMV therapy. The secondary outcome was CMV-related hospitalization. Additional outcomes included incidence of acute cellular rejection (ACR) ≥ grade 2R, death, cardiac allograft vasculopathy (CAV), and leukopenia. RESULTS Of 563 CMV R+ HT recipients, 344 (61.1%) received UP. PET was associated with increased risk for the primary (adjusted HR 3.95, 95% CI: 2.65-5.88, p < .001) and secondary (adjusted HR 3.19, 95% CI: 1.47-6.94, p = .004) outcomes, and with increased ACR ≥ grade 2R (PET 59.4% vs. UP 34.4%, p < .001). Incidence of detectable CAV was similar at 1 year (PET 8.2% vs. UP 9.5%, p = .698). UP was associated with increased incidence of leukopenia within 6 months post-HT (PET 34.7% vs. UP 43.6%, p = .036). CONCLUSION The use of a PET CMV prophylaxis strategy in intermediate risk HT recipients associated with increased risk of CMV infection and CMV-related hospitalization, and may associate with worse post-HT graft outcomes.
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Affiliation(s)
- Joseph B. Lerman
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Cynthia L. Green
- Duke Clinical Research Institute, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Maria R. Molina
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Valmiki Maharaj
- Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Juan M. Ortega-Legaspi
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Maureen Flattery
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Eileen K. Maziarz
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Keyur B. Shah
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Cindy M. Martin
- Department of Cardiovascular Medicine, Houston Methodist Hospital, Houston, TX
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Palak Shah
- Heart Failure, MCS and Transplant, Inova Heart and Vascular Institute, Falls Church, VA
| | - Alanna A. Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Adam D. DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Robert T. Cole
- Samsky Advanced Heart Failure Center, Piedmont Heart Institute, Atlanta, GA
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Van Aelst LNL, Droogné W, Vörös G, Van Cleemput J. Combination prophylaxis in CMV high risk heart transplant recipients: A single center experience. Clin Transplant 2023; 37:e14848. [PMID: 36374223 DOI: 10.1111/ctr.14848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/24/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) is the most clinically relevant infectious agent following heart transplantation (HTX). Data on the beneficial effects of prophylactic use of CMV immunoglobulins (CMVIG) are scarce. METHODS In this single-center, retrospective study, we reported patient outcomes following cardiac transplantation using prophylactic CMV treatment, including CMVIG. Distinct clinically relevant outcomes were compared across different CMV risk groups (CMV D-/R-, CMV D-/R+, CMV D+/R+, and CMV D+/R- or CMV high risk group). RESULTS We included 272 heart transplant procedures, performed between 1/1/2009 and 1/11/2020. Sixty-one (22%) procedures belonged to the CMV high risk group, while 96 (35%), 50 (18%), and 65 (24%) were CMV D-/R-, CMV D-/R+, and CMV D+/R+, respectively. Baseline donor and recipient characteristics (sex, age, body mass index, cause of death, indication for HTX), ischemia times and baseline immunosuppressive regimens were similar across the different CMV risk groups, yet fewer patients were bridged with a mechanical circulatory support in the CMV D+/R- group. CMV disease following cardiac transplantation was more common in the CMV D+/R- risk group (n = 40 or 66.7%; p < .001), yet mortality and re-transplantation rates, cardiac allograft vasculopathy (CAV) severity, rejection episodes, and development of donor-specific antibodies (DSA), post-transplant lymphoproliferative diseases (PTLD), and EBV infections were similar across all four CMV risk groups. CONCLUSION High risk CMV D+/R- patients had a similar survival compared to low and intermediate CMV risk groups using a prophylactic strategy combining CMVIG and viral DNA polymerase inhibitors. This may be related to a number of factors unrelated to prophylaxis strategy as two out of three CMV D+/R- recipients developed CMV primary infection after prophylaxis was discontinued.
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Affiliation(s)
- Lucas N L Van Aelst
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Walter Droogné
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Gabor Vörös
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Johan Van Cleemput
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
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7
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Bergmark BA, Zelniker TA, Kim M, Mehra MR, Stewart GC, Page DS, Woodcome EL, Givertz MM. Early aspirin use, allograft rejection, and cardiac allograft vasculopathy in heart transplantation. Clin Transplant 2021; 35:e14424. [PMID: 34254366 DOI: 10.1111/ctr.14424] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 07/01/2021] [Accepted: 07/04/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Early aspirin (ASA) use after orthotopic heart transplantation (OHT) has been associated with lower rates of cardiac allograft vasculopathy (CAV). We hypothesized that the inverse association between ASA use and CAV incidence may be most pronounced in patients with allograft rejection. METHODS Patients receiving OHT at a single center 2004-2010 (n = 120) were categorized by early ASA use post-transplant (ASA use for > 6 months in the first year) and the presence of biopsy-defined acute cellular rejection (ACR) and/or antibody-mediated rejection (AMR) during 5-year follow-up. Propensity scores for ASA treatment were estimated using boosting models and applied by inverse probability of treatment weighting. The association between ASA use and time to moderate/severe CAV (ISHLT ≥ 2) was investigated. RESULTS Among patients with ACR or AMR, ASA therapy was associated with significantly lower rates of CAV≥ 2 (3.3 vs. 30.1%; P = .001; HRadj .07; 95% CI .01-.52), whereas ASA therapy was not associated with lower rates of CAV in patients with no rejection (5.6 vs. 5.3%; P = .90; HRadj 1.26; 95% CI .08-20.30; pinteraction = .09). CONCLUSIONS Early ASA use after OHT was associated with lower rates of moderate to severe CAV only in those patients with episodes of allograft rejection.
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Affiliation(s)
- Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Boston, MA, USA.,Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas A Zelniker
- Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Miae Kim
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Mandeep R Mehra
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Garrick C Stewart
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Deborah S Page
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Erica L Woodcome
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA, USA
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Yaiw KC, Mohammad AA, Taher C, Cui HL, Costa H, Kostopoulou ON, Jung M, Assinger A, Wilhelmi V, Yang J, Strååt K, Rahbar A, Pernow J, Söderberg-Nauclér C. Human Cytomegalovirus Reduces Endothelin-1 Expression in Both Endothelial and Vascular Smooth Muscle Cells. Microorganisms 2021; 9:microorganisms9061137. [PMID: 34070407 PMCID: PMC8229579 DOI: 10.3390/microorganisms9061137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/16/2022] Open
Abstract
Human cytomegalovirus (HCMV) is an opportunistic pathogen that has been implicated in the pathogenesis of atherosclerosis. Endothelin-1 (ET-1), a potent vasoconstrictive peptide, is overexpressed and strongly associated with many vasculopathies. The main objective of this study was to investigate whether HCMV could affect ET-1 production. As such, both endothelial and smooth muscle cells, two primary cell types involved in the pathogenesis of atherosclerosis, were infected with HCMV in vitro and ET-1 mRNA and proteins were assessed by quantitative PCR assay, immunofluorescence staining and ELISA. HCMV infection significantly decreased ET-1 mRNA and secreted bioactive ET-1 levels from both cell types and promoted accumulation of the ET-1 precursor protein in infected endothelial cells. This was associated with inhibition of expression of the endothelin converting enzyme-1 (ECE-1), which cleaves the ET-1 precursor protein to mature ET-1. Ganciclovir treatment did not prevent the virus suppressive effects on ET-1 expression. Consistent with this observation we identified that the IE2-p86 protein predominantly modulated ET-1 expression. Whether the pronounced effects of HCMV in reducing ET-1 expression in vitro may lead to consequences for regulation of the vascular tone in vivo remains to be proven.
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Affiliation(s)
- Koon-Chu Yaiw
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
- Correspondence: (K.-C.Y.); (C.S.-N.)
| | - Abdul-Aleem Mohammad
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Chato Taher
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Huanhuan Leah Cui
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Helena Costa
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Ourania N. Kostopoulou
- Department of Oncology and Pathology, Karolinska Institutet, SE 171 64 Stockholm, Sweden;
| | - Masany Jung
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Alice Assinger
- Institute of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, A-1090 Vienna, Austria;
| | - Vanessa Wilhelmi
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - Jiangning Yang
- Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital Solna, SE 171 64 Stockholm, Sweden; (J.Y.); (J.P.)
| | - Klas Strååt
- Department of Medicine, Division of Hematology, BioClinicum and Centre for Molecular Medicine, Karolinska University, Hospital Solna and Karolinska Institutet, SE 171 64 Stockholm, Sweden;
| | - Afsar Rahbar
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
| | - John Pernow
- Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital Solna, SE 171 64 Stockholm, Sweden; (J.Y.); (J.P.)
| | - Cecilia Söderberg-Nauclér
- Department of Medicine, Solna, Microbial Pathogenesis Unit, Karolinska Institutet, SE 171 64 Stockholm, Sweden; (A.-A.M.); (C.T.); (H.L.C.); (H.C.); (M.J.); (V.W.); (A.R.)
- Division of Neurology, Karolinska University Hospital, SE 171 64 Stockholm, Sweden
- Correspondence: (K.-C.Y.); (C.S.-N.)
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9
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Hodowanec AC, Pikis A, Singer ME. The Development of Therapeutics for the Treatment and Prevention of CMV Disease in the Transplant Population: A Regulatory Perspective. J Infect Dis 2021; 221:S109-S112. [PMID: 32134476 DOI: 10.1093/infdis/jiz389] [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] [Indexed: 11/14/2022] Open
Abstract
Cytomegalovirus (CMV) remains an important pathogen in the transplant population. As such, the US Food and Drug Administration has published a guidance to encourage and inform the development of therapeutics for the treatment and prevention of CMV disease in this population. This review summarizes important phase 3 trial design considerations for industry and provides rationale for some of the recommendations included in the guidance.
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Affiliation(s)
- Aimee C Hodowanec
- Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Office of Infectious Diseases, Division of Antiviral, Silver Spring, Maryland
| | - Andreas Pikis
- Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Office of Infectious Diseases, Division of Antiviral, Silver Spring, Maryland
| | - Mary E Singer
- Food and Drug Administration, Center for Drug Evaluation and Research, Office of New Drugs, Office of Infectious Diseases, Division of Antiviral, Silver Spring, Maryland
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10
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Boutolleau D, Coutance G, Désiré E, Bouglé A, Bréchot N, Leprince P, Varnous S. Association between cytomegalovirus infection and allograft rejection in a large contemporary cohort of heart transplant recipients. Transpl Infect Dis 2021; 23:e13569. [PMID: 33452851 DOI: 10.1111/tid.13569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 12/29/2020] [Accepted: 01/04/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection remains a common complication after heart transplantation (HTx). The association between CMV infection and allograft rejection is debated in the era of efficient prophylactic antiviral therapies. METHODS This single-center cohort study utilized a highly phenotyped database of HTx recipients (2012-2016). The primary endpoint was the analysis of the association between CMV infection (CMV load ≥ 500 IU/mL whole blood) and the risk of allograft rejection (cellular rejection ≥ 1R1B, antibody-mediated rejection ≥ pAMR1). Secondary endpoints included the analysis of a higher CMV load threshold (≥10 000 IU/mL) and different risk periods after PCR positivity. A mixed-effect logistic regression model with a random intercept was applied. Results were adjusted for important risk factors of rejection. RESULTS Overall, 384 patients were included and 6388 CMV loads and 3,494 endomyocardial biopsies were analyzed. CMV infections ≥ 500 IU/mL were diagnosed on 1223 (19.2%) blood samples from 284 (72.1%) patients and allograft rejections on 246 biopsies (7%) from 149 patients (38.8%). We did not find any association between CMV infection ≥ 500 IU/mL and rejection (univariable: OR 0.94, 95% CI [0.61, 1.45], P = .78, multivariable: OR 0.86, 95% CI [0.55, 1.33], P = .85). These results were consistent when analyzing a higher CMV load threshold and different periods of risk, reinforced by internal validation procedures and a posteriori calculation of the power (primary endpoint: power = 0.82, 95% CI [0.79-0.84]) and reproducible across different clinical scenarios. CONCLUSIONS CMV infection was not associated with an increased risk of rejection in a contemporary cohort of HTx recipients.
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Affiliation(s)
- David Boutolleau
- Virology Department, Sorbonne Université, INSERM UMR U1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), Team 3 THERAVIR, and Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, National Reference Centre for Herpesviruses, Paris, France
| | - Guillaume Coutance
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Eva Désiré
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Adrien Bouglé
- Department of Anesthesiology and Critical Care Medicine, Sorbonne Université, UMR INSERM 1166, IHU ICAN, Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Institute, Pitié-Salpêtrière Hospital, Paris, France
| | - Nicolas Bréchot
- Department of Medical Intensive Care Unit, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France.,INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
| | - Shaida Varnous
- Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, Paris, France
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11
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Das BB, Prusty BK, Niu J, Sue PK. Cytomegalovirus infection and allograft rejection among pediatric heart transplant recipients in the era of valganciclovir prophylaxis. Pediatr Transplant 2020; 24:e13750. [PMID: 32573886 DOI: 10.1111/petr.13750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/27/2020] [Accepted: 05/03/2020] [Indexed: 12/28/2022]
Abstract
CMV infection remains a significant cause of morbidity among pediatric HTx recipients We explored the implications of CMV infection on post-transplant outcomes among CMV risk-stratified pediatric HTx recipients receiving VGC prophylaxis. Children who underwent HTx between January 2010 and October 2016 were stratified according to CMV risk at time of transplant and evaluated for evidence of post-transplant CMV infection, rejection, CAV, and graft loss. Among 97 children, 41 (42%) were considered HR or IR risk for CMV infection and received VGC prophylaxis. CMV DNAemia was observed in 34% of children, including 71% HR, 40% IR, and 18% LR individuals. Median time to CMV DNAemia following VGC prophylaxis was 32D among HR vs 277D in IR subjects (P = .042). No difference in overall graft loss was noted among groups, but CMV HR children had decreased rejection-free survival (3.5 years) compared to IR (6 years, P = .015) and LR children (8 years, P = .0003). CMV was noted on EMB in 13% of children but was not associated with increased CAV, rejection or graft loss. High-risk CMV status was associated with decreased time to CMV infection despite VGC prophylaxis, compared to IR, and decreased rejection-free survival times compared to both IR and LR recipients. Detection of CMV on EMB was not associated with increased rejection, CAV or graft loss. Additional studies are needed to explore the impact of CMV infection on rejection-free survival in HTx recipients.
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Affiliation(s)
- Bibhuti B Das
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Bhupesh K Prusty
- Institute for Virology and Immunobiology, University of Wuerzburg, Wuerzburg, Germany
| | - Jianli Niu
- Office of Human Research, Memorial Healthcare System, Hollywood, Florida, USA
| | - Paul K Sue
- Division of Infectious Diseases, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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12
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The Association Between Cytomegalovirus Infection and Cardiac Allograft Vasculopathy in the Era of Antiviral Valganciclovir Prophylaxis. Transplantation 2020; 104:1508-1518. [PMID: 31644496 PMCID: PMC7306257 DOI: 10.1097/tp.0000000000003015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Supplemental Digital Content is available in the text. Previous studies on the association between cytomegalovirus (CMV) infection and cardiac allograft vasculopathy (CAV) were conducted on patients transplanted in the prevalganciclovir prophylaxis era. The aim of our study is to evaluate this relation in heart transplantation (HTx) recipients treated according to current prophylactic and immunosuppressive regimens.
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13
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Ponz de Antonio I, Rodríguez Chaverri A, García Reyne A, Carrasco Antón N, Lora Pablos D, López Medrano F, de Dios S, Jurado A, Folgueira MD, García-Cosio Carmena MD, Arribas Ynsaurriaga F, Aguado JM, Lumbreras C, Delgado Jiménez JF. Impact of late-onset cytomegalovirus infection in the development of cardiac allograft vasculopathy in heart transplant recipients. Transpl Infect Dis 2020; 23:e13479. [PMID: 32996216 DOI: 10.1111/tid.13479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/29/2020] [Accepted: 09/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The impact of late-onset cytomegalovirus (CMV) infection (LOCI) on cardiac allograft vasculopathy (CAV) has yet to be established. METHODS A retrospective study was performed for patients who had undergone heart transplantation (HT) between January 1995 and October 2017 to analyze epidemiology of LOCI (any positive level of CMV pp65 antigenemia or DNAemia after 100 days, without previous CMV replication) and its association with CAV. Our main hypothesis was that LOCI causes less direct and indirect effects compared to early onset infection (EOCI). RESULTS Late-onset cytomegalovirus infection developed in 57 of 410 patients (13.9%) in a median time of 4.7 months post-transplant. CAV at 10 years was diagnosed in 31.6% of patients with LOCI, 34.6% with EOCI, and in 19.3% of CMV-uninfected patients. In the multivariate analysis, EOCI was an independent variable for developing CAV (HR 1.8, 95% CI 1.13-2.82, P = .01). Patients with LOCI showed a trend toward a higher risk of CAV, but the difference was not statistically significant (HR 1.7, 95% CI 0.95-3.08, P = .07). In the complementary log-log model, LOCI and EOCI had a similar CAV-free survival, and a higher probability of developing CAV than CMV-uninfected patients (P = .02). CONCLUSIONS Cytomegalovirus infection after HT may result in the same long-term events regardless of its onset, with a higher risk of developing CAV at 10 years than patients without CMV.
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Affiliation(s)
- Inés Ponz de Antonio
- Cardiology Department, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Adriana Rodríguez Chaverri
- Cardiology Department, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Ana García Reyne
- Infectious Disease Unit, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Nerea Carrasco Antón
- Infectious Disease Unit, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - David Lora Pablos
- Centro de Investigacion Biomedica Epidemiologia y Salud Publica (CIBERESP), Madrid, Spain
| | - Francisco López Medrano
- Infectious Disease Unit, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Santiago de Dios
- Cardiology Department, Hospital Sanitas La Zarzuela, Madrid, Spain
| | - Alfonso Jurado
- Cardiology Department, University Hospital La Paz, Madrid, Spain
| | - María D Folgueira
- Microbiology Department, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - María D García-Cosio Carmena
- Cardiology Department, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Fernando Arribas Ynsaurriaga
- Cardiology Department, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain.,Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - José M Aguado
- Infectious Disease Unit, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Carlos Lumbreras
- Infectious Disease Unit, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Juan F Delgado Jiménez
- Cardiology Department, University Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain.,Centro de Investigación Biomédica En Red Cardiovascular (CIBERCV), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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14
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Hori A, Fujimura T, Murakami M, Park J, Kawamoto S. Intravenous immunoglobulin (IVIg) acts directly on conventional T cells to suppress T cell receptor signaling. Biochem Biophys Res Commun 2019; 522:792-798. [PMID: 31787231 DOI: 10.1016/j.bbrc.2019.11.169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/21/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022]
Abstract
Intravenous immunoglobulin (IVIg) therapy is widely used to treat autoimmune and infectious disorders. Despite the clinical efficacy of IVIg therapy, its precise immunosuppressive mechanisms remain unclear. Here, we provide evidence that IVIg acts directly on T cells to suppress their activation upon T cell receptor (TCR) ligation. IVIg suppressed the proliferation of murine splenocytes upon stimulation with anti-CD3 antibody and T cell-tropic mitogens. These immunosuppressive effects of IVIg were still intact against purified T cells, and the depletion of naturally-occurring regulatory T cells (nTreg) had no effect on T cell regulatory activity. Instead, we found that IVIg negatively regulated TCR signaling; IVIg co-stimulation impaired IκB degradation, nuclear translocation of the nuclear factor of activated T cells (NFAT), and the activation of mitogen-activated protein kinase (MAPK, Erk1/2). These results suggest an additional new immunosuppressive role of IVIg, which acts directly on conventional T cells to suppress the TCR signaling pathway.
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Affiliation(s)
- Ayane Hori
- Hiroshima Research Center for Healthy Aging (HiHA), Hiroshima University, Higashi-Hiroshima, Japan; Department of Molecular Biotechnology, Graduate School of Advanced Sciences of Matter, Hiroshima University, Higashi-Hiroshima, Japan
| | - Takashi Fujimura
- Hiroshima Research Center for Healthy Aging (HiHA), Hiroshima University, Higashi-Hiroshima, Japan; Unit of Biotechnology, Graduate School of Integrated Sciences for Life, Hiroshima University, Higashi-Hiroshima, Japan
| | - Mai Murakami
- Faculty of Engineering, Hiroshima University, Higashi-Hiroshima, Japan
| | - Jungyeon Park
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
| | - Seiji Kawamoto
- Hiroshima Research Center for Healthy Aging (HiHA), Hiroshima University, Higashi-Hiroshima, Japan; Unit of Biotechnology, Graduate School of Integrated Sciences for Life, Hiroshima University, Higashi-Hiroshima, Japan.
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15
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Zhang Z, Qiu L, Yan S, Wang JJ, Thomas PM, Kandpal M, Zhao L, Iovane A, Liu XF, Thorp EB, Chen Q, Hummel M, Kanwar YS, Abecassis MM. A clinically relevant murine model unmasks a "two-hit" mechanism for reactivation and dissemination of cytomegalovirus after kidney transplant. Am J Transplant 2019; 19:2421-2433. [PMID: 30947382 PMCID: PMC6873708 DOI: 10.1111/ajt.15376] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/17/2019] [Accepted: 03/24/2019] [Indexed: 01/25/2023]
Abstract
Reactivation of latent cytomegalovirus remains an important complication after transplant. Although immunosuppression (IS) has been implicated as a primary cause, we have previously shown that the implantation response of a kidney allograft can lead to early transcriptional activation of latent murine cytomegalovirus (MCMV) genes in an immune-competent host and to MCMV reactivation and dissemination to other organs in a genetically immune-deficient recipient. We now describe a model that allows us to separately analyze the impact of the implantation effect vs that of a clinically relevant IS regimen. Treatment with IS of latently infected mice alone does not induce viral reactivation, but transplant of latently infected allogeneic kidneys combined with IS facilitates MCMV reactivation in the graft and dissemination to other organs. The IS regimen effectively dampens allo-immune inflammatory pathways and depletes recipient anti-MCMV but does not affect ischemia-reperfusion injury pathways. MCMV reactivation similar to that seen in allogeneic transplants combined with also occurs after syngeneic transplants. Thus, our data strongly suggest that while ischemia-reperfusion injury of the implanted graft is sufficient and necessary to initiate transcriptional reactivation of latent MCMV ("first hit"), IS is permissive to the first hit and facilitates dissemination to other organs ("second hit").
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Affiliation(s)
- Zheng Zhang
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois,Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Longhui Qiu
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Shixian Yan
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Jiao-Jing Wang
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Paul M. Thomas
- Department of Chemistry and Chemistry of Life Processes Institute, Northwestern University, Evanston, Illinois
| | - Manoj Kandpal
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois,Preventive Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Lihui Zhao
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois,Preventive Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Andre Iovane
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Xue-feng Liu
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois,Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Edward B. Thorp
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Qing Chen
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Mary Hummel
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois,Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois,Department of Microbiology and Immunology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Yashpal S. Kanwar
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois,Department of Nephrology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Michael M. Abecassis
- Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois,Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois,Department of Microbiology and Immunology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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16
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Hodowanec AC, Pikis A, Komatsu TE, Sampson MR, Younis IR, O'Rear JJ, Singer ME. Treatment and Prevention of CMV Disease in Transplant Recipients: Current Knowledge and Future Perspectives. J Clin Pharmacol 2018; 59:784-798. [PMID: 30586161 DOI: 10.1002/jcph.1363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/26/2018] [Indexed: 12/29/2022]
Abstract
This review summarizes the significant impact of cytomegalovirus (CMV) infection on solid organ and hematopoietic stem cell transplant recipients. A discussion of the various CMV prevention and treatment strategies is provided, including a detailed description of each of the available CMV antiviral drugs.
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Affiliation(s)
- Aimee C Hodowanec
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Andreas Pikis
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Takashi E Komatsu
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Mario R Sampson
- Center for Drug Evaluation and Research, Office of Translational Sciences, Office of Clinical Pharmacology, Division of Clinical Pharmacology IV, Food and Drug Administration, Silver Spring, MD, USA
| | - Islam R Younis
- Center for Drug Evaluation and Research, Office of Translational Sciences, Office of Clinical Pharmacology, Division of Clinical Pharmacology IV, Food and Drug Administration, Silver Spring, MD, USA
| | - Julian J O'Rear
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Mary E Singer
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
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17
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Britt WJ, Prichard MN. New therapies for human cytomegalovirus infections. Antiviral Res 2018; 159:153-174. [PMID: 30227153 DOI: 10.1016/j.antiviral.2018.09.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/28/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
Abstract
The recent approval of letermovir marks a new era of therapy for human cytomegalovirus (HCMV) infections, particularly for the prevention of HCMV disease in hematopoietic stem cell transplant recipients. For almost 30 years ganciclovir has been the therapy of choice for these infections and by today's standards this drug exhibits only modest antiviral activity that is often insufficient to completely suppress viral replication, and drives the selection of drug-resistant variants that continue to replicate and contribute to disease. While ganciclovir remains the therapy of choice, additional drugs that inhibit novel molecular targets, such as letermovir, will be required as highly effective combination therapies are developed not only for the treatment of immunocompromised hosts, but also for congenitally infected infants. Sustained efforts, largely in the biotech industry and academia, have identified additional highly active lead compounds that have progressed into clinical studies with varying levels of success and at least two have the potential to be approved in the near future. Some of the new drugs in the pipeline inhibit new molecular targets, remain effective against isolates that have developed resistance to existing therapies, and promise to augment existing therapeutic regimens. Here, we will describe some of the unique features of HCMV biology and discuss their effect on therapeutic needs. Existing drugs will also be discussed and some of the more promising candidates will be reviewed with an emphasis on those progressing through clinical studies. The in vitro and in vivo antiviral activity, spectrum of antiviral activity, and mechanism of action of new compounds will be reviewed to provide an update on potential new therapies for HCMV infections that have progressed significantly in recent years.
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Affiliation(s)
- William J Britt
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham AL 35233-1711, USA
| | - Mark N Prichard
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham AL 35233-1711, USA.
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18
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Long-term prognostic value of invasive and non-invasive measures early after heart transplantation. Int J Cardiol 2018; 260:31-35. [PMID: 29622448 DOI: 10.1016/j.ijcard.2018.01.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 01/13/2018] [Accepted: 01/16/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Invasively assessed coronary microvascular resistance early after heart transplantation predicts worse long-term outcome; however, little is known about the relationship between microvascular resistance, left ventricular function and outcomes in this setting. METHODS A total of 100 cardiac transplant recipients had fractional flow reserve (FFR) and the index of microcirculatory resistance (IMR) measured in the left anterior descending artery and echocardiographic assessment of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) at 1 year after heart transplantation. The primary endpoint was the composite of death and retransplantation occurring beyond the first post-operative year. RESULTS The mean FFR, IMR, LVEF, and GLS values at 1 year were 0.87 ± 0.06, 21.3 ± 17.3, 60.4 ± 5.4%, and 14.2 ± 2.4%, respectively. FFR and IMR had no significant correlation with LVEF and GLS. During a mean follow-up of 6.7 ± 4.2 years, the primary endpoint occurred in 24 patients (24.0%). By ROC curve analysis, IMR = 19.3 and GLS = 13.3% were the best cutoff values for predicting death or retransplantation. Cumulative event-free survival was significantly lower in patients with higher IMR (log-rank p = 0.02) and lower GLS (log-rank p < 0.001). Cumulative event-free survival can be further stratified by the combination of IMR and GLS (long-rank p < 0.001). By multivariable Cox proportional hazards model, higher IMR and lower GLS were independently associated with long-term death or retransplantation (elevated IMR, hazard ratio = 2.50, p = 0.04 and reduced GLS, hazard ratio = 3.79, p = 0.003, respectively). CONCLUSION Invasively assessed IMR does not correlate with GLS at 1 year after heart transplantation. IMR and GLS determined at 1 year may be used as independent predictors of late death or retransplantation.
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19
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Echenique IA, Angarone MP, Rich JD, Anderson AS, Stosor V. Cytomegalovirus infection in heart transplantation: A single center experience. Transpl Infect Dis 2018; 20:e12896. [PMID: 29602266 DOI: 10.1111/tid.12896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 01/08/2018] [Accepted: 01/14/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection remains a major complication after heart transplantation with varying prophylaxis strategies employed. We sought to determine the impact of valganciclovir (VGC) duration on the epidemiology of CMV infections after heart transplantation. METHODS We performed a prospective cohort study of CMV donor (D) or recipient (R) seropositive heart transplant recipients from 2005 to 2012 who completed VGC prophylaxis, ranging from 3 to 12 months according to serostatus and induction immunosuppression. Univariate and multivariate logistic regression was performed. RESULTS Among 159 heart transplant recipients during the study period, 130 (82%) were eligible for VGC prophylaxis. CMV D/R serostatus was as follows: 24% D+/R-, 30% D+/R+, and 29% D-/R+. 65% and 21% received basiliximab and thymoglobulin induction, respectively, followed by maintenance tacrolimus, mycophenolate mofetil, and prednisone. Twenty-one (16%) recipients suffered CMV infection. There was no association with comorbidities including diabetes mellitus, chronic kidney disease, or mechanical assist devices, nor were there associations with rejection, treatments of rejection, or mortality. When VGC prophylaxis duration was stratified by ≤6 vs ≥12 months, time from heart transplantation to CMV infection was delayed (median 247 vs 452 days, P = .002) but there was no difference in days from VGC discontinuation to onset of CMV infection (median 72 vs 83 days, P = .31). CMV infection occurred most frequently within 6-16 weeks of VGC cessation, and 95% of infections occurred during the 6 months post-prophylaxis period. CONCLUSIONS Relative to ≤6 months, ≥12 months of VGC did not reduce incidence of CMV infection and only delayed time to onset. 95% of CMV infection occurs within 6 months after cessation of VGC.
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Affiliation(s)
| | - Michael P Angarone
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jonathan D Rich
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Allen S Anderson
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Valentina Stosor
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Organ Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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20
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Goekler J, Zuckermann A, Kaider A, Angleitner P, Osorio-Jaramillo E, Moayedifar R, Uyanik-Uenal K, Kainz FM, Masetti M, Laufer G, Aliabadi-Zuckermann AZ. Diminished impact of cytomegalovirus infection on graft vasculopathy development in the antiviral prophylaxis era - a retrospective study. Transpl Int 2018; 31:909-916. [DOI: 10.1111/tri.13155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 11/27/2017] [Accepted: 03/15/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Johannes Goekler
- Department of Cardiac Surgery; Medical University of Vienna; Vienna Austria
| | - Andreas Zuckermann
- Department of Cardiac Surgery; Medical University of Vienna; Vienna Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics and Intelligent Systems; Medical University of Vienna; Vienna Austria
| | - Philipp Angleitner
- Department of Cardiac Surgery; Medical University of Vienna; Vienna Austria
| | | | - Roxana Moayedifar
- Department of Cardiac Surgery; Medical University of Vienna; Vienna Austria
| | | | - Frieda-Marie Kainz
- Department of Cardiac Surgery; Medical University of Vienna; Vienna Austria
| | - Marco Masetti
- Department of Cardiology; University of Bologna; Bologna Italy
| | - Guenther Laufer
- Department of Cardiac Surgery; Medical University of Vienna; Vienna Austria
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21
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Peled Y, Lavee J, Raichlin E, Katz M, Arad M, Kassif Y, Peled A, Asher E, Elian D, Har-Zahav Y, Shlomo N, Freimark D, Goldenberg I, Klempfner R. Early aspirin initiation following heart transplantation is associated with reduced risk of allograft vasculopathy during long-term follow-up. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13133] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Yael Peled
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Jacob Lavee
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Eugenia Raichlin
- Cardiology Department; Loyola University Medical Center; Maywood IL USA
| | - Moshe Katz
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Michael Arad
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Yigal Kassif
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Amir Peled
- Clalit Health Services; Central Region; Tel Aviv Israel
| | - Elad Asher
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Dan Elian
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Yedael Har-Zahav
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
| | - Nir Shlomo
- Israeli Association for Cardiovascular Trials; Sheba Medical Center; Israel
| | - Dov Freimark
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Ilan Goldenberg
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
- Israeli Association for Cardiovascular Trials; Sheba Medical Center; Israel
| | - Robert Klempfner
- The Leviev Heart Center; Sheba Medical Center; Tel Hashomer Israel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
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22
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Early aspirin use and the development of cardiac allograft vasculopathy. J Heart Lung Transplant 2017; 36:1344-1349. [DOI: 10.1016/j.healun.2017.06.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/19/2017] [Accepted: 06/28/2017] [Indexed: 11/18/2022] Open
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23
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Abstract
Human immunodeficiency virus (HIV)-infected adults who take stable antiretroviral therapy (ART) are at risk for early onset of age-related diseases. This is likely due to a complex interaction between traditional risk factors, HIV infection itself, and other factors, such as underlying immune dysfunction and persistent inflammation. HIV disrupts the balance between the host and coinfecting microbes, worsening control of these potential pathogens. For example, HIV-infected adults are more likely than the general population to have subclinical bursts of cytomegalovirus (CMV) replication at mucosal sites. Production of antigens can activate the immune system and stimulate HIV replication, and it could contribute to the pathogenesis of adverse outcomes of aging, like cardiovascular disease and neurocognitive impairment. Further investigation of the relationships between CMV, immune dysfunction, and unsuccessful aging during chronic HIV infection is warranted.
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Affiliation(s)
- Sara Gianella
- Department of Medicine, Division of Infectious Disease, University of California-San Diego, La Jolla
| | - Scott Letendre
- Department of Medicine, Division of Infectious Disease, University of California-San Diego, La Jolla
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24
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van Gent R, Metselaar HJ, Kwekkeboom J. Immunomodulation by hyperimmunoglobulins after solid organ transplantation: Beyond prevention of viral infection. Transplant Rev (Orlando) 2017; 31:78-86. [PMID: 28131494 DOI: 10.1016/j.trre.2017.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 12/12/2022]
Abstract
Hyperimmunoglobulins are pharmaceutical formulations of human IgG which contain high titers of antibodies against specific viruses. They have been successfully used in solid organ transplantation (SOT) to prevent Cytomegalovirus (CMV) and Hepatitis B Virus (HBV) infection. The introduction of effective and cheaper antiviral drugs has resulted in decreasing usage of hyperimmunoglobulins in SOT. However, it may still be attractive to combine antiviral drug therapy with hyperimmunoglobulins after SOT, as there is some evidence that hyperimmunoglobulins, similar to high doses of intravenous immunoglobulins (IVIgs), might exert anti-inflammatory activity and thereby prevent immunological graft damage and improve graft and patient survival. In this review we discuss the existing clinical evidence for beneficial anti-inflammatory effects of hyperimmunoglobulins after cardiac, lung, kidney, and liver transplantation. Only a limited number of studies have addressed this issue, and these studies often included small patient cohorts and showed considerable variations in the type, intensity and duration of treatment regimens. Due to these limitations, it is difficult to draw firm conclusions. Retrospective studies consistently demonstrated that addition of CMV hyperimmunoglobulin (CMV-Ig) to antiviral drug prophylaxis after lung transplantation is associated with reduced rates of CMV disease and bronchiolitis obliterans syndrome (BOS), and improved patient survival. The doses of CMV-Ig administered after SOT are much lower than the minimal effective dose of IVIg used for anti-inflammatory therapy in auto-immune diseases. Therefore, it is questionable whether the reduced incidence of BOS is the result of 'direct' anti-inflammatory effects of CMV-Ig or is caused by a reduction of CMV infection, which is a risk factor for BOS. No or very limited evidence for better prevention of immunological graft damage by anti-CMV combination therapy is available for heart, kidney and liver transplant patients. In liver transplantation published evidence suggests that the high-doses of Hepatitis B virus hyperimmunoglobulin (HBIg) administered to prevent HBV-infection may reduce the risk of acute rejection, while combination therapy of HBIg and antiviral drugs in HBV-infected patients is consistently associated with better graft and patient survival compared to antiviral monotherapy. Well-designed prospective randomized studies with larger patient cohorts are needed to substantiate the current limited evidence for anti-inflammatory benefits of hyperimmunoglobulins besides prevention of CMV and HBV infection after SOT.
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Affiliation(s)
- Rogier van Gent
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Jaap Kwekkeboom
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands.
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Effects of Granulocyte and Monocyte Adsorptive Apheresis in Renal Transplantation Recipients With Concomitant Cytomegalovirus Infection. Transplant Proc 2017; 48:929-32. [PMID: 27234770 DOI: 10.1016/j.transproceed.2015.12.127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 12/30/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Granulocyte and monocyte adsorptive apheresis (GMAA) is widely used as a treatment for active ulcerative colitis (UC) in Japan. Much attention has been paid to the possibility of GMAA for the treatment and control of cytomegalovirus (CMV) reactivation in patients with refractory UC and concomitant CMV infection. In this study, the effects of the combination of GMAA and antiviral therapy were examined in renal transplant recipients with concomitant CMV infection. METHODS Combination therapy of GMAA and antiviral drugs was performed 9 times in 7 renal transplant recipients with concomitant CMV infection. Four of the cases were positive for CMV-IgG, and 3 were negative. The clinical presentation of CMV infection was viremia in 6 cases and disease (CMV retinitis) in 1 case. CMV infection was diagnosed by using an antigenemia assay (C7-HRP). GMAA session was performed once, and the duration of the session was 120 min. Immediately after the GMAA session, ganciclovir was administered at 5 mg/kg/body weight. CMV infection was monitored based on C7-HRP and CMV-DNA in the peripheral blood samples. RESULTS All cases became negative for C7-HRP and CMV-DNA within 21 days (median, 14 days; range, 3-21 days) and 17 days (median, 6 days; range, 3-17 days), respectively, after starting the combination therapy. No side effects of GMAA were observed. CONCLUSIONS This case series found that GMAA in combination with antiviral drugs may shorten the duration of treatment against CMV infection in renal transplant recipients. Further studies in a larger number of patients are required to confirm these results.
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26
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Han SH. Immunological Prediction of Cytomegalovirus (CMV) Replication Risk in Solid Organ Transplantation Recipients: Approaches for Regulating the Targeted Anti-CMV Prevention Strategies. Infect Chemother 2017; 49:161-175. [PMID: 29027383 PMCID: PMC5620383 DOI: 10.3947/ic.2017.49.3.161] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The current cytomegalovirus (CMV) prevention strategies in solid organ transplantation (SOT) recipients have contributed towards overcoming the detrimental effects caused by CMV lytic infection, and improving the long-term success rate of graft survival. Although the quantification of CMV in peripheral blood is the standard method, and an excellent end-point for diagnosing CMV replication and modulating the anti-CMV prevention strategies in SOT recipients, a novel biomarker mimicking the CMV control mechanism is required. CMV-specific immune monitoring can be employed as a basic tool predicting CMV infection or disease after SOT, since uncontrolled CMV replication mostly originates from the impairment of immune responses against CMV under immunosuppressive conditions in SOT recipients. Several studies conducted during the past few decades have indicated the possibility of measuring the CMV-specific cell-mediated immune response in clinical situations. Among several analytical assays, the most advancing standardized tool is the QuantiFERON®-CMV assay. The T-Track® CMV kit that uses the standardized enzyme-linked immunospot assay is also widely employed. In addition to these assays, immunophenotyping and intracellular cytokine analysis using flow cytometry (with fluorescence-labeled monoclonal antibodies or peptide-major histocompatibility complex multimers) needs to be adequately standardized and validated for potential clinical applications.
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Affiliation(s)
- Sang Hoon Han
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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27
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Current Perspectives on Cytomegalovirus in Heart Transplantation. CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0121-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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28
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Kaminski H, Fishman JA. The Cell Biology of Cytomegalovirus: Implications for Transplantation. Am J Transplant 2016; 16:2254-69. [PMID: 26991039 DOI: 10.1111/ajt.13791] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/17/2016] [Accepted: 03/07/2016] [Indexed: 01/25/2023]
Abstract
Interpretation of clinical data regarding the impact of cytomegalovirus (CMV) infection on allograft function is complicated by the diversity of viral strains and substantial variability of cellular receptors and viral gene expression in different tissues. Variation also exists in nonspecific (monocytes and dendritic cells) and specific (NK cells, antibodies) responses that augment T cell antiviral activities. Innate immune signaling pathways and expanded pools of memory NK cells and γδ T cells also serve to amplify host responses to infection. The clinical impact of specific memory T cell anti-CMV responses that cross-react with graft antigens and alloantigens is uncertain but appears to contribute to graft injury and to the abrogation of allograft tolerance. These responses are modified by diverse immunosuppressive regimens and by underlying host immune deficits. The impact of CMV infection on the transplant recipient reflects cellular changes and corresponding host responses, the convergence of which has been termed the "indirect effects" of CMV infection. Future studies will clarify interactions between CMV infection and allograft injury and will guide interventions that may enhance clinical outcomes in transplantation.
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Affiliation(s)
- H Kaminski
- Kidney Transplant Unit, CHU Bordeaux Pellegrin, Place Raba Léon, Bordeaux, France
| | - J A Fishman
- Transplant Infectious Disease and Immunocompromised Host Program and MGH Transplant Center, Massachusetts General Hospital, Boston, MA
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29
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Torre-Cisneros J, Aguado J, Caston J, Almenar L, Alonso A, Cantisán S, Carratalá J, Cervera C, Cordero E, Fariñas M, Fernández-Ruiz M, Fortún J, Frauca E, Gavaldá J, Hernández D, Herrero I, Len O, Lopez-Medrano F, Manito N, Marcos M, Martín-Dávila P, Monforte V, Montejo M, Moreno A, Muñoz P, Navarro D, Pérez-Romero P, Rodriguez-Bernot A, Rumbao J, San Juan R, Vaquero J, Vidal E. Management of cytomegalovirus infection in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations. Transplant Rev (Orlando) 2016; 30:119-43. [DOI: 10.1016/j.trre.2016.04.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 04/02/2016] [Accepted: 04/04/2016] [Indexed: 02/06/2023]
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30
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Potena L, Solidoro P, Patrucco F, Borgese L. Treatment and prevention of cytomegalovirus infection in heart and lung transplantation: an update. Expert Opin Pharmacother 2016; 17:1611-22. [PMID: 27340928 DOI: 10.1080/14656566.2016.1199684] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Heart and lung transplantation are standard therapeutic strategies to improve survival and quality of life in selected patients with end-stage heart or lung diseases. Cytomegalovirus (CMV) is one the most clinically relevant and frequent post-transplant infectious agents, which may cause direct acute syndromes, and chronic indirect graft-related injury. Despite effective antiviral drugs being available to prevent and treat CMV infection, due to the immunosuppression burden and the specific characteristics of thoracic grafts, CMV infection remains a major clinical problem in heart and lung transplant recipients. AREAS COVERED We performed an extensive literature search focused on studies specifically including heart or lung transplantation, when available, or kidney transplant recipients when data on thoracic transplants were not available. We discuss the pros and cons supporting the use of currently available drugs and strategies for CMV prevention and treatment, highlighting current unmet needs. EXPERT OPINION While (Val)Ganciclovir remains the cornerstone of anti-CMV therapy, prolonged universal prophylaxis may expose a large number of patients to an excess of drug toxicity. Additional drugs with lower toxicity may be available in the context of anti-CMV prophylaxis, and effective CMV-risk stratification, by means of novel immune monitoring assays, which may help to customize the therapeutic approach.
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Affiliation(s)
- Luciano Potena
- a Heart and Lung Transplant Program, Academic Hospital S. Orsola-Malpighi , Bologna University , Bologna , Italy
| | - Paolo Solidoro
- b Lung Transplant Center, Cardiovascular Thoracic Department , A.O.U. Città della Salute e della Scienza di Torino , Turin , Italy
| | - Filippo Patrucco
- b Lung Transplant Center, Cardiovascular Thoracic Department , A.O.U. Città della Salute e della Scienza di Torino , Turin , Italy
| | - Laura Borgese
- a Heart and Lung Transplant Program, Academic Hospital S. Orsola-Malpighi , Bologna University , Bologna , Italy
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31
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Cytomegalovirus Infection in Pediatric Renal Transplantation and the Impact of Chemoprophylaxis With (Val-)Ganciclovir. Transplantation 2016; 100:862-70. [DOI: 10.1097/tp.0000000000000888] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Abstract
Cardiac allograft vasculopathy (CAV) has a high prevalence among patients that have undergone heart transplantation. Cardiac allograft vasculopathy is a multifactorial process in which the immune system is the driving force. In this review, the data on the immunological and fibrotic processes that are involved in the development of CAV are summarized. Areas where a lack of knowledge exists and possible additional research can be completed are pinpointed. During the pathogenesis of CAV, cells from the innate and the adaptive immune system cooperate to reject the foreign heart. This inflammatory response results in dysfunction of the endothelium and migration and proliferation of smooth muscle cells (SMCs). Apoptosis and factors secreted by both the endothelium as well as the SMCs lead to fibrosis. The migration of SMCs together with fibrosis provoke concentric intimal thickening of the coronary arteries, which is the main characteristic of CAV.
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33
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Rea F, Potena L, Yonan N, Wagner F, Calabrese F. Cytomegalovirus Hyper Immunoglobulin for CMV Prophylaxis in Thoracic Transplantation. Transplantation 2016; 100 Suppl 3:S19-26. [PMID: 26900991 PMCID: PMC4764018 DOI: 10.1097/tp.0000000000001096] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/15/2015] [Accepted: 11/14/2015] [Indexed: 12/11/2022]
Abstract
Cytomegalovirus (CMV) infection negatively influences both short- and long-term outcomes after cardiothoracic transplantation. In heart transplantation, registry analyses have shown that CMV immunoglobulin (CMVIG) with or without virostatic prophylaxis is associated with a significant reduction in mortality and graft loss versus no prophylaxis, particularly in high-risk donor (D)+/recipient (R)- transplants. Randomized comparative trials are lacking but retrospective data suggest that addition of CMVIG to antiviral prophylaxis may reduce rates of CMV-related events after heart transplantation, including the incidence of acute rejection or chronic allograft vasculopathy. However, available data consistently indicate that when CMVIG is used, it should be administered with concomitant antiviral therapy, and that evidence concerning preemptive management with CMVIG is limited, but promising. In lung transplantation, CMVIG should again only be used with concomitant antiviral therapy. Retrospective studies have shown convincing evidence that addition of CMVIG to antiviral prophylaxis lowers CMV endpoints and mortality. The current balance of evidence suggests that CMVIG prophylaxis reduces the risk of bronchiolitis obliterans syndrome, but a controlled trial is awaited. Overall, the relatively limited current data set suggests that prophylaxis with CMVIG in combination with antiviral therapy appears effective in D+/R- heart transplant patients, whereas in lung transplantation, addition of CMVIG in recipients of a CMV-positive graft may offer an advantage in terms of CMV infection and disease.
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Affiliation(s)
- Federico Rea
- Thoracic Surgical Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
| | - Luciano Potena
- Heart and Lung Transplant Program, Cardiovascular Department, Academic Hospital Sant' Orsola Malpighi Bologna, Bologna, Italy
| | - Nizar Yonan
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, United Kingdom
| | - Florian Wagner
- Department of Cardiovascular Surgery, Hamburg University Heart Center, Hamburg, Germany
| | - Fiorella Calabrese
- Thoracic Pathology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
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34
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Johansson I, Andersson R, Friman V, Selimovic N, Hanzen L, Nasic S, Nyström U, Sigurdardottir V. Cytomegalovirus infection and disease reduce 10-year cardiac allograft vasculopathy-free survival in heart transplant recipients. BMC Infect Dis 2015; 15:582. [PMID: 26703239 PMCID: PMC4690411 DOI: 10.1186/s12879-015-1321-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 12/12/2015] [Indexed: 11/24/2022] Open
Abstract
Background Cytomegalovirus (CMV) is associated with an increased risk of cardiac allograft vasculopathy (CAV), the major limiting factor for long-term survival after heart transplantation (HTx). The purpose of this study was to evaluate the impact of CMV infection during long-term follow-up after HTx. Methods A retrospective, single-centre study analyzed 226 HTx recipients (mean age 45 ± 13 years, 78 % men) who underwent transplantation between January 1988 and December 2000. The incidence and risk factors for CMV infection during the first year after transplantation were studied. Risk factors for CAV were included in an analyses of CAV-free survival within 10 years post-transplant. The effect of CMV infection on the grade of CAV was analyzed. Results Survival to 10 years post-transplant was higher in patients with no CMV infection (69 %) compared with patients with CMV disease (55 %; p = 0.018) or asymptomatic CMV infection (54 %; p = 0.053). CAV-free survival time was higher in patients with no CMV infection (6.7 years; 95 % CI, 6.0–7.4) compared with CMV disease (4.2 years; CI, 3.2–5.2; p < 0.001) or asymptomatic CMV infection (5.4 years; CI, 4.3–6.4; p = 0.013). In univariate analysis, recipient age, donor age, coronary artery disease (CAD), asymptomatic CMV infection and CMV disease were significantly associated with CAV-free survival. In multivariate regression analysis, CMV disease, asymptomatic CMV infection, CAD and donor age remained independent predictors of CAV-free survival at 10 years post-transplant. Conclusions CAV-free survival was significantly reduced in patients with CMV disease and asymptomatic CMV infection compared to patients without CMV infection. These findings highlight the importance of close monitoring of CMV viral load and appropriate therapeutic strategies for preventing asymptomatic CMV infection.
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Affiliation(s)
- Inger Johansson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Rune Andersson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Vanda Friman
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Nedim Selimovic
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Lars Hanzen
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.
| | - Salmir Nasic
- Research and Development Centre, Skaraborg Hospital, Skövde, Sweden.
| | - Ulla Nyström
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Vilborg Sigurdardottir
- Department of Cardiology, Swiss Cardiovascular Centre, University Hospital (Inselspital Bern) and University of Bern, Bern, Switzerland.
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35
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Hollis IB, Reed BN, Moranville MP. Medication management of cardiac allograft vasculopathy after heart transplantation. Pharmacotherapy 2015; 35:489-501. [PMID: 26011142 DOI: 10.1002/phar.1580] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is a common complication following heart transplantation (HT), resulting in diminished graft survival. The preferred strategy for preventing CAV is optimal medical management; however, for patients who develop CAV, delaying disease progression through effective medication management is equally important. A review of the literature regarding medication management of CAV was conducted via a search of the MEDLINE database. Studies were included if they were published in English, conducted in humans ≥ 18 years of age or older, and used noninvestigational medications. Immunosuppressive medications such as the antiproliferative mycophenolate, the calcineurin inhibitor tacrolimus, and the proliferation signal inhibitors sirolimus and everolimus have been shown to prevent the development of CAV. Certain cardiovascular medications, such as HMG-CoA reductase inhibitors (statins), gemfibrozil, calcium channel blockers, and angiotensin-converting enzyme inhibitors, have also demonstrated efficacy in preventing this disease process. Prevention of CAV has also been observed with prophylaxis against cytomegalovirus infection and antioxidant medications. Despite being commonly used in HT patients, neither antiplatelet agents nor glycemic control have proved effective at preventing CAV. Only sirolimus has been shown to arrest the progress of existing CAV.
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Affiliation(s)
- Ian B Hollis
- Department of Pharmacy, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Brent N Reed
- School of Pharmacy, University of Maryland, Baltimore, Maryland
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36
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Influence of cytomegalovirus infection in the development of cardiac allograft vasculopathy after heart transplantation. J Heart Lung Transplant 2015; 34:1112-9. [DOI: 10.1016/j.healun.2015.03.015] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 02/16/2015] [Accepted: 03/16/2015] [Indexed: 11/17/2022] Open
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37
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Durante-Mangoni E, Andini R, Pinto D, Iossa D, Molaro R, Agrusta F, Casillo R, Grimaldi M, Utili R. Effect of the immunosuppressive regimen on the incidence of cytomegalovirus infection in 378 heart transplant recipients: A single centre, prospective cohort study. J Clin Virol 2015; 68:37-42. [DOI: 10.1016/j.jcv.2015.04.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/17/2015] [Accepted: 04/21/2015] [Indexed: 01/24/2023]
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38
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Viral surveillance and subclinical viral infection in pediatric kidney transplantation. Pediatr Nephrol 2015; 30:741-8. [PMID: 25125226 PMCID: PMC6192669 DOI: 10.1007/s00467-014-2866-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 05/19/2014] [Accepted: 05/21/2014] [Indexed: 12/20/2022]
Abstract
The more potent immunosuppressive therapy that has successfully reduced the incidence of acute rejection and improved graft outcomes has also resulted in a higher incidence of viral complications. Sensitive molecular methods now allow for the detection of subclinical viral infection, which is increasingly recognized due to the adoption of routine post-transplant viral surveillance protocols. The goal of viral surveillance is the detection of subclinical viral infection that triggers an intervention; one that either prevents progression to viral disease or leads to early diagnosis of viral disease, which is associated with improved outcomes. Knowledge of the epidemiology and natural history of subclinical viral infection and viral disease, as well as patient-specific risk factors, is required to establish the optimal surveillance schedule which achieves the goal of early diagnosis. Evidence that detection of subclinical viral infection can impact viral disease is variable depending on the virus. This review will summarize the current data on the role of viral surveillance for BK virus (BKV), cytomegalovirus (CMV), and the Epstein-Barr virus (EBV) in the pediatric kidney transplant population.
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Imamura T, Kinugawa K, Nitta D, Fujino T, Inaba T, Maki H, Hatano M, Kinoshita O, Nawata K, Yao A, Kyo S, Ono M. Late rejection occurred in recipients who experienced acute cellular rejection within the first year after heart transplantation. Int Heart J 2015; 56:174-9. [PMID: 25740393 DOI: 10.1536/ihj.14-187] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Serial endomyocardial biopsies (EMBs) are scheduled even several years after heart transplantation (HTx) to monitor for late rejection (LR). However, repeated EMBs are associated with an increased risk for fatal complications and decrease the quality of life of the recipient. We retrospectively analyzed clinical data from 42 adult recipients who had received HTx and were followed > 1 year at the University of Tokyo Hospital. Five recipients experienced LR at 1130 ± 157 days after HTx, and all 5 had experienced acute cellular rejection (ACR) with ISHLT grade ≥ 2R within the first year, which was treated with methylprednisolone pulse therapy (sensitivity, 1.000; specificity, 0.7027). Logistic regression analyses demonstrated that positive panel reactive antibody (PRA) was the only significant predictor for LR among all parameters at 1 year after HTx (P = 0.020, odds ratio 24.00). Among the 5 recipients with LR, LR occurred earlier in the two PRA positive recipients than in those with a negative PRA (981 ± 12 versus 1230 ± 110 days, P = 0.042). Among the perioperative parameters, gender mismatch [n = 13 (31%)] was the only significant predictor for ACR within the first year in logistic regression analyses (P = 0.042, odds ratio 4.200). In conclusion, the current schedule of serial EMBs should perhaps be reconsidered for recipients without any history of ACR within the first year due to their lower risk of LR.
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Affiliation(s)
- Teruhiko Imamura
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo
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40
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Santos CAQ, Brennan DC, Fraser VJ, Olsen MA. Incidence, risk factors, and outcomes of delayed-onset cytomegalovirus disease in a large, retrospective cohort of heart transplant recipients. Transplant Proc 2014; 46:3585-92. [PMID: 25498094 PMCID: PMC4270011 DOI: 10.1016/j.transproceed.2014.08.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/19/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delayed-onset cytomegalovirus (CMV) disease can occur among heart transplant recipients after stopping anti-CMV prophylaxis. We evaluated a large, retrospective cohort of heart transplant recipients in the United States through the use of billing data from 3 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) to determine the epidemiology of delayed-onset CMV disease coded during hospital readmission. METHODS We identified 2280 adult heart transplant recipients from 2004 to 2010 through the use of the California, Florida, and New York SID. Demographics, comorbidities, heart failure etiology, CMV disease, and inpatient death were identified. CMV disease was classified as early-onset (≤100 days) or delayed-onset (>100 days after transplant). Possible tissue invasion by CMV was determined through the use of codes for CMV pneumonitis, hepatitis, and gastrointestinal endoscopy. Multivariate analysis was performed with the use of Cox proportional hazards models. RESULTS Delayed-onset CMV disease occurred in 7.5% (170/2280) and early-onset CMV disease occurred in 2.0% (45/2280) of heart transplant recipients. Risk factors for delayed-onset CMV disease included residence in a non-metropolitan locale (aHR. 1.8; 95% confidence interval [CI], 1.0-3.3) and ischemic cardiomyopathy as heart failure etiology (aHR, 1.8; 95% CI, 1.3-2.5). Inpatient death >100 days after transplant was associated with delayed-onset CMV disease with possible tissue invasion (aHR, 2.0; 95% CI, 1.1-3.8), transplant failure or rejection (aHR, 4.0; 95% CI, 2.7-5.8), and renal failure (aHR, 1.5; 95% CI, 1.1-2.0). CONCLUSIONS Delayed-onset CMV disease is more common than early-onset CMV disease among heart transplant recipients. These results suggest that delayed-onset tissue-invasive CMV disease may be associated with an increased risk of death.
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Affiliation(s)
- Carlos A. Q. Santos
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Daniel C. Brennan
- Division of Renal Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Victoria J. Fraser
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Margaret A. Olsen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, United States of America
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41
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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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42
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Affiliation(s)
- Vincent C Emery
- Department of Microbial and Cellular Sciences, University of Surrey, Guildford, United Kingdom
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43
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Ponroy N, Taveira A, Mueller NJ, Millard AL. Statins demonstrate a broad anti-cytomegalovirus activity in vitro in ganciclovir-susceptible and resistant strains. J Med Virol 2014; 87:141-53. [DOI: 10.1002/jmv.23998] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2014] [Indexed: 12/17/2022]
Affiliation(s)
- Nicolas Ponroy
- Division of Infectious Diseases and Hospital Epidemiology; University Hospital; Zürich Switzerland
| | - Aline Taveira
- Division of Infectious Diseases and Hospital Epidemiology; University Hospital; Zürich Switzerland
| | - Nicolas J. Mueller
- Division of Infectious Diseases and Hospital Epidemiology; University Hospital; Zürich Switzerland
| | - Anne-Laure Millard
- Division of Infectious Diseases and Hospital Epidemiology; University Hospital; Zürich Switzerland
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44
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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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45
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van Gent R, Jaadar H, Tjon ASW, Mancham S, Kwekkeboom J. T-cell inhibitory capacity of hyperimmunoglobulins is influenced by the production process. Int Immunopharmacol 2014; 19:142-4. [PMID: 24462495 DOI: 10.1016/j.intimp.2014.01.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 12/11/2013] [Accepted: 01/09/2014] [Indexed: 01/11/2023]
Abstract
Intravenous immunoglobulin (IVIg) preparations are widely used for anti-inflammatory therapy of autoimmune and systemic inflammatory diseases. Hyperimmunoglobulins enriched in neutralizing antibodies against viruses can, in addition to their virus-neutralizing activity, also exert immunomodulatory activity. Previously, we observed that Cytotect®, an anti-CMV hyperimmunoglobulin, was less effective in suppressing human T-cell responses in vitro compared to Hepatect® CP, an anti-HBV hyperimmunoglobulin. We hypothesized that the poor immunomodulatory activity of Cytotect® results from treatment with β-propiolactone during the manufacturing process. The manufacturer of these hyperimmunoglobulins has now introduced a new anti-CMV hyperimmunoglobulin, called Cytotect® CP, in which β-propiolactone treatment is omitted. Here we show that Cytotect® CP inhibits PHA-driven T-cell proliferation and cytokine production with similar efficacy as Hepatect® CP, whereas the former Cytotect® does not. In addition, Cytotect® CP inhibits allogeneic T-cell responses better than Cytotect®. Our results advocate the use of hyperimmunoglobulins that have not been exposed to β-propiolactone in order to benefit from their immunomodulatory properties.
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Affiliation(s)
- Rogier van Gent
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Haziz Jaadar
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Angela S W Tjon
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Shanta Mancham
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Jaap Kwekkeboom
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands.
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46
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Reischig T. Cytomegalovirus-associated renal allograft rejection: new challenges for antiviral preventive strategies. Expert Rev Anti Infect Ther 2014; 8:903-10. [DOI: 10.1586/eri.10.63] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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47
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Mwintshi K, Brennan DC. Prevention and management of cytomegalovirus infection in solid-organ transplantation. Expert Rev Anti Infect Ther 2014; 5:295-304. [PMID: 17402844 DOI: 10.1586/14787210.5.2.295] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cytomegalovirus (CMV) is the most common opportunistic viral infection to occur following solid-organ transplantation. This review will discuss the current strategies of management of CMV in solid-organ transplantation and their challenges. There are two principal approaches for preventing CMV disease in recipients of solid-organ transplants: prophylactic and pre-emptive. Ganciclovir is the most studied and used antiviral for both treatment and prevention, and is the first-line treatment for CMV infection and CMV disease in transplant recipients. There is no consensus regarding the most appropriate prevention method and the approach to CMV disease prevention differs among transplantation centers owing to the paucity of data comparing the two strategies head-to-head. Currently, the recommended treatment for CMV disease is intravenous ganciclovir.
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Affiliation(s)
- Kabeya Mwintshi
- Washington University School of Medicine, 660 S. Euclid Avenue, Internal Medicine/Renal Division, Campus Box 8126, St. Louis, MO 63110, USA.
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48
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Söderberg-Nauclér C. Treatment of cytomegalovirus infections beyond acute disease to improve human health. Expert Rev Anti Infect Ther 2014; 12:211-22. [PMID: 24404994 DOI: 10.1586/14787210.2014.870472] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Human cytomegalovirus is a common virus that establishes latency and persistence after a primary infection in 50-90% of populations worldwide. In otherwise healthy persons, the infection is generally mild or asymptomatic, although it may cause mononucleosis, prolonged episodes of fever, and hepatitis. However, in AIDS patients and transplant recipients who are immunosuppressed, severe, life-threatening infections may develop. CMV is also the most common congenital infection and may cause birth defects and deafness. Emerging evidence shows a high prevalence of this virus in patients with chronic inflammatory diseases or tumours of different origin, such as breast, colon, and prostate cancer, neuroblastoma, medulloblastoma, and glioblastoma. Several drugs are available to treat CMV infections. This review will highlight the possibility of using anti-CMV therapy to improve outcome not only in patients with acute CMV infections but also in patients with inflammatory diseases and cancer.
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Affiliation(s)
- Cecilia Söderberg-Nauclér
- Department of Medicine, Center for Molecular Medicine, Karolinska Institute, SE-171 76 Stockholm, Sweden
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49
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Abstract
Although human cytomegalovirus (HCMV) primary infection is generally asymptomatic, in immune-compromised patients HCMV increases morbidity and mortality. As a member of the betaherpesvirus family, in vivo studies of HCMV are limited due to its species specificity. CMVs from other species are often used as surrogates to express HCMV genes/proteins or used as models for inferring HCMV protein function in humans. Using innovative experiments, these animal models have answered important questions about CMV's life cycle, dissemination, pathogenesis, immune evasion, and host immune response. This chapter provides CMV biologists with an overview of the insights gained using these animal models. Subsequent chapters will provide details of the specifics of the experimental methods developed for each of the animal models discussed here.
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Affiliation(s)
- Pranay Dogra
- Department of Microbiology, University of Tennessee, Knoxville, TN, USA
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50
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Savva GM, Pachnio A, Kaul B, Morgan K, Huppert FA, Brayne C, Moss PAH. Cytomegalovirus infection is associated with increased mortality in the older population. Aging Cell 2013; 12:381-7. [PMID: 23442093 DOI: 10.1111/acel.12059] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2013] [Indexed: 11/30/2022] Open
Abstract
Cytomegalovirus (CMV) is a common herpesvirus infection and stimulates the expansion of very large numbers of CMV-specific T cells that reduce the CD4/CD8 ratio and suppress the number of naïve T cells. CMV infection has been associated with frailty and impaired survival. We investigated the correlates of CMV and the impact of the CMV infection on mortality within a cohort of 511 individuals aged at least 65 years who were followed up for 18 years. The mean age of the participants was 74 years of which 70% were CMV-seropositive. CMV was strongly linked to socio-economic status, and CMV infection increased the annual mortality rate by 42% (Hazard ratio = 1.42, 95% CI: 1.11-1.76 after adjusting for age, sex and baseline socio-economic and health variables) corresponding to 3.7 years lower life expectancy from age 65. Infection was associated with a near doubling of cardiovascular deaths, whereas there was no increase in mortality from other causes. These results show that CMV infection markedly increases the mortality rate in healthy older individuals due to an excess of vascular deaths. These findings may have significant implications for the study of immune senescence and if confirmed more generally could have important implications for measures to optimize the health of the elderly.
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Affiliation(s)
- George M. Savva
- Department of Public Health and Primary Care Institute of Public Health University of Cambridge Robinson Way Cambridge CB20SRUK
| | - Annette Pachnio
- School for Cancer Sciences University of Birmingham Birmingham B15 2TTUK
| | - Baksho Kaul
- School for Cancer Sciences University of Birmingham Birmingham B15 2TTUK
| | - Kevin Morgan
- School of Sport Exercise and Health Sciences Loughborough University Ashby Road Loughborough UK
| | - Felicia A. Huppert
- Department of Psychiatry Addenbrookes Hospital University of Cambridge Cambridge UK
| | - Carol Brayne
- Department of Public Health and Primary Care Institute of Public Health University of Cambridge Robinson Way Cambridge CB20SRUK
| | - Paul A. H. Moss
- School for Cancer Sciences University of Birmingham Birmingham B15 2TTUK
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