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Fatly ZA, Betjes MGH, Dik WA, Fouchier RAM, Reinders MEJ, de Weerd AE. Mycophenolate mofetil hampers antibody responses to a broad range of vaccinations in kidney transplant recipients: Results from a randomized controlled study. J Infect 2024; 88:106133. [PMID: 38432583 DOI: 10.1016/j.jinf.2024.106133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/10/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES To study the effect of mycophenolate mofetil (MMF) on various vaccination responses in kidney transplant recipients. METHODS In a randomized controlled trial (EudraCT nr.: 2014-001372-66), low immunologically risk kidney transplant recipients were randomized to TAC/MMF or TAC-monotherapy (TACmono), six months post-transplantation. One year after transplantation, in a pre-specified sub-study, recipients were vaccinated against pneumococcus, tetanus and influenza. Blood was sampled before and 21 days after vaccination. Adequate vaccination responses were defined by international criteria. A post-hoc analysis was conducted on SARS-CoV-2 vaccination responses within the same cohort. RESULTS Seventy-one recipients received pneumococcal and tetanus vaccines (TAC/MMF: n = 37, TACmono: n = 34), with 29 also vaccinated against influenza. When vaccinated, recipients were 60 (54-66) years old, with median eGFR of 54 (44-67) ml/min, tacrolimus trough levels 6.1 (5.4-7.0) ug/L in both groups and TAC/MMF daily MMF dose of 1000 (500-2000) mg. Adequate vaccination responses were: pneumococcal (TAC/MMF 43%, TACmono 74%, p = 0.016), tetanus (TAC/MMF 35%, TACmono 82%, p < 0.0001) and influenza (TAC/MMF 20%, TACmono 71%, p = 0.0092). Only 7% of TAC/MMF responded adequately to all three compared to 36% of TACmono (p = 0.080). Additionally, 40% of TAC/MMF responded inadequately to all three, whereas all TACmono patients responded adequately to at least one vaccination (p = 0.041). Lower SARS-CoV-2 vaccination antibody responses correlated with lower pneumococcal antibody vaccination responses (correlation coefficient: 0.41, p = 0.040). CONCLUSIONS MMF on top of tacrolimus severely hampers antibody responses to a broad range of vaccinations.
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Affiliation(s)
- Z Al Fatly
- Erasmus MC Transplant Institute, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - M G H Betjes
- Erasmus MC Transplant Institute, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - W A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - R A M Fouchier
- Department of Viroscience, Erasmus Medical Center, Rotterdam, the Netherlands
| | - M E J Reinders
- Erasmus MC Transplant Institute, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A E de Weerd
- Erasmus MC Transplant Institute, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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2
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Miotto IZ, Neto CF, de Oliveira WRP. Cutaneous infections from viral sources in solid organ transplant recipients. Transpl Immunol 2023; 78:101838. [PMID: 37085124 DOI: 10.1016/j.trim.2023.101838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/16/2023] [Accepted: 04/16/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Solid organ transplant recipients (SOTRs) are susceptible to various dermatological complications caused by long-term immunosuppressive therapy. Of these complications, viral infections are noteworthy because of their high prevalence and the potential morbidity associated with viral carcinogenesis. OBJECTIVES To evaluate the occurrence of cutaneous viral infections in SOTRs and their correlation with clinical features, transplant type, and the length and intensity of immunosuppressive therapy. METHODS This retrospective cohort study included SOTRs followed up at the Department of Dermatology in a tertiary hospital. The outcomes analyzed were the occurrence of cutaneous viral infections, including human papillomavirus (HPV) infection, herpes simplex, herpes zoster, molluscum contagiosum, Merkel cell carcinoma, Kaposi's sarcoma, and cytomegalovirus, and the occurrence of HPV-related neoplasms. Clinical variables, such as length and intensity of immunosuppression, type of transplanted organ, and comorbidities, were analyzed as possible risk factors for cutaneous viral infections in SOTRs. RESULTS A total of 528 SOTRs were included in this study, among which 53.8% had one or more viral infections. Of these, 10% developed a virus-associated malignancy (HPV-associated carcinoma, Merkel cell carcinoma, or Kaposi's sarcoma). The higher risk of viral infections among SOTRs was associated with cyclosporine intake (1.40-fold higher risk) and younger age at transplantation. The use of an immunosuppressive regimen, including additional drugs, was associated with a higher risk of genital HPV infection (1.50-fold higher risk for each incremental drug). CONCLUSIONS The occurrence of cutaneous viral infections in SOTRs is directly associated with the duration and intensity of immunosuppressive therapy. Patients at higher risk were those taking drugs with a stronger impact on cellular immunity and/or those on an immunosuppressive regimen comprising various drugs.
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Affiliation(s)
- Isadora Zago Miotto
- Department of Dermatology, University of São Paulo Medical School, Av Dr Enéas de Carvalho Aguiar, 255, Zip Code, 05403-900, São Paulo, Brazil.
| | - Cyro Festa Neto
- Department of Dermatology, University of São Paulo Medical School, Av Dr Enéas de Carvalho Aguiar, 255, Zip Code, 05403-900, São Paulo, Brazil
| | - Walmar Roncalli Pereira de Oliveira
- Department of Dermatology, University of São Paulo Medical School, Av Dr Enéas de Carvalho Aguiar, 255, Zip Code, 05403-900, São Paulo, Brazil.
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3
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Puttarajappa CM, Schinstock CA, Wu CM, Leca N, Kumar V, Vasudev BS, Hariharan S. KDOQI US Commentary on the 2020 KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Am J Kidney Dis 2021; 77:833-856. [PMID: 33745779 DOI: 10.1053/j.ajkd.2020.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Evaluation of patients for kidney transplant candidacy is a comprehensive process that involves a detailed assessment of medical and surgical issues, psychosocial factors, and patients' physical and cognitive abilities with an aim of balancing the benefits of transplantation and potential risks of surgery and long-term immunosuppression. There is considerable variability among transplant centers in their approach to evaluation and decision-making regarding transplant candidacy. The 2020 KDIGO (Kidney Disease: Improving Guidelines Outcome) clinical practice guideline on the evaluation and management of candidates for kidney transplantation provides practice recommendations that can serve as a useful reference guide to transplant professionals. The guideline, covering a broad range of topics, was developed by an international group of experts from transplant and nephrology through a review of literature published until May 2019. A work group of US transplant nephrologists convened by NKF-KDOQI (National Kidney Foundation-Kidney Disease Quality Initiative) chose key topics for this commentary with a goal of presenting a broad discussion to the US transplant community. Each section of this article has a summary of the key KDIGO guideline recommendations, followed by a brief commentary on the recommendations, their clinical utility, and potential implementation challenges. The KDOQI work group agrees broadly with the KDIGO recommendations but also recognizes and highlights the decision-making challenges that arise from lack of high-quality evidence and the need to balance equity with utility of organ transplantation.
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Affiliation(s)
- Chethan M Puttarajappa
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Carrie A Schinstock
- Division of Nephrology & Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Christine M Wu
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Vineeta Kumar
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Brahm S Vasudev
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sundaram Hariharan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
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4
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Teoh CW, Korus M, Lorenzo A, Langlois V. Preparing the Child with End-Stage Renal Disease for a Renal Transplant: the Pre-transplant Assessment. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00225-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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5
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Basic-Jukic N, Juric I, Furic-Cunko V, Kastelan Z. Central nervous system infections in renal transplant recipients. Transpl Infect Dis 2020; 22:e13341. [PMID: 32453874 DOI: 10.1111/tid.13341] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/21/2020] [Accepted: 05/17/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND The aim of this study is to determine the incidence, etiology, clinical characteristics, and outcomes of renal transplant recipients diagnosed and treated for central nervous system (CNS) infection at our institution. METHODS We analyzed data from all renal transplant recipients between January 2007 and December 2019 that were diagnosed and treated for CNS infections at our institution. RESULTS Of 1374 patients who received renal allografts, 13 were diagnosed with CNS infections (9 males), with a mean age of 53.5 years. Patients were diagnosed with CNS infections between 2 months and 11 years after the transplantation. Causative agents included JC virus, Streptococcus pneumoniae, Cryptococcus neoformans, Herpes zoster virus, Mycobacterium tuberculosis, Listeria monocytogenes, and West Nile virus. One patient had concomitant Nocardia and Neisseria infection. Immunosuppression was reduced in all patients. The patient with JC encephalitis and the patient with concomitant Neisseria and Nocardia meningitis died. One patient was returned to dialysis. Other patients recovered with differing levels of neurologic sequelae. CONCLUSION Central nervous system infections in renal transplant recipients are rare. However, they are associated with significant morbidity and mortality. A high level of awareness is needed: neurological symptoms may be nonspecific and caused by non-infectious conditions related to the underlying disease, or side-effects of immunosuppressive drugs.
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Affiliation(s)
- Nikolina Basic-Jukic
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia.,Department of Urology, University Hospital Centre Zagreb, Zagreb, Croatia.,Faculty of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivana Juric
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia.,Department of Urology, University Hospital Centre Zagreb, Zagreb, Croatia.,Faculty of Medicine, University of Zagreb, Zagreb, Croatia
| | - Vesna Furic-Cunko
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia.,Department of Urology, University Hospital Centre Zagreb, Zagreb, Croatia.,Faculty of Medicine, University of Zagreb, Zagreb, Croatia
| | - Zeljko Kastelan
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia.,Department of Urology, University Hospital Centre Zagreb, Zagreb, Croatia.,Faculty of Medicine, University of Zagreb, Zagreb, Croatia
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6
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Yoeli JK, Yoeli D, Miloh TA, Rana A, Goss JA, Munoz-Rivas F. Measles, mumps, rubella (vaccine) and varicella vaccines in pediatric liver transplant: An initial analysis of post-transplant immunity. Pediatr Transplant 2019; 23:e13490. [PMID: 31219224 DOI: 10.1111/petr.13490] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 04/09/2019] [Accepted: 04/14/2019] [Indexed: 12/12/2022]
Abstract
Varicella and measles infection represents a significant source of morbidity and mortality for pediatric LT recipients. We evaluated the prevalence and correlates of post-transplant immunity in pediatric LT recipients previously immunized against measles (n = 72) and varicella (n = 67). Sixteen of seventy-two (22%) patients were measles non-immune, and 42/67 (63%) were varicella non-immune after LT. Median time from LT to titers for measles and varicella was 4.0 and 3.3 years, respectively. In the measles cohort, non-immune patients received fewer pretransplant vaccine doses (P = 0.026) and were younger at both time of vaccination (P = 0.006) and LT (P = 0.004) compared with immune patients. Upon multivariable analysis, weight > 10 kg at LT (OR 5.91, 95% CI 1.27-27.41) and technical variant graft (OR 0.07, 95% CI 0.01-0.37) were independently, significantly associated with measles immunity. In the varicella cohort, non-immune patients received fewer pretransplant vaccine doses (P = 0.028), were younger at transplant (P = 0.022), and had less time lapse between their last vaccine and transplant (P = 0.012) compared with immune patients. Upon multivariate analysis, time > 1 year from last vaccine to LT was independently, significantly associated with varicella immunity (OR 3.78, CI 1.30-11.01). This study demonstrates that non-immunity to measles and varicella is a prevalent problem after liver transplantation in children and identifies 3 unique risk factors for non-immunity in this high-risk population.
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Affiliation(s)
- Jordan K Yoeli
- School of Medicine, University of Colorado, Denver, Colorado
| | - Dor Yoeli
- School of Medicine, University of Colorado, Denver, Colorado
| | - Tamir A Miloh
- Division of Pediatric Hepatology and Liver Transplant Medicine, Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Abbas Rana
- Division of Abdominal Transplantation and Hepatobiliary Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - John A Goss
- Division of Abdominal Transplantation and Hepatobiliary Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Flor Munoz-Rivas
- Section of Infectious Diseases, Transplant Infectious Diseases, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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Arora S, Kipp G, Bhanot N, Sureshkumar KK. Vaccinations in kidney transplant recipients: Clearing the muddy waters. World J Transplant 2019; 9:1-13. [PMID: 30697516 PMCID: PMC6347668 DOI: 10.5500/wjt.v9.i1.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/13/2018] [Accepted: 01/01/2019] [Indexed: 02/05/2023] Open
Abstract
Vaccine preventable diseases account for a significant proportion of morbidity and mortality in transplant recipients and cause adverse outcomes to the patient and allograft. Patients should be screened for vaccination history at the time of pre-transplant evaluation and vaccinated at least four weeks prior to transplantation. For non-immune patients, dead-vaccines can be administered starting at six months post-transplant. Live attenuated vaccines are contraindicated after transplant due to concern for infectious complications from the vaccine and every effort should be made to vaccinate prior to transplant. Since transplant recipients are on life-long immunosuppression, these patients may have lower rates of serological conversion, lower mean antibody titers and waning of protective immunity over shorter period as compared to general population. Recommendations regarding booster dose in kidney transplant recipients with sub-optimal serological response are lacking. Travel plans should be part of routine post-transplant assessment and pre-travel vaccines and counseling should be provided. More studies are needed on vaccination schedules, serological response, need for booster doses and safety of live attenuated vaccines in this special population.
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Affiliation(s)
- Swati Arora
- Divisions of Nephrology and Hypertension, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Gretchen Kipp
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Nitin Bhanot
- Infectious Diseases, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Kalathil K Sureshkumar
- Divisions of Nephrology and Hypertension, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
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8
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Wang L, Verschuuren EAM, van Leer-Buter CC, Bakker SJL, de Joode AAE, Westra J, Bos NA. Herpes Zoster and Immunogenicity and Safety of Zoster Vaccines in Transplant Patients: A Narrative Review of the Literature. Front Immunol 2018; 9:1632. [PMID: 30079064 PMCID: PMC6062765 DOI: 10.3389/fimmu.2018.01632] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/02/2018] [Indexed: 12/14/2022] Open
Abstract
This narrative review focuses on the herpes zoster (HZ) and its prevention in transplant patients. Varicella zoster virus (VZV) is highly contagious and distributed worldwide in humans. Primary VZV infection usually causes varicella and then establishes a lifelong latency in dorsal root ganglia. Reactivation of VZV leads to HZ and related complications such as postherpetic neuralgia. Age and decreased immunity against VZV are important risk factors for developing HZ. Transplant patients are at increased risk for developing HZ and related complications due to their immunocompromised status and the need for lifetime immunosuppression. Diagnosis of HZ in transplant patients is often clinically difficult, and VZV-specific antibodies should be determined by serologic testing to document prior exposure to VZV during their pre-transplant evaluation process. Although antiviral agents are available, vaccination should be recommended for preventing HZ in transplant patients considering their complicated condition and weak organ function. Currently, there are two licensed HZ vaccines, of which one is a live-attenuated vaccine and the other is a HZ subunit vaccine. Both vaccines have shown promising safety and efficacy in transplants patients and especially the subunit vaccine could be administered post-transplant since this vaccine does not contain any live virus. Larger studies are needed about safety and immunogenicity of HZ vaccines in transplant populations, and extra efforts are needed to increase vaccine usage according to guidelines.
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Affiliation(s)
- Lei Wang
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Erik A M Verschuuren
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Coretta C van Leer-Buter
- Department of Medical Microbiology, Division of Clinical Virology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Anoek A E de Joode
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Nicolaas A Bos
- Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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9
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Camargo LF, Lother AM, Mazzali M, Stucchi RSB. Immunization in end stage renal disease: The perception of waiting list patients. Transpl Infect Dis 2018; 20:e12831. [PMID: 29337400 DOI: 10.1111/tid.12831] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 11/08/2017] [Accepted: 12/15/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND The number of patients with chronic kidney disease is increasing worldwide, as well as the number of patients in kidney transplant waiting lists. In order to prevent infections related to immunosuppressive therapy, immunization guidelines for CKD patients before transplantation have been proposed. The aim of the present study was to evaluate adherence to immunization in a cohort of CKD patients in transplant waiting list and their renal replacement therapy clinics. METHODS CKD patients older than 18 years old, receiving renal replacement therapy longer than 12 months and included in kidney transplant waiting list at University of Campinas (Unicamp) were enrolled. RESULTS From February 2014 to December 2015, 105 patients fulfilled the inclusion criteria. Complete hepatitis B vaccination was observed in 73% and influenza vaccine in 67%. None of the other vaccine protocols reached 50% of coverage. Patients receiving immunization at primary health units presented higher coverage for diphtheria, tetanus (dT), measles, mumps, rubella (MMR), and hepatitis B vaccines, while patients immunized at renal replacement therapy clinics showed higher prevalence of pneumococcus (pneumo23). CONCLUSION The low rates of immunization could reflect the RRT's clinics knowledge about the vaccines guidelines and its application on daily care. We suggest an integration between transplant center and RRT clinics, through lectures, periodic checking of vaccination cards, and easy to follow guidelines in order to provide a better vaccine coverage and to obtain higher immunization rates.
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Affiliation(s)
- Leonardo Figueiredo Camargo
- Division of Nephrology, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil.,Renal Transplant Unit, Clinics Hospital, University of Campinas, Campinas, SP, Brazil
| | | | - Marilda Mazzali
- Division of Nephrology, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil.,Renal Transplant Unit, Clinics Hospital, University of Campinas, Campinas, SP, Brazil
| | - Raquel S B Stucchi
- Division of Infectious Diseases, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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10
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Abstract
The α herpes viruses HSV-1, HSV-2, and VZV often reactivate in the setting of immune suppression after solid organ transplantation. Oral or genital mucocutaneous disease is the most common clinical manifestation of HSV disease while VZV manifests as varicella (or chickenpox) or reactivation herpes zoster, characterized by a diffuse rash, or a painful unilateral vesicular eruption in a dermatomal distribution, respectively. The diagnosis of HSV and VZV is primarily based on history and clinical presentation, although diagnostic tests may be necessary for atypical presentations of disease. Treatment usually involves oral or intravenous antiviral therapy, depending on severity of illness.
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Affiliation(s)
- Cybele Lara Abad
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN; The William J. Von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN.
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11
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van Kessel DA, Hoffman TW, Kwakkel-van Erp JM, Oudijk EJD, Zanen P, Rijkers GT, Grutters JC. Long-term Follow-up of Humoral Immune Status in Adult Lung Transplant Recipients. Transplantation 2017; 101:2477-2483. [PMID: 28198768 DOI: 10.1097/tp.0000000000001685] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lung transplant recipients have an increased risk for infections in the posttransplant period due to immunosuppressive therapy. Protection against infections can be achieved through vaccination, but the optimal vaccination schedule in lung transplant recipients is unknown. Data on long-term immunological follow up and vaccination responses after lung transplantation are scarce. METHODS Here we present long-term immunological follow up of a cohort of 55 lung transplant recipients. This includes detailed antibody responses after 23-valent pneumococcal polysaccharide vaccination (23vPPV). RESULTS All patients were vaccinated with 23vPPV before transplantation. Median follow-up after transplantation was 6.6 years (379 patient-years). After transplantation, there is a significant decrease of all immunoglobulins, IgG subclasses and pneumococcal polysaccharide antibodies. After the first year posttransplantation, there is a gradual increase of all immunoglobulins and IgG subclasses, but values were always significantly lower than in the pretransplant period. After a median of 4.4 years posttransplantation, patients were revaccinated with 23vPPV. The pneumococcal polysaccharide antibody response was impaired in 87% of patients (ie, antibody titer above cutoff and twofold increase between pre and postvaccination values for <70% of serotypes). CONCLUSIONS We found that impairment of humoral immunity was most outspoken in the first year after lung transplantation. Immunoglobulin levels remain decreased several years after transplantation and the response to pneumococcal polysaccharide vaccine was significantly lower posttransplantation compared to the pretransplantation response. However, most patients did show a partial response to vaccination. Based on our results, revaccination with pneumococcal vaccines after transplantation should be considered 1 year after transplantation.
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Affiliation(s)
- Diana A van Kessel
- 1 Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands. 2 Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands. 3 Department of Medical Microbiology and Immunology, St. Antonius Hospital, Nieuwegein, The Netherlands. 4 Department of Science, University College Roosevelt, Middelburg, The Netherlands
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12
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van Veen KEB, Brouwer MC, van der Ende A, van de Beek D. Bacterial meningitis in solid organ transplant recipients: a population-based prospective study. Transpl Infect Dis 2017; 18:674-680. [PMID: 27385317 PMCID: PMC5113686 DOI: 10.1111/tid.12570] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/04/2016] [Accepted: 04/29/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients are at risk of infections of the central nervous system. However, the incidence and clinical course of bacterial meningitis in SOT recipients are unclear. We studied occurrence, disease course, and prognosis of bacterial meningitis in SOT recipients in the Netherlands. METHODS All patients with a medical history of solid organ transplantation were selected from our nationwide prospective cohort study on community-acquired bacterial meningitis in patients >16 years old, performed from March 1, 2006 to October 31, 2014. Data on patient history, symptoms and signs on admission, treatment, and outcome were collected prospectively. For transplant recipients, additional information was collected retrospectively. RESULTS We identified 6 SOT recipients, all receiving renal transplants. The annual incidence of bacterial meningitis was 7-fold higher (95% confidence interval [CI] 2.94-17.02, P < 0.001) for renal transplant recipients as compared with the general population (9.56 [95% CI 3.98-22.96] vs. 1.35 [95% CI 1.28-1.43] per 100,000 patients per year). One of the 6 patients (17%) presented with the classic presentation of bacterial meningitis (fever, neck stiffness, and change in mental status). Seizures were common, occurring in 33% of patients. Streptococcus pneumoniae and Listeria monocytogenes were identified in 2 patients each, and Escherichia coli and Pseudomonas aeruginosa were both identified once. Four of 6 patients (67%) had an unfavorable functional outcome. CONCLUSION Bacterial meningitis is a rare but devastating complication of solid organ transplantation. SOT recipients are at high risk for developing meningitis, and recognition of this condition may be difficult, owing to atypical clinical manifestation.
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Affiliation(s)
- K E B van Veen
- Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Neurology, Medical Center Haaglanden, The Hague, the Netherlands
| | - M C Brouwer
- Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - A van der Ende
- Department of Medical Microbiology Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,The Netherlands Reference Laboratory for Bacterial Meningitis, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - D van de Beek
- Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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13
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Sarmiento E, Jaramillo M, Calahorra L, Fernandez-Yañez J, Gomez-Sanchez M, Crespo-Leiro MG, Paniagua M, Almenar L, Cebrian M, Rabago G, Levy B, Segovia J, Gomez-Bueno M, Lopez J, Mirabet S, Navarro J, Rodriguez-Molina JJ, Fernandez-Cruz E, Carbone J. Evaluation of humoral immunity profiles to identify heart recipients at risk for development of severe infections: A multicenter prospective study. J Heart Lung Transplant 2016; 36:529-539. [PMID: 27866926 DOI: 10.1016/j.healun.2016.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/17/2016] [Accepted: 10/12/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND New biomarkers are necessary to improve detection of the risk of infection in heart transplantation. We performed a multicenter study to evaluate humoral immunity profiles that could better enable us to identify heart recipients at risk of severe infections. METHODS We prospectively analyzed 170 adult heart recipients at 8 centers in Spain. Study points were before transplantation and 7 and 30 days after transplantation. Immune parameters included IgG, IgM, IgA and complement factors C3 and C4, and titers of specific antibody to pneumococcal polysaccharide antigens (anti-PPS) and to cytomegalovirus (CMV). To evaluate potential immunologic mechanisms leading to IgG hypogammaglobulinemia, before heart transplantation we assessed serum B-cell activating factor (BAFF) levels using enzyme-linked immunoassay. The clinical follow-up period lasted 6 months. Clinical outcome was need for intravenous anti-microbials for therapy of infection. RESULTS During follow-up, 53 patients (31.2%) developed at least 1 severe infection. We confirmed that IgG hypogammaglobulinemia at Day 7 (defined as IgG <600 mg/dl) is a risk factor for infection in general, bacterial infections in particular, and CMV disease. At Day 7 after transplantation, the combination of IgG <600 mg/dl + C3 <80 mg/dl was more strongly associated with the outcome (adjusted odds ratio 7.40; 95% confidence interval 1.48 to 37.03; p = 0.014). We found that quantification of anti-CMV antibody titers and lower anti-PPS antibody concentrations were independent predictors of CMV disease and bacterial infections, respectively. Higher pre-transplant BAFF levels were a risk factor of acute cellular rejection. CONCLUSION Early immunologic monitoring of humoral immunity profiles proved useful for the identification of heart recipients who are at risk of severe infection.
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Affiliation(s)
- Elizabeth Sarmiento
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Maria Jaramillo
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Leticia Calahorra
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Juan Fernandez-Yañez
- Cardiology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Maria G Crespo-Leiro
- Cardiology Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Maria Paniagua
- Cardiology Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Luis Almenar
- Heart Failure and Heart Transplant Unit, Cardiology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Monica Cebrian
- Heart Failure and Heart Transplant Unit, Cardiology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Gregorio Rabago
- Heart Surgery Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Beltran Levy
- Heart Surgery Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Javier Segovia
- Heart Failure and Cardiomyopathy Unit, Heart Failure and Heart Transplant Section, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Manuel Gomez-Bueno
- Heart Failure and Cardiomyopathy Unit, Heart Failure and Heart Transplant Section, Department of Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Javier Lopez
- Heart Failure and Heart Transplant Unit, Hospital Clínico Universitario, Valladolid, Spain
| | - Sonia Mirabet
- Cardiology Department, Sant Pau Hospital, Barcelona, Spain
| | - Joaquin Navarro
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Eduardo Fernandez-Cruz
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.
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14
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Malone K, Clark S, Palmer JA, Lopez S, Pradhan M, Furth S, Kim J, Fisher B, Laskin B. A quality improvement initiative to increase pneumococcal vaccination coverage among children after kidney transplant. Pediatr Transplant 2016; 20:783-9. [PMID: 27334506 PMCID: PMC4993651 DOI: 10.1111/petr.12742] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2016] [Indexed: 01/19/2023]
Abstract
Pneumococcal vaccination rates among children receiving a kidney transplant remain suboptimal. Current practice guidelines in the United States recommend giving the PPSV23 after priming with the PCV13. We conducted a QI initiative to increase pneumococcal vaccine rates in our kidney transplant recipients by developing an age-based vaccine algorithm, obtaining vaccine records, and generating reminders for patients and clinicians. A monthly report from the EHR tracked outcomes. The process metric was missed vaccine opportunities, and the overall objective was to improve coverage with both the PCV13 and PPSV23. Over the first six months, we increased the percentage of visits where the vaccine was given from a baseline of 4% to 33%. However, by the end of the 12-month period, the percentage of eligible visits where the vaccine was given decreased to 8.7%. Nevertheless, over the 12-month observation period, we were able to increase the percentage of transplant patients receiving the PCV13 and PPSV23 from 6% to 52%. Utilizing an age-based algorithm and the electronic medical record, vaccine champions can track both missed visit opportunities and the number of vaccinated patients to improve pneumococcal immunization coverage for these high-risk patients.
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Affiliation(s)
- Kathryn Malone
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, PA,Research Institute, Children’s Hospital Colorado, Denver, CO
| | - Stephanie Clark
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jo Ann Palmer
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sonya Lopez
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Madhura Pradhan
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Susan Furth
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jason Kim
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brian Fisher
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Laskin
- Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, PA
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15
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Miller RM, Rohde KA, Tingle MTA, Moran JJM, Hayney MS. Antibody responses to influenza vaccine in pre- and post-lung transplant patients. Clin Transplant 2016; 30:606-12. [PMID: 26928266 DOI: 10.1111/ctr.12726] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although pre-transplant immunization is routinely recommended, this recommendation is based on little data. The primary objective of this study was to compare antibody responses in lung transplant patients who received influenza vaccine before the transplant, within the first six months of transplant, between 13 and 60 months post-transplant, and 110 months or beyond transplant. METHODS This prospective cohort study included 357 total immunization events performed over five yr to measure H1N1, H3N2, and B antibody responses to the influenza vaccine in pre- and post-lung transplant patients. Geometric mean titers, seroprotection (antibody titer at least 1:40), seroconversion (fourfold increase between pre and post), and mean fold increases were compared. RESULTS The geometric mean titer distributions were different for H3N2 and B (ANOVA; p = 0.002 for both). Pre-transplant antibody concentrations were higher compared to the 13- to 60-month group for H3N2 (corrected p = 0.002) and the healthy group for B (corrected p = 0.001). The ≥110-month group had higher seroconversion rates compared to the 13- to 60-month group for H3N2 and B viruses. CONCLUSION Lung pre-transplant patients and the long-term survivors have higher responses to the influenza vaccine than early post-transplant and the transplant control groups.
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Affiliation(s)
- Ryan M Miller
- University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - Kalynn A Rohde
- University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - Michael T A Tingle
- University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - John J M Moran
- University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
| | - Mary S Hayney
- University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin, USA
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16
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Abstract
Solid organ and hematopoietic stem cell transplant recipients may be exposed to diseases which may be prevented through live attenuated virus vaccines (LAVV). Because of their immunosuppression, these diseases can lead to severe complications in transplant recipients. Despite increasing evidence regarding the safety and effectiveness of certain LAVV, these vaccines are still contraindicated for immunocompromised patients, such as transplant recipients. We review the available studies on LAVV, such as varicella zoster, measles-mumps-rubella, influenza, yellow fever, polio, and Japanese encephalitis vaccines in transplant patients. We discuss the current recommendations and the potential risks, as well as the expected benefits of LAVV immunization in this population.
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Affiliation(s)
- Charlotte M Verolet
- Pediatric Infectious Diseases Unit, Division of General Pediatrics, Department of Pediatrics, University Hospitals of Geneva & University of Geneva Medical School, Geneva, Switzerland,
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17
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Kim YJ, Kim SI. Vaccination Strategy in Organ Transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2014. [DOI: 10.4285/jkstn.2014.28.4.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Youn Jeong Kim
- Division of Infectious Disease, Department of Internal Medicine, Seoul St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Il Kim
- Division of Infectious Disease, Department of Internal Medicine, Seoul St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea
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