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Roy S, Kaul A, Bhadhuria DS, Prasad N, Garg A, Marak RSK, Patel MR, Behera MR, Kushwaha RS, Yachha M. Clinico-epidemiological characteristics of early- versus late-onset cytomegalovirus disease among renal transplant recipients: A two-decade experience. Transpl Immunol 2024; 84:102040. [PMID: 38565378 DOI: 10.1016/j.trim.2024.102040] [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: 11/14/2023] [Revised: 03/17/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Reactivation of cytomegalovirus (CMV) infection in transplant patients is high because of immunosuppression. We have evaluated the clinical and epidemiological characteristics of early versus late onset of CMV infection among renal transplant recipients. METHODS A single center retrospective observational study was conducted among renal transplant recipients who underwent kidney transplant between January 2002 and December 2021. CMV disease was classified as early or late depending on its detection prior to or after 90 days post-transplantation. Herein, we reported the differences between early and late onset of CMV disease with respect to clinical symptoms, the use of immunosuppression and the impact on graft outcomes. RESULTS Out of total 2164 renal transplant recipients, 156 patients (7.2%) were diagnosed with CMV disease. Among these 156 patients, 25 patients (16%) had early CMV while 131 patients (84%) had late CMV. Overall, the two groups did not differ with respect to the induction or maintenance of immunosuppressive agents. However, the proportion of CMV syndrome was greater among early (56.0%) than late (26.7%) CMV groups (p = 0.01). In contrast, tissue invasive disease was more frequent among late (73.3%) in comparison to early (44.0%) CMV groups (p = 0.01). Among clinical symptoms, diarrhea was more frequent in late (63.4%) vs. early (36%) CMV-affected patients (p = 0.01). Graft loss occurred in 4.0% of early CMV group vs. 25.2% of late CMV group (p = 0.03). Neither of the clinical groups differed with respect to occurrence of biopsy-proven allograft rejection post-infection. CONCLUSIONS Early CMV disease presents more frequently as CMV syndrome while late CMV disease usually manifests itself as tissue invasive disease. Graft loss is more common in patients with late onset of CMV disease.
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Affiliation(s)
- Shuvam Roy
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Anupma Kaul
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
| | - Dharmendra Singh Bhadhuria
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Narayan Prasad
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Atul Garg
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Rungmei S K Marak
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Manas Ranjan Patel
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Manas Ranjan Behera
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Ravi Shankar Kushwaha
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Monika Yachha
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Huh K, Lee SO, Kim J, Lee SJ, Choe PG, Kang JM, Yang J, Sung H, Kim SH, Moon C, Seok H, Shi HJ, Wi YM, Jeong SJ, Park WB, Kim YJ, Kim J, Ahn HJ, Kim NJ, Peck KR, Kim MS, Kim SI. Prevention of Cytomegalovirus Infection in Solid Organ Transplant Recipients: Guidelines by the Korean Society of Infectious Diseases and the Korean Society for Transplantation. Infect Chemother 2024; 56:101-121. [PMID: 38527780 PMCID: PMC10990892 DOI: 10.3947/ic.2024.0016] [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: 01/26/2024] [Accepted: 03/04/2024] [Indexed: 03/27/2024] Open
Abstract
Cytomegalovirus (CMV) is the most important opportunistic viral pathogen in solid organ transplant (SOT) recipients. The Korean guideline for the prevention of CMV infection in SOT recipients was developed jointly by the Korean Society for Infectious Diseases and the Korean Society of Transplantation. CMV serostatus of both donors and recipients should be screened before transplantation to best assess the risk of CMV infection after SOT. Seronegative recipients receiving organs from seropositive donors face the highest risk, followed by seropositive recipients. Either antiviral prophylaxis or preemptive therapy can be used to prevent CMV infection. While both strategies have been demonstrated to prevent CMV infection post-transplant, each has its own advantages and disadvantages. CMV serostatus, transplant organ, other risk factors, and practical issues should be considered for the selection of preventive measures. There is no universal viral load threshold to guide treatment in preemptive therapy. Each institution should define and validate its own threshold. Valganciclovir is the favored agent for both prophylaxis and preemptive therapy. The evaluation of CMV-specific cell-mediated immunity and the monitoring of viral load kinetics are gaining interest, but there was insufficient evidence to issue recommendations. Specific considerations on pediatric transplant recipients are included.
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Affiliation(s)
- Kyungmin Huh
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Jungok Kim
- Division of Infectious Diseases, Department of Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Su Jin Lee
- Division of Infectious Diseases, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Man Kang
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeseok Yang
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Si-Ho Kim
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Busan Paik Hospital, College of Medicine, Busan, Korea
| | - Hyeri Seok
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Korea University Medicine, Ansan, Korea
| | - Hye Jin Shi
- Division of Infectious Diseases, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Yu Mi Wi
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Youn Jeong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Joon Ahn
- Department of Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myoung Soo Kim
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Il Kim
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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3
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Bestard O, Kaminski H, Couzi L, Fernández-Ruiz M, Manuel O. Cytomegalovirus Cell-Mediated Immunity: Ready for Routine Use? Transpl Int 2023; 36:11963. [PMID: 38020746 PMCID: PMC10661902 DOI: 10.3389/ti.2023.11963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023]
Abstract
Utilizing assays that assess specific T-cell-mediated immunity against cytomegalovirus (CMV) holds the potential to enhance personalized strategies aimed at preventing and treating CMV in organ transplantation. This includes improved risk stratification during transplantation compared to relying solely on CMV serostatus, as well as determining the optimal duration of antiviral prophylaxis, deciding on antiviral therapy when asymptomatic replication occurs, and estimating the risk of recurrence. In this review, we initially provide an overlook of the current concepts into the immune control of CMV after transplantation. We then summarize the existent literature on the clinical experience of the use of immune monitoring in organ transplantation, with a particular interest on the outcomes of interventional trials. Current evidence indicates that cell-mediated immune assays are helpful in identifying patients at low risk for replication for whom preventive measures against CMV can be safely withheld. As more data accumulates from these and other clinical scenarios, it is foreseeable that these assays will likely become part of the routine clinical practice in organ transplantation.
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Affiliation(s)
- Oriol Bestard
- Nephrology and Kidney Transplant Department, Vall Hebron University Hospital, Barcelona, Spain
- Nephrology and Kidney Transplant Research Laboratory, Vall Hebrón Institut de Recerca (VHIR), Barcelona, Spain
| | - Hannah Kaminski
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
- UMR 5164-ImmunoConcEpT, University of Bordeaux, Centre National de la Recherche Scientifique (CNRS), Bordeaux University, Bordeaux, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
- UMR 5164-ImmunoConcEpT, University of Bordeaux, Centre National de la Recherche Scientifique (CNRS), Bordeaux University, Bordeaux, France
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Oriol Manuel
- Infectious Diseases Service and Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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4
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Bharati J, Anandh U, Kotton CN, Mueller T, Shingada AK, Ramachandran R. Diagnosis, Prevention, and Treatment of Infections in Kidney Transplantation. Semin Nephrol 2023; 43:151486. [PMID: 38378396 DOI: 10.1016/j.semnephrol.2023.151486] [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] [Indexed: 02/22/2024]
Abstract
Kidney transplant often is complicated by infections in the recipient from therapy-related and patient-related risk factors. Infections in kidney transplant recipients are associated with increased morbidity, mortality, and allograft dysfunction. There is a predictable timeline after kidney transplant regarding the types of pathogens causing infections, reflecting the net state of immunosuppression. In the early post-transplant period, bacterial infections comprise two thirds of all infections, followed by viral and fungal infections. Infections occurring early after kidney transplantation are generally the result of postoperative complications. In most cases, opportunistic infections occur within 6 months after kidney transplantation. They may be caused by a new infection, a donor-derived infection, or reactivation of a latent infection. Community-acquired pneumonia, upper respiratory tract infections, urinary tract infections, and gastrointestinal infections are the most common infections in the late period after transplantation when the net immunosuppression is minimal. It is crucial to seek information on the time after transplant, reflecting the net state of immunosuppression, previous history of exposure/infections, geography, and seasonal outbreaks. It is imperative that we develop regionally specific guidelines on screening, prevention, and management of infections after kidney transplantation.
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Affiliation(s)
- Joyita Bharati
- Section of Nephrology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
| | - Urmila Anandh
- Department of Nephrology, Amrita Hospitals, Faridabad, Delhi National Capital Region, India
| | - Camille N Kotton
- Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thomas Mueller
- Renal Transplant Program, University Hospital of Zurich, Zurich, Switzerland
| | | | - Raja Ramachandran
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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5
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Pierrotti LC, Clemente WT. New Perspectives in Cytomegalovirus After Transplant: The Role of Immunosuppressant Management. Transplantation 2023; 107:1669-1670. [PMID: 37046377 DOI: 10.1097/tp.0000000000004560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Affiliation(s)
- Ligia C Pierrotti
- Infectious Diseases Division, Hospital das Clinicas, Universidade de São Paulo, São Paulo, Brazil
| | - Wanessa T Clemente
- Department of Laboratory Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
- Liver Transplant Program-Transplant Infectious Diseases. Hospital das Clínicas EBSERH/UFMG, Belo Horizonte, Brazil
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6
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Elalouf A. Infections after organ transplantation and immune response. Transpl Immunol 2023; 77:101798. [PMID: 36731780 DOI: 10.1016/j.trim.2023.101798] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/08/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
Organ transplantation has provided another chance of survival for end-stage organ failure patients. Yet, transplant rejection is still a main challenging factor. Immunosuppressive drugs have been used to avoid rejection and suppress the immune response against allografts. Thus, immunosuppressants increase the risk of infection in immunocompromised organ transplant recipients. The infection risk reflects the relationship between the nature and severity of immunosuppression and infectious diseases. Furthermore, immunosuppressants show an immunological impact on the genetics of innate and adaptive immune responses. This effect usually reactivates the post-transplant infection in the donor and recipient tissues since T-cell activation has a substantial role in allograft rejection. Meanwhile, different infections have been found to activate the T-cells into CD4+ helper T-cell subset and CD8+ cytotoxic T-lymphocyte that affect the infection and the allograft. Therefore, the best management and preventive strategies of immunosuppression, antimicrobial prophylaxis, and intensive medical care are required for successful organ transplantation. This review addresses the activation of immune responses against different infections in immunocompromised individuals after organ transplantation.
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Affiliation(s)
- Amir Elalouf
- Bar-Ilan University, Department of Management, Ramat Gan 5290002, Israel.
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7
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Abstract
Cell death, particularly that of tubule epithelial cells, contributes critically to the pathophysiology of kidney disease. A body of evidence accumulated over the past 15 years has ascribed a central pathophysiological role to a particular form of regulated necrosis, termed necroptosis, to acute tubular necrosis, nephron loss and maladaptive renal fibrogenesis. Unlike apoptosis, which is a non-immunogenic process, necroptosis results in the release of cellular contents and cytokines, which triggers an inflammatory response in neighbouring tissue. This necroinflammatory environment can lead to severe organ dysfunction and cause lasting tissue injury in the kidney. Despite evidence of a link between necroptosis and various kidney diseases, there are no available therapeutic options to target this process. Greater understanding of the molecular mechanisms, triggers and regulators of necroptosis in acute and chronic kidney diseases may identify shortcomings in current approaches to therapeutically target necroptosis regulators and lead to the development of innovative therapeutic approaches.
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8
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Tang Y, Guo J, Li J, Zhou J, Mao X, Qiu T. Risk factors for cytomegalovirus infection and disease after kidney transplantation: A meta-analysis. Transpl Immunol 2022; 74:101677. [PMID: 35901951 DOI: 10.1016/j.trim.2022.101677] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To investigate the risk factors for cytomegalovirus (CMV) infection and disease in kidney transplantation recipient, and provide references for the prevention and control of CMV infection and disease in kidney transplantation patients. METHODS Chinese and international literature related to risk factors for CMV infection and disease in renal transplant recipients was searched using databases, including China National Knowledge Infrastructure; WanFang Data; Wiper; Chinese Biomedical Literature database; PubMed; Embase; Web of Science, and the Cochrane Register of Controlled Trials. Two researchers independently screened the literature, extracted the data, and evaluated the quality of the literature according to published standards. A meta-analysis was performed using RevMan 5.4 software to extract the risk factors for CMV infection and disease in renal transplant recipients. RESULTS A total of 59,847 subjects were included in 24 studies. The risk factors for CMV infection were ATG [OR = 2.76, 95% CI (2.10, 3.63), P < 0.00001], Donor (D) CMV-IgG(+) Receptor (R)(-): (D+/R-) [OR = 2.97, 95% CI (1.63, 5.44), P = 0.004 < 0.05], recipient age [OR = 1.96, 95% CI (1.50, 2.54), P < 0.00001], lymphocytopenia [OR = 3.26, 95% CI (1.46, 7.31), P < 0.00001], and mycophenolate [OR = 3.22, 95% CI (2.02, 5.46), P < 0.00001]. The protective factor for CMV infection was glomerular filtration rate (GFR) [OR = 0.98, 95% CI (0.97, 0.99), P < 0.00001], and the uncertain factors were the use of tacrolimus [OR = 0.91, 95% CI (0.64, 1.28), P = 0.58 > 0.05], rejection [OR = 1.32, 95% CI (0.49, 3.53), P = 0.58 > 0.05], donor age [OR = 1.00, 95% CI (0.99, 1.01), P = 0.67 > 0.5], and preemptive therapy [OR = 0.51, 95% CI (0.11, 2.36), P = 0.86 > 0.05]. The risk factors for CMV disease were D+/R- [OR = 4.78, 95% CI (3.76, 6.07), P < 0.00001], ATG [OR = 1.83, 95% CI (1.25, 2.67), P < 0.00001], rejection [OR = 1.42, 95% CI (1.26, 1.59), P < 0.00001], mycophenolate [OR = 1.67, 95% CI (1.38, 2.02), P < 0.00001], recipient age [OR = 1.03, 95% CI (1.02, 1.03), P < 0.00001], donor age [OR = 1.01, 95% CI (1.00, 1.01), P = 0.001 < 0.05], Donor (D) CMV-IgG(+) Receptor(R)(+): (D+/R+) [OR = 1.92, 95% CI (1.49, 2.46), P < 0.00001], the use of prednisolone [OR = 1.59, 95% CI (1.32, 1.92), P < 0.00001], and diabetes mellitus[OR = 1.18, 95% CI (1.01, 1.37), P = 0.03 < 0.05], and the uncertain factors were donor type [OR = 4.10, 95% CI (0.28, 59.79), P = 0.30 > 0.05], time of transplantation [OR = 0.95, 95% CI (0.78, 1.16), P = 0.64 > 0.05], and the use of cyclosporine [OR = 1.50, 95% CI (0.62, 3.64), P = 0.37 > 0.05]. CONCLUSION There are many factors influencing CMV infection and disease in kidney transplant patients. Risk factors should be carefully monitored, protective factors strengthened, and more attention paid to uncertain factors.
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Affiliation(s)
- Yan Tang
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Jiayu Guo
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Jinke Li
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Jiangqiao Zhou
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Xiaolan Mao
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
| | - Tao Qiu
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China.
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9
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Agrawal A, Ison MG, Danziger-Isakov L. Long-Term Infectious Complications of Kidney Transplantation. Clin J Am Soc Nephrol 2022; 17:286-295. [PMID: 33879502 PMCID: PMC8823942 DOI: 10.2215/cjn.15971020] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Infections remain a common complication of solid-organ transplantation. Most infections in the first month after transplant are typically health care-associated infections, whereas late infections, beyond 6-12 months, are community-acquired infections. Opportunistic infections most frequently present in the first 12 months post-transplant and can be modulated on prior exposures and use of prophylaxis. In this review, we summarize the current epidemiology of postkidney transplant infections with a focus on key viral (BK polyomavirus, cytomegalovirus, Epstein-Barr virus, and norovirus), bacterial (urinary tract infections and Clostridioides difficile colitis), and fungal infections. Current guidelines for safe living post-transplant are also summarized. Literature supporting prophylaxis and vaccination is also provided.
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Affiliation(s)
- Akansha Agrawal
- Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael G. Ison
- Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lara Danziger-Isakov
- Division of Pediatric Infectious Diseases, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
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10
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Meshram HS, Kute VB, Chauhan S, Dave R, Patel H, Banerjee S, Desai S, Kumar D, Navadiya V, Mishra V. Mucormycosis as SARS-CoV2 sequelae in kidney transplant recipients: a single-center experience from India. Int Urol Nephrol 2021; 54:1693-1703. [PMID: 34792722 PMCID: PMC8600912 DOI: 10.1007/s11255-021-03057-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/11/2021] [Indexed: 12/19/2022]
Abstract
Purpose Coronavirus disease (COVID-19) sequelae in the transplant population are scarcely reported. Post-COVID-19 mucormycosis is one of such sequelae, which is a dreadful and rare entity. The purpose of this report was to study the full spectrum of this dual infection in kidney transplant recipients (KTR). Methods We did a comprehensive analysis of 11 mucormycosis cases in KTR who recovered from COVID-19 in IKDRC, Ahmedabad, Gujarat, India during the study period from Nov 2020 to May 2021. We also looked for the risk factors for mucormycosis with a historical cohort of 157 KTR who did not develop mucormycosis. Results The median age (interquartile range, range) of the cohort was 42 (33.5–50, 26–60) years with 54.5% diabetes. COVID-19 severity ranged from mild (n = 10) to severe cases (n = 1). The duration from COVID-19 recovery to presentation was 7 (7–7, 4–14) days. Ten cases were Rhino-orbital-cerebral-mucormycosis (ROCM) and one had pulmonary mucormycosis. Functional endoscopic sinus surgery (FESS) was performed in all cases of ROCM. The duration of antifungal therapy was 28 (24–30, 21–62) days. The mortality rate reported was 27%. The risk factors for post-transplant mucormycosis were diabetes (18% vs 54.5%; p-value = 0.01), lymphopenia [12 (10–18) vs 20 (12–26) %; p-value = 0.15] and a higher neutrophil–lymphocyte ratio [7 (4.6–8.3) vs 3.85 (3.3–5.8); p-value = 0.5]. Conclusion The morbidity and mortality with post-COVID-19 mucormycosis are high. Post-transplant patients with diabetes are more prone to this dual infection. Preparedness and early identification is the key to improve the outcomes.
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Affiliation(s)
- Hari Shankar Meshram
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Vivek B Kute
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India.
| | - Sanshriti Chauhan
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Ruchir Dave
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Himanshu Patel
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Subho Banerjee
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Sudeep Desai
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Deepak Kumar
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Vijay Navadiya
- Department of Nephrology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Vineet Mishra
- Department of Gynecology, Institute of Kidney Diseases and Research Centre, Dr HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
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11
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Adebiyi O, Umukoro P, Sharfuddin A, Taber T, Chen J, Lane KA, Li X, Goggins W, Yaqub MS. Patient and Graft Survival Outcomes During 2 Eras of Immunosuppression Protocols in Kidney Transplantation: Indiana University Retrospective Cohort Experience. Transplant Proc 2021; 53:2841-2852. [PMID: 34774307 DOI: 10.1016/j.transproceed.2021.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Since 1964 when Indiana University performed its first kidney transplant, immunosuppression protocol was steroid-based until 2004 when steroid-free immunosuppression protocol was adopted. We describe clinical outcomes on our patients administered early steroid withdrawal (ESW) protocol (5 days) compared with our historical cohort (HC), who were on chronic steroid-based immunosuppression. METHODS We performed a retrospective study evaluating kidney transplant recipients between 1993 and 2003 (HC, n = 1689) and between 2005 and 2016 (ESW cohort, n = 2097) at the Indiana University program, with a median follow-up of 10.5 years and 6.1 years, respectively. Primary outcomes were patient and death-censored graft survival at 1, 3, and 5 years in both study cohorts. Secondary outcomes were 1-year rates of biopsy-proven acute rejection; graft function at 1, 3, and 5 years; and risk of post-transplant infection (BK virus and cytomegalovirus) in the ESW cohort. Cox proportional model and Kaplan-Meier estimates were used to estimate survival probabilities. Fisher exact tests were used to compare episodes of acute rejection in the ESW cohort. RESULTS No difference was observed in patient survival between the ESW and HC cohorts (P = .13). Compared with the ESW cohort, death-censored graft survival was significantly worse in the HC (5 year: 86.4% vs 90.6%, log-rank P < .001). One-year acute rejection reported in the ESW cohort alone was 15.7% and significantly worse in Black patients and younger patients (P < .05). CONCLUSIONS In this sizeable single-center cohort study with significant ethnic diversity, ESW is a viable alternative to steroid-based immunosuppression protocol in kidney transplant recipients.
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Affiliation(s)
| | - Peter Umukoro
- Indiana University Health Transplant, Indianapolis, Indiana
| | | | - Tim Taber
- Indiana University Health Transplant, Indianapolis, Indiana
| | - Jeanne Chen
- Indiana University Health Transplant, Indianapolis, Indiana
| | - Kathleen A Lane
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis Indiana
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis Indiana
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12
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[Viral infections in urology]. Urologe A 2021; 60:1150-1158. [PMID: 34228144 PMCID: PMC8258472 DOI: 10.1007/s00120-021-01589-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 11/25/2022]
Abstract
Einleitung Die COVID-19-Pandemie („coronavirus disease 2019“) hat eindrucksvoll gezeigt, dass Infektionskrankheiten enorme Auswirkungen auf das Gesundheitswesen und darüber hinaus haben können. In der Urologie spielen Viren bei spezifischen Entitäten eine Rolle, wo sich der Urologe mit Viruserkrankungen beschäftigen muss. Methodik Diese Übersichtsarbeit hat zum Ziel in der Urologie relevante Virusinfektionen zu beschreiben und insbesondere die Impfprävention hervorzuheben. Es erfolgte eine selektive Literaturrecherche zu den Themen „COVID und Urologie“, „Urogenitale Virusinfektionen“, „Virale urologische Infektionen in der Transplantationsmedizin“ sowie „Impfprävention von Viruserkrankungen“. Ergebnisse Coronaviren sind Viren, die bereits 2‑mal lokale Epidemien verursacht haben (SARS- [„severe acute respiratory syndrome“] und MERS-Epidemie [„middle east respiratory syndrome“]). Die Tatsache, dass die SARS-CoV-2-Erkrankung („severe acute respiratory syndrome coronavirus 2“) auch ohne Symptome ansteckend ist, hat im Wesentlichen zu der raschen Ausbreitung und weltweiten Pandemie geführt. Eine Vielzahl von Viren, die auch eine Virämie induzieren können, wurde im Ejakulat nachgewiesen und wird damit mit einer etwaigen urogenitalen Infektion in Verbindung gebracht. Hierzu zählen u. a. das Mumps‑, Coxsackie-Viren oder Enteroviren. Es wurde auch gezeigt, dass auch eine Zika-Virusinfektion sexuell über die Spermien als Carrier übertragen werden kann. Somit spielen Viren auch eine wichtige Rolle in der Reproduktion. Bei der Nierentransplantation sind Urologen häufig mit viralen Infektionen konfrontiert. Die effektivste Waffe gegenüber Viren stellt die Impfprävention dar. Schlussfolgerung Äthiopathogenetisch ist der Urogenitaltrakt im Rahmen einer Virämie oder über eine Reaktivierung durch eine Immunsuppression am häufigsten mitbetroffen. Therapeutisch kommt der Immunmodulation sowie der Impfprophylaxe eine führende Rolle zu.
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Santos CAQ, Rhee Y, Hollinger EF, Olaitan OK, Schadde E, Peev V, Saltzberg SN, Hertl M. Comparative incidence and outcomes of COVID-19 in kidney or kidney-pancreas transplant recipients versus kidney or kidney-pancreas waitlisted patients: A single-center study. Clin Transplant 2021; 35:e14362. [PMID: 33998716 PMCID: PMC8209946 DOI: 10.1111/ctr.14362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND COVID-19 epidemiologic studies comparing immunosuppressed and immunocompetent patients may provide insight into the impact of immunosuppressants on outcomes. METHODS In this retrospective cohort study, we assembled kidney or kidney-pancreas transplant recipients who underwent transplant from January 1, 2010, to June 30, 2020, and kidney or kidney-pancreas waitlisted patients who were ever on the waitlist from January 1, 2019, to June 30, 2020. We identified laboratory-confirmed COVID-19 until January 31, 2021, and tracked its outcomes by leveraging informatics infrastructure developed for an outcomes research network. RESULTS COVID-19 was identified in 62 of 887 kidney or kidney-pancreas transplant recipients and 20 of 434 kidney or kidney-pancreas waitlisted patients (7.0% vs. 4.6%, p = .092). Of these patients with COVID-19, hospitalization occurred in 48 of 62 transplant recipients and 8 of 20 waitlisted patients (77% vs. 40%, p = .002); intensive care unit admission occurred in 18 of 62 transplant recipients and 2 of 20 waitlisted patients (29% vs. 10%, p = .085); and 7 transplant recipients were mechanically ventilated and died, whereas no waitlisted patients were mechanically ventilated or died (11% vs. 0%, p = .116). CONCLUSIONS Our study provides single-center data and an informatics approach that can be used to inform the design of multicenter studies.
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Affiliation(s)
- Carlos A Q Santos
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Yoona Rhee
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Edward F Hollinger
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Oyedolamu K Olaitan
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Erik Schadde
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Vasil Peev
- Division of Nephrology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Samuel N Saltzberg
- Division of Nephrology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Martin Hertl
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
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14
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Andrade-Sierra J, Heredia-Pimentel A, Rojas-Campos E, Ramírez Flores D, Cerrillos-Gutierrez JI, Miranda-Díaz AG, Evangelista-Carrillo LA, Martínez-Martínez P, Jalomo-Martínez B, Gonzalez-Espinoza E, Gómez-Navarro B, Medina-Pérez M, Nieves-Hernández JJ. Cytomegalovirus in renal transplant recipients from living donors with and without valganciclovir prophylaxis and with immunosuppression based on anti-thymocyte globulin or basiliximab. Int J Infect Dis 2021; 107:18-24. [PMID: 33862205 DOI: 10.1016/j.ijid.2021.04.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In our population, anti-thymocyte globulin (ATG) of 1 mg/Kg/day for 4 days is used; which permits not using valgancyclovir (VGC) prophylaxis in some renal transplant recipients (RTR) with moderate risk (R+), to reduce costs. This study aimed to determine the incidence and risk of developing cytomegalovirus (CMV), with or without prophylaxis, when exposed to low doses of ATG or basiliximab (BSL). PATIENTS AND METHODS A retrospective cohort included 265 RTR with follow-up of 12 months. Prophylaxis was used in R-/D+ and some R+. Tacrolimus (TAC), mycophenolate mofetil, and prednisone were used in all patients. Logistic regression analysis was performed to estimate the risk of CMV in RTR with or without VGC. RESULTS Cytomegalovirus was documented in 46 (17.3%) patients: 20 (43.5%) with CMV infection, and 26 (56.5%) with CMV disease. Anti-thymocyte globulin was used in 39 patients (85%): 32 R+, six D+/R-, and one D-/R-. ATG was used in 90% (27 of 30) of patients with CMV and without prophylaxis. The multivariate analysis showed an association of risk for CMV with the absence of prophylaxis (RR 2.29; 95% CI 1.08-4.86), ATG use (RR 3.7; 95% CI 1.50-9.13), TAC toxicity (RR 3.77; 95% CI 1.41-10.13), and lymphocytes at the sixth post-transplant month (RR 1.77; 95% CI 1.0-3.16). CONCLUSIONS Low doses of ATG favored the development of CMV and a lower survival free of CMV compared with BSL. In scenarios where resources for employing VGC are limited, BSL could be an acceptable strategy.
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Affiliation(s)
- Jorge Andrade-Sierra
- Department of Physiology, University Health Sciences Center, University of Guadalajara, Guadalajara, Jalisco, Mexico; Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico.
| | - Alejandro Heredia-Pimentel
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Enrique Rojas-Campos
- Medical Research Unit in Renal Diseases, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Diana Ramírez Flores
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - José I Cerrillos-Gutierrez
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Alejandra G Miranda-Díaz
- Department of Physiology, University Health Sciences Center, University of Guadalajara, Guadalajara, Jalisco, Mexico
| | - Luis A Evangelista-Carrillo
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Petra Martínez-Martínez
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Basilio Jalomo-Martínez
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Eduardo Gonzalez-Espinoza
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Benjamin Gómez-Navarro
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Miguel Medina-Pérez
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
| | - Juan José Nieves-Hernández
- Department of Nephrology and Organ Transplant Unit, Specialties Hospital, National Western Medical Centre, Mexican Institute of Social Security, Guadalajara, Jalisco, Mexico
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15
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Melgarejo I, Jorgensen D, Hariharan S, Puttarajappa CM. Bimonthly viral monitoring for late-onset cytomegalovirus infection in kidney transplant recipients. Clin Transplant 2021; 35:e14259. [PMID: 33605490 DOI: 10.1111/ctr.14259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/04/2021] [Accepted: 02/13/2021] [Indexed: 12/25/2022]
Abstract
Kidney transplant recipients with high-risk cytomegalovirus (CMV) serostatus (seropositive donor to seronegative recipient) are at risk for late-onset CMV after cessation of antiviral prophylaxis. We report findings from a strategy of bimonthly (every 2 weeks) CMV screening for late-onset CMV. This is a single-center retrospective cohort study of 70 high-risk CMV kidney transplant recipients transplanted between June 2016 and September 2018. Patients were monitored at 6-12 months post-transplantation for late-onset CMV using bimonthly CMV nucleic acid testing (NAT). Adherence to screening and its correlation with CMV-related hospitalizations were assessed. Failure to prevent CMV-related hospitalization was classified into three categories (non-adherence to CMV testing, rapid CMV progression, and health system failure). Twenty-one (30%) patients developed CMV DNAemia, of whom 10 (14%) required hospitalization. Reasons for CMV-related hospitalization despite screening were (i) screening non-adherence (50%), (ii) rapid progression (40%), and (iii) health system failure (10%). Adherence to screening was associated with lower viral counts at diagnosis (r = -.44, p = .049) and a trend towards lower risk of CMV-related hospitalization (OR: 0.97 per 1% increase in adherence; 95% CI: 0.94-1.00; p = .06). Bimonthly monitoring for late-onset CMV allows for early CMV detection and may lower CMV-related hospitalization.
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Affiliation(s)
- Ivy Melgarejo
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dana Jorgensen
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sundaram Hariharan
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chethan M Puttarajappa
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
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Bischof N, Wehmeier C, Dickenmann M, Hirt-Minkowski P, Amico P, Steiger J, Naegele K, Hirsch HH, Schaub S. Revisiting cytomegalovirus serostatus and replication as risk factors for inferior long-term outcomes in the current era of renal transplantation. Nephrol Dial Transplant 2020; 35:346-356. [PMID: 31943075 DOI: 10.1093/ndt/gfz268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/15/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) serostatus and CMV replication are considered as risk factors for inferior graft and patient survival after renal transplantation, but long-term outcome data are limited. The aim of this retrospective single-centre study was to investigate the impact of CMV serostatus and CMV replication/disease on long-term outcomes in a well-defined cohort managed by a standardized CMV prevention/treatment protocol. METHODS We investigated 599 consecutive kidney transplantations having a CMV prevention protocol consisting of either prophylaxis (D+/R- and R+ with ATG induction) or screening/deferred therapy (R+ without ATG induction). Patients were grouped according to CMV serostatus [high risk (D+/R-): n = 122; intermediate risk (R+): n = 306; low risk (D-/R-): n = 171] and occurrence of CMV replication/disease (no CMV replication: n = 419; asymptomatic CMV replication: n = 110; CMV syndrome: n = 39; tissue-invasive CMV disease: n = 31). The median follow-up time was 6.5 years. RESULTS Graft and patient survival were not different among the three CMV serostatus groups as well as the four CMV replication/disease groups (P ≥ 0.44). Eighty-seven patients died, 17 due to infections (21%), but none was attributable to CMV. The overall hospitalization incidence for CMV-related infection was 3% (17/599 patients). The incidence of clinical and (sub)clinical rejection was similar among the groups (P ≥ 0.17). In a multivariate Cox proportional hazard model, neither CMV serostatus, nor CMV replication, nor CMV disease were independent predictors for patient death or graft failure, respectively. CONCLUSIONS This retrospective single-centre study suggests that the negative impact of CMV infection on long-term patient and allograft survival as well as on allograft rejection can be largely eliminated with current diagnostic/therapeutic management.
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Affiliation(s)
- Nicole Bischof
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Patricia Hirt-Minkowski
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Patrizia Amico
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Jürg Steiger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland.,Transplantation Immunology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Klaudia Naegele
- Clinical Virology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Hans H Hirsch
- Clinic for Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.,Transplantation and Clinical Virology, Department of Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland.,Transplantation Immunology, Department of Biomedicine, University of Basel, Basel, Switzerland.,HLA-Diagnostic and Immunogenetics, Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
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17
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Waller KMJ, De La Mata NL, Hedley JA, Rosales BM, O'Leary MJ, Cavazzoni E, Ramachandran V, Rawlinson WD, Kelly PJ, Wyburn KR, Webster AC. New blood-borne virus infections among organ transplant recipients: An Australian data-linked cohort study examining donor transmissions and other HIV, hepatitis C and hepatitis B notifications, 2000-2015. Transpl Infect Dis 2020; 22:e13437. [PMID: 32767859 DOI: 10.1111/tid.13437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Blood-borne viral infections can complicate organ transplantation. Systematic monitoring to distinguish donor-transmitted infections from other new infections post transplant is challenging. Administrative health data can be informative. We aimed to quantify post-transplant viral infections, specifically those transmitted by donors and those reactivating or arising new in recipients. METHODS We linked transplant registries with administrative health data for all solid organ donor-recipient pairs in New South Wales, Australia, 2000-2015. All new recipient notifications of hepatitis B (HBV), C (HCV), or human immunodeficiency virus (HIV) after transplant were identified. Proven/probable donor transmissions within 12 months of transplant were classified using an international algorithm. RESULTS Of 2120 organ donors, there were 72 with a viral infection (9/72 active, 63/72 past). These 72 donors donated to 173 recipients, of whom 24/173 already had the same infection as their donor, and 149/173 did not, so were at risk of donor transmission. Among those at risk, 3/149 recipients had proven/probable viral transmissions (1 HCV, 2 HBV); none were unrecognized by donation services. There were no deaths from transmissions. There were no donor transmissions from donors without known blood-borne viruses. An additional 68 recipients had new virus notifications, of whom 2/68 died, due to HBV infection. CONCLUSION This work confirms the safety of organ donation in an Australian cohort, with no unrecognized viral transmissions and most donors with viral infections not transmitting the virus. This may support targeted increases in donation from donors with viral infections. However, other new virus notifications post transplant were substantial and are preventable. Data linkage can enhance current biovigilance systems.
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Affiliation(s)
- Karen M J Waller
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - Nicole L De La Mata
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - James A Hedley
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - Brenda M Rosales
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia.,Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Michael J O'Leary
- New South Wales Organ and Tissue Donation Service, Sydney, NSW, Australia.,Department of Intensive Care Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Elena Cavazzoni
- New South Wales Organ and Tissue Donation Service, Sydney, NSW, Australia
| | - Vidiya Ramachandran
- Serology and Virology Division, NSW Health Pathology Randwick Prince of Wales Hospital, Randwick, NSW, Australia
| | - William D Rawlinson
- Serology and Virology Division, NSW Health Pathology Randwick Prince of Wales Hospital, Randwick, NSW, Australia.,Schools of SOMS, BABS and Women's and Children's, University of NSW, Kensington, NSW, Australia
| | - Patrick J Kelly
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - Kate R Wyburn
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Faculty of Health and Medicine, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Angela C Webster
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
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18
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Kato K, Cooper M. Small bowel perforation secondary to CMV-positive terminal ileitis postrenal transplant. BMJ Case Rep 2019; 12:12/11/e231662. [PMID: 31772132 DOI: 10.1136/bcr-2019-231662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cytomegalovirus (CMV) infection of the gastrointestinal tract is common in immunosuppressed patients; however, small bowel perforation from tissue-invasive CMV disease after many years of immunosuppressive therapy is a rare complication requiring timely medical and surgical intervention. We report a case of a postrenal transplant patient who presented to the emergency department with severe lower abdominal pain with CT of the abdomen/pelvis revealing a small bowel perforation. He underwent an emergent laparoscopic right hemicolectomy, and his histopathology of the terminal ileum was positive for CMV disease. He was successfully treated with intravenous ganciclovir postoperatively. We discuss the pathophysiology, histopathological features and treatment of CMV infection.
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Affiliation(s)
- Kosuke Kato
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Michelle Cooper
- Department of General Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
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19
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Pérez-Flores I, Santiago JL, Fernández-Pérez C, Urcelay E, Moreno de la Higuera MÁ, Romero NC, Cubillo BR, Sánchez-Fructuoso AI. Impacts of Interleukin-18 Polymorphisms on the Incidence of Delayed-Onset Cytomegalovirus Infection in a Cohort of Kidney Transplant Recipients. Open Forum Infect Dis 2019; 6:ofz325. [PMID: 31660404 PMCID: PMC6798256 DOI: 10.1093/ofid/ofz325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/16/2019] [Indexed: 12/26/2022] Open
Abstract
Background The incidence of cytomegalovirus (CMV) infection in solid organ transplant recipients may be reduced by antiviral prophylaxis, but this strategy may lead to delayed-onset CMV infection. The proinflammatory cytokine interleukin (IL)-18 plays a major role in viral host defense responses. This study examines the impacts of 2 single-nucleotide polymorphisms (SNPs) in the promoter region of the IL-18 gene, -607C/A (rs1946518) and -137G/C (rs187238), on the incidence of delayed-onset CMV infection in patients undergoing kidney transplant. Methods This retrospective study analyzed 2 IL-18 SNPs in consecutive adult kidney transplant recipients using real-time polymerase chain reaction with TaqMan probes. Participants were enrolled over the period 2005–2013 and stratified according to their IL-18 SNP genotype. The concordance index (Harrell’s c-index) was used as a measure of the discriminatory power of the predictive models constructed with bootstrapping to correct for optimistic bias. Results Seven hundred nine patients received transplants in the study period, and 498 met selection criteria. Cytomegalovirus infection and disease incidence were 38% and 7.5%, respectively. In multivariate competing risk regression models, carriers of the -607C/-137G haplotype who received prophylaxis showed a higher incidence of CMV replication after antiviral agent discontinuation (hazard ratio = 2.42 [95% confidence interval, 1.11–5.26]; P = .026), whereas CMV disease was not observed in those given prophylaxis who were noncarriers of this polymorphism (P = .009). Conclusions Our findings suggest that the -607C/-137G IL-18 haplotype is associated with a higher incidence of postprophylaxis CMV replication. The prior identification of this polymorphism could help select alternative measures to prevent delayed-onset CMV infection in these patients.
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Affiliation(s)
- Isabel Pérez-Flores
- Nephrology Department, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Cristina Fernández-Pérez
- Clinical Research and Methodology Unit, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Madrid, Spain
| | - Elena Urcelay
- Kidney Transplant Group Hospital Clínico San Carlos, Madrid, Spain
| | | | - Natividad Calvo Romero
- Nephrology Department, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Beatriz Rodríguez Cubillo
- Nephrology Department, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
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20
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Jorgenson MR, Descourouez JL, Lyu B, Astor BC, Garg N, Smith JA, Mandelbrot DA. The risk of cytomegalovirus infection after treatment of acute rejection in renal transplant recipients. Clin Transplant 2019; 33:e13636. [PMID: 31194887 DOI: 10.1111/ctr.13636] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/02/2019] [Accepted: 06/07/2019] [Indexed: 12/20/2022]
Abstract
The risk of cytomegalovirus infection (CMV) after rejection treatment is poorly understood. To investigate this, we conducted a case/control (1:2) analysis of adult renal transplant recipients between January 1, 2005 and December 31, 2015, via incidence density sampling and survival analysis. Our objective was to evaluate the association of prior acute rejection with subsequent CMV, including epidemiology and outcomes. There were 2481 eligible renal transplants within the study period and 251 distinct CMV infections. Despite the use of antiviral prophylaxis rejection was a significant risk factor for CMV on unadjusted (HR 1.73 [1.34, 2.24] P < 0.05) and adjusted analysis (HR 1.46 [1.06, 2.04] P < 0.05). When matching cases to controls patients with CMV had significantly more rejection prior to CMV diagnosis (26.7% vs 14.2%, P < 0.01). CMV was associated with a twofold increased risk of prior rejection on unadjusted (OR 1.94, 95%CI: 1.28-2.96, P < 0.01) and adjusted analysis (OR 2.16, 95% CI: 1.31-3.58, P < 0.01). Patients with rejection preceding CMV had significantly increased graft loss (HR 2.89, 95% CI: 1.65-5.09, P < 0.01) and mortality (HR 1.82, 95% CI: 1.12-4.24, P = 0.03) as compared to those CMV cases without rejection. In conclusion, rejection is a risk factor for CMV infection that appears to persist for 1 year. Preceding rejection events increased risk of graft loss and mortality in CMV patients. Given this, prolonged surveillance monitoring for CMV after rejection may be warranted. Studies are needed investigating optimal monitoring strategies.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Beini Lyu
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brad C Astor
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Neetika Garg
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jeannina A Smith
- Department of Medicine, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Didier A Mandelbrot
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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21
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Killer Immunoglobulin-Like Receptor 2DS2 (KIR2DS2), KIR2DL2-HLA-C1, and KIR2DL3 as Genetic Markers for Stratifying the Risk of Cytomegalovirus Infection in Kidney Transplant Recipients. Int J Mol Sci 2019; 20:ijms20030546. [PMID: 30696053 PMCID: PMC6387393 DOI: 10.3390/ijms20030546] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/10/2019] [Accepted: 01/24/2019] [Indexed: 12/13/2022] Open
Abstract
Infection with cytomegalovirus (CMV) remains a major problem in kidney transplant recipients, resulting in serious infectious complications and occasionally mortality. Accumulating evidence indicates that natural killer cell immunoglobulin-like receptors (KIRs) and their ligands affect the susceptibility to various diseases, including viral infections (e.g., CMV infection). We investigated whether KIR genes and their ligands affect the occurrence of CMV infection in a group of 138 kidney transplant recipients who were observed for 720 days posttransplantation. We typed the recipients for the presence of KIR genes (human leukocyte antigen C1 [HLA-C1], HLA-C2, HLA-A, HLA-B, and HLA-DR1) by polymerase chain reaction with sequence-specific primers. The multivariate analysis revealed that the lack of KIR2DS2 (p = 0.035), the presence of KIR2DL3 (p = 0.075), and the presence of KIR2DL2–HLA-C1 (p = 0.044) were risk factors for posttransplant CMV infection. We also found that a lower estimated glomerular filtration rate (p = 0.036), an earlier time of antiviral prophylaxis initiation (p = 0.025), lymphocytopenia (p = 0.012), and pretransplant serostatus (donor-positive/recipient-negative; p = 0.042) were independent risk factors for posttransplant CMV infection. In conclusion, our findings confirm that the KIR/HLA genotype plays a significant role in anti-CMV immunity and suggest the contribution of both environmental and genetic factors to the incidence of CMV infection after kidney transplantation.
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The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. Transplantation 2019; 102:900-931. [PMID: 29596116 DOI: 10.1097/tp.0000000000002191] [Citation(s) in RCA: 699] [Impact Index Per Article: 139.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite recent advances, cytomegalovirus (CMV) infections remain one of the most common complications affecting solid organ transplant recipients, conveying higher risks of complications, graft loss, morbidity, and mortality. Research in the field and development of prior consensus guidelines supported by The Transplantation Society has allowed a more standardized approach to CMV management. An international multidisciplinary panel of experts was convened to expand and revise evidence and expert opinion-based consensus guidelines on CMV management including prevention, treatment, diagnostics, immunology, drug resistance, and pediatric issues. Highlights include advances in molecular and immunologic diagnostics, improved understanding of diagnostic thresholds, optimized methods of prevention, advances in the use of novel antiviral therapies and certain immunosuppressive agents, and more savvy approaches to treatment resistant/refractory disease. The following report summarizes the updated recommendations.
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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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Single-center analysis of infectious complications in older adults during the first year after kidney transplantation. Eur J Clin Microbiol Infect Dis 2018; 38:141-148. [PMID: 30353487 DOI: 10.1007/s10096-018-3405-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/15/2018] [Indexed: 12/29/2022]
Abstract
Infections are among the top three causes of death of older adults in the first year after kidney transplantation (KT). Our aim was to describe infectious complications among KT recipients aged ≥ 65 during the first 12 months post-transplant. Single-center retrospective cohort study. Ninety-one KTs had been performed in patients ≥ 65 years of age between 2011 and 2015. 92.3% of the patients developed at least one infection. Infectious episodes increased the risk of future infection by 10% (p = 0.0018) with each infection portending a greater risk. At a patient level, viral (71.4%) and bacterial (70.2%) infections predominated. Urinary tract infections were the most frequent complication (30.3%), followed by cytomegalovirus infections (22.7%). Infections were the main reason for readmission. 7.7% of the patients developed rejection; and overall 3.3% lost their graft. Mortality at 1 year was 9.9%. Older KT recipients have a high incidence of infectious complications the first year after KT. Infections were the number one reason for readmission, and an infection episode predicted future infections for the individual patient. Despite these complications, the majority of older KT recipients were alive with a functioning graft at 1 year.
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Impact of Phlebotomist-Only Venipuncture and Central Line Avoidance for Blood Culture in a Large Tertiary Care University Hospital. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Puttarajappa CM, Hariharan S, Smith KJ. A Markov Analysis of Screening for Late-Onset Cytomegalovirus Disease in Cytomegalovirus High-Risk Kidney Transplant Recipients. Clin J Am Soc Nephrol 2018; 13:290-298. [PMID: 29025787 PMCID: PMC5967425 DOI: 10.2215/cjn.05080517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/06/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Management strategies are unclear for late-onset cytomegalovirus infection occurring beyond 6 months of antiviral prophylaxis in cytomegalovirus high-risk (cytomegalovirus IgG positive to cytomegalovirus IgG negative) kidney transplant recipients. Hybrid strategies (prophylaxis followed by screening) have been investigated but with inconclusive results. There are clinical and potential cost benefits of preventing cytomegalovirus-related hospitalizations and associated increased risks of patient and graft failure. We used decision analysis to evaluate the utility of postprophylaxis screening for late-onset cytomegalovirus infection. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We used the Markov decision analysis model incorporating costs and utilities for various cytomegalovirus clinical states (asymptomatic cytomegalovirus, mild cytomegalovirus infection, and cytomegalovirus infection necessitating hospitalization) to estimate cost-effectiveness of postprophylaxis cytomegalovirus screening strategies. Five strategies were compared: no screening and screening at 1-, 2-, 3-, or 4-week intervals. Progression to severe cytomegalovirus infection was modeled on cytomegalovirus replication kinetics. Incremental cost-effectiveness ratios were calculated as a ratio of cost difference between two strategies to difference in quality-adjusted life-years starting with the low-cost strategy. One-way and probabilistic sensitivity analyses were performed to test model's robustness. RESULTS There was an incremental gain in quality-adjusted life-years with increasing screening frequency. Incremental cost-effectiveness ratios were $783 per quality-adjusted life-year (every 4 weeks over no screening), $1861 per quality-adjusted life-year (every 3 weeks over every 4 weeks), $10,947 per quality-adjusted life-year (every 2 weeks over every 3 weeks), and $197,086 per quality-adjusted life-year (weekly over every 2 weeks). Findings were sensitive to screening cost, cost of hospitalization, postprophylaxis cytomegalovirus incidence, and graft loss after cytomegalovirus infection. No screening was favored when willingness to pay threshold was <$14,000 per quality-adjusted life-year, whereas screening weekly was favored when willingness to pay threshold was >$185,000 per quality-adjusted life-year. Screening every 2 weeks was the dominant strategy between willingness to pay range of $14,000-$185,000 per quality-adjusted life-year. CONCLUSIONS In cytomegalovirus high-risk kidney transplant recipients, compared with no screening, screening for postprophylactic cytomegalovirus viremia is associated with gains in quality-adjusted life-years and seems to be cost effective. A strategy of screening every 2 weeks was the most cost-effective strategy across a wide range of willingness to pay thresholds.
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Affiliation(s)
- Chethan M. Puttarajappa
- Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania; and
- Renal-Electrolyte Division, Department of Medicine and
| | - Sundaram Hariharan
- Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania; and
- Renal-Electrolyte Division, Department of Medicine and
| | - Kenneth J. Smith
- Department of Medicine, Section of Decision Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
Cytomegalovirus (CMV), human herpes virus (HHV)-6, and HHV-7 are ubiquitous β-herpesviruses that can cause opportunistic infection and disease in kidney transplant recipients. Active CMV infection and disease are associated with acute allograft failure and death, and HHV-6 and HHV-7 replication are associated with CMV disease. CMV prevention strategies are used commonly after kidney transplantation, and include prophylaxis with antiviral medications and preemptive treatment upon the detection of asymptomatic viral replication in blood. Both approaches decrease CMV disease and allograft rejection, but CMV prophylaxis is preferred for high-risk patients because it is easy to administer and may be more effective in real-world settings. CMV disease commonly occurs even with current preventive strategies, whereas HHV-6 and HHV-7 diseases are rare. The clinical manifestations of CMV, HHV-6, and HHV-7 are nonspecific, and laboratory confirmation is essential to establishing diagnoses. Although nucleic acid testing has supplanted other diagnostic modalities given its high sensitivity and specificity, histopathologic examination sometimes is necessary to identify disease definitively. Ganciclovir and valganciclovir are the treatments of choice for CMV and HHV-6, and foscarnet can be used to treat HHV-7. Treatment duration should be informed by the initial severity of disease, and subsequent clinical and virologic responses.
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Selvey LA, Lim WH, Boan P, Swaminathan R, Slimings C, Harrison AE, Chakera A. Cytomegalovirus viraemia and mortality in renal transplant recipients in the era of antiviral prophylaxis. Lessons from the western Australian experience. BMC Infect Dis 2017; 17:501. [PMID: 28716027 PMCID: PMC5514475 DOI: 10.1186/s12879-017-2599-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 07/11/2017] [Indexed: 12/12/2022] Open
Abstract
Background Cytomegalovirus (CMV) establishes a lifelong infection that is efficiently controlled by the immune system; this infection can be reactivated in case of immunosuppression such as following solid organ transplantation. CMV viraemia has been associated with CMV disease, as well as increased mortality and allograft failure. Prophylactic antiviral medication is routinely given to renal transplant recipients, but reactivation during and following cessation of antiviral prophylaxis is known to occur. The aims of this study were to assess the incidence, timing and impact of CMV viraemia in renal transplant recipients and to determine the level of viraemia associated with adverse clinical outcomes. Methods Data from all adult (18 years and over) Western Australian renal transplant recipients transplanted between 1 January 2007 and 31 December 2012 were obtained from the Australia and New Zealand Dialysis and Transplant registry and were supplemented with data obtained from clinical records. Potential risk factors for detectable CMV viraemia (≥600 copies/ml) and all-cause mortality were assessed using univariable analysis and Cox Proportional Hazards Regression. Results There were 438 transplants performed on 435 recipients. The following factors increased the risk of CMV viraemia with viral loads ≥600 copies/ml: Donor positive/Recipient negative status; receiving a graft from a deceased donor; and receiving a graft from a donor aged 60 years and over. CMV viraemia with viral loads ≥656 copies/ml was a risk factor for death following renal transplantation, as was being aged 65 years and above at transplant, being Aboriginal and having vascular disease. Importantly 37% of the episodes of CMV viraemia with viral loads ≥656 copies/ml occurred while the patients were expected to be on CMV prophylaxis. Conclusions CMV viraemia (≥656 copies/ml) was associated with all-cause mortality in multivariable analysis, and CMV viraemia at ≥656 copies/ml commonly occurred during the period when renal transplant recipients were expected to be on antiviral prophylaxis. A greater vigilance in monitoring CMV levels if antiviral prophylaxis is stopped prematurely or poor patient compliance is suspected could protect some renal transplant recipients from adverse outcomes such as premature mortality.
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Affiliation(s)
- Linda A Selvey
- School of Public Health, Curtin University, Bentley, WA, Australia.
| | - Wai H Lim
- ANZDATA Registry, Adelaide, Australia.,Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, WA, Australia
| | - Ramyasuda Swaminathan
- Department of Nephrology and Renal Transplantation, Fiona Stanley Hospital, Murdoch, WA, Australia
| | | | - Amy E Harrison
- School of Public Health, Curtin University, Bentley, WA, Australia
| | - Aron Chakera
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Translational Renal Research Group, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, WA, Australia
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29
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Imaoka Y, Ohira M, Ishiyama K, Ide K, Kobayashi T, Tahara H, Ohdan H. Perforation of the gallbladder in a patient with acute cytomegalovirus cholecystitis shortly following renal transplantation. Transpl Infect Dis 2017; 19. [PMID: 28605108 DOI: 10.1111/tid.12733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 03/06/2017] [Accepted: 03/25/2017] [Indexed: 11/29/2022]
Abstract
A 74-year-old man with end-stage renal failure secondary to diabetes received a living donor renal transplant (cytomegalovirus [CMV]-seropositive recipient from a CMV-seropositive donor). Computed tomography scan revealed a gallbladder with hemorrhage. On postoperative day 27, cholecystography revealed gallbladder perforation; he underwent an emergency operation. Histological examination of the gallbladder wall was positive for multiple viral inclusion bodies. We report a very rare case of both hemorrhagic and perforated CMV cholecystitis within a month following renal transplantation.
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Affiliation(s)
- Yuki Imaoka
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kohei Ishiyama
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
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Targeted preemptive therapy according to perceived risk of CMV infection after kidney transplantation. Braz J Infect Dis 2016; 20:576-584. [PMID: 27643978 PMCID: PMC9427657 DOI: 10.1016/j.bjid.2016.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/05/2016] [Accepted: 08/09/2016] [Indexed: 11/21/2022] Open
Abstract
Background Methods Results Conclusion
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Abstract
Over the past 5 years, early hospital readmissions have become a national focus. With several recent publications highlighting the high rates of early hospital readmissions among transplant recipients, more work is needed to identify risk factors and strategies for reducing unnecessary readmissions among this patient population. Although the American Society of Transplant Surgeons is advocating the exclusion of transplant recipients from the calculation of hospital readmission rates, the outcome of their advocacy efforts remains uncertain. One potential strategy for reducing early hospital readmissions is to critically examine care received by transplant recipients in the emergency department (ED), a critical pathway to readmission. As a starting point, research is needed to assess rates of ED presentation among transplant recipients, diagnostic algorithms, and communication among clinical teams. Mixed-methods studies that enhance understanding of system-level barriers to optimized evaluation and treatment of transplant recipients in the ED may lead to quality improvement interventions that reduce unnecessary readmissions, even if the rates of transplant recipients presenting to the ED remains high.
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32
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Santos CAQ, Brennan DC, Olsen MA. Accuracy of Inpatient International Classification of Diseases, Ninth Revision, Clinical Modification Coding for Cytomegalovirus After Kidney Transplantation. Transplant Proc 2016; 47:1772-6. [PMID: 26293049 DOI: 10.1016/j.transproceed.2015.04.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding for cytomegalovirus (CMV) has been used as a proxy for active CMV infection or disease occurring in the inpatient setting in retrospective studies of kidney transplant recipients using large amounts of administrative data. However, the accuracy of inpatient CMV coding has not been determined. METHODS We identified 393 kidney transplant recipients who were readmitted to Barnes-Jewish Hospital in St. Louis, Missouri from January 1, 2007 to December 31, 2011 to determine the accuracy of the ICD-9-CM diagnosis code for CMV (078.5) in identifying active CMV infection or disease (asymptomatic viremia, CMV syndrome, or tissue-invasive CMV disease) in the inpatient setting, using microbiological, histopathologic, or ophthalmologic evidence for CMV as the gold standard. RESULTS The sensitivity and positive predictive value of CMV coding in identifying active CMV infection or disease were 0.77 and 0.71, respectively. The specificity and negative predictive value were both 0.98. The sensitivity of CMV coding in identifying CMV syndrome or tissue-invasive CMV disease was 0.93. CONCLUSIONS CMV coding had good accuracy in identifying active CMV infection or disease among readmitted kidney transplant recipients in our hospital. Further validation studies of CMV coding in other hospitals are needed to obtain more generalizable estimates of the accuracy of CMV coding.
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Affiliation(s)
- C A Q Santos
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
| | - D C Brennan
- Division of Renal Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - M A Olsen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Malvezzi P, Jouve T, Rostaing L. Use of Everolimus-based Immunosuppression to Decrease Cytomegalovirus Infection After Kidney Transplant. EXP CLIN TRANSPLANT 2016; 14:361-6. [PMID: 27041365 DOI: 10.6002/ect.2015.0292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Cytomegalovirus infection and disease remain an issue in solid-organ transplant. Universal prophylaxis is more cost-effective than a preemptive strategy and is associated with significantly less Cytomegalovirus resistance after kidney transplant, especially in Cytomegalovirus-seropositive donors and Cytomegalovirus-seronegative recipients. MATERIALS AND METHODS Registry data and meta-analyses have shown that mammalian target of rapamycin inhibitors (sirolimus- and everolimus-based immunosuppression) are associated with significantly less Cytomegalovirus events in de novo kidney transplant patients than in patients who are treated with calcineurin inhibitors plus mycophenolate-based immunosuppression. RESULTS Recent pooled analyses of 3 randomized controlled trials in de novo kidney transplant patients, where immunosuppression was based on cyclosporine with either mycophenolate or everolimus, showed that patients who received everolimus had significantly less Cytomegalovirus events (Cytomegalovirus viremia, Cytomegalovirus infection/disease) than those who received mycophenolate, with or without cytomegalovirus as prophylaxis. An even more recent prospective randomized controlled study on de novo kidney transplant patients with no anticytomegalovirus prophylaxis demonstrated that everolimus-based immunosuppression plus low-dose tacrolimus was associated with significantly less Cytomegalovirus infection than standard-dose tacrolimus plus mycophenolate. CONCLUSIONS The potential benefits are not fully known of such a therapeutic strategy to limit the long-term indirect effects mediated by Cytomegalovirus infections.
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Affiliation(s)
- Paolo Malvezzi
- From the Clinique Universitaire de Néphrologie, Unité de Transplantation Rénale, CHU Grenoble
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Razonable RR, Blumberg EA. It's not too late: a proposal to standardize the terminology of "late-onset" cytomegalovirus infection and disease in solid organ transplant recipients. Transpl Infect Dis 2015; 17:779-84. [PMID: 26771688 DOI: 10.1111/tid.12447] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- R R Razonable
- Division of Infectious Diseases, Department of Medicine and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - E A Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Tedesco-Silva H, Felipe C, Ferreira A, Cristelli M, Oliveira N, Sandes-Freitas T, Aguiar W, Campos E, Gerbase-DeLima M, Franco M, Medina-Pestana J. Reduced Incidence of Cytomegalovirus Infection in Kidney Transplant Recipients Receiving Everolimus and Reduced Tacrolimus Doses. Am J Transplant 2015; 15:2655-64. [PMID: 25988935 DOI: 10.1111/ajt.13327] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/05/2015] [Accepted: 03/25/2015] [Indexed: 01/25/2023]
Abstract
This study compared the incidence of CMV infection/disease in de novo kidney transplant recipients receiving everolimus or mycophenolate and no CMV pharmacological prophylaxis. We randomized 288 patients to receive a single 3 mg/kg dose of antithymocyte globulin, tacrolimus, everolimus, and prednisone (r-ATG/EVR, n = 85); basiliximab, tacrolimus, everolimus, and prednisone (BAS/EVR, n = 102); or basiliximab, tacrolimus, mycophenolate, and prednisone (BAS/MPS, n = 101). The primary end-point was the incidence of first CMV infection/disease in the intention-to-treat population at 12 months. Patients treated with r-ATG/EVR showed a 90% proportional reduction (4.7% vs. 37.6%, HR 0.10, 95% CI 0.037-0.29; p < 0.001), while those treated with BAS/EVR showed a 75% proportional reduction (10.8% vs. 37.6%, HR 0.25, 95% CI 0.13-0.48; p < 0.001) in the incidence of CMV infection/disease compared to BAS/MPS. There were no differences in the incidence of acute rejection (9.4 vs. 18.6 vs. 15.8%, p = 0.403), wound-healing complications, delayed graft function, and proteinuria. Mean estimated glomerular filtration rate was lower in BAS/EVR (65.7 ± 21.8 vs. 60.6 ± 20.9 vs. 69.5 ± 21.5 ml/min, p = 0.021). In de novo kidney transplant recipients receiving no pharmacological CMV prophylaxis, reduced-dose tacrolimus and everolimus was associated with a significant reduction in the incidence of CMV infection/disease compared to standard tacrolimus dose and mycophenolate (ClinicalTrials.gov NCT01354301).
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Affiliation(s)
- H Tedesco-Silva
- Nephrology Division, Hospital do Rim - UNIFESP, São Paulo, Brazil
| | - C Felipe
- Nephrology Division, Hospital do Rim - UNIFESP, São Paulo, Brazil
| | - A Ferreira
- Nephrology Division, Hospital do Rim - UNIFESP, São Paulo, Brazil
| | - M Cristelli
- Nephrology Division, Hospital do Rim - UNIFESP, São Paulo, Brazil
| | - N Oliveira
- Nephrology Division, Hospital do Rim - UNIFESP, São Paulo, Brazil
| | - T Sandes-Freitas
- Nephrology Division, Hospital do Rim - UNIFESP, São Paulo, Brazil
| | - W Aguiar
- Urology Division, Hospital do Rim - UNIFESP, São Paulo, Brazil
| | - E Campos
- Department of Immunogenetic, AFIP São Paulo, São Paulo, Brazil
| | | | - M Franco
- Department of Pathology, UNIFESP, São Paulo, Brazil
| | - J Medina-Pestana
- Nephrology Division, Hospital do Rim - UNIFESP, São Paulo, Brazil
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36
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Tu G, Ju M, Zheng Y, Xu M, Rong R, Zhu D, Zhu T, Luo Z. Early- and late-onset severe pneumonia after renal transplantation. Int J Clin Exp Med 2015; 8:1324-1332. [PMID: 25785133 PMCID: PMC4358588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 01/08/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND The aim of this study was to clarify the distinctions in the clinical characteristics and outcomes between early- and late-onset severe pneumonia after renal transplantation requiring ICU admission. METHODS The data were retrospectively collected in consecutive renal recipients with severe pneumonia from January 1, 2009, to December 31, 2013, in a tertiary ICU. We classified the patients according to the time of pneumonia onset as follows: early-onset severe pneumonia (E-SP) corresponded to a pulmonary infection occurring during the first year following the transplantation, and late-onset severe pneumonia (L-SP) corresponded to a pulmonary infection occurring after the first year following the transplantation. RESULTS In the E-SP patients, fungi (42.1%) and viruses (31.6%) were the most common pathogens. Twenty-three (71.9%) patients received non-invasive ventilation (NIV), 15 (65.2%) of whom were intubated. The median duration of the ICU and hospital stays was 11 ± 5 and 19 ± 4 days, respectively. In the L-SP patients, bacteria (42.1%) and viruses (26.3%) were the predominant pathogens. Four of 15 (26.7%) patients failed NIV treatment. The median duration of the ICU and hospital stays was 9 ± 3 and 16 ± 3 days, respectively. The ICU mortality among the E-SP patients was 18.8% (6 of 32), compared with 7.1% (2 of 28) in the L-SP group (P = 0.264). CONCLUSIONS Early-onset severe pneumonia in renal transplant recipients resulted in a more serious condition, higher rate of NIV failure, longer duration of mechanical ventilation, and increased length of ICU and hospital stays.
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Affiliation(s)
- Guowei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan UniversityShanghai, P. R. China
| | - Minjie Ju
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan UniversityShanghai, P. R. China
| | - Yijun Zheng
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan UniversityShanghai, P. R. China
| | - Ming Xu
- Department of Urology, Zhongshan Hospital, Fudan UniversityShanghai, P. R. China
| | - Ruiming Rong
- Department of Urology, Zhongshan Hospital, Fudan UniversityShanghai, P. R. China
| | - Duming Zhu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan UniversityShanghai, P. R. China
| | - Tongyu Zhu
- Department of Urology, Zhongshan Hospital, Fudan UniversityShanghai, P. R. China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan UniversityShanghai, P. R. China
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