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Fernández-García OA, Hernandez C, Robbins M, Kabbani D, Doucette K, Cervera C. Cytomegalovirus surveillance after antiviral prophylaxis in CMV mismatched transplant patients: Does recurrent cytomegalovirus DNAemia impact patient survival? Transpl Infect Dis 2024; 26:e14292. [PMID: 38728099 DOI: 10.1111/tid.14292] [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: 02/06/2024] [Revised: 04/03/2024] [Accepted: 04/19/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Cytomegalovirus (CMV) mismatched, donor IgG-positive/recipient IgG-negative, solid organ transplant recipients (SOTRs) are at high risk of CMV invasive disease. Post-prophylaxis disease is an issue in this population. Some programs employ surveillance after prophylaxis (SAP) to limit the incidence of post-prophylaxis disease. METHODS This was a single-center retrospective cohort study that included all CMV mismatched SOTRs from 2003 to 2017. Patients underwent SAP with weekly CMV plasma viral load for 12 weeks. The subjects were classified into three post-prophylaxis DNAemia patterns: no DNAemia, one episode of DNAemia, and multiple episodes of DNAemia. We calculated the cumulative incidence of each DNAemia pattern. We also determined 5-year mortality based on DNAemia pattern stratified by organ transplant type. RESULTS Post-prophylaxis recurrent DNAemia occurred in 63% of lung recipients and 32% of non-lung recipients (p = .003). Tissue invasive CMV disease was diagnosed in 3% of the population and CMV syndrome was diagnosed in 33%. Recurrent DNAemia was not associated with 5-year mortality. CONCLUSION In this cohort, undergoing SAP tissue invasive disease was uncommon and CMV DNAemia recurrence did not have an impact on long-term mortality.
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Affiliation(s)
- Oscar A Fernández-García
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Hernandez
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mark Robbins
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Doucette
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Li Ka Shing Institute of Virology, Edmonton, Alberta, Canada
| | - Carlos Cervera
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Li Ka Shing Institute of Virology, Edmonton, Alberta, Canada
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2
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Shirini K, Kamberi S, Drachenberg C, Haririan A, Saharia K, Meier RPH. Renal transplantation using kidneys from a donor with high grade cytomegalovirus viraemia: case report and literature review. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00359-1. [PMID: 38991589 DOI: 10.1016/s1473-3099(24)00359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 07/13/2024]
Abstract
Transplanting organs from cytomegalovirus-seropositive donors into cytomegalovirus-seronegative recipients is an accepted practice. However, outcomes following transplantation of organs from donors with active cytomegalovirus disease are unknown. We present a case involving a patient aged 61 years with end-stage renal disease, seropositive for cytomegalovirus, who underwent dual kidney transplant from a donor with high-grade cytomegalovirus viraemia. The donor was on immunosuppressive therapy for systemic lupus erythematosus and interstitial lung disease and had been admitted with respiratory failure. The donor had high-grade cytomegalovirus viraemia with probable cytomegalovirus pneumonitis (cytomegalovirus viral load >100 000 international units [IU]/mL in plasma and 319 000 IU/mL in bronchoalveolar lavage). Renal biopsy at organ procurement showed the absence of cytomegalovirus inclusions. Following transplantation, the recipient had delayed graft function, with renal recovery after 1 week. The patient received basiliximab induction and standard tacrolimus-based maintenance immunosuppression. He received ganciclovir and valganciclovir treatment for 1 month, followed by valganciclovir prophylaxis (or viral load monitoring, when prophylaxis had to be paused) for 2 additional months to prevent donor-derived cytomegalovirus infection. Transient cytomegalovirus viraemia (peaking at 4480 IU/mL) developed at 4 months and resolved with 1 month of valganciclovir treatment. The patient is doing well 1 year after transplantation, with adequate kidney function. This case highlights the successful and safe transplantation of kidneys from a donor with cytomegalovirus disease into a cytomegalovirus-seropositive recipient. Further research is needed to confirm our findings and define post-transplantation management.
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Affiliation(s)
- Kasra Shirini
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shani Kamberi
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cynthia Drachenberg
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abdolreza Haririan
- Division of Nephrology, Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kapil Saharia
- Institute of Human Virology, Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raphael P H Meier
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
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3
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Wang Y, Yan M, Zhang P, Wu X, Huang S, Chen S, Rong Y, Sheng Y, Wang Y, Mao G, Chen L, Wang S, Yang B. Structure elucidation and antiviral activity of a cold water-extracted mannogalactofucan Ts1-1A from Trametes sanguinea against human cytomegalovirus in vitro. Carbohydr Polym 2024; 335:122101. [PMID: 38616079 DOI: 10.1016/j.carbpol.2024.122101] [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: 01/17/2024] [Revised: 03/09/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024]
Abstract
In this study, we purified a partially acetylated heteropolysaccharide (Ts1-1A) from the fruit bodies of Trametes sanguinea Lloyd through cold water extraction and serial chromatographic separation. The purified polysaccharide Ts1-1A (12.8 kDa) was characterized as a branched mannogalactofucan with a backbone of alternately connected 1,3-linked α-Fucp and 1,6-linked α-Galp, which was partially substituted by non-reducing end units of β-Manp at O-2 and O-3 positions of 1,6-linked α-Galp. Ts1-1A showed pronounced anti-human cytomegalovirus activity at the concentration of 200 and 500 μg/mL in systematical assessments including morphological changes, western blotting, qPCR, indirect immunofluorescence and tissue culture infective dose assays. Moreover, Ts1-1A exerted its antiviral activity at two distinct stages of viral proliferation manifesting as significantly inhibiting viral protein (IE1/2 and p52) expression and reducing viral gene (UL123, UL44 and UL32) replication in the HCMV-infected WI-38 cells. At viral attachment stage, Ts1-1A interacted with HCMV and prevented HCMV from attaching to its host cells. While at early phase of viral replication stage, Ts1-1A suppressed HCMV replication by downregulating NQO1 and HO-1 proteins related to oxidative stress as an antioxidant. To sum up, Ts1-1A is a promising anti-HCMV agent which could be developed for HCMV infection prevention and therapy.
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Affiliation(s)
- Yiran Wang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China
| | - Mengxia Yan
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China
| | - Panpan Zhang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China
| | - Xinna Wu
- Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou 310030, PR China
| | - Siyang Huang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China
| | - Siru Chen
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China
| | - Yizhou Rong
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China
| | - Yunjie Sheng
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China
| | - Yangyang Wang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China
| | - Genxiang Mao
- Zhejiang Provincial Key Lab of Geriatrics & Geriatrics Institute of Zhejiang Province, Department of Geriatrics, Zhejiang Hospital, Hangzhou 310030, PR China.
| | - Libing Chen
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China.
| | - Sanying Wang
- Zhejiang Provincial Key Lab of Geriatrics & Geriatrics Institute of Zhejiang Province, Department of Geriatrics, Zhejiang Hospital, Hangzhou 310030, PR China.
| | - Bo Yang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, No. 260 Baichuan Street, Hangzhou 311402, PR China.
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4
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Ibrahim D, Byrns J, Maziarz E, Alexander BD, Saullo JL. Use of Letermovir for Primary and Secondary Cytomegalovirus Prophylaxis in Abdominal Organ Transplantation: A Single Center Experience. J Pharm Pract 2024; 37:770-779. [PMID: 37280011 DOI: 10.1177/08971900231176430] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Background: Cytomegalovirus (CMV) infection after abdominal organ transplantation is associated with increased morbidity and mortality. The use of valganciclovir for CMV prophylaxis is limited by drug-induced myelosuppression and potential emergence of resistance. Letermovir is approved for primary CMV prophylaxis in CMV seropositive allogeneic hematopoietic cell transplant recipients. However, it is increasingly used off-label for prophylaxis in solid organ transplant (SOT) recipients. Methods: Based on pharmacy records, we examined retrospectively the use of letermovir for CMV prophylaxis in abdominal transplant recipients initiated on therapy at our center from January 1, 2018 through October 15, 2020. Data were summarized using descriptive statistics. Results: Twelve episodes of letermovir prophylaxis occurred in ten patients. Four patients received primary and 6 patients received secondary prophylaxis during the study period, with 1 patient receiving letermovir secondary prophylaxis on 3 separate occasions. All patients receiving letermovir for primary prophylaxis had successful outcomes. However, letermovir secondary prophylaxis was unsuccessful in 5 of the 8 episodes (62.5%) due to breakthrough CMV DNAemia and/or disease. Only 1 patient discontinued therapy due to adverse effects. Conclusion: Although letermovir was generally well tolerated, the high rate of failure when used as secondary prophylaxis was noteworthy. Additional controlled clinical trials assessing the safety and efficacy of letermovir prophylaxis in SOT recipients are warranted.
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Affiliation(s)
- Dima Ibrahim
- Division of Infectious Diseases, Burjeel Medical City, Abu Dhabi, UAE
- Duke University Medical Center, Durham, NC, USA
| | - Jennifer Byrns
- Department of Pharmacy, Duke University Medical Center, Durham, NC, USA
| | - Eileen Maziarz
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Barbara D Alexander
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Jennifer L Saullo
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
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5
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Tajima T, Martinez OM, Bernstein D, Boyd SD, Gratzinger D, Lum G, Sasaki K, Tan B, Twist CJ, Weinberg K, Armstrong B, Desai DM, Mazariegos GV, Chin C, Fishbein TM, Tekin A, Venick RS, Krams SM, Esquivel CO. Epstein-Barr virus-associated post-transplant lymphoproliferative disorders in pediatric transplantation: A prospective multicenter study in the United States. Pediatr Transplant 2024; 28:e14763. [PMID: 38682750 PMCID: PMC11115376 DOI: 10.1111/petr.14763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/26/2024] [Accepted: 04/08/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Epstein-Barr virus (EBV)-associated post-transplant lymphoproliferative disorders (PTLD) is the most common malignancy in children after transplant; however, difficulties for early detection may worsen the prognosis. METHODS The prospective, multicenter, study enrolled 944 children (≤21 years of age). Of these, 872 received liver, heart, kidney, intestinal, or multivisceral transplants in seven US centers between 2014 and 2019 (NCT02182986). In total, 34 pediatric EBV+ PTLD (3.9%) were identified by biopsy. Variables included sex, age, race, ethnicity, transplanted organ, EBV viral load, pre-transplant EBV serology, immunosuppression, response to chemotherapy and rituximab, and histopathological diagnosis. RESULTS The uni-/multivariable competing risk analyses revealed the combination of EBV-seropositive donor and EBV-naïve recipient (D+R-) was a significant risk factor for PTLD development (sub-hazard ratio: 2.79 [1.34-5.78], p = .006) and EBV DNAemia (2.65 [1.72-4.09], p < .001). Patients with D+R- were significantly more associated with monomorphic/polymorphic PTLD than those with the other combinations (p = .02). Patients with monomorphic/polymorphic PTLD (n = 21) had significantly more EBV DNAemia than non-PTLD patients (p < .001) and an earlier clinical presentation of PTLD than patients with hyperplasias (p < .001), within 6-month post-transplant. Among non-liver transplant recipients, monomorphic/polymorphic PTLD were significantly more frequent than hyperplasias in patients ≥5 years of age at transplant (p = .01). CONCLUSIONS D+R- is a risk factor for PTLD and EBV DNAemia and associated with the incidence of monomorphic/polymorphic PTLD. Intensive follow-up of EBV viral load within 6-month post-transplant, especially for patients with D+R- and/or non-liver transplant recipients ≥5 years of age at transplant, may help detect monomorphic/polymorphic PTLD early in pediatric transplant.
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Affiliation(s)
- Tetsuya Tajima
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Olivia M Martinez
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel Bernstein
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Scott D Boyd
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Dita Gratzinger
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Grant Lum
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kazunari Sasaki
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Brent Tan
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Clare J Twist
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Kenneth Weinberg
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Brian Armstrong
- Rho Federal Systems Division, Rho, Durham, North Carolina, USA
| | - Dev M Desai
- Division of Surgical Transplantation, University of Texas (UT) Southwestern Medical Center, Dallas, Texas, USA
| | - George V Mazariegos
- Department of Pediatrics, University of Pittsburgh Medical Center (UPMC) Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Clifford Chin
- Department of Pediatrics and Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, Ohio, USA
| | - Thomas M Fishbein
- Department of Surgery and Pediatrics, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Akin Tekin
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert S Venick
- Department of Pediatric Gastroenterology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Sheri M Krams
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Carlos O Esquivel
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
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6
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Mooslechner AA, Schuller M, Pfeifer V, Klötzer KA, Prietl B, Kirsch AH, Stiegler P, Sucher R, Sourij H, Rosenkranz AR, Eller K. Pre-Transplant Frequencies of FoxP3 +CD25 + in CD3 +CD8 + T Cells as Potential Predictors for CMV in CMV-Intermediate Risk Kidney Transplant Recipients. Transpl Int 2024; 37:12963. [PMID: 38868358 PMCID: PMC11167633 DOI: 10.3389/ti.2024.12963] [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: 03/07/2024] [Accepted: 05/15/2024] [Indexed: 06/14/2024]
Abstract
Cytomegalovirus (CMV) infection detrimentally influences graft survival in kidney transplant recipients, with the risk primarily determined by recipient and donor serostatus. However, recipient CD8+ T cells play a crucial role in CMV control. The optimal preventive strategy (prophylaxis vs. pre-emptive treatment), particularly for seropositive (intermediate risk) recipients, remains uncertain. We investigated CD8+ T cell subpopulation dynamics and CMV occurrence (DNAemia ≥ 100 IU/mL) in 65 kidney transplant recipients, collecting peripheral blood mononuclear cells before (T1) and 1 year after transplantation (T2). Comparing the two timepoints, we found an increase in granulocyte, monocyte and CD3+CD8+ T cells numbers, while FoxP3+CD25+, LAG-3+ and PD-1+ frequencies were reduced at T2. CMV DNAemia occurred in 33 recipients (55.8%) during the first year. Intermediate risk patients were disproportionally affected by posttransplant CMV (N = 29/45, 64.4%). Intermediate risk recipients developing CMV after transplantation exhibited lower leukocyte, monocyte, and granulocyte counts and higher FoxP3+CD25+ frequencies in CD3+CD8+ T cells pre-transplantation compared to patients staying CMV negative. Pre-transplant FoxP3+CD25+ in CD3+CD8+ T cells had the best discriminatory potential for CMV infection prediction within the first year after transplantation (AUC: 0.746). The FoxP3+CD25+ CD3+CD8+ T cell subset may aid in selecting intermediate risk kidney transplant recipients for CMV prophylaxis.
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Affiliation(s)
- Agnes A. Mooslechner
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria
| | - Max Schuller
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Verena Pfeifer
- Center for Biomarker Research in Medicine, CBmed GmbH, Graz, Austria
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Konstantin A. Klötzer
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Barbara Prietl
- Center for Biomarker Research in Medicine, CBmed GmbH, Graz, Austria
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander H. Kirsch
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp Stiegler
- Division of General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Robert Sucher
- Division of General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander R. Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Kathrin Eller
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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7
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Krueger MB, Bonifacius A, Dragon AC, Santamorena MM, Nashan B, Taubert R, Kalinke U, Maecker-Kolhoff B, Blasczyk R, Eiz-Vesper B. In Vitro Profiling of Commonly Used Post-transplant Immunosuppressants Reveals Distinct Impact on Antiviral T-cell Immunity Towards CMV. Transpl Int 2024; 37:12720. [PMID: 38655204 PMCID: PMC11035762 DOI: 10.3389/ti.2024.12720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/27/2024] [Indexed: 04/26/2024]
Abstract
Infectious complications, including widespread human cytomegalovirus (CMV) disease, frequently occur after hematopoietic stem cell and solid organ transplantation due to immunosuppressive treatment causing impairment of T-cell immunity. Therefore, in-depth analysis of the impact of immunosuppressants on antiviral T cells is needed. We analyzed the impact of mTOR inhibitors sirolimus (SIR/S) and everolimus (EVR/E), calcineurin inhibitor tacrolimus (TAC/T), purine synthesis inhibitor mycophenolic acid (MPA/M), glucocorticoid prednisolone (PRE/P) and common double (T+S/E/M/P) and triple (T+S/E/M+P) combinations on antiviral T-cell functionality. T-cell activation and effector molecule production upon antigenic stimulation was impaired in presence of T+P and triple combinations. SIR, EVR and MPA exclusively inhibited T-cell proliferation, TAC inhibited activation and cytokine production and PRE inhibited various aspects of T-cell functionality including cytotoxicity. This was reflected in an in vitro infection model, where elimination of CMV-infected human fibroblasts by CMV-specific T cells was reduced in presence of PRE and all triple combinations. CMV-specific memory T cells were inhibited by TAC and PRE, which was also reflected with double (T+P) and triple combinations. EBV- and SARS-CoV-2-specific T cells were similarly affected. These results highlight the need to optimize immune monitoring to identify patients who may benefit from individually tailored immunosuppression.
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Affiliation(s)
- Markus Benedikt Krueger
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Agnes Bonifacius
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
| | - Anna Christina Dragon
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Maria Michela Santamorena
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Björn Nashan
- Clinic for Hepatopancreaticobiliary Surgery and Transplantation, First Affiliated Hospital, University of Science and Technology of China, Hefei, China
| | - Richard Taubert
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Ulrich Kalinke
- TWINCORE, Centre for Experimental and Clinical Infection Research, A Joint Venture Between the Helmholtz Centre for Infection Research and the Hannover Medical School, Hannover, Germany
| | - Britta Maecker-Kolhoff
- German Center for Infection Research (DZIF), Braunschweig, Germany
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Britta Eiz-Vesper
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
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8
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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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9
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Monday LM, Keri V, Chandrasekar PH. Advances in pharmacotherapies for cytomegalovirus infection: what is the current state of play? Expert Opin Pharmacother 2024; 25:685-694. [PMID: 38717943 DOI: 10.1080/14656566.2024.2353627] [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: 01/18/2024] [Accepted: 05/07/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Cytomegalovirus (CMV) remains a serious opportunistic infection in hematopoietic cell transplant (HCT) and solid-organ transplant (SOT) recipients. Traditional anti-CMV drugs are limited by toxicities and the development of resistance. Letermovir and maribavir are newly approved antivirals for the prevention and treatment of CMV. AREAS COVERED Prior reviews have discussed use of letermovir for prevention of CMV after HCT and maribavir for resistant or refractory (R/R) CMV post HCT or SOT. Subsequent data have expanded their use including letermovir for primary CMV prophylaxis in high-risk renal transplant recipients and new recommendations for extending prophylaxis through day + 200 in certain HCT patients. Data on the use of maribavir for first asymptomatic CMV infection post-HCT has also been published. This review compares the pharmacology of anti-CMV agents and discusses the updated literature of these new drugs in the prevention and treatment of CMV. EXPERT OPINION Letermovir and maribavir are much needed tools that spare toxicities of ganciclovir, foscarnet, and cidofovir. High cost is a challenge preventing their integration into clinical practice in resource-limited countries. Transplant centers need to exercise restraint in overuse to avoid resistance, particularly in the setting of high viral loads.
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Affiliation(s)
- Lea M Monday
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Vishakh Keri
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA
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10
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Schultz BG, Bullano M, Paratane D, Rajagopalan K. Cytomegalovirus related hospitalization costs among hematopoietic stem cell and solid organ transplant recipients treated with maribavir versus investigator-assigned therapy: A US-based study. Transpl Infect Dis 2024; 26:e14216. [PMID: 38221739 DOI: 10.1111/tid.14216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/19/2023] [Accepted: 12/02/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Cytomegalovirus (CMV) infections among hematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) recipients impose a significant health care resource utilization (HCRU)-related economic burden. Maribavir (MBV), a novel anti-viral therapy (AVT), approved by the United States Food and Drug Administration for post-transplant CMV infections refractory (with/without resistance) to conventional AVTs has demonstrated lower hospital length of stay (LOS) versus investigator-assigned therapy (IAT; valgancilovir, ganciclovir, foscarnet, or cidofovir) in a phase 3 trial (SOLSTICE). This study estimated the HCRU costs of MBV versus IAT. METHODS An economic model was developed to estimate HCRU costs for patients treated with MBV or IAT. Mean per-patient-per-year (PPPY) HCRU costs were calculated using (i) annualized mean hospital LOS in SOLSTICE, and (ii) CMV-related direct costs from published literature. Probabilistic sensitivity analysis with Monte-Carlo simulations assessed model robustness. RESULTS Of 352 randomized patients receiving MBV (n = 235) or IAT (n = 117) for 8 weeks in SOLSTICE, 40% had HSCT and 60% had SOT. Mean overall PPPY HCRU costs of overall hospital-LOS were $67,205 (95% confidence interval [CI]: $33,767, $231,275) versus $145,501 (95% CI: $62,064, $589,505) for MBV and IAT groups, respectively. Mean PPPY ICU and non-ICU stay costs were: $32,231 (95% CI: $5,248, $184,524) versus $45,307 (95% CI: $3,957, $481,740) for MBV and IAT groups, and $82,237 (95% CI: $40,397, $156,945) MBV versus $228,329 (95% CI: $94,442, $517,476) for MBV and IAT groups, respectively. MBV demonstrated cost savings in over 99.99% of simulations. CONCLUSIONS This analysis suggests that Mean PPPY HCRU costs were 29%-64% lower with MBV versus other-AVTs.
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Affiliation(s)
- Bob G Schultz
- US Medical Affairs Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | - Michael Bullano
- US Medical Affairs Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | - Deepika Paratane
- Health Economics and Outcomes Research, Anlitiks, Inc., Windermere, Florida, USA
| | - Krithika Rajagopalan
- Health Economics and Outcomes Research, Anlitiks, Inc., Windermere, Florida, USA
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11
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Magda G. Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial. Infect Dis Clin North Am 2024; 38:121-147. [PMID: 38280760 DOI: 10.1016/j.idc.2023.12.001] [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: 01/29/2024]
Abstract
Opportunistic infections are a leading cause of lung transplant recipient morbidity and mortality. Risk factors for infection include continuous exposure of the lung allograft to the external environment, high levels of immunosuppression, impaired mucociliary clearance and decreased cough reflex, and impact of the native lung microbiome in single lung transplant recipients. Infection risk is mitigated through careful pretransplant screening of recipients and donors, implementation of antimicrobial prophylaxis strategies, and routine surveillance posttransplant. This review describes common viral, fungal, and mycobacterial infectious after lung transplant and provides recommendations on prevention and treatment.
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Affiliation(s)
- Gabriela Magda
- Columbia University Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street PH-14, New York, NY 10032, USA.
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12
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Kotton CN, Torre-Cisneros J, Yakoub-Agha I. Slaying the "Troll of Transplantation"-new frontiers in cytomegalovirus management: A report from the CMV International Symposium 2023. Transpl Infect Dis 2024; 26:e14183. [PMID: 37942955 DOI: 10.1111/tid.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023]
Abstract
The 2023 International CMV Symposium took place in Barcelona in May 2023. During the 2-day meeting, delegates and faculty discussed the ongoing challenge of managing the risk of cytomegalovirus infection (the Troll of Transplantation) after solid organ or hematopoietic cell transplantation. Opportunities to improve outcomes of transplant recipients by applying advances in antiviral prophylaxis or pre-emptive therapy, immunotherapy, and monitoring of cell-mediated immunity to routine clinical practice were debated and relevant educational clinical cases presented. This review summarizes the presentations, cases, and discussions from the meeting and describes how further advances are needed before the Troll of Transplantation is slain.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Torre-Cisneros
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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13
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Morrison SA, Thanamayooran A, Tennankore K, Vinson AJ. Association Between First Post-operative Day Urine Output Following Kidney Transplantation and Short-Term and Long-Term Outcomes: A Retrospective Cohort Study. Can J Kidney Health Dis 2023; 11:20543581231221630. [PMID: 38161390 PMCID: PMC10757439 DOI: 10.1177/20543581231221630] [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] [Received: 06/05/2023] [Accepted: 11/05/2023] [Indexed: 01/03/2024] Open
Abstract
Background The relationship between post-operative urine output (UO) following kidney transplantation and long-term graft function has not been well described. Objective In this study, we examined the association between decreased UO on post-operative day 1 (POD1) and post-transplant outcomes. Design This is a retrospective cohort study. Setting Atlantic Canada. Patients Patients from the 4 Atlantic Canadian provinces (Nova Scotia, New Brunswick, Newfoundland, and Prince Edward Island) who received a live or deceased donor kidney transplant from 2006 through 2019 through the multiorgan transplant program at the Queen Elizabeth II Health Sciences Centre (QEII) hospital in Halifax, Nova Scotia. Measurements Using multivariable Cox proportional hazards models, we assessed the association of low POD1 UO (defined as ≤1000 mL) with death-censored graft loss (DCGL). In secondary analyses, we used adjusted logistic regression or Cox models as appropriate to assess the impact of UO on delayed graft function (DGF), prolonged length of stay (greater than the median for the entire cohort), and death. Results Of the 991 patients included, 151 (15.2%) had a UO ≤1000 mL on POD1. Low UO was independently associated with DCGL (hazard ratio [HR] = 4.00, 95% confidence interval [CI] = 95% CI = 1.55-10.32), DGF (odds ratio [OR] = 45.25, 95% CI = 23.00-89.02), and prolonged length of stay (OR = 5.06, 95% CI = 2.95-8.69), but not death (HR = 0.81, 95% CI = 0.31-2.09). Limitations This was a single-center, retrospective, observational study and therefore has inherent limitations of generalizability, data collection, and residual confounding. Conclusions Overall, reduced post-operative UO following kidney transplantation is associated with an increased risk of DCGL, DGF, and prolonged hospital length of stay.
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Affiliation(s)
- Steven A. Morrison
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Aran Thanamayooran
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karthik Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amanda J. Vinson
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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14
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Romao EA, Yamamoto AY, Gaspar GG, Garcia TMP, Muglia VA, Nardin MEP, Molina CAF, de Figueiredo VCTP, Moyses-Neto M. Significant Increase in Cytomegalovirus (CMV) Infection in Solid Organ Transplants Associated With Increased Use of Thymoglobulin as Induction Therapy? Transplant Proc 2023; 55:2035-2040. [PMID: 37778934 DOI: 10.1016/j.transproceed.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/06/2023] [Accepted: 08/04/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection remains one of the most common viral pathogens affecting solid organ transplants (SOT). In 10 years of following the outcome of transplants, we noticed an increased incidence of CMV infection, along with increased use of rabbit anti-thymocyte globulin (rATG). The study aims to assess the incidence of active CMV infection and disease, response to treatment, and recurrence in a cohort of SOT. Furthermore, we look for correlating the CMV incidence with the type of induction therapy: r-ATG or interleukin 2 receptor-blocking antibody (basiliximab). METHODS This was a single-center, retrospective 10-year study in patients submitted to kidney, kidney-liver, and kidney-pancreas transplants who used a preemptive therapy protocol for CMV. RESULTS Among the 476 enrolled transplant recipients, 306 (64.2 %) had at least one episode of CMV infection (replication), and 71/306 patients (23.2 %) presented CMV-related disease. The most frequent clinical conditions associated with CMV disease were gastrointestinal. Among the 476 transplant patients, 333 received immunosuppressive induction with rATG (69.9 %); 140 (29.4 %) received induction with interleukin 2 receptor-blocking antibody (basiliximab). The initial maintenance immunosuppressive therapy in the patients who presented CMV infection was primarily performed with prednisone, tacrolimus, and sodium mycophenolate (91.7 %). The induction with rATG increased from 35.2%-94.6% in 10 years. The incidence of CMV infection was 20.7 % in the first year of observation and gradually increased to 87.3 % in the last year. CONCLUSIONS The data suggest that the increase in the use of rATG in recent years could be responsible for the very expressive increase in the incidence of CMV infection/disease.
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Affiliation(s)
- Elen Almeida Romao
- Division of Nephrology, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Aparecida Yulie Yamamoto
- Clinical Virology Laboratory, Hospital das Clinicas, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Gilberto Gambero Gaspar
- Division Of Infectious Disease, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Tania Marisa Pisi Garcia
- Division of Nephrology, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Valmir Aparecido Muglia
- Division of Nephrology, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Maria Estela Papini Nardin
- Division of Nephrology, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | | | | | - Miguel Moyses-Neto
- Division of Nephrology, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil.
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Li X, Zhong Y, Qiao Y, Li H, Hu X, Imani S, Zheng S, Li J. Advances and Challenges in Cytomegalovirus Detection Methods for Liver Transplant Donors. Diagnostics (Basel) 2023; 13:3310. [PMID: 37958206 PMCID: PMC10649722 DOI: 10.3390/diagnostics13213310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/07/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
Cytomegalovirus (CMV) infection is a highly prevalent opportunistic infection among liver transplant recipients. When the liver donor is infected with CMV, there is a risk of transmission to the recipient, leading to CMV infection. To improve the postoperative outcome of liver transplantation, it is crucial to shift the focus of CMV detection to the donor and achieve early diagnosis, as well as implement effective preventative and therapeutic measures. However, the commonly used CMV detection methods in the past had limitations that prevented their early and accurate diagnosis in liver transplant donors. This review focuses on the latest advancements in CMV detection methods that can potentially be applied to liver transplant donors. The objective is to compare and evaluate their clinical utility, thereby providing guidance and support for rapid and accurate diagnosis of CMV infection in the clinic. The clustered regularly interspaced short palindromic repeats-associated proteins (CRISPR-Cas) system-based assay emerges as a promising method for detecting the virus, offering great prospects for early and expedient CMV infection diagnosis in clinical settings.
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Affiliation(s)
- Xiaoping Li
- Key Laboratory of Pollution Exposure and Health Intervention of Zhejiang Province, Shulan International Medical College, Zhejiang Shuren University, Hangzhou 310015, China
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yiwu Zhong
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yinbiao Qiao
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China
| | - Haoyu Li
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China
- Jinan Microecological Biomedicine Shandong Laboratory, Jinan 250117, China
| | - Xu Hu
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Saber Imani
- Shulan International Medical College, Zhejiang Shuren University, Hangzhou 310015, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China
- Jinan Microecological Biomedicine Shandong Laboratory, Jinan 250117, China
| | - Jianhui Li
- Zhejiang Chinese Medical University, Hangzhou 310053, China
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
- NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China
- Jinan Microecological Biomedicine Shandong Laboratory, Jinan 250117, China
- The Organ Repair and Regeneration Medicine Institute of Hangzhou, Hangzhou 310003, China
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16
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Streck NT, Espy MJ, Ferber MJ, Klee EW, Razonable RR, Gonzalez D, Sayada C, Heaton PR, Chou S, Binnicker MJ. Use of next-generation sequencing to detect mutations associated with antiviral drug resistance in cytomegalovirus. J Clin Microbiol 2023; 61:e0042923. [PMID: 37750719 PMCID: PMC10595055 DOI: 10.1128/jcm.00429-23] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/25/2023] [Indexed: 09/27/2023] Open
Abstract
Cytomegalovirus (CMV) is a significant cause of morbidity and mortality among immunocompromised hosts, including transplant recipients. Antiviral prophylaxis or treatment is used to reduce the incidence of CMV disease in this patient population; however, there is concern about increasing antiviral resistance. Detection of antiviral resistance in CMV was traditionally accomplished using Sanger sequencing of UL54 and UL97 genes, in which specific mutations may result in reduced antiviral activity. In this study, a novel next-generation sequencing (NGS) method was developed and validated to detect mutations in UL54/UL97 associated with antiviral resistance. Plasma samples (n = 27) submitted for antiviral resistance testing by Sanger sequencing were also analyzed using the NGS method. When compared to Sanger sequencing, the NGS assay demonstrated 100% (27/27) overall agreement for determining antiviral resistance/susceptibility and 88% (22/25) agreement at the level of resistance-associated mutations. The limit of detection of the NGS method was determined to be 500 IU/mL, and the lower threshold for detecting mutations associated with resistance was established at 15%. The NGS assay represents a novel laboratory tool that assists healthcare providers in treating patients who are infected with CMV harboring resistance-associated mutations and who may benefit from tailored antiviral therapy.
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Affiliation(s)
- Nicholas T. Streck
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J. Espy
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew J. Ferber
- Division of Laboratory Genetics and Genomics, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric W. Klee
- Division of Biomedical Statistics and Informatics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raymund R. Razonable
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Phillip R. Heaton
- Health Partners Medical Laboratory and Pathology Services, Bloomington, Minnesota, USA
| | - Sunwen Chou
- Research Service, Department of Veterans Affairs Medical Center, Portland, Oregon, USA
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17
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Bassel M, Romanus D, Bo T, Sundberg AK, Okala S, Hirji I. Retrospective chart review of transplant recipients with cytomegalovirus infection who received maribavir in the Phase 3 SOLSTICE trial: Data at 52 weeks post-maribavir treatment initiation. Antivir Ther 2023; 28:13596535231195431. [PMID: 37657421 DOI: 10.1177/13596535231195431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is a frequent complication in haematopoietic cell/solid organ transplant (HCT/SOT) recipients. Previous studies report all-cause mortality rates of 31% and 50% in HCT/SOT recipients post-treatment initiation with conventional anti-CMV therapies for refractory or resistant CMV. METHODS This was a multi-country, retrospective medical chart review study of HCT/SOT recipients with refractory CMV infection with or without resistance (R/R) who were randomized to the maribavir arm in the open-label Phase 3 SOLSTICE trial. Patients came from 21 SOLSTICE sites across 6 countries; each site randomized ≥3 patients to the maribavir arm. Patients were followed for 52 weeks (SOLSTICE trial period: 20 weeks; follow-up chart review period: 32 weeks). The primary outcomes were mortality and graft status. RESULTS Of 234 patients who were randomized and received maribavir in SOLSTICE, chart abstraction was completed for all 109 patients enrolled across 21 trial sites (SOT, 68/142; HCT, 41/92). At 52 weeks, overall mortality was 15.6% (17/109) and survival probability was 0.84. Among SOT recipients, survival probability was 0.96, and 3 (4.4%) deaths occurred during the chart review period. For the HCT recipients, survival probability was 0.65 with 14 (34.1%) deaths; 8 occurred during SOLSTICE and 6 during the chart review period. No new graft loss or re-transplantation occurred during the chart review period. CONCLUSIONS Overall mortality at 52 weeks post-maribavir treatment initiation in this sub-cohort of patients from the SOLSTICE trial was lower than that previously reported for similar populations treated with conventional therapies for R/R cytomegalovirus infection.
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Affiliation(s)
| | - Dorothy Romanus
- Takeda Development Center Americas, Inc., Lexington, MA, USA
| | - Tien Bo
- Takeda Development Center Americas, Inc., Lexington, MA, USA
| | | | | | - Ishan Hirji
- Takeda Development Center Americas, Inc., Lexington, MA, USA
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Maenaka A, Kinoshita K, Hara H, Cooper DKC. The case for the therapeutic use of mechanistic/mammalian target of rapamycin (mTOR) inhibitors in xenotransplantation. Xenotransplantation 2023; 30:e12802. [PMID: 37029499 PMCID: PMC11286223 DOI: 10.1111/xen.12802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/23/2023] [Indexed: 04/09/2023]
Abstract
The mechanistic/mammalian target of rapamycin (mTOR) is one of the systems that are necessary to maintain cell homeostasis, such as survival, proliferation, and differentiation. mTOR inhibitors (mTOR-Is) are utilized as immunosuppressants and anti-cancer drugs. In organ allotransplantation, current regimens infrequently include an mTOR-I, which are positioned more commonly as alternative immunosuppressants. In clinical allotransplantation, long-term efficacy has been established, but there is a significant incidence of adverse events, for example, inhibition of wound healing, buccal ulceration, anemia, hyperglycemia, dyslipidemia, and thrombocytopenia, some of which are dose-dependent. mTOR-Is have properties that may be especially beneficial in xenotransplantation. These include suppression of T cell proliferation, increases in the number of T regulatory cells, inhibition of pig graft growth, and anti-inflammatory, anti-viral, and anti-cancer effects. We here review the potential benefits and risks of mTOR-Is in xenotransplantation and suggest that the benefits exceed the adverse effects.
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Affiliation(s)
- Akihiro Maenaka
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Kohei Kinoshita
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Hidetaka Hara
- College of Veterinary Medicine, Yunnan Agricultural University, Kunming, Yunnan, China
| | - David K. C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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19
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Opportunistic Infections Post-Lung Transplantation: Viral, Fungal, and Mycobacterial. Clin Chest Med 2023; 44:159-177. [PMID: 36774162 DOI: 10.1016/j.ccm.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Opportunistic infections are a leading cause of lung transplant recipient morbidity and mortality. Risk factors for infection include continuous exposure of the lung allograft to the external environment, high levels of immunosuppression, impaired mucociliary clearance and decreased cough reflex, and impact of the native lung microbiome in single lung transplant recipients. Infection risk is mitigated through careful pretransplant screening of recipients and donors, implementation of antimicrobial prophylaxis strategies, and routine surveillance posttransplant. This review describes common viral, fungal, and mycobacterial infectious after lung transplant and provides recommendations on prevention and treatment.
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20
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Diena D, Allesina A, Fop F, Mella A, Cavallo R, Costa C, Dolla C, Gallo E, De Rosa FG, Lavacca A, Giraudi R, Mariano F, Biancone L. Relationship between Cytomegalovirus Viremia and Long-Term Outcomes in Kidney Transplant Recipients with Different Donor Ages. Microorganisms 2023; 11:microorganisms11020458. [PMID: 36838423 PMCID: PMC9961719 DOI: 10.3390/microorganisms11020458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
OBJECTIVES To explore the Cytomegalovirus (CMV) burden on the long-term post-transplant course in different donor ages, we evaluated the incidence and risk factors for CMV in our kidney-transplanted patients (KTs) with extensive adoption of expanded-criteria donors (ECDs). METHODS Retrospective evaluation of 929 consecutive first KTs (49.5% receiving an organ from a donor ≥ 60 years) performed between 01-2003 and 12-2013. Overall survival was estimated using Kaplan-Meier curves; cumulative incidence function was additionally analyzed to consider the potential role of death with a functioning graft as a competitive event with graft dysfunction and to avoid overestimation. Apart from regular DNAemia monitoring in all patients, prophylaxis was adopted in high-risk groups (D+/R- or recipients of anti-thymocyte globulin induction), with pre-emptive therapy in the remaining groups. RESULTS CMV incidence was 19.5% (4-34.9% according to serostatus combination: D-/R-, D-/R+, D+/R+, D+/R-). Donor and recipient age, recipient pre-transplant hypertension, DR antigen compatibility, cold ischemia time, and post-transplant early complications, including rejection, urologic and renal artery stenosis, and lower renal function and proteinuria ≥ 0.5 g/day at one year after KT were associated with CMV. CMV determined lower death-censored graft survival (DCGS) (p < 0.01), with a prominent effect in R+ (p < 0.01) and without impact in R- (p = 0.32 in D-/R- and p = 0.006 in D+/R-). Interestingly, CMV occurrence influenced DCGS only in KTs who received grafts from donors < 50 or 50-69 years old (p < 0.01), while it was not significant with older donors (p = 0.07). The analysis of the cumulative incidence of graft loss accounting for death as a competing risk confirmed all these findings. In multivariate analysis, CMV replication/disease in the first year was an independent predictor for DCGS (HR 1.73 [1.3-2.3]). CONCLUSIONS In a large population with extensive ECD adoption, CMV viremia in the first year demonstrates its harmful effect with an independent role for graft loss and significant impact among R+ recipients and KTs with donors < 70 years.
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Affiliation(s)
- Davide Diena
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
- Renal Unit, Santa Croce e Carle Hospital, 12100 Cuneo, Italy
| | - Anna Allesina
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Fabrizio Fop
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Alberto Mella
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Rossana Cavallo
- Microbiology and Virology Unit, University of Turin, 10126 Turin, Italy
| | - Cristina Costa
- Microbiology and Virology Unit, University of Turin, 10126 Turin, Italy
| | - Caterina Dolla
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Ester Gallo
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, A.O.U. Città Della Salute e Della Scienza di Torino, 10126 Turin, Italy
| | - Antonio Lavacca
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Roberta Giraudi
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Filippo Mariano
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
- Correspondence: ; Tel.: +39-011-6336797
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21
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Freedman SR, Saunders K, Plazak ME, Ravichandran BR, Saharia KK, Masters BM, Sparkes T. Impact of high MELD scores on CMV viremia following liver transplantation. Transpl Infect Dis 2023; 25:e14001. [PMID: 36508446 DOI: 10.1111/tid.14001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/20/2022] [Accepted: 11/03/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Advanced liver disease or cirrhosis is associated with an increased risk of infections; however, the impact of high pretransplant model for end-stage liver disease (MELD) score on cytomegalovirus (CMV) viremia after liver transplantation is unknown. METHODS This single-center, retrospective, cohort study evaluated CMV high-risk (CMV immunoglobulin G D+/R-) liver transplant recipients who received valganciclovir prophylaxis for 3 months between 2009 and 2019. Patients were stratified by pretransplant MELD score of <35 (low MELD) and ≥35 (high MELD). The primary outcome was 12-month CMV viremia, and secondary outcomes included CMV resistance and tissue invasive disease, mortality, biopsy-proven acute rejection (BPAR), leukopenia, and thrombocytopenia. Multivariable Cox proportional-hazards modeling was used to assess the association of MELD score with the time to CMV viremia. RESULTS There were 162 and 79 patients in the low and high MELD groups, respectively. Pretransplant MELD score ≥35 was associated with an increased risk of CMV viremia (hazard ratio [HR] 1.73; confidence interval 1.06-2.82, p = .03). CMV viremia occurred at 162 ± 61 days in the low MELD group and 139 ± 62 days in the high MELD group. Although BPAR occurred early at 30 days (13-59) in the low-MELD group and at 18 days (11-66) in the high-MELD group (p = .56), BPAR was not associated with an increased risk of CMV viremia (HR 1.55 [0.93-2.60], p = .1). DISCUSSION MELD scores ≥35 were associated with an increased hazards of CMV viremia. In liver transplant recipients with MELD scores ≥35 who are CMV high-risk, additional CMV intervention may be warranted.
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Affiliation(s)
- Sari R Freedman
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Kenneth Saunders
- Department of Pharmacy, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Michael E Plazak
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Bharath R Ravichandran
- Department of Pharmacy, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Kapil K Saharia
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brian M Masters
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Tracy Sparkes
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
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22
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Rousselière A, Delbos L, Foureau A, Reynaud-Gaubert M, Roux A, Demant X, Le Pavec J, Kessler R, Mornex JF, Messika J, Falque L, Le Borgne A, Boussaud V, Tissot A, Hombourger S, Bressollette-Bodin C, Charreau B. Changes in HCMV immune cell frequency and phenotype are associated with chronic lung allograft dysfunction. Front Immunol 2023; 14:1143875. [PMID: 37187736 PMCID: PMC10175754 DOI: 10.3389/fimmu.2023.1143875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
Background Human cytomegalovirus (HCMV) infection is common and often severe in lung transplant recipients (LTRs), and it is a risk factor associated with chronic lung allograft dysfunction (CLAD). The complex interplay between HCMV and allograft rejection is still unclear. Currently, no treatment is available to reverse CLAD after diagnosis, and the identification of reliable biomarkers that can predict the early development of CLAD is needed. This study investigated the HCMV immunity in LTRs who will develop CLAD. Methods This study quantified and phenotyped conventional (HLA-A2pp65) and HLA-E-restricted (HLA-EUL40) anti-HCMV CD8+ T (CD8 T) cell responses induced by infection in LTRs developing CLAD or maintaining a stable allograft. The homeostasis of immune subsets (B, CD4T, CD8 T, NK, and γδT cells) post-primary infection associated with CLAD was also investigated. Results At M18 post-transplantation, HLA-EUL40 CD8 T responses were less frequently found in HCMV+ LTRs (21.7%) developing CLAD (CLAD) than in LTRs (55%) keeping a functional graft (STABLE). In contrast, HLA-A2pp65 CD8 T was equally detected in 45% of STABLE and 47.8% of CLAD LTRs. The frequency of HLA-EUL40 and HLA-A2pp65 CD8 T among blood CD8 T cells shows lower median values in CLAD LTRs. Immunophenotype reveals an altered expression profile for HLA-EUL40 CD8 T in CLAD patients with a decreased expression for CD56 and the acquisition of PD-1. In STABLE LTRs, HCMV primary infection causes a decrease in B cells and inflation of CD8 T, CD57+/NKG2C+ NK, and δ2-γδT cells. In CLAD LTRs, the regulation of B, total CD8 T, and δ2+γδT cells is maintained, but total NK, CD57+/NKG2C+ NK, and δ2-γδT subsets are markedly reduced, while CD57 is overexpressed across T lymphocytes. Conclusions CLAD is associated with significant changes in anti-HCMV immune cell responses. Our findings propose that the presence of dysfunctional HCMV-specific HLA-E-restricted CD8 T cells together with post-infection changes in the immune cell distribution affecting NK and γδT cells defines an early immune signature for CLAD in HCMV+ LTRs. Such a signature may be of interest for the monitoring of LTRs and may allow an early stratification of LTRs at risk of CLAD.
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Affiliation(s)
- Amélie Rousselière
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche Translationnelle en Transplantation et Immunologie, Nantes, France
| | - Laurence Delbos
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche Translationnelle en Transplantation et Immunologie, Nantes, France
| | - Aurore Foureau
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche Translationnelle en Transplantation et Immunologie, Nantes, France
- Nantes Université, CHU Nantes, Service de Pneumologie, Institut du thorax, Nantes, France
| | - Martine Reynaud-Gaubert
- CHU de Marseille, APHM, Hôpital Nord, Service de Pneumologie et Equipe de Transplantation pulmonaire; Marseille, France; Aix-Marseille Université, Marseille, France
| | - Antoine Roux
- Hôpital Foch, Service de pneumologie, Suresnes, France
| | - Xavier Demant
- Hôpital Haut-Lévêque, Service de pneumologie, CHU de Bordeaux, Bordeaux, France
| | - Jérôme Le Pavec
- Service de Pneumologie et de Transplantation Pulmonaire, Groupe Hospitalier Marie-Lannelongue -Paris Saint Joseph, Le Plessis-Robinson, France
- Université Paris-Saclay, Le Kremlin Bicêtre, France
- UMR_S 999, Université Paris–Sud, Inserm, Groupe hospitalier Marie-Lannelongue-Saint Joseph, Le Plessis-Robinson, France
| | - Romain Kessler
- Groupe de transplantation pulmonaire des hôpitaux universitaires de Strasbourg, Inserm-Université de Strasbourg, Strasbourg, France
| | - Jean-François Mornex
- Université de Lyon, Université Lyon1, INRAE, IVPC, Lyon, France
- Hospices Civils de Lyon, GHE, Service de Pneumologie, Inserm, Lyon, France
| | - Jonathan Messika
- APHP, Nord-Université Paris Cité, Hôpital Bichat-Claude Bernard, Service de Pneumologie B et Transplantation Pulmonaire, Paris, France
- Physiopathology and Epidemiology of Respiratory Diseases, UMR1152 INSERM and Université de Paris, Paris, France
| | - Loïc Falque
- Service Hospitalier Universitaire Pneumologie et Physiologie, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, Grenoble, France
| | | | - Véronique Boussaud
- Service de Pneumologie, Hôpital Européen Georges-Pompidou, Paris, France
| | - Adrien Tissot
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche Translationnelle en Transplantation et Immunologie, Nantes, France
- Nantes Université, CHU Nantes, Service de Pneumologie, Institut du thorax, Nantes, France
| | - Sophie Hombourger
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche Translationnelle en Transplantation et Immunologie, Nantes, France
| | - Céline Bressollette-Bodin
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche Translationnelle en Transplantation et Immunologie, Nantes, France
- CHU Nantes, Nantes Université, Laboratoire de Virologie, Nantes, France
| | - Béatrice Charreau
- Nantes Université, CHU Nantes, Inserm, Centre de Recherche Translationnelle en Transplantation et Immunologie, Nantes, France
- CHU Nantes, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, France
- *Correspondence: Béatrice Charreau,
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23
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Whole Blood versus Plasma Samples-How Does the Type of Specimen Collected for Testing Affect the Monitoring of Cytomegalovirus Viremia? Pathogens 2022; 11:pathogens11111384. [PMID: 36422636 PMCID: PMC9697577 DOI: 10.3390/pathogens11111384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/13/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Viral infections, or their reactivations, are one of the most important groups of transplantation complications that can occur among recipients of both hematopoietic cells and solid organ transplants. They are the most commonly caused by cytomegalovirus (CMV). Currently, the use of whole blood or plasma samples is recommended for CMV viral load monitoring. The aim of the study was to assess and compare the level of CMV DNA, depending on the type of clinical material—whole blood or plasma fraction derived from the same patient. The studies were carried out on 156 whole blood samples in which the presence of CMV genetic material was confirmed and the corresponding plasma samples from the same rounds of sampling. CMV DNA was not present in 59 (37.8%) of plasma samples compared to whole blood-positive counterparts. Of the samples positive in both types of clinical specimen, 77 (79.4%) had higher viral DNA levels in the whole blood samples. There were statistically significant differences in the detected CMV DNA load in the whole blood compared to plasma fraction counterparts (p < 0.001). The detected CMV DNA value is usually higher in whole blood compared to plasma samples of the same patient. Due to the variability in CMV viral load depending on the clinical material used for a particular patient, one type of specimen should be always used consequently for CMV viremia monitoring.
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24
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Choi HI, Kang DY, Kim MS, Lee SE, Ahn JM, Lee JY, Kim YH, Park DW, Jung SH, Kim JJ. Long-term efficacy of everolimus as de novo immunosuppressant on the cardiac allograft vasculopathy in heart transplant recipients. Atherosclerosis 2022; 357:1-8. [PMID: 35981436 DOI: 10.1016/j.atherosclerosis.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/14/2022] [Accepted: 08/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Data on the long-term effects of everolimus (EVL) on the de novo immunosuppression of heart transplant (HT) recipients with progressive cardiac allograft vasculopathy (CAV) and vascular remodeling are lacking. Hence, in this study, we aimed to determine the long-term safety and efficacy of EVL as a de novo immunosuppressant therapy for CAV progression and the clinical outcomes after HT. METHODS We retrospectively reviewed the medical records of 144 HT recipients who survived for at least one year after HT. CAV progression was assessed via serial coronary intravascular ultrasonography (IVUS) in recipients who underwent at least two IVUS studies. RESULTS A significant attenuation in the percentage of the atheroma volume progression was observed in those who took EVL (1.2%) compared with those who took cyclosporin (CSA; 7.3%; p = 0.005 vs. EVL) or tacrolimus (TAC; 6.6%; p = 0.0052 vs. EVL) at 1 year after HT. This trend persisted for the next 3 and 5 years after HT. Moreover, the remodeling index was greater in the EVL (1.08) group than in the CSA (0.23) or TAC (-0.25) groups 1 year after HT. The results of the Kaplan-Meier analysis over a median follow-up period of 8 years revealed that there was no statistical difference in the primary endpoint between the three groups. CONCLUSIONS De novo immunosuppression with EVL is associated with attenuated CAV progression for the first 5 years of follow-up via IVUS. Moreover, EVL has comparable long-term clinical outcomes to those of CSA- or TAC-based protocols.
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Affiliation(s)
- Hyo-In Choi
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul, 03181, South Korea
| | - Do-Yoon Kang
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Min-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Sang Eun Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Jung-Min Ahn
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Jong-Young Lee
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul, 03181, South Korea
| | - Yong-Hak Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Duk-Woo Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea
| | - Jae-Joong Kim
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 05505, South Korea.
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25
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Nakamura MR, Requião-Moura LR, Gallo RM, Botelho C, Taddeo J, Viana LA, Felipe CR, Medina-Pestana J, Tedesco-Silva H. Transition from antigenemia to quantitative nucleic acid amplification testing in cytomegalovirus-seropositive kidney transplant recipients receiving preemptive therapy for cytomegalovirus infection. Sci Rep 2022; 12:12783. [PMID: 35896770 PMCID: PMC9329426 DOI: 10.1038/s41598-022-16847-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 07/18/2022] [Indexed: 11/09/2022] Open
Abstract
Due to the high costs, the strategy to reduce the impact of cytomegalovirus (CMV) after kidney transplant (KT) involves preemptive treatment in low and middle-income countries. Thus, this retrospective cohort study compared the performance of antigenemia transitioned to quantitative nucleic acid amplification testing, RT-PCR, in CMV-seropositive KT recipients receiving preemptive treatment as a strategy to prevent CMV infection. Between 2016 and 2018, 363 patients were enrolled and received preemptive treatment based on antigenemia (n = 177) or RT-PCR (n = 186). The primary outcome was CMV disease. Secondarily, the CMV-related events were composed of CMV-infection and disease, which occurred first. There were no differences in 1-year cumulative incidence of CMV-disease (23.7% vs. 19.1%, p = 0.41), CMV-related events (50.8% vs. 44.1%, p = 0.20), neither in time to diagnosis (47.0 vs. 47.0 days) among patients conducted by antigenemia vs. RT-PCR, respectively. The length of CMV first treatment was longer with RT-PCR (20.0 vs. 27.5 days, p < 0.001), while the rate of retreatment was not different (14.7% vs. 11.8%, p = 0.48). In the Cox regression, acute rejection within 30 days was associated with an increased the risk (HR = 2.34; 95% CI = 1.12-4.89; p = 0.024), while each increase of 1 mL/min/1.73 m2 of 30-day eGFR was associated with a 2% reduction risk of CMV-disease (HR = 0.98; 95% CI = 0.97-0.99; p = 0.001). In conclusion, acute rejection and glomerular filtration rate are risk factors for CMV disease, showing comparable performance in the impact of CMV-related events between antigenemia and RT-PCR for preemptive treatment.
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Affiliation(s)
- Mônica Rika Nakamura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil.,Nephrology Division, Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Lúcio R Requião-Moura
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil. .,Nephrology Division, Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil.
| | | | - Camila Botelho
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
| | - Júlia Taddeo
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil
| | | | - Cláudia Rosso Felipe
- Nephrology Division, Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - José Medina-Pestana
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil.,Nephrology Division, Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Hélio Tedesco-Silva
- Hospital do Rim, Fundação Oswaldo Ramos, São Paulo, Brazil.,Nephrology Division, Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
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26
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De-novo CMV infection manifesting as interstitial nephritis in a high-risk kidney recipient with concurrent urologic complications: lessons for the clinical nephrologist. J Nephrol 2022; 35:1923-1926. [PMID: 35749007 DOI: 10.1007/s40620-022-01373-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 10/17/2022]
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27
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Teschner D, Knop J, Piehl C, Junker S, Witzke O. Cytomegalovirus infection and rehospitalization rates after allogeneic hematopoietic stem cell and solid organ transplantation: a retrospective cohort study using German claims data. Infection 2022; 50:1543-1555. [PMID: 35633464 PMCID: PMC9705421 DOI: 10.1007/s15010-022-01847-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/03/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aimed to describe the cytomegalovirus (CMV) infection rate, rehospitalizations, and comorbidities following allogeneic hematopoietic stem cell transplantation (allo-HSCT) and solid organ transplantation (SOT). METHODS Patients who received allo-HSCT or SOT in 01/07/2015-30/06/2018 were identified using anonymized German claims data. The transplantation-related hospital admission date was defined as the index date, and patients were followed for up to 12 months (or death, first event relevant). The frequency of CMV infections (confirmed outpatient/inpatient diagnoses, ICD-10-GM codes: B25.-/B27.1) and the rate, number, and duration of all-cause rehospitalizations in the follow-up period were evaluated. RESULTS A total of 226 allo-HSCT and 250 SOT patients were identified (mean age 52.8 years, 38.9% female). During the 12 months after transplantation, 29.2% of allo-HSCT patients and 16.8% of SOT patients received a CMV diagnosis. The majority of these diagnoses were given during the initial hospitalization or within the following 3 months. Across transplantation types, CMV patients had more hospital readmission days per patient-year (allo-HSCT 93.3 vs. 49.4, p = 0.001; SOT 42.0 vs. 20.7, p = 0.005), with a longer mean duration of readmissions (allo-HSCT 22.4 vs. 15.4 days, p < 0.001; SOT 11.6 vs. 7.5 days, p = 0.003). Comorbidity burden in transplantation patients was substantial, with several diagnoses being significantly more common among patients with CMV vs. non-CMV. One-year mortality did not differ significantly between patients with/without CMV. CONCLUSION Burden of transplant recipients with CMV in terms of rehospitalizations and comorbidities is substantial, highlighting the need for improved CMV prevention and treatment.
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Affiliation(s)
- Daniel Teschner
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany.,Department of Hematology, Medical Oncology, and Pneumology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jana Knop
- Takeda Pharma Vertrieb GmbH & Co. KG, Berlin, Germany
| | | | - Sophia Junker
- Ingress-Health HWM GmbH, A Wholly Owned Subsidiary of Cytel Inc., Berlin, Germany.
| | - Oliver Witzke
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, Essen, Germany.,University Duisburg-Essen, Duisburg, Germany
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28
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Sommerer C, Schröter I, Gruneberg K, Schindler D, Behnisch R, Morath C, Renders L, Heemann U, Schnitzler P, Melk A, Della Penna A, Nadalin S, Heeg K, Meuer S, Zeier M, Giese T. Incidences of infectious events in a renal transplant cohort of the German Center of Infectious Diseases (DZIF). Open Forum Infect Dis 2022; 9:ofac243. [PMID: 35855001 PMCID: PMC9280327 DOI: 10.1093/ofid/ofac243] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/11/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Infectious complications are a major cause of morbidity and mortality after kidney transplantation.
Methods
In this transplant cohort study at the German Center of Infectious Diseases (DZIF), we evaluated all infections occurring during the first year after renal transplantation. We assessed microbial etiology, incidence rates, and temporal occurrence of these infections.
Results
Of 804 renal transplant recipients (65.2% male, 51 ± 14 years), 439 (54.6%) had 972 infections within the first year after transplantation. Almost half of these infections (47.8%) occurred within the first three months. Bacteria were responsible for 66.4% (645/972) of all infections, followed by viral (28.9%[281/972]) and fungal (4.7%[46/972]) pathogens. The urinary tract was the most common site of infection (42.4%). Enterococcus was most frequently isolated bacteria (20.9%), followed by E.coli (17.6%) and Klebsiella (12.5%). E.coli was the leading pathogen in recipients <50 years of age, whereas Enterococcus predominated in older recipients. Resistant bacteria were responsible for at least one infection in 9.5% (76/804) of all recipients. Viral infections occurred in 201 recipients (25.0%). Of these, herpes viruses predominated (140/281[49.8%]) and cytomegalovirus had the highest incidence rate (12.3%). In the 46 fungal infections, Candida albicans (40.8%) was most commonly isolated. Other fungal opportunistic pathogens, including Aspergillus fumigatus and Pneumocystis, were rare.
Conclusions
Renal allograft recipients in Germany experience a high burden of infectious complications in the first year after transplantation. Bacteria were the predominating pathogen, followed by opportunistic infections such as cytomegalovirus. Microbial etiology varied between age groups and resistant bacteria were identified in 10% of recipients.
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Affiliation(s)
- Claudia Sommerer
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Iris Schröter
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Katrin Gruneberg
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Daniela Schindler
- Department of Nephrology, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Rouven Behnisch
- Institute of Medical Biometry, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Morath
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar of the Technical University Munich, Munich, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Andrea Della Penna
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Klaus Heeg
- Department of Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Stefan Meuer
- Department of Immunology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Martin Zeier
- Nephrology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
| | - Thomas Giese
- Department of Immunology, University Hospital Heidelberg, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Germany
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29
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Levi S, Davidovits M, Alfandari H, Dagan A, Borovitz Y, Bilavsky E, Landau D, Haskin O. EBV, CMV, and BK viral infections in pediatric kidney transplantation: Frequency, risk factors, treatment, and outcomes. Pediatr Transplant 2022; 26:e14199. [PMID: 34817112 DOI: 10.1111/petr.14199] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/26/2021] [Accepted: 11/06/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Improved short- and long-term outcomes of kidney transplantation have been achieved over the past decades due to improved immunosuppression. This may have increased the risk for infections and, particularly, for the viral infections: cytomegalovirus (CMV), Epstein-Barr virus (EBV), and polyoma BK virus (BKV). METHODS A retrospective review of viremic CMV, EBV, and BKV infections in pediatric renal transplant recipients treated and followed by a national referral center over a 10-year period. RESULTS Sixty-seven patients (68% males) received 68 kidney grafts (62% from living donors) during the study period; the mean follow-up period was 5.2 ± 2.4 years. Twenty-seven viremic episodes were documented (CMV: 13, EBV: 6, BKV: 8) in 24 patients (35.2%). The median time (interquartile range) to viremia post-transplant was 11 (4-38) months. The viral infection rate was significantly higher in the years 2014-2015 than in previous years (61% vs. 29%, p = .017). Compared to patients who did not develop viremia, patients with viremias were younger at the time of transplantation, were more likely to receive thymoglobulin induction pre-transplant and to develop an acute rejection. Multiple logistic regression modeling identified transplant year and recipient's age as significant risk factors for viremia. Graft outcome and eGFR at the last follow-up was similar between patients who did and did not develop viremia. CONCLUSIONS Viral infections continue to be a major cause of morbidity in pediatric kidney transplant recipients. However, with close monitoring and prompt intervention, patient and renal outcomes remain favorable.
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Affiliation(s)
- Shelly Levi
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Miriam Davidovits
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadas Alfandari
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Dagan
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Borovitz
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efraim Bilavsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pediatrics C, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Daniel Landau
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Haskin
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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30
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Rabbani N, Kronmal RA, Wagner T, Kemna M, Albers EL, Hong B, Friedland-Little J, Spencer K, Law YM. Association Between Cytomegalovirus Serostatus, Antiviral Therapy, and Allograft Survival in Pediatric Heart Transplantation. Transpl Int 2022; 35:10121. [PMID: 35368645 PMCID: PMC8964945 DOI: 10.3389/ti.2022.10121] [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] [Received: 10/18/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
Background: Cytomegalovirus (CMV) is an important complication of heart transplantation and has been associated with graft loss in adults. The data in pediatric transplantation, however, is limited and conflicting. We conducted a large-scale cohort study to better characterize the relationship between CMV serostatus, CMV antiviral use, and graft survival in pediatric heart transplantation. Methods: 4,968 pediatric recipients of solitary heart transplants from the Scientific Registry of Transplant Recipients were stratified into three groups based on donor or recipient seropositivity and antiviral use: CMV seronegative (CMV-) transplants, CMV seropositive (CMV+) transplants without antiviral therapy, and CMV+ transplants with antiviral therapy. The primary endpoint was retransplantation or death. Results: CMV+ transplants without antiviral therapy experienced worse graft survival than CMV+ transplants with antiviral therapy (10-year: 57 vs 65%). CMV+ transplants with antiviral therapy experienced similar survival as CMV- transplants. Compared to CMV seronegativity, CMV seropositivity without antiviral therapy had a hazard ratio of 1.21 (1.07–1.37 95% CI, p-value = .003). Amongst CMV+ transplants, antiviral therapy had a hazard ratio of .82 (0.74–.92 95% CI, p-value < .001). During the first year after transplantation, these hazard ratios were 1.32 (1.06–1.64 95% CI, p-value .014) and .59 (.48–.73 95% CI, p-value < .001), respectively. Conclusions: CMV seropositivity is associated with an increased risk of graft loss in pediatric heart transplant recipients, which occurs early after transplantation and may be mitigated by antiviral therapy.
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Affiliation(s)
- Naveed Rabbani
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | - Richard A Kronmal
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Thor Wagner
- Division of Pediatric Infectious Diseases, Seattle Children's Hospital, Seattle, WA, United States
| | - Mariska Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | - Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | - Borah Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | | | - Kathryn Spencer
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, United States
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31
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Fernández-García OA, García-Juárez I, Belaunzarán-Zamudio PF, Vilatoba M, Wisniowski-Yáñez A, Salomón-Ávila J, Bobadilla-Del-Valle M, Sifuentes-Osornio J, Cuellar-Rodríguez JM. Incidence of Cytomegalovirus disease and viral replication kinetics in seropositive liver transplant recipients managed under preemptive therapy in a tertiary-care center in Mexico City: a retrospective cohort study. BMC Infect Dis 2022; 22:155. [PMID: 35164684 PMCID: PMC8845382 DOI: 10.1186/s12879-022-07123-w] [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] [Received: 08/26/2021] [Accepted: 01/31/2022] [Indexed: 11/30/2022] Open
Abstract
Background In the absence of an adequate prevention strategy, up to 20% of CMV IgG+ liver transplant recipients (LTR) will develop CMV disease. Despite improved reporting in CMV-DNAemia, there is no consensus as to what the ideal CMV-DNAemia cutoff for a successful preemptive strategy is. Each transplant centre establishes their own threshold. We aimed to determine the effectiveness of our preventive strategy in CMV IgG+ LTR, and evaluate CMV replication kinetics. Methods In this retrospective study we determined the incidence of CMV disease in the first 6 months following transplantation in CMV seropositive LTR in a tertiary-care centre in Mexico. Secondary outcomes were determining the number of patients who required preemptive therapy (treatment cutoff ≥ 4000 UI/ml), adherence to the centre’s prevention protocol and calculation of viral replication kinetics. Results One-hundred and twenty-four patients met inclusion criteria. Four patients (3.2%) developed CMV disease. Ninety-six (85%) had detectable DNAemia and 25 (22%) asymptomatic patients received preemptive therapy, none of them developed CMV disease. The highest viral loads were observed on the second posttransplant month. The number of viral load measurements decreased over time. Patients with DNAemia ≥ 4000 UI/ml had a faster viral load growth rate, shorter viral load duplication time, and higher basic reproductive number. Viral load growth rate and autoimmune hepatitis were associated with development of DNAemia ≥ 4000 UI/ml. Conclusion Cytomegalovirus disease occurred in 3.2% of the study subjects. Preemptive therapy using a threshold of CMV ≥ 4000 UI/ml was effective in reducing the incidence of end-organ disease. The viral replication parameters described in this population highlight the importance of frequent monitoring, a challenging feat for transplant programs in low- and middle-income countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07123-w.
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Affiliation(s)
- Oscar A Fernández-García
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Ignacio García-Juárez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Pablo Francisco Belaunzarán-Zamudio
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Mario Vilatoba
- Transplant Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Andrea Wisniowski-Yáñez
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Jacobo Salomón-Ávila
- Independient Researcher, Teresa 703, Jardines del Santuario, 31206, Chihuahua, Mexico
| | - Miriam Bobadilla-Del-Valle
- Clinical Microbiology Laboratory, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - José Sifuentes-Osornio
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Jennifer M Cuellar-Rodríguez
- Infectious Diseases Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico.
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32
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Munting A, Manuel O. Viral infections in lung transplantation. J Thorac Dis 2022; 13:6673-6694. [PMID: 34992844 PMCID: PMC8662465 DOI: 10.21037/jtd-2021-24] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/21/2021] [Indexed: 12/15/2022]
Abstract
Viral infections account for up to 30% of all infectious complications in lung transplant recipients, remaining a significant cause of morbidity and even mortality. Impact of viral infections is not only due to the direct effects of viral replication, but also to immunologically-mediated lung injury that may lead to acute rejection and chronic lung allograft dysfunction. This has particularly been seen in infections caused by herpesviruses and respiratory viruses. The implementation of universal preventive measures against cytomegalovirus (CMV) and influenza (by means of antiviral prophylaxis and vaccination, respectively) and administration of early antiviral treatment have reduced the burden of these diseases and potentially their role in affecting allograft outcomes. New antivirals against CMV for prophylaxis and for treatment of antiviral-resistant CMV infection are currently being evaluated in transplant recipients, and may continue to improve the management of CMV in lung transplant recipients. However, new therapeutic and preventive strategies are highly needed for other viruses such as respiratory syncytial virus (RSV) or parainfluenza virus (PIV), including new antivirals and vaccines. This is particularly important in the advent of the COVID-19 pandemic, for which several unanswered questions remain, in particular on the best antiviral and immunomodulatory regimen for decreasing mortality specifically in lung transplant recipients. In conclusion, the appropriate management of viral complications after transplantation remain an essential step to continue improving survival and quality of life of lung transplant recipients.
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Affiliation(s)
- Aline Munting
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Oriol Manuel
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland.,Transplantation Center, Lausanne University Hospital, Lausanne, Switzerland
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33
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Madden I, Baudouin V, Charbit M, Ranchin B, Roussey G, Novo R, Garaix F, Decramer S, Fila M, Merieau E, Vrillon I, Zaloszyc A, Hogan J, Harambat J. National survey of prevention and management of CMV infection in pediatric kidney transplantation in comparison to clinical practice guidelines. Front Pediatr 2022; 10:1057352. [PMID: 36589153 PMCID: PMC9800817 DOI: 10.3389/fped.2022.1057352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) is one of the most frequent opportunistic infections in kidney transplant (KT) recipients and is a risk factor for patient and graft survival after KT. Center-to-center variation, optimal prevention and treatment strategies in pediatric KT are currently unknown. This survey aimed to assess current CMV prevention and treatment strategies used among French pediatric KT centers. METHODS A web-based survey was sent to all 13 French pediatric kidney transplantation centers. RESULTS Twelve (92%) centers responded to the survey. All centers used prophylaxis for the donor-positive/recipient-negative (D+/R-) group. For R + patients, 54% used prophylaxis, 37% used a pre-emptive strategy. In the low-risk group, D-/R-, 50% used a pre-emptive approach and 50% had no specific prevention strategy. The antiviral used by all centers for prophylaxis was valganciclovir (VGCV). The duration of prophylaxis varied from 3 to 7 months and the duration of viral load monitoring varied from 6 months to indefinitely. No center used a hybrid/sequential approach. For the treatment of CMV DNAemia, VGCV or intravenous GCV were used. Therapeutic drug monitoring of VGCV was performed in 5 centers (42%). Five centers reported drug resistance. Eight centers (67%) administered VGCV during the treatment of acute graft rejection. CONCLUSIONS There is uniformity in CMV management in some areas among pediatric KT centers in France but not in others which remain diverse and are not up to date with current guidelines, suggesting unnecessary variation which could be reduced with better evidence to inform practice.
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Affiliation(s)
- Iona Madden
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | | | - Marina Charbit
- Pediatric Nephrology Unit, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - Bruno Ranchin
- Pediatric Nephrology Unit, Hospices Civils de Lyon, Lyon, France
| | - Gwenaëlle Roussey
- Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
| | - Robert Novo
- Pediatric Nephrology Unit, Lille University Hospital, Lille, France
| | - Florentine Garaix
- Pediatric Nephrology Unit, AP-Hôpitaux de Marseille, Marseille, France
| | - Stéphane Decramer
- Pediatric Nephrology Unit, Toulouse University Hospital, Toulouse, France
| | - Marc Fila
- Pediatric Nephrology Unit, Montpellier University Hospital, Montpellier, France
| | - Elodie Merieau
- Pediatric Nephrology Unit, Tours University Hospital, Tours, France
| | - Isabelle Vrillon
- Pediatric Nephrology Unit, Nancy University Hospital, Nancy, France
| | - Ariane Zaloszyc
- Pediatric Nephrology Unit, Strasbourg University Hospital, Strasbourg, France
| | - Julien Hogan
- Pediatric Nephrology Unit, Robert Debré Hospital, APHP, Paris, France
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
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34
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Cheng WY, Avery RK, Thompson-Leduc P, Cheung HC, Bo T, Duh MS, Hirji I. Evaluation of treatment patterns, healthcare resource utilization, and costs among patients receiving treatment for cytomegalovirus following allogeneic hematopoietic cell or solid organ transplantation. J Med Econ 2022; 25:367-380. [PMID: 35240904 DOI: 10.1080/13696998.2022.2046388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM Management of cytomegalovirus (CMV) infection/disease in transplant recipients may be complicated by toxicities and resistance to conventional antivirals, adding to the overall healthcare burden. We characterized treatment patterns, healthcare resource utilization (HCRU), and costs to elucidate the healthcare burden associated with CMV therapies post-transplant. MATERIALS AND METHODS A retrospective, longitudinal cohort study of transplant recipients using data from a US commercial insurance claims database (2013-2017) was conducted. Patients with a claim for post-transplant CMV diagnosis and anti-CMV treatment (ganciclovir, valganciclovir, foscarnet, or cidofovir) were identified (Treated CMV cohort) and compared with patients with neither a claim for CMV diagnosis nor anti-CMV treatment (No CMV cohort) for outcomes including HCRU and associated costs. Allogeneic hematopoietic cell transplantation (HCT) or solid organ transplantation (SOT) recipients were analyzed separately. Anti-CMV treatment patterns were assessed in the Treated CMV cohort. Costs were evaluated among subgroups with myelosuppression or nephrotoxicity. RESULTS Overall, 412 allogeneic HCT and 899 SOT patients were included in the Treated CMV cohorts, of which 41.7% and 52.5%, respectively, received multiple antiviral courses. Treated CMV cohorts compared with No CMV cohorts had higher mean monthly healthcare visits per patient (allogeneic HCT: 8.83 vs 6.61, SOT: 5.61 vs 4.45) and had an incremental adjusted mean monthly cost per patient differences of $8,157 (allogeneic HCT, p < .004) and $2,182 (SOT, p < .004). Among Treated CMV cohorts, HCRU and costs increased with additional CMV antiviral treatment courses. Mean monthly costs were higher for patients with than without myelosuppression or nephrotoxicity. LIMITATIONS Results may not be generalizable to patients covered by government insurance or outside the USA. CONCLUSIONS CMV post-transplant managed with conventional treatment is associated with substantial HCRU and costs. The burden remains particularly high for patients requiring multiple treatment courses for post-transplant CMV or for transplant recipients who develop myelosuppression or nephrotoxicity.
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Affiliation(s)
- Wendy Y Cheng
- Health Economics and Outcomes Research, Analysis Group, Inc, Boston, MA, USA
| | - Robin K Avery
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA
| | | | - Hoi Ching Cheung
- Health Economics and Outcomes Research, Analysis Group, Inc, Boston, MA, USA
| | - Tien Bo
- Medical Affairs, Takeda Development Center Americas, Inc, Lexington, MA, USA
| | - Mei Sheng Duh
- Health Economics and Outcomes Research, Analysis Group, Inc, Boston, MA, USA
| | - Ishan Hirji
- Global Evidence & Outcomes, Takeda Development Center Americas, Inc, Lexington, MA, USA
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35
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Saullo JL, Baker AW, Snyder LD, Reynolds JM, Zaffiri L, Eichenberger EM, Ferrari A, Steinbrink JM, Maziarz EK, Bacchus M, Berry H, Kakoullis SA, Wolfe CR. Cytomegalovirus prevention in thoracic organ transplantation: A single-center evaluation of letermovir prophylaxis. J Heart Lung Transplant 2021; 41:508-515. [PMID: 35031206 PMCID: PMC9121640 DOI: 10.1016/j.healun.2021.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/23/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is common following thoracic organ transplantation and causes substantial morbidity and mortality. Letermovir is a novel antiviral agent used off-label in this population for CMV prevention. Our goal was to understand patterns of letermovir use and effectiveness when applied for CMV prophylaxis after thoracic transplantation. METHODS We retrospectively evaluated letermovir use among thoracic transplant recipients at an academic transplant center who initiated letermovir from January 2018 to October2019 for CMV prophylaxis. We analyzed indication, timing, and duration of prophylaxis; tolerability; and occurrence of breakthrough CMV DNAemia and disease. RESULTS Forty-two episodes of letermovir prophylaxis occurred in 41 patients, including 37 lung and 4 heart transplant recipients. Primary prophylaxis (26/42, 61.9%) was utilized mainly due to myelosuppression (25/26, 96.2%) and was initiated a median of 315 days post-transplant (interquartile range [IQR] 125-1139 days). Sixteen episodes of secondary prophylaxis (16/42, 38.1%) were initiated a median of 695 days post-transplant (IQR 537-1156 days) due to myelosuppression (10/16, 62.5%) or prior CMV resistance (6/16, 37.5%). Median duration of letermovir prophylaxis was 282 days (IQR 131-433 days). Adverse effects required letermovir cessation in 5/42 (11.9%) episodes. Only one episode (2.4%) was complicated by clinically significant breakthrough CMV infection. Transient low-level CMV DNAemia (<450 IU/ml) occurred in 15 episodes (35.7%) but did not require letermovir cessation. CONCLUSIONS Letermovir was well tolerated and effective during extended prophylactic courses with only one case of breakthrough CMV infection in this cohort of thoracic transplant recipients. Further prospective trials of letermovir prophylaxis in this population are warranted.
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Affiliation(s)
- Jennifer L Saullo
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina.
| | - Arthur W Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Laurie D Snyder
- Division of Pulmonary, Allergy and Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - John M Reynolds
- Division of Pulmonary, Allergy and Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Lorenzo Zaffiri
- Division of Pulmonary, Allergy and Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Emily M Eichenberger
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Alana Ferrari
- Department of Pharmacy, University of Virginia Medical Center, Charlottesville, Virginia
| | - Julie M Steinbrink
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Eileen K Maziarz
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Melissa Bacchus
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Holly Berry
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina
| | - Stylianos A Kakoullis
- Division of Pulmonary and Intensive Care Medicine, European University of Cyprus School of Medicine, Engomi, Nicosia Cyprus
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
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Stampf S, Mueller NJ, van Delden C, Pascual M, Manuel O, Banz V, Binet I, De Geest S, Bochud PY, Leichtle A, Schaub S, Steiger J, Koller M. Cohort profile: The Swiss Transplant Cohort Study (STCS): A nationwide longitudinal cohort study of all solid organ recipients in Switzerland. BMJ Open 2021; 11:e051176. [PMID: 34911712 PMCID: PMC8679072 DOI: 10.1136/bmjopen-2021-051176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE The Swiss Transplant Cohort Study (STCS) is a prospective multicentre cohort study which started to actively enrol study participants in May 2008. It takes advantage of combining data from all transplant programmes in one unique system to perform comprehensive nationwide reporting and to promote translational and clinical post-transplant outcome research in the framework of Swiss transplantation medicine. PARTICIPANTS Over 5500 solid organ transplant recipients have been enrolled in all six Swiss transplant centres by end of 2019, around three-quarter of them for kidney and liver transplants. Ninety-three per cent of all transplanted recipients have consented to study participation, almost all of them (99%) contributed to bio-sampling. The STCS genomic data set includes around 3000 patients. FINDINGS TO DATE Detailed clinical and laboratory data in high granularity as well as patient-reported outcomes from transplant recipients and activities in Switzerland are available in the last decade. Interdisciplinary contributions in diverse fields of transplantation medicine such as infectious diseases, genomics, oncology, immunology and psychosocial science have resulted in approximately 70 scientific papers getting published in peer-review journals so far. FUTURE PLANS The STCS will deepen its efforts in personalised medicine and digital epidemiology, and will also focus on allocation research and the use of causal inference methods to make complex matters in transplant medicine more understandable and transparent.
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Affiliation(s)
- Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Christian van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Manuel Pascual
- Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Oriol Manuel
- Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Service of Infectious Diseases, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vanessa Banz
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital Bern and Bern University, Bern, Switzerland
| | - Isabelle Binet
- Nephrology and Transplantation Medicine, Kantonsspital St Gallen, Sankt Gallen, Switzerland
| | - Sabina De Geest
- Department of Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Pierre-Yves Bochud
- Service of Infectious Diseases, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexander Leichtle
- Center for Laboratory Medicine, University Institute of Clinical Chemistry, Inselspital University Hospital Bern, Bern, Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Jürg Steiger
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Michael Koller
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
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37
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Ahn R, Schaenman J, Qian Z, Pickering H, Groysberg V, Rossetti M, Llamas M, Hoffmann A, Gjertson D, Deng M, Bunnapradist S, Reed EF. Acute and Chronic Changes in Gene Expression After CMV DNAemia in Kidney Transplant Recipients. Front Immunol 2021; 12:750659. [PMID: 34867983 PMCID: PMC8634678 DOI: 10.3389/fimmu.2021.750659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022] Open
Abstract
Cytomegalovirus (CMV) viremia continues to cause significant morbidity and mortality in kidney transplant patients with clinical complications including organ rejection and death. Whole blood gene expression dynamics in CMV viremic patients from onset of DNAemia through convalescence has not been well studied to date in humans. To evaluate how CMV infection impacts whole blood leukocyte gene expression over time, we evaluated a matched cohort of 62 kidney transplant recipients with and without CMV DNAemia using blood samples collected at multiple time points during the 12-month period after transplant. While transcriptomic differences were minimal at baseline between DNAemic and non-DNAemic patients, hundreds of genes were differentially expressed at the long-term timepoint, including genes enriching for pathways important for macrophages, interferon, and IL-8 signaling. Amongst patients with CMV DNAemia, the greatest amount of transcriptomic change occurred between baseline and 1-week post-DNAemia, with increase in pathways for interferon signaling and cytotoxic T cell function. Time-course gene set analysis of these differentially expressed genes revealed that most of the enriched pathways had a significant time-trend. While many pathways that were significantly down- or upregulated at 1 week returned to baseline-like levels, we noted that several pathways important in adaptive and innate cell function remained upregulated at the long-term timepoint after resolution of CMV DNAemia. Differential expression analysis and time-course gene set analysis revealed the dynamics of genes and pathways involved in the immune response to CMV DNAemia in kidney transplant patients. Understanding transcriptional changes caused by CMV DNAemia may identify the mechanism behind patient vulnerability to CMV reactivation and increased risk of rejection in transplant recipients and suggest protective strategies to counter the negative immunologic impact of CMV. These findings provide a framework to identify immune correlates for risk assessment and guiding need for extending antiviral prophylaxis.
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Affiliation(s)
- Richard Ahn
- Department of Microbiology, Immunology, and Molecular Genetics, University of California Los Angeles, Los Angeles, CA, United States.,Institute for Quantitative and Computational Biosciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Joanna Schaenman
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Zachary Qian
- Department of Microbiology, Immunology, and Molecular Genetics, University of California Los Angeles, Los Angeles, CA, United States.,Institute for Quantitative and Computational Biosciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Harry Pickering
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Victoria Groysberg
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Maura Rossetti
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Megan Llamas
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Alexander Hoffmann
- Department of Microbiology, Immunology, and Molecular Genetics, University of California Los Angeles, Los Angeles, CA, United States.,Institute for Quantitative and Computational Biosciences, University of California Los Angeles, Los Angeles, CA, United States
| | - David Gjertson
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States.,Department of Biostatistics, University of California Los Angeles, Los Angeles, CA, United States
| | - Mario Deng
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Suphamai Bunnapradist
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Elaine F Reed
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, United States
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38
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Requião-Moura LR. Local evidence on the cytomegalovirus viral load threshold for preemptive treatment is welcome, and a comment on indirect effects. J Bras Nefrol 2021; 43:457-459. [PMID: 34747434 PMCID: PMC8940103 DOI: 10.1590/2175-8239-jbn-2021-e009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Lúcio R Requião-Moura
- Universidade Federal de São Paulo, Departamento de Medicina, Disciplina de Nefrologia, São Paulo, SP, Brasil.,Hospital Israelita Albert Einstein, Unidade de Transplante Renal, São Paulo, SP, Brasil
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39
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Charlotte R, François P, Jonathan M, Véronique B, Olivier B, Tristan D, Séverine F, Jérôme L, Adrien T, Claire D, Espérie B, Eve C, Antoine R. Use of anti-CMV immunoglobulins in lung transplant recipients: The French experience. Transpl Infect Dis 2021; 23:e13754. [PMID: 34723405 DOI: 10.1111/tid.13754] [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: 12/02/2020] [Revised: 09/28/2021] [Accepted: 10/11/2021] [Indexed: 02/05/2023]
Abstract
RATIONAL Pending the authorization of new anti-CMV drugs with fewer adverse effects, exploring the possibilities offered by CMV immunoglobulins (CMVIG) seems necessary. In France, access to CMVIG requires official authorization by the national Health authority and is restricted to second line rescue therapy for CMV infection/disease. The aim of this multicenter retrospective study is to describe the indications and clinical situations that justified its use in France. METHODS A multicenter retrospective study included 22 lung transplant patients over a 3-year period. Data on clinical indication, tolerance and efficacy were collected. RESULTS The main indication for CMVIG initiation, which was documented in 17 of them (82%) was complex clinical situations resulting from side effects to antiviral drug. CMVIG indication was documented as treatment for 15 patients (68%) and as a secondary prophylaxis for 7 patients (32%). Only one side effect (pruritus during infusion with no anaphylactic symptoms) attributable to CMVIG was reported. After CMVIG initiation, no recurrence of infection or disease was observed during a median follow-up of 174 (12-682) days after treatment initiation for respectively 68% and 66% of the patients. CONCLUSION This study describes an unusual indication of CMVIG use as a last resort treatment in complex situations, based on clinical needs. CMVIG could be useful to change the course of CMV infection with minimal adverse effects or comorbidity.
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Affiliation(s)
- Roy Charlotte
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | | | - Messika Jonathan
- Pulmonology Department and Lung Transplant Centre, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Boussaud Véronique
- Pulmonology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Brugière Olivier
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Degot Tristan
- Department of Respiratory Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Feuillet Séverine
- Department of Cardio-Thoracic Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Lepavec Jérôme
- Department of Cardio-Thoracic Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Tissot Adrien
- Pulmonology Department, Institut du Thorax, Nantes University Hospital, Nantes, France
| | - Dromer Claire
- Pulmonology Department, Bordeaux University Hospital, Bordeaux, France
| | - Burnet Espérie
- Pulmonology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Camps Eve
- Pharmacy Department, Foch Hospital, Suresnes, France
| | - Roux Antoine
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, Suresnes, France.,Versailles-Saint-Quentin-en-Yvelines University, Versailles, France
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Lodding IP, Jørgensen M, Bennedbæk M, Kirkby N, Naegele K, Gustafsson F, Perch M, Rasmussen A, Sengeløv H, Sørensen SS, Hirsch HH, Lundgren JD. Development and Dynamics of Cytomegalovirus UL97 Ganciclovir Resistance Mutations in Transplant Recipients Detected by Next-Generation Sequencing. Open Forum Infect Dis 2021; 8:ofab462. [PMID: 34660835 PMCID: PMC8514173 DOI: 10.1093/ofid/ofab462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background (Val)ganciclovir resistance mutations in CMV UL97 (UL97-GCV-R) complicate anti-CMV therapy in recipients of solid organ and hematopoietic stem cell transplants, but comprehensive data on prevalence, emergence, and outcome are scarce. Methods Using next-generation sequencing (NGS; Illumina MiSeq platform), we analyzed UL97-GCV-R in patients with available plasma samples and refractory CMV replication/DNAemia (n = 87) containing viral loads ≥910 IU/mL. Twenty-one patients with CMV DNAemia resolving under antiviral therapy were analyzed as controls. Detected mutations were considered induced and of potential clinical significance if they increased by ≥10% compared with the first detected frequency or if they had a maximum frequency ≥25%. Results Nineteen of 87 (21.8%) with refractory CMV replication had ≥1 UL97-GCV-R detected by NGS, in comparison to 0/21 of the controls (P = .02). One-third of the recipients had 2 or more induced UL97-GCV-R mutations. The most frequently induced mutations affected codons 595 (42% [8/19]), 594 (32% [6/19]), and 603 (32% [6/19]). C592G was present in all episodes of both cases and controls at frequencies <15%, but never induced. UL97-GCV-R tended to be more frequent in donor/recipient CMV immunoglobulin G mismatch or following failure to complete primary prophylaxis, and many developed invasive CMV disease. Conclusions UL97-GCV-R is common among transplant patients with refractory CMV replication. Early testing by NGS allows for identification of major mutations at codons 595, 594, and 603 and excludes a major role of C592G in ganciclovir resistance. Large prospective studies on UL97-GCV-R are warranted.
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Affiliation(s)
- Isabelle P Lodding
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen, Denmark.,Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - Mette Jørgensen
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen, Denmark
| | - Marc Bennedbæk
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen, Denmark
| | - Nikolai Kirkby
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Klaudia Naegele
- Clinical Virology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland.,Transplantation & Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Abdominal Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Sengeløv
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - Søren S Sørensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Nephrology, Rigshospitalet, Copenhagen, Denmark
| | - Hans H Hirsch
- Clinical Virology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland.,Transplantation & Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Jens D Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Ataya M, Redondo-Pachón D, Llinàs-Mallol L, Yélamos J, Alari-Pahissa E, Pérez-Sáez MJ, Altadill M, Raïch-Regué D, Vilches C, Pascual J, Crespo M, López-Botet M. Long-Term Evolution of the Adaptive NKG2C + NK Cell Response to Cytomegalovirus Infection in Kidney Transplantation: An Insight on the Diversity of Host-Pathogen Interaction. THE JOURNAL OF IMMUNOLOGY 2021; 207:1882-1890. [PMID: 34470855 DOI: 10.4049/jimmunol.2100055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 08/01/2021] [Indexed: 11/19/2022]
Abstract
Human CMV infection is frequent in kidney transplant recipients (KTR). Pretransplant Ag-specific T cells and adaptive NKG2C+ NK cells associate with reduced incidence of infection in CMV+ KTR. Expansions of adaptive NKG2C+ NK cells were reported in posttransplant CMV-infected KTR. To further explore this issue, NKG2C+ NK, CD8+, and TcRγδ T cells were analyzed pretransplant and at different time points posttransplant for ≥24 mo in a cohort of CMV+ KTR (n = 112), stratified according to CMV viremia detection. In cryopreserved samples from a subgroup (n = 49), adaptive NKG2C+ NK cell markers and T cell subsets were compared after a longer follow-up (median, 56 mo), assessing the frequencies of CMV-specific T cells and viremia at the last time point. Increased proportions of NKG2C+ NK, CD8+, and TcRγδ T cells were detected along posttransplant evolution in viremia(+) KTR. However, the individual magnitude and kinetics of the NKG2C+ NK response was variable and only exceptionally detected among viremia(-) KTR, presumably reflecting subclinical viral replication events. NKG2C+ expansions were independent of KLRC2 zygosity and associated with higher viral loads at diagnosis; no relation with other clinical parameters was perceived. Increased proportions of adaptive NKG2C+ NK cells (CD57+, ILT2+, FcεRIγ-) were observed after resolution of viremia long-term posttransplant, coinciding with increased CD8+ and Vδ2- γδ T cells; at that stage CMV-specific T cells were comparable to viremia(-) cases. These data suggest that adaptive NKG2C+ NK cells participate with T cells to restore CMV replication control, although their relative contribution cannot be discerned.
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Affiliation(s)
| | - Dolores Redondo-Pachón
- Instituto Hospital del Mar de Investigaciones Médicas, Barcelona, Spain.,Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | | | - José Yélamos
- Instituto Hospital del Mar de Investigaciones Médicas, Barcelona, Spain.,Immunology Laboratory, Department of Pathology, Hospital del Mar, Barcelona, Spain; and
| | | | - María J Pérez-Sáez
- Instituto Hospital del Mar de Investigaciones Médicas, Barcelona, Spain.,Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | | | - Dàlia Raïch-Regué
- Instituto Hospital del Mar de Investigaciones Médicas, Barcelona, Spain
| | - Carlos Vilches
- Immunogenetics-HLA, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Majadahonda, Madrid, Spain
| | - Julio Pascual
- Instituto Hospital del Mar de Investigaciones Médicas, Barcelona, Spain.,Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Marta Crespo
- Instituto Hospital del Mar de Investigaciones Médicas, Barcelona, Spain.,Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Miguel López-Botet
- Universitat Pompeu Fabra, Barcelona, Spain; .,Instituto Hospital del Mar de Investigaciones Médicas, Barcelona, Spain.,Immunology Laboratory, Department of Pathology, Hospital del Mar, Barcelona, Spain; and
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Immohr MB, Akhyari P, Böttger C, Mehdiani A, Dalyanoglu H, Westenfeld R, Oehler D, Tudorache I, Aubin H, Lichtenberg A, Boeken U. Cytomegalovirus mismatch after heart transplantation: Impact of antiviral prophylaxis and intravenous hyperimmune globulin. IMMUNITY INFLAMMATION AND DISEASE 2021; 9:1554-1562. [PMID: 34525263 PMCID: PMC8589400 DOI: 10.1002/iid3.508] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/11/2022]
Abstract
Objective Cytomegalovirus (CMV) infections are correlated with complications following heart transplantation (HTx) and impaired outcome. The impact of a serologic mismatch between donor and recipient and the necessity of prophylactic virostatic medication is still a matter of concern. Methods We retrospectively reviewed all patients that underwent HTx between 2010 and 2020 in our department. The recipients (n = 176) could be categorized into four risk groups depending on their serologic CMV matching (D+/R− = donor CMV‐IgG positive and recipient CMV‐IgG negative, n = 32; D−/R+, n = 51; D−/R−, n = 35; D+/R+, n = 58). All patients followed the same protocol of CMV prophylaxis with application of ganciclovir/valganciclovir and intravenous CMV hyperimmune globulin. RESULTS Incidence of postoperative morbidity such as primary graft dysfunction, neurological events, infections, and graft rejection were comparable between all groups (p > .05). However, the incidence of postoperative acute kidney injury with hemodialysis was by trend increased in the D−/R+ group (72.0%) compared to the other groups. In‐hospital CMV‐DNAemia was observed in serologic positive recipients only (D+/R−: 0.0%, D−/R+: 25.0%, D−/R−: 0.0%, D+/R+: 13.3%, p < .01). During the first year, a total of 18 patients developed CMV‐DNAemia (D+/R−: 31.6%, D−/R+: 31.9%, D−/R−: 3.4%, D+/R+: 11.1%, p = .03). Conclusions Seropositive recipients carry an important risk for CMV‐DNAemia. However, we did not observe differences in perioperative morbidity and mortality regarding CMV matching, which might be related to regularly administer prophylactic virostatics and additional CMV‐IVIG for risk constellations. For high‐risk constellation, long‐term application of CMV‐IVIG during the first year after transplant may be beneficial.
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Affiliation(s)
- Moritz B Immohr
- Department of Cardiac Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Charlotte Böttger
- Department of Cardiac Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Arash Mehdiani
- Department of Cardiac Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Oehler
- Department of Cardiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Callemeyn J, Senev A, Coemans M, Lerut E, Sprangers B, Kuypers D, Koenig A, Thaunat O, Emonds MP, Naesens M. Missing Self-Induced Microvascular Rejection of Kidney Allografts: A Population-Based Study. J Am Soc Nephrol 2021; 32:2070-2082. [PMID: 34301794 PMCID: PMC8455279 DOI: 10.1681/asn.2020111558] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/29/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Circulating anti-HLA donor-specific antibodies (HLA-DSA) are often absent in kidney transplant recipients with microvascular inflammation (MVI). Missing self, the inability of donor endothelial cells to provide HLA I-mediated signals to inhibitory killer cell Ig-like receptors (KIRs) on recipient natural killer cells, can cause endothelial damage in vitro, and has been associated with HLA-DSA-negative MVI. However, missing self's clinical importance as a nonhumoral trigger of allograft rejection remains unclear. METHODS In a population-based study of 924 consecutive kidney transplantations between March 2004 and February 2013, we performed high-resolution donor and recipient HLA typing and recipient KIR genotyping. Missing self was defined as the absence of A3/A11, Bw4, C1, or C2 donor genotype, with the presence of the corresponding educated recipient inhibitory KIR gene. RESULTS We identified missing self in 399 of 924 transplantations. Co-occurrence of missing self types had an additive effect in increasing MVI risk, with a threshold at two concurrent types (hazard ratio [HR], 1.78; 95% confidence interval [95% CI], 1.26 to 2.53), independent of HLA-DSA (HR, 5.65; 95% CI, 4.01 to 7.96). Missing self and lesions of cellular rejection were not associated. No HLA-DSAs were detectable in 146 of 222 recipients with MVI; 28 of the 146 had at least two missing self types. Missing self associated with transplant glomerulopathy after MVI (HR, 2.51; 95% CI, 1.12 to 5.62), although allograft survival was better than with HLA-DSA-associated MVI. CONCLUSION Missing self specifically and cumulatively increases MVI risk after kidney transplantation, independent of HLA-DSA. Systematic evaluation of missing self improves understanding of HLA-DSA-negative MVI and might be relevant for improved diagnostic classification and patient risk stratification.
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Affiliation(s)
- Jasper Callemeyn
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Aleksandar Senev
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross‐Flanders, Mechelen, Belgium
| | - Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium
| | - Evelyne Lerut
- Department of Morphology and Molecular Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium,Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology, KU Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Alice Koenig
- International Center of Infectiology research (CIRI), French Institute of Health and Medical Research (INSERM) Unit 1111, Claude Bernard University Lyon I, National Center for Scientific Research (CNRS) Mixed University Unit (UMR) 5308, Ecole Normale Supérieure de Lyon, University of Lyon, Lyon, France,Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France,Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Lyon, France
| | - Olivier Thaunat
- International Center of Infectiology research (CIRI), French Institute of Health and Medical Research (INSERM) Unit 1111, Claude Bernard University Lyon I, National Center for Scientific Research (CNRS) Mixed University Unit (UMR) 5308, Ecole Normale Supérieure de Lyon, University of Lyon, Lyon, France,Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France,Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Lyon, France
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross‐Flanders, Mechelen, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Nephrology and Renal Transplantation Research Group, KU Leuven, Leuven, Belgium,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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Cytomegalovirus Latency Exacerbated small-for-size Liver Graft Injury through Activation of CCL19/CCR7 in Hepatic Stellate Cells. Transplantation 2021; 106:519-530. [PMID: 34156186 DOI: 10.1097/tp.0000000000003846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The interplay between cytomegalovirus (CMV) latency and graft malfunction after living donor liver transplantation (LDLT) remains poorly defined due to the complexity of clinical confounding factors. Here, we aimed to investigate the effects of CMV latency on small-for-size graft injury and to get further insight on the pathogenic role of hepatic stellate cells (HSCs) in this process. METHODS Rat orthotopic liver transplantation with small-for-size grafts was performed in a CMV latent model developed in immunocompetent Sprague Dawley (SD) rats using Priscott strain. Post-transplant graft injury including hepatocyte damage, stellate cell activation and fibrogenesis were evaluated. Differential gene expression of HSCs in response to CMV latency was screened by cDNA microarray. Clinical validation was further conducted in human biopsies. RESULTS CMV latency aggravated hepatocyte apoptosis/necrosis in the early phase, enhanced HSC expansion and graft fibrosis during the middle-late phase in small-for-size liver grafts of the rat model. cDNA microarray mining revealed CCL19/CCR7 as one of the most noteworthy pathways bridging HSC activation and liver graft injury in the presence of CMV latency. Together with CCL19 upregulation, coherent overexpression of CCR7 in accumulated HSCs was confirmed in both rat and human CMV latent recipients. Moreover, addition of CCL19 in vitro promoted HSC migration by increasing the level of matrix metalloproteinase-2 (MMP2). CONCLUSION Our data demonstrated that CMV latency aggravated early/late phase liver graft damage and fibrogenesis via CCL19/CCR7/HSCs axis. Blockade of CMV latency-related stellate cell activation may shed light on the strategy of graft protection clinically.
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Caurio CFB, Allende OS, Kist R, Santos KL, Vasconcellos ICS, Rozales FP, Lana DFD, Praetzel BM, Alegretti AP, Pasqualotto AC. Clinical validation of an in-house quantitative real time PCR assay for cytomegalovirus infection using the 1st WHO International Standard in kidney transplant patients. ACTA ACUST UNITED AC 2021; 43:530-538. [PMID: 33970997 PMCID: PMC8940123 DOI: 10.1590/2175-8239-jbn-2020-0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/18/2021] [Indexed: 12/01/2022]
Abstract
Introduction: Cytomegalovirus (CMV) is one of the most common agents of infection in solid
organ transplant patients, with significant morbidity and mortality. Objective: This study aimed to establish a threshold for initiation of preemptive
treatment. In addition, the study compared the performance of antigenemia
with qPCR results. Study design: This was a prospective cohort study conducted in 2017 in a single kidney
transplant center in Brazil. Clinical validation was performed by comparing
in-house qPCR results, against standard of care at that time (Pp65 CMV
Antigenemia). ROC curve analysis was performed to determine the ideal
threshold for initiation of preemptive therapy based on the qPCR test
results. Results: Two hundred and thirty two samples from 30 patients were tested with both
antigenemia and qPCR, from which 163 (70.26%) were concordant (Kappa
coefficient: 0.435, p<0.001; Spearman correlation:
0.663). PCR allowed for early diagnoses. The median number of days for the
first positive result was 50 (range, 24-105) for antigenemia and 42 (range,
24-74) for qPCR (p<0.001). ROC curve analysis revealed
that at a threshold of 3,430 IU/mL (Log 3.54), qPCR had a sensitivity of
97.06% and a specificity of 74.24% (AUC 0.92617 ± 0.0185,
p<0.001), in the prediction of 10 cells/105
leukocytes by antigenemia and physician's decision to treat. Conclusions: CMV Pp65 antigenemia and CMV qPCR showed fair agreement and a moderate
correlation in this study. The in-house qPCR was revealed to be an accurate
method to determine CMV DNAemia in kidney transplant patients, resulting in
positive results weeks before antigenemia.
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Affiliation(s)
- Cassia F B Caurio
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | - Odelta S Allende
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil
| | - Roger Kist
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | - Kênya L Santos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | - Izadora C S Vasconcellos
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | | | - Daiane F Dalla Lana
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | - Bruno M Praetzel
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | | | - Alessandro C Pasqualotto
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
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46
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García-Ríos E, Nuévalos M, Mancebo FJ, Pérez-Romero P. Is It Feasible to Use CMV-Specific T-Cell Adoptive Transfer as Treatment Against Infection in SOT Recipients? Front Immunol 2021; 12:657144. [PMID: 33968058 PMCID: PMC8104120 DOI: 10.3389/fimmu.2021.657144] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/06/2021] [Indexed: 12/19/2022] Open
Abstract
During the last decade, many studies have demonstrated the role of CMV specific T-cell immune response on controlling CMV replication and dissemination. In fact, it is well established that transplanted patients lacking CMV-specific T-cell immunity have an increased occurrence of CMV replication episodes and CMV-related complications. In this context, the use of adoptive transfer of CMV-specific T-cells has been widely investigated and applied to Hematopoietic Stem Cell Transplant patients and may be useful as a therapeutic alternative, to reconstitute the CMV specific T-cell response and to control CMV viremia in patients receiving a transplantation. However, only few authors have explored the use of T-cell adoptive transfer in SOT recipients. We propose a novel review in which we provide an overview of the impact of using CMV-specific T-cell adoptive transfer on the control of CMV infection in SOT recipients, the different approaches to stimulate, isolate and expand CMV-specific T-cells developed over the years and a discussion of the possible use of CMV adoptive cellular therapy in this SOT population. Given the timeliness and importance of this topic, we believe that such an analysis will provide important insights into CMV infection and its treatment/prevention.
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Affiliation(s)
- Estéfani García-Ríos
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
| | - Marcos Nuévalos
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
| | - Francisco J Mancebo
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
| | - Pilar Pérez-Romero
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
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47
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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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48
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Schaenman J, Phonphok K, Spanuchart I, Duong T, Sievers TM, Lum E, Reed EF, Bunnapradist S. Early cytomegalovirus DNAemia and antiviral dose adjustment in high vs intermediate risk kidney transplant recipients. Transpl Infect Dis 2021; 23:e13457. [PMID: 32892447 PMCID: PMC7962879 DOI: 10.1111/tid.13457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 06/24/2020] [Accepted: 08/11/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection continues to negatively affect outcomes for solid organ transplant recipients, despite the advent of strategies for preemptive surveillance and prophylaxis. The impact is especially great for CMV seronegative recipients of donor seropositive organs, who typically lack the ability to control CMV infection at the time of transplantation. METHODS We reviewed episodes of CMV DNAemia in a modern cohort of kidney transplant recipients over a 3-year period at a high-volume transplant center to investigate the frequency of DNAemia during antiviral prophylaxis. RESULTS Despite receipt of antiviral prophylaxis per current guidelines, 75 cases of CMV DNAemia were observed in the first 100 days after transplantation. For high risk patients, median time to DNAemia was 75 days after transplantation, and the majority of patients had experienced dose-reduction of valganciclovir due to renal insufficiency. Review of CMV seropositive intermediate risk patients demonstrated DNAemia occurring earlier after transplantation compared with high risk patients with a median time of 64 days (P = .029). The impact of valganciclovir dose adjustment was less notable in the intermediate risk group. CONCLUSIONS Guidelines recommend beginning routine surveillance for CMV after the completion of antiviral prophylaxis. Our findings suggest that closer monitoring may be beneficial, especially for high risk patients at risk for DNAemia. Patients requiring dose adjustment of valganciclovir due to renal insufficiency may be at increased risk for CMV DNAemia. Improved methods for CMV prophylaxis and evaluation of immunologic risk for CMV DNAemia and disease are needed to improve patient outcomes after kidney transplantation.
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Affiliation(s)
- Joanna Schaenman
- Division of Infectious Diseases, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Korntip Phonphok
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Ittikorn Spanuchart
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Tin Duong
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Theodore M. Sievers
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Erik Lum
- Division of Nephrology, David Geffen School of Medicine, Los Angeles, CA 90095
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, Los Angeles, CA 90095
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49
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Yu S, Dangi A, Burnette M, Abecassis MM, Thorp EB, Luo X. Acute murine cytomegalovirus disrupts established transplantation tolerance and causes recipient allo-sensitization. Am J Transplant 2021; 21:515-524. [PMID: 32659030 PMCID: PMC7855505 DOI: 10.1111/ajt.16197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 01/25/2023]
Abstract
We have previously shown that acute cytomegalovirus (CMV) infection disrupts the induction of transplantation tolerance. However, what impact acute CMV infection would have on the maintenance of established tolerance and on subsequent recipient allo-sensitization is a clinically important unanswered question. Here we used an allogeneic murine islet transplantation tolerance model to examine the impact of acute CMV infection on: (a) disruption of established transplantation tolerance during tolerance maintenance; and (b) the possibility of recipient allo-sensitization by CMV-mediated disruption of stable tolerance. We demonstrated that acute CMV infection abrogated transplantation tolerance during the maintenance stage in 50%-60% recipients. We further demonstrated that acute CMV infection-mediated tolerance disruption led to recipient allo-sensitization by reverting the tolerant state of allo-specific T cells and promoting their differentiation to allo-specific memory cells. Consequently, a second same-donor islet allograft was rejected in an accelerated fashion by these recipients. Our study therefore supports close monitoring for allo-sensitization in previously tolerant transplant recipients in whom tolerance maintenance is disrupted by an episode of acute CMV infection.
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Affiliation(s)
- Shuangjin Yu
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina,Division of Organ transplantation, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Anil Dangi
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Melanie Burnette
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Edward B. Thorp
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xunrong Luo
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina,Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina
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50
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Räihä J, Ortiz F, Mannonen L, Loginov R, Lempinen M, Lautenschlager I, Helanterä I. The burden of cytomegalovirus infection remains high in high-risk kidney transplant recipients despite six-month valganciclovir prophylaxis. Transpl Infect Dis 2021; 23:e13577. [PMID: 33527660 DOI: 10.1111/tid.13577] [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: 07/11/2020] [Revised: 01/09/2021] [Accepted: 01/17/2021] [Indexed: 12/28/2022]
Abstract
Cytomegalovirus continues to be a concern after transplantation despite prophylaxis regimens. Our aim was to analyse post-prophylaxis primary cytomegalovirus infections among kidney transplant recipients after 6-month valganciclovir prophylaxis and to determine the usefulness of surveillance after prophylaxis. Data from all cytomegalovirus D+/R- kidney transplant recipients from January 2004 to October 2018 at our center who received 6-month prophylaxis with valganciclovir were retrospectively analysed (N = 481). Detailed analyses were performed for 136 patients who were monitored every 2-4 weeks for DNAemia after the discontinuation of prophylaxis. Post-prophylaxis primary cytomegalovirus infection occurred in 182/481 (38%) patients median 264 days after transplantation (IQR: 226-367) and median 84 days after the end of prophylaxis (IQR: 46-187). In 49% patients, cytomegalovirus infection occurred over 3 months after the end of prophylaxis. Cytomegalovirus infection was not associated with lower patient or graft survival and no independent risk factors for infection were found. From patients monitored closely, 71/136 (52%) patients developed post-prophylaxis primary cytomegalovirus infection. Altogether, 52/136 (38%) patients were diagnosed with probable post-prophylaxis cytomegalovirus disease and 19/136 (14%) patients had asymptomatic CMV infection. Recurrent infection occurred in 38/71 (39%) patients. The incidence of post-prophylaxis primary cytomegalovirus infection among D+/R- kidney transplant recipients remains high despite 6-month prophylaxis. Surveillance after prophylaxis was challenging as a considerable portion of the infections occurred late and already symptomatic.
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Affiliation(s)
- Juulia Räihä
- Abdominal Center, Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Fernanda Ortiz
- Abdominal Center, Department of Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Laura Mannonen
- Department of Virology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Raisa Loginov
- Department of Virology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marko Lempinen
- Abdominal Center, Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Irmeli Lautenschlager
- Department of Virology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Abdominal Center, Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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