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Fernández S, Grafia I, Peyrony O, Canet E, Vigneron C, Monet C, Issa N, Decavele M, Moreau AS, Lautrette A, Lacave G, Morel G, Cadoz C, Argaud L, Statlender L, Azem K, Quenot JP, Lesieur O, Fernández J, Farrero M, Marcos MÁ, Lemiale V, Castro P, Azoulay É. Clinical characteristics and outcomes of immunocompromised critically ill patients with cytomegalovirus end-organ disease: a multicenter retrospective cohort study. Crit Care 2024; 28:243. [PMID: 39014504 PMCID: PMC11251242 DOI: 10.1186/s13054-024-05029-4] [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: 05/18/2024] [Accepted: 07/08/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection in patients with cellular immune deficiencies is associated with significant morbidity and mortality. However, data on CMV end-organ disease (CMV-EOD) in critically ill, immunocompromised patients are scarce. Our objective here was to describe the clinical characteristics and outcomes of CMV-EOD in this population. METHODS We conducted a multicenter, international, retrospective, observational study in adults who had CMV-EOD and were admitted to any of 18 intensive care units (ICUs) in France, Israel, and Spain in January 2010-December 2021. Patients with AIDS were excluded. We collected the clinical characteristics and outcomes of each patient. Survivors and non-survivors were compared, and multivariate analysis was performed to identify risk factors for hospital mortality. RESULTS We studied 185 patients, including 80 (43.2%) with hematologic malignancies, 55 (29.7%) with solid organ transplantation, 31 (16.8%) on immunosuppressants, 16 (8.6%) with solid malignancies, and 3 (1.6%) with primary immunodeficiencies. The most common CMV-EOD was pneumonia (n = 115, [62.2%] including 55 [47.8%] with a respiratory co-pathogen), followed by CMV gastrointestinal disease (n = 64 [34.6%]). More than one organ was involved in 16 (8.8%) patients. Histopathological evidence was obtained for 10/115 (8.7%) patients with pneumonia and 43/64 (67.2%) with GI disease. Other opportunistic infections were diagnosed in 69 (37.3%) patients. Hospital mortality was 61.4% overall and was significantly higher in the group with hematologic malignancies (75% vs. 51%, P = 0.001). Factors independently associated with higher hospital mortality were hematologic malignancy with active graft-versus-host disease (OR 5.02; 95% CI 1.15-27.30), CMV pneumonia (OR 2.57; 95% CI 1.13-6.03), lymphocytes < 0.30 × 109/L at diagnosis of CMV-EOD (OR 2.40; 95% CI 1.05-5.69), worse SOFA score at ICU admission (OR 1.18; 95% CI 1.04-1.35), and older age (OR 1.04; 95% CI 1.01-1.07). CONCLUSIONS Mortality was high in critically ill, immunocompromised patients with CMV-EOD and varied considerably with the cause of immunodeficiency and organ involved by CMV. Three of the four independent risk factors identified here are also known to be associated with higher mortality in the absence of CMV-EOD. CMV pneumonia was rarely proven by histopathology and was the most severe CMV-EOD.
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Affiliation(s)
- Sara Fernández
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain.
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
| | - Ignacio Grafia
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain
- Department of Medical Oncology, IDIBAPS, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, CHU de Nantes, Université de Nantes, Nantes, France
| | - Clara Vigneron
- Médecine Intensive et Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Clément Monet
- Anesthesia and Critical Care Department, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS, Montpellier, France
| | - Nahéma Issa
- Medical Intensive Care Unit, Hôpital Saint André, CHU Bordeaux, Bordeaux, France
| | - Maxens Decavele
- Medical Intensive Care Unit (Department R3S), Pitié-Salpêtrière University Hospital, Sorbonne University Hospitals, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- INSERM Research Unit UMRS1158, Experimental and Clinical Respiratory Neurophysiology, Sorbonne University, Paris, France
| | | | - Alexandre Lautrette
- Medical Intensive Care Unit, Jean Perrin Oncology Institut and Montpied Teaching Hospital, Clermont-Ferrand, France
| | - Guillaume Lacave
- Medical-Surgical Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Guillaume Morel
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | - Cyril Cadoz
- Réanimation Polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Liran Statlender
- General Intensive Care Unit, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karam Azem
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Anesthesiology Department, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Jean-Pierre Quenot
- Deparment of Intensive Care, Burgundy University Hospital, Dijon, France
| | - Olivier Lesieur
- Intensive Care Unit, La Rochelle General Hospital, La Rochelle, France
| | - Javier Fernández
- Liver Intensive Care Unit, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- EF-Clif, Barcelona, Spain
| | - Marta Farrero
- Heart Failure Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Mª Ángeles Marcos
- Microbiology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Virgine Lemiale
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Élie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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Katada Y, Nakagawa S, Nagao M, Umemura K, Itohara K, Nishikawa A, Hashi S, Katsube Y, Hira D, Ohsumi A, Nakajima D, Date H, Terada T. Trough ganciclovir concentration as predictor of leukopenia in lung transplant recipients receiving valganciclovir prophylaxis. Transpl Infect Dis 2023; 25:e14141. [PMID: 37639301 DOI: 10.1111/tid.14141] [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: 06/16/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Valganciclovir is the first-line agent for Cytomegalovirus prophylaxis after lung transplantation. However, its use is associated with a relatively high risk of hematological toxicity. This study aimed to investigate the relationship between trough ganciclovir concentration and hematologic toxicity in lung transplantation patients receiving valganciclovir prophylaxis, and identify factors that affect ganciclovir pharmacokinetics in this population. METHODS This prospective observational study included 24 lung transplant patients receiving valganciclovir prophylaxis. The cutoff value of trough ganciclovir concentration was estimated using receiver operating characteristic analysis in leukopenia grade 3 and higher. Population pharmacokinetic analysis was performed using a nonlinear mixed-effects modeling program. RESULTS The trough ganciclovir concentration was significantly higher in the group with leukopenia grades 3 or higher than in the group with grades less than or equal to 2 (1605.7 ± 860.1 ng/mL [n = 3] vs. 380.5 ± 175.8 ng/mL (n = 21), p < .001). The cutoff value of trough ganciclovir concentration for predicting greater than or equal to grade 3 leukopenia was estimated as 872.0 ng/mL. Creatinine clearance and lung re-transplantation were found to have a significant impact on the total body clearance of valganciclovir. Ganciclovir clearance was decreased in patients with reduced creatine clearance or re-transplantation. CONCLUSION These results suggest that higher ganciclovir trough concentrations are associated with an increased risk of leukopenia grade 3 or higher, and that creatinine clearance and lung re-transplantation affected the pharmacokinetics of ganciclovir.
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Affiliation(s)
- Yoshiki Katada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
- Department of Infection Control and Prevention, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Miki Nagao
- Department of Infection Control and Prevention, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Keisuke Umemura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Asami Nishikawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
- Department of Infection Control and Prevention, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Sachiyo Hashi
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Yurie Katsube
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Daiki Hira
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
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COVID-19, SARS-CoV-2 Vaccination, and Human Herpesviruses Infections. Vaccines (Basel) 2023; 11:vaccines11020232. [PMID: 36851110 PMCID: PMC9963083 DOI: 10.3390/vaccines11020232] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
There are several human herpesviruses. A common characteristic of infection by these viruses is latency, by which the virus assumes a non-replicative state, subverting the attentions of the host's immune response. In immunocompetent hosts, herpesviruses are immunologically controlled, although periodic virus shedding can occur. In situations where immunological control is lost, herpesviruses can reactivate and produce clinically apparent disease. It is now becoming apparent that COVID-19 or exposure to COVID-19 vaccines can exert several effects on the immune system. The pandemic of COVID-19 shows no sign of abating, with new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) variants continuing to evolve. Several COVID-19 vaccines have been developed, and much of the world's population has either experienced COVID-19 or been vaccinated against it. There are an increasing number of reports of associations between herpesvirus infections or reactivations and COVID-19 or COVID-19 vaccination. For instance, a positive cytomegalovirus serostatus may indicate a greater likelihood of severe COVID-19, and herpes simplex virus reactivation may be linked to increased mortality. Epstein-Barr virus reactivation appears to be associated with post-acute sequelae of COVID-19. Finally, herpes zoster has been reported to be associated with COVID-19 vaccination. This brief narrative review will provide several insights into associations between herpesvirus infections or reactivations and COVID-19 or SARS-CoV-2 vaccination.
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Mora VM, Ussetti P, de Pablo A, Iturbe D, Laporta R, Alonso R, Aguilar M, Quezada CA, Cifrián JM. Evaluation of Two Different CMV-Immunoglobulin Regimens for Combined CMV Prophylaxis in High-Risk Patients following Lung Transplant. Microorganisms 2022; 11:microorganisms11010032. [PMID: 36677327 PMCID: PMC9864217 DOI: 10.3390/microorganisms11010032] [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: 11/29/2022] [Revised: 12/09/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The clinical benefits of the common off-label use of cytomegalovirus (CMV)-specific immunoglobulin (CMV-Ig) combined with antivirals in organ transplantation have not been previously assessed. The objective was to compare the risk of CMV infection and other post-transplantation outcomes between two CMV-Ig prophylaxis regimens in lung transplant recipients; Methods: Retrospective study of 124 donor CMV positive/recipient negative (D+/R-) patients receiving preventive ganciclovir/valganciclovir for 12 months, of whom 62 received adjunctive CMV-Ig as per label indication (short regimen [SR-Ig]; i.e., 7 doses over 2.5 months) and were compared to 62 who received an extended off-label regimen (ER-Ig) consisting of 17 doses over one year after transplantation. RESULTS The incidence of CMV infection or disease, acute rejection, chronic lung allograft dysfunction, and survival did not differ between the two CMV-Ig schedules. Although the time to the first CMV infection after transplantation was shorter in the ER-Ig than in the SR-Ig adjunctive group (log-rank: p = 0.002), the risk was independently predicted by antiviral cessation (odds ratio = 3.74; 95% confidence interval = 1.04-13.51; p = 0.030), whereas the CMV-Ig schedule had no effect. CONCLUSIONS Extending the adjunctive CMV-Ig prophylaxis beyond the manufacturer's recommendations up to one year does not confer additional clinical benefits regarding lung post-transplantation outcomes.
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Affiliation(s)
- Víctor M. Mora
- Service of Respiratory Medicine, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
- Genetic Epidemiology and Atherosclerosis in Systemic Inflammatory Diseases Group, IDIVAL, 39008 Santander, Spain
- Correspondence: ; Tel.: +34-942-20-25-20 (ext. 75915)
| | - Piedad Ussetti
- Department of Neumology, Hospital Puerta de Hierro, Majadahonda, 28222 Madrid, Spain
| | - Alicia de Pablo
- Department of Neumology, Hospital Universitario 12 de octubre, 28041 Madrid, Spain
| | - David Iturbe
- Service of Respiratory Medicine, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
- Genetic Epidemiology and Atherosclerosis in Systemic Inflammatory Diseases Group, IDIVAL, 39008 Santander, Spain
| | - Rosalía Laporta
- Department of Neumology, Hospital Puerta de Hierro, Majadahonda, 28222 Madrid, Spain
| | - Rodrigo Alonso
- Department of Neumology, Hospital Universitario 12 de octubre, 28041 Madrid, Spain
| | - Myriam Aguilar
- Department of Neumology, Hospital Puerta de Hierro, Majadahonda, 28222 Madrid, Spain
| | - Carlos A. Quezada
- Department of Neumology, Hospital Universitario 12 de octubre, 28041 Madrid, Spain
| | - José M. Cifrián
- Service of Respiratory Medicine, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
- Genetic Epidemiology and Atherosclerosis in Systemic Inflammatory Diseases Group, IDIVAL, 39008 Santander, Spain
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Fifteen-Year Surveillance of LTR Receiving Pre-Emptive Therapy for CMV Infection: Prevention of CMV Disease and Incidence of CLAD. Microorganisms 2022; 10:microorganisms10122339. [PMID: 36557592 PMCID: PMC9788487 DOI: 10.3390/microorganisms10122339] [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: 10/11/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/29/2022] Open
Abstract
The efficacy of pre-emptive therapy in the prevention of cytomegalovirus (CMV) disease and the potential association of CMV infection with the occurrence of chronic lung allograft dysfunction (CLAD) was evaluated in 129 lung transplant recipients receiving pre-emptive therapy based on pp65-antigenemia or CMV-DNA in the blood and in the bronchoalveolar lavage. Seventy-one (55%) patients received pre-emptive ganciclovir/valganciclovir (GCV/VGCV) for CMV infection for a median of 28 (9-191) days. Possible CMV disease occurred in six (5%) patients and was healed after the GCV/VGCV therapy. The cumulative incidence of CLAD was 38% and 54% at 5 and 10 years. Acute rejection and CMV load in the blood (but not in the lung) were independent predictors of the occurrence of CLAD. Pre-emptive therapy is highly effective in preventing CMV disease in lung recipients and does not induce a superior incidence of CLAD compared to what reported for other cohorts of patients who received an extended antiviral prophylaxis.
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6
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Tang Y, Guo J, Li J, Zhou J, Mao X, Qiu T. Risk factors for cytomegalovirus infection and disease after kidney transplantation: A meta-analysis. Transpl Immunol 2022; 74:101677. [PMID: 35901951 DOI: 10.1016/j.trim.2022.101677] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To investigate the risk factors for cytomegalovirus (CMV) infection and disease in kidney transplantation recipient, and provide references for the prevention and control of CMV infection and disease in kidney transplantation patients. METHODS Chinese and international literature related to risk factors for CMV infection and disease in renal transplant recipients was searched using databases, including China National Knowledge Infrastructure; WanFang Data; Wiper; Chinese Biomedical Literature database; PubMed; Embase; Web of Science, and the Cochrane Register of Controlled Trials. Two researchers independently screened the literature, extracted the data, and evaluated the quality of the literature according to published standards. A meta-analysis was performed using RevMan 5.4 software to extract the risk factors for CMV infection and disease in renal transplant recipients. RESULTS A total of 59,847 subjects were included in 24 studies. The risk factors for CMV infection were ATG [OR = 2.76, 95% CI (2.10, 3.63), P < 0.00001], Donor (D) CMV-IgG(+) Receptor (R)(-): (D+/R-) [OR = 2.97, 95% CI (1.63, 5.44), P = 0.004 < 0.05], recipient age [OR = 1.96, 95% CI (1.50, 2.54), P < 0.00001], lymphocytopenia [OR = 3.26, 95% CI (1.46, 7.31), P < 0.00001], and mycophenolate [OR = 3.22, 95% CI (2.02, 5.46), P < 0.00001]. The protective factor for CMV infection was glomerular filtration rate (GFR) [OR = 0.98, 95% CI (0.97, 0.99), P < 0.00001], and the uncertain factors were the use of tacrolimus [OR = 0.91, 95% CI (0.64, 1.28), P = 0.58 > 0.05], rejection [OR = 1.32, 95% CI (0.49, 3.53), P = 0.58 > 0.05], donor age [OR = 1.00, 95% CI (0.99, 1.01), P = 0.67 > 0.5], and preemptive therapy [OR = 0.51, 95% CI (0.11, 2.36), P = 0.86 > 0.05]. The risk factors for CMV disease were D+/R- [OR = 4.78, 95% CI (3.76, 6.07), P < 0.00001], ATG [OR = 1.83, 95% CI (1.25, 2.67), P < 0.00001], rejection [OR = 1.42, 95% CI (1.26, 1.59), P < 0.00001], mycophenolate [OR = 1.67, 95% CI (1.38, 2.02), P < 0.00001], recipient age [OR = 1.03, 95% CI (1.02, 1.03), P < 0.00001], donor age [OR = 1.01, 95% CI (1.00, 1.01), P = 0.001 < 0.05], Donor (D) CMV-IgG(+) Receptor(R)(+): (D+/R+) [OR = 1.92, 95% CI (1.49, 2.46), P < 0.00001], the use of prednisolone [OR = 1.59, 95% CI (1.32, 1.92), P < 0.00001], and diabetes mellitus[OR = 1.18, 95% CI (1.01, 1.37), P = 0.03 < 0.05], and the uncertain factors were donor type [OR = 4.10, 95% CI (0.28, 59.79), P = 0.30 > 0.05], time of transplantation [OR = 0.95, 95% CI (0.78, 1.16), P = 0.64 > 0.05], and the use of cyclosporine [OR = 1.50, 95% CI (0.62, 3.64), P = 0.37 > 0.05]. CONCLUSION There are many factors influencing CMV infection and disease in kidney transplant patients. Risk factors should be carefully monitored, protective factors strengthened, and more attention paid to uncertain factors.
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Affiliation(s)
- Yan Tang
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Jiayu Guo
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Jinke Li
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Jiangqiao Zhou
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Xiaolan Mao
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
| | - Tao Qiu
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China.
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7
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Solidoro P, Patrucco F, Boffini M, Rinaldi M, Airoldi C, Costa C, Cavallo R, Albera C. Cellular and humoral cytomegalovirus immunity changes in one-year combined prophylaxis after lung transplantation: suggestions from and for clinical practice. Ther Adv Respir Dis 2020; 14:1753466620981851. [PMID: 33356914 PMCID: PMC7780175 DOI: 10.1177/1753466620981851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Immune responses, both cellular and humoral, against cytomegalovirus (CMV) are used to predict CMV manifestations in solid organ recipients. The aim of this study is to evaluate CMV enzyme-linked immunospot (ELISPOT) assay and serology during CMV infections, their concordance and variations after lung transplantation (LTx). Methods: We retrospectively analysed in one year the follow-up data of 43 patients receiving combined CMV prophylaxis with antiviral agents and CMV-specific immunoglobulin G (IgG). CMV infections were investigated by using molecular analyses on both 167 bronchoalveolar lavage and biopsy specimens and 1134 blood samples. Cellular CMV immunity was assessed with specific ELISPOT whereas the humoral one was assessed by quantifying specific immunoglobulins. Results: At the first month after LTx the majority of patients were ELISPOT responders (52.3%) and 30.9% were non-responders. ELISPOT responders had a lower incidence of CMV viremia (p = 0.047), whereas neither effects on CMV pulmonary asymptomatic infection nor on acute rejection were observed. Responders had a higher CMV IgG titre (p < 0.0001) in particular at the first month after LTx (p = 0.0001). Concordance among CMV ELISPOT assay and IgG levels was moderate (Cohen’s K 0.524), with an agreement of 89.8%. All ELISPOT responders maintained their status and almost all non-responders became responders during follow-up (92.3%); the percentage of IgG seropositive subjects increased from 74.4% at the first month of follow-up to 97.4% after 1 year. Conclusions: Despite a moderate concordance with serology, ELISPOT response predicted a lower incidence of CMV viremia in LTx patients; no effects were reported on pulmonary clinical manifestations nor on acute rejection. The ELISPOT response as well as serology changed during the follow-up, not only after first CMV contact. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Paolo Solidoro
- Division of Respiratory Medicine, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, Torino, Italy.,Medical Sciences Department, University of Turin, Torino, Italy
| | - Filippo Patrucco
- Division of Respiratory Medicine, Cardiovascular and Thoracic Department, University of Turin, AOU Città della Salute e della Scienza di Torino, C.so Bramante 88/90, Torino, 10126, Italy.,Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Massimo Boffini
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, University of Turin, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mauro Rinaldi
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, University of Turin, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Chiara Airoldi
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Cristina Costa
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Rossana Cavallo
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Carlo Albera
- Division of Respiratory Medicine, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, Torino, Italy.,Medical Sciences Department, University of Turin, Torino, Italy
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8
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Van Leer Buter CC, de Voogd DWK, Blokzijl H, de Joode AAE, Berger SP, Verschuuren EAM, Niesters HGM. Antiviral-resistant cytomegalovirus infections in solid organ transplantation in the Netherlands. J Antimicrob Chemother 2020; 74:2370-2376. [PMID: 31093660 PMCID: PMC7183806 DOI: 10.1093/jac/dkz196] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/01/2019] [Accepted: 04/03/2019] [Indexed: 02/07/2023] Open
Abstract
Objectives Antiviral resistance in cytomegalovirus (CMV) may result from mutations in the molecular targets of antiviral agents. The aim of this study was to investigate both the prevalence of resistance-associated mutations and the factors associated with antiviral resistance in solid organ transplant (SOT) patients with repeated high CMV loads during antiviral treatment. Methods SOT patients were selected retrospectively, based on CMV loads of >30000 IU/mL at least twice in a period during which treatment was given. Patient samples were tested for antiviral resistance by Sanger sequencing the UL97 and UL54 genes of CMV, which code for the viral kinase and polymerase. Factors predisposing to and resulting from the development of antiviral resistance mutations were analysed. Results Multiple samples from 113 SOT patients were tested, showing resistance-associated mutations in 25 patients (22%). A further 20 (18%) patients showed mutations that were not known to be associated with antiviral resistance. Several factors were associated with development of resistance-associated mutations in UL97 as well as UL54, including human leucocyte antigen (HLA) mismatch, which occurred more frequently in the group of patients with resistance mutations. High-level resistance mutations were most frequently seen in UL97. Conclusions This study shows that by selecting patients solely on the basis of virological response to treatment, more patients with antiviral resistance mutations are identified. In this study we confirm findings by other groups that primary infections are associated with resistance development. Moreover, we show that HLA mismatch is associated with the development of antiviral resistance, which suggests a role for host immunity in the development of resistance.
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Affiliation(s)
- Coretta C Van Leer Buter
- Department of Medical Microbiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Danielle W K de Voogd
- Department of Medical Microbiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Anoek A E de Joode
- Division of Nephrology, Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Division of Nephrology, Department of Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Erik A M Verschuuren
- Department of Pulmonary Diseases, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hubert G M Niesters
- Department of Medical Microbiology, University Medical Centre Groningen, Groningen, The Netherlands
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9
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Solidoro P, Patrucco F, Libertucci D, Verri G, Sidoti F, Curtoni A, Boffini M, Simonato E, Rinaldi M, Cavallo R, Costa C. Tailored combined cytomegalovirus management in lung transplantation: a retrospective analysis. Ther Adv Respir Dis 2020; 13:1753466619878555. [PMID: 31566097 PMCID: PMC6769221 DOI: 10.1177/1753466619878555] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is no univocal prophylactic regimen to prevent cytomegalovirus (CMV) infection/disease in lung transplantation (LT) recipients. The aim of this study is to evaluate short-term clinical outcomes of a tailored combined CMV management approach. METHODS After 1-year follow up, 43 LT patients receiving combined CMV prophylaxis with antiviral agents and CMV-specific IgG were evaluated in a retrospective observational study. Systemic and lung viral infections were investigated by molecular methods on a total of 1134 whole blood and 167 bronchoalveolar lavage (BAL) and biopsy specimens. CMV immunity was assessed by ELISPOT assay. Clinical and therapeutic data were also evaluated. RESULTS We found 2/167 cases of CMV pneumonia (1.2%), both in the donor-positive/recipient-positive (D+/R+) population, and 51/167 cases of CMV pulmonary infection (BAL positivity 30.5%). However, only 32/167 patients (19.1%) were treated due to their weak immunological response at CMV ELISPOT assay. Viremia ⩾100,000 copies/mL occurred in 33/1134 specimens (2.9%). Regarding CMV-serological matching (D/R), the D+/R- population had more CMV viremia episodes (p < 0.05) and fewer viremia-free days (p < 0.001). CONCLUSIONS Compared to previous findings, our study shows a lower incidence of CMV pneumonia and viremia despite the presence of a substantial CMV load. In addition, our findings further confirm the D+/R- group to be a high-risk population for CMV viremia. Overall, a good immunological response seems to protect patients from CMV viremia and pneumonia but not from CMV alveolar replication. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Paolo Solidoro
- Cardiovascular and Thoracic Department, Division of Respiratory Diseases, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Filippo Patrucco
- Cardiovascular and Thoracic Department, Division of Respiratory Diseases, University of Turin, Città della Salute e della Scienza di Torino, C.so Bramante 88/90, Torino, 10126, Italy
| | - Daniela Libertucci
- Cardiovascular and Thoracic Department, Division of Respiratory Diseases, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Giulia Verri
- Cardiovascular and Thoracic Department, Division of Respiratory Diseases, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Francesca Sidoti
- Public Health and Pediatrics Department, Division of Virology, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Antonio Curtoni
- Public Health and Pediatrics Department, Division of Virology, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Massimo Boffini
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Erika Simonato
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mauro Rinaldi
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Rossana Cavallo
- Public Health and Pediatrics Department, Division of Virology, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Cristina Costa
- Public Health and Pediatrics Department, Division of Virology, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
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10
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Marron RM, Vega Sanchez ME, Clauss H, Mamary AJ. Acute Hypoxemic Respiratory Failure and Native Lung Idiopathic Pulmonary Fibrosis Exacerbation in Single-lung Transplant Patients with Cytomegalovirus Disease: A Case Series. Transplant Proc 2019; 51:3391-3394. [PMID: 31733804 DOI: 10.1016/j.transproceed.2019.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/25/2019] [Accepted: 07/09/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Our case series describes three patients who have received single-lung transplantations for idiopathic pulmonary fibrosis (IPF) that develop cytomegalovirus (CMV) disease and hypoxemic respiratory failure with radiographic opacification of the native lung and sparing of the allograft. RESULTS Hypoxemia resolved with treatment and with resolution of CMV viremia. Viral infections causing IPF exacerbations have been described in the literature, however, pulmonary CMV disease in single-lung transplant recipients has typically been observed as pneumonitis of the allograft. CONCLUSIONS These clinical scenarios are consistent with acute exacerbation of native-lung IPF and subradiographic pneumonitis of the allograft caused by CMV disease.
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Affiliation(s)
- Robert M Marron
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
| | - Maria Elena Vega Sanchez
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Heather Clauss
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - A James Mamary
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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11
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Heliövaara E, Husain S, Martinu T, Singer LG, Cypel M, Humar A, Keshavjee S, Tikkanen J. Drug-resistant cytomegalovirus infection after lung transplantation: Incidence, characteristics, and clinical outcomes. J Heart Lung Transplant 2019; 38:1268-1274. [PMID: 31570289 DOI: 10.1016/j.healun.2019.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/28/2019] [Accepted: 09/03/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection and development of CMV drug resistance can cause significant morbidity and mortality in patients with lung transplantation (LTX). We investigated the incidence of CMV drug resistance in adult patients with LTX and characterized this patient group and its outcomes. METHODS We analyzed a single-center retrospective cohort of 735 patients who received LTX between January 2012 and October 2017. We assessed the incidences of CMV UL97 and UL54 genotyping for clinically suspected drug resistance and confirmed drug resistance. Case-matched controls (3 control patients for each resistant patient) were identified by matching for CMV serological status, development of CMV disease or significant viremia (≥3,000 IU/ml), and transplantation date. RESULTS The incidence of drug-resistant CMV was 1.98% (11/556) in donor and/or recipient CMV-positive patients and 4.7% (7/150) in donor-positive/recipient-negative patients. Altogether, 27 patients were tested for drug resistance, and 11 strains were resistant, 8 sensitive, and 8 inconclusive. No differences in immunosuppression, acute rejection, or pre-transplant sensitization were seen between case-matched groups. The peak CMV viral load and mean duration of viremia were significantly higher in the resistant group (324,000 vs. 117,000 mean IU/ml, p = 0.048 and 140 vs. 55 days, p < 0.001, respectively). The resistant group had increased overall mortality after onset of viremia compared with controls (3-year mortality 70% vs. 30%; p = 0.01). CONCLUSIONS Drug-resistant CMV infection is rare, but patients who develop it have decreased overall survival. Peak CMV viral load and duration of CMV viremia were associated with development of resistant CMV infection.
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Affiliation(s)
- Elina Heliövaara
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Atul Humar
- Division of Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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12
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Paez-Vega A, Cantisan S, Vaquero JM, Vidal E, Luque-Pineda A, Lobo-Acosta MÁ, Pérez AB, Alonso-Moralejo R, Iturbe D, Monforte V, Otero-Gonzalez I, Pastor A, Ussetti P, Torre-Cisneros J. Efficacy and safety of the combination of reduced duration prophylaxis followed by immuno-guided prophylaxis to prevent cytomegalovirus disease in lung transplant recipients (CYTOCOR STUDY): an open-label, randomised, non-inferiority clinical trial. BMJ Open 2019; 9:e030648. [PMID: 31420397 PMCID: PMC6701703 DOI: 10.1136/bmjopen-2019-030648] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Prolonged use of antivirals to prevent the development of cytomegalovirus (CMV) disease in lung transplant patients has been shown to have significant side effects, for which alternatives are being sought to reduce their use. The monitoring of cell immunity against CMV could be an alternative as it has shown to be useful in identifying transplant patients at low risk of infection, who could benefit from shorter prophylaxis. The aim of the CYTOCOR study is to demonstrate that the combination of a reduced prophylaxis strategy with subsequent CMV-specific immunological monitoring would allow CMV infection to be controlled in lung transplant patients as effectively as the usual strategy (prophylaxis followed by pre-emptive therapy), while reducing the side effects of antivirals due to the shorter duration of prophylaxis. METHODS AND ANALYSIS Phase III randomised, open, multicentre, parallel, non-inferiority clinical trial to study the efficacy and safety of the combination of a prophylaxis strategy up to month +3 post-transplant followed by immuno-guided prophylaxis using the QuantiFERON-CMV technique up to month +12 post-transplant to prevent CMV disease in CMV-seropositive lung transplant recipients. This strategy will be compared with a combination of a usual prophylaxis strategy up to month +6 post-transplant followed by pre-emptive therapy up to month +12. To study the incidence of CMV disease, patients will be followed up to 18 months post-transplantation. A total of 150 patients are expected to be recruited for the study. ETHICS AND PUBLIC DISSEMINATION The clinical trial has been approved by the Research Ethics Committees and authorised by the Spanish Agency of Medicines and Medical Devices (AEMPS).If the hypothesis of this clinical trial is verified, the dissemination of the results could change clinical practice by increasing knowledge about the safety and efficacy of discontinuing valganciclovir prophylaxis in lung transplant recipients. TRIAL REGISTRATION NUMBER NCT03699254.
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Affiliation(s)
- Aurora Paez-Vega
- Infectious Diseases Group, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
- Spanish Network for Research in Infectious Diseases (REIPI, RD16/0016/0008), Instituto de Salud Carlos III, Madrid, Spain
| | - Sara Cantisan
- Infectious Diseases Group, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
- Spanish Network for Research in Infectious Diseases (REIPI, RD16/0016/0008), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Unit, Reina Sofía University Hospital, Cordoba, Spain
| | - José Manuel Vaquero
- Thoracic Surgery and Lung Transplantation Unit, Reina Sofía University Hospital, Cordoba, Spain
| | - Elisa Vidal
- Infectious Diseases Group, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
- Spanish Network for Research in Infectious Diseases (REIPI, RD16/0016/0008), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Unit, Reina Sofía University Hospital, Cordoba, Spain
| | - Antonio Luque-Pineda
- Clinical Trial Unit, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Reina Sofía University Hospital/University of Córdoba (SCReN PT17/0017/0032), Cordoba, Spain
| | - María Ángeles Lobo-Acosta
- Clinical Trial Unit, Virgen del Rocío University Hospital (CTU-HUVR), (SCReNPT13/0002/0010-PT17/0017/0012), Sevilla, Spain
| | - Ana Belén Pérez
- Infectious Diseases Group, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
- Microbiology Unit, Reina Sofía University Hospital, Cordoba, Spain
| | - Rodrigo Alonso-Moralejo
- Neumology Service, Instituto de Investigación i+12 Hospital Universitario 12 de Octubre. (REIPI, RD16/0016/0002), Madrid, Spain
| | - David Iturbe
- Neumology Service, University Hospital Marqués de Valdecilla-IDIVAL (REIPI, RD16/0016/0007), Santander, Spain
| | - Victor Monforte
- Respiratory Department, Vall d' Hebron Barcelona Hospital Campus. Universitat Autónoma de Barcelona, (REIPI, RD16/0016/0003), Barcelona, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Isabel Otero-Gonzalez
- Neumology Service, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC) Sergas Universidade da Coruña (UDC), (REIPI, RD16/0016/0006), As Xubias, A Coruna, Spain
| | - Amparo Pastor
- Lung Transplant Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Piedad Ussetti
- Neumology Service, Puerta de Hierro-Majadahonda University Hospital, Majadahonda, Spain
| | - Julian Torre-Cisneros
- Infectious Diseases Group, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
- Spanish Network for Research in Infectious Diseases (REIPI, RD16/0016/0008), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Unit, Reina Sofía University Hospital, Cordoba, Spain
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13
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NKG2C Natural Killer Cells in Bronchoalveolar Lavage Are Associated With Cytomegalovirus Viremia and Poor Outcomes in Lung Allograft Recipients. Transplantation 2019; 103:493-501. [PMID: 30211828 DOI: 10.1097/tp.0000000000002450] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is a risk factor for chronic lung allograft dysfunction (CLAD), which limits survival in lung allograft recipients. Natural killer (NK) cells that express the NKG2C receptor mediate CMV-specific immune responses. We hypothesized that NKG2C NK cells responding to CMV in the lung allograft would reduce CMV-related inflammation and would improve CLAD-free survival. METHODS We prospectively followed 130 subjects who underwent lung transplantation from 2012 to 2016. Bronchoalveolar lavage (BAL) NK cells were immunophenotyped for NKG2C, maturation, and proliferation markers. CMV viral load, serologies, serial spirometry, and mortality were recorded from medical records. Natural killer cell subset association with CMV endpoints were made using generalized estimating equation-adjusted linear models. BAL NKG2C NK cell association with CLAD-free survival was assessed by Cox proportional hazards modeling. RESULTS NKG2C NK cells were more mature and proliferative than NKG2C NK cells and represented a median of 7.8% of BAL NK cells. The NKG2C NK cell proportion increased prior to the first detection of viremia and was nearly tripled in subjects with high level viremia (>1000 copies/mL) compared with no detected viremia. Subjects with increased BAL NKG2C NK cells, relative to the median, had a significantly increased risk for CLAD or death (hazard ratio, 4.2; 95% confidence interval, 1.2-13.3). CONCLUSIONS The BAL NKG2C NK cell proportion may be a relevant biomarker for assessing risk of CMV viremia and quantifying potential CMV-related graft injury that can lead to CLAD or death.
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14
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Steensels D, Reynders M, Descheemaeker P, Curran MD, Hites M, Etienne I, Montesinos I. Epidemiology and clinical impact of viral, atypical, and fungal respiratory pathogens in symptomatic immunocompromised patients: a two-center study using a multi-parameter customized respiratory Taqman® array card. Eur J Clin Microbiol Infect Dis 2019; 38:1507-1514. [PMID: 31111372 PMCID: PMC7087587 DOI: 10.1007/s10096-019-03579-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 05/01/2019] [Indexed: 11/24/2022]
Abstract
The prevalence of respiratory viruses in immunocompromised adult patients and the association with clinical outcomes is still underexplored. Our goal was to assess the epidemiology and the potential clinical impact of respiratory viral infections in a high-risk patient population. Two large hospitals performed a respiratory Taqman array card (TAC), targeting 24 viruses, 8 bacteria, and 2 fungi simultaneously, on 435 samples from 397 symptomatic immunocompromised patients. Clinical details were collected retrospectively using a structured case report form. An overall positivity rate of 68% was found (51% mono- and 17% co-infections). Pathogen distribution was as follows: influenza A (20.7%), rhinoviruses (15.2%), coronaviruses (7.8%), Pneumocystis jirovecii (7.4%), RSV (7.1%), and CMV (6.0%) were the most frequently encountered, followed by HSV (5.5%), hMPV (4.4%), parainfluenza viruses (3.9%), influenza B (3.7%), and Aspergillus species (3.7%). Other pathogens were not detected or detected only in ≤ 1% of samples. Hospital and ICU admission rates were 84% and 11%, respectively. The presence of a pathogen was strongly associated with higher need for supplemental oxygen (p = 0.001), but it had no impact on ICU admission, mechanical ventilation requirement, antibacterial therapy, or mortality. In conclusion, our study described the epidemiology of respiratory pathogens in a large group of symptomatic immunocompromised patients and provides evidence of a relationship between pathogen detection and the need for supplemental oxygen. This association was still found after the exclusion of the results positive for influenza viruses, suggesting that non-influenza viruses contribute to severe respiratory illness in patients with compromised immunity.
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Affiliation(s)
- Deborah Steensels
- Department of Clinical Microbiology, CUB-Erasme, Université Libre de Bruxelles, Brussels, Belgium.
| | - Marijke Reynders
- Department of Clinical Microbiology, AZ St-Jan Brugge-Oostende Hospital, Bruges, Belgium
| | - Patrick Descheemaeker
- Department of Clinical Microbiology, AZ St-Jan Brugge-Oostende Hospital, Bruges, Belgium
| | - Martin D Curran
- Public Health England, Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge, UK
| | - Maya Hites
- Department of Infectious Diseases, CUB-Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Isabelle Etienne
- Department of Pulmonology - Pulmonary Transplant, CUB-Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Isabel Montesinos
- Department of Clinical Microbiology, CUB-Erasme, Université Libre de Bruxelles, Brussels, Belgium
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15
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Kabbani D, Hirji A, Hernandez C, Malhi H, Mabilangan C, Chandrarathne S, Halloran K, Weinkauf J, Kapasi A, Lien D, Preiksaitis J, Cervera C. High incidence of clinically significant cytomegalovirus infection in CMV D+/R+ lung transplant recipients receiving 3 months of antiviral prophylaxis. Transpl Infect Dis 2019; 21:e13094. [PMID: 30985048 DOI: 10.1111/tid.13094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/27/2019] [Accepted: 03/31/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Universal antiviral prophylaxis is the preferred preventive strategy for lung transplant recipients (LTRs) at risk of CMV infection. We compared the risk of CMV infection between CMV D+/R + and D-/R + LTRs after 3 months of prophylaxis. METHODS This was a retrospective review of CMV R + LTRs transplanted between 2005 and 2013. Patients dying before completing 3 months, or receiving >180 days of prophylaxis were excluded. The primary outcome was proportion of LTRs who developed CMV infection and clinically significant CMV infection defined as CMV infection leading to preemptive therapy or CMV disease. RESULTS We analyzed 90 D+/R + and 72 D-/R + with a median follow up of 730 days. CMV infection and disease was more common in D+/R + compared to D-/R+ (CMV infection 66% vs 40%; P = 0.001; CMV disease 13% vs 4% P = 0.045). Fifty-nine patients developed at least one episode of clinically significant CMV infection (41/90 [46%] D+/R + and 18/72 [25%] D-/R + P=0.007) with recurrence occurring in 29 LTRs (49% of patients with previous CMV infection), of which 22 (76%) were CMV D+/R+. Thirty percent had side effects related to CMV therapy. CONCLUSION Three months prophylaxis in D+/R + LTRs was associated with high rates of clinically significant CMV infection and recurrences.
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Affiliation(s)
- Dima Kabbani
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
| | - Alim Hirji
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Cristina Hernandez
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
| | - Harjot Malhi
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Curtis Mabilangan
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
| | - Sanjaya Chandrarathne
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kieran Halloran
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Justin Weinkauf
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ali Kapasi
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Dale Lien
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jutta Preiksaitis
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
| | - Carlos Cervera
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
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16
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Gudiol C, Sabé N, Carratalà J. Is hospital-acquired pneumonia different in transplant recipients? Clin Microbiol Infect 2019; 25:1186-1194. [PMID: 30986554 DOI: 10.1016/j.cmi.2019.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 12/25/2022]
Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are serious complications in transplant patients. The aim of this review is to summarize the evidence regarding nosocomial pneumonia in transplant recipients, including HAP in non-ventilated patients and VAP, and to identify future directions for improvement.A comprehensive literature search in the PubMed/MEDLINE database was performed. Articles written in English and published between 1990 and November 2018 were included. HAP/VAP in transplant patients usually occurs early post-transplant, particularly during neutropenia in haematopoietic stem cell transplant recipients. Bacteria are the leading cause of nosocomial pneumonia for both immunocompetent and transplant recipients, being Gram negative organisms, and especially Pseudomonas aeruginosa, highly prevalent. Multidrug-resistant bacteria are of special concern. Pneumonia in the transplant setting may be caused by opportunistic pathogens, and the differential diagnosis needs to be extended to other non-infectious complications. The most relevant opportunistic pathogens are Aspergillus fumigatus, Pneumocystis jirovecii and cytomegalovirus. Nevertheless, they are an exceptional cause of nosocomial pneumonia, and usually occur in severely immunosuppressed patients not receiving antimicrobial prophylaxis. Performing bronchoalveolar lavage may improve the rate of aetiological diagnosis, leading to a change in therapeutic management and improved outcomes. The optimal length of antibiotic therapy for bacterial HAP/VAP has not been well defined, but it should perhaps be longer than in the general population. Mortality associated with HAP/VAP is high. HAP/VAP in transplant patients is frequent and is associated with increased mortality. There is room for improvement in gaining knowledge about the management of HAP/VAP in this population.
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Affiliation(s)
- C Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Spain; REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
| | - N Sabé
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Spain; REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
| | - J Carratalà
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Spain; REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain.
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17
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Ono G, Medina Pestana JO, Aranha Camargo LF. Late cytomegalovirus (CMV) infections after kidney transplantation under the preemptive strategy: Risk factors and clinical aspects. Transpl Infect Dis 2018; 21:e13035. [PMID: 30548901 DOI: 10.1111/tid.13035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/14/2018] [Accepted: 11/23/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Late cytomegalovirus infections (LCMV) after the cessation of prophylaxis are well described. We aimed to assess clinical and epidemiological data on late-occurring cytomegalovirus (CMV) infections in the absence of CMV prophylaxis in a cohort of kidney transplant patients. METHODS In a cohort of kidney transplant recipients not employing CMV-specific prophylaxis, patients with CMV infections occurring after 6 months of transplantation were compared to patients with CMV infections diagnosed within the first 6 months (early infections). The main objectives were to compare clinical outcomes and evaluate risk factors for late CMV infection. RESULTS A total of 556 patients were evaluated. Forty-three patients with LCMV infections were compared to 513 patients with early CMV infections. LCMV infections occurred after a median of 473 days of transplantation and had a more severe course, with a statistically significant higher rate of invasive disease and graft loss (60.5% vs 21.6% and 11.6% vs 3.1% respectively). Thirty-day mortality was twice as high for patients with LCMV, but did not reach statistical significance (9.3% vs 4.3%). By multivariate analysis, employment of antilymphocyte therapy early after transplantation and tacrolimus as initial immunosuppressive therapy were significantly protective for the occurrence of LCMV infections. CONCLUSION Late CMV infections in the absence of specific prophylaxis after kidney transplantation have a more severe outcome when compared to early infections and occur in patients less immunosuppressed early after transplantation.
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Affiliation(s)
- Gislaine Ono
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
| | - José Osmar Medina Pestana
- Department of Medicine, Head of transplant division Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
| | - Luís Fernando Aranha Camargo
- Division of Infectious Diseases, Department of Medicine, Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil
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Britt WJ, Prichard MN. New therapies for human cytomegalovirus infections. Antiviral Res 2018; 159:153-174. [PMID: 30227153 DOI: 10.1016/j.antiviral.2018.09.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/28/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
Abstract
The recent approval of letermovir marks a new era of therapy for human cytomegalovirus (HCMV) infections, particularly for the prevention of HCMV disease in hematopoietic stem cell transplant recipients. For almost 30 years ganciclovir has been the therapy of choice for these infections and by today's standards this drug exhibits only modest antiviral activity that is often insufficient to completely suppress viral replication, and drives the selection of drug-resistant variants that continue to replicate and contribute to disease. While ganciclovir remains the therapy of choice, additional drugs that inhibit novel molecular targets, such as letermovir, will be required as highly effective combination therapies are developed not only for the treatment of immunocompromised hosts, but also for congenitally infected infants. Sustained efforts, largely in the biotech industry and academia, have identified additional highly active lead compounds that have progressed into clinical studies with varying levels of success and at least two have the potential to be approved in the near future. Some of the new drugs in the pipeline inhibit new molecular targets, remain effective against isolates that have developed resistance to existing therapies, and promise to augment existing therapeutic regimens. Here, we will describe some of the unique features of HCMV biology and discuss their effect on therapeutic needs. Existing drugs will also be discussed and some of the more promising candidates will be reviewed with an emphasis on those progressing through clinical studies. The in vitro and in vivo antiviral activity, spectrum of antiviral activity, and mechanism of action of new compounds will be reviewed to provide an update on potential new therapies for HCMV infections that have progressed significantly in recent years.
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Affiliation(s)
- William J Britt
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham AL 35233-1711, USA
| | - Mark N Prichard
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham AL 35233-1711, USA.
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Cytomegalovirus Viral Load in Bronchoalveolar Lavage to Diagnose Lung Transplant Associated CMV Pneumonia. Transplantation 2018; 102:326-332. [PMID: 28846557 DOI: 10.1097/tp.0000000000001927] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diagnostic yield for cytomegalovirus (CMV) polymerase chain reaction (PCR) viral load in bronchoalveolar lavage (BAL) or in plasma to diagnose CMV pneumonia in lung transplant recipients remains uncertain and was investigated in a large cohort of consecutive lung transplant recipients. METHODS Bronchoscopies within the first year of lung transplantation with CMV detectable in BAL by PCR (ie, viral load, ≥273 IU/mL) were included (66 recipients; 145 bronchoscopies); at each bronchoscopy episode, 2 independent experts reviewed clinical and laboratory information to determine whether the patient at that time fulfilled the criteria for CMV pneumonia per current international recommendations. Corresponding plasma CMV PCR viral load determined at time of the bronchoscopy (n = 126) was also studied. Optimal CMV PCR viral load cutoff for CMV pneumonia diagnosis was determined using receiver operating characteristics. RESULTS CMV was detected in BAL with CMV PCR in 145 episodes, and 34 (23%) of these episodes fulfilled the criteria for CMV pneumonia. The area under the curve-receiver operating characteristics for CMV in BAL was 90% at the optimum cutoff (4545 IU/mL) with a corresponding sensitivity of 91% and specificity of 77% (in plasma the corresponding values were 274 IU/mL, 63% and 76%, respectively). CONCLUSIONS CMV PCR viral load in BAL had a high performance to diagnose CMV pneumonia in lung transplant recipients; plasma CMV viral load did not reliably aid as a diagnostic tool.
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20
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Mabilangan C, Preiksaitis J, Cervera C. Impact of donor and recipient cytomegalovirus serology on long-term survival of lung transplant recipients. Transpl Infect Dis 2018; 20:e12964. [PMID: 29981174 DOI: 10.1111/tid.12964] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/27/2018] [Accepted: 06/30/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pre-transplant cytomegalovirus (CMV) serostatus has been associated with lung transplant patient survival. We retrospectively analyzed the relationship between pre-transplant donor/recipient CMV serostatus and long-term mortality in a cohort of lung transplant recipients at our center. METHOD Adult (Age >17 years) lung recipients transplanted between July 1985-December 2015 were analyzed. Variables included age, sex, pre-transplant donor (D)/recipient (R) serostatus [D-/R-, D-/R+, D+/R+, D+/R-], CMV infection within 2 years of transplant and transplant eras divided by changes in CMV prevention strategies: Era 1 (pre-ganciclovir, July 1985-April 1998), Era 2 (oral ganciclovir, May 1998-December 2004), Era 3 (valganciclovir, January 2005-December 2015). Survival analysis and Cox regression were performed at 10 years. RESULTS A total of 652 lung recipients were analyzed. Twenty percent were CMV mismatched pre-transplant and 45% had CMV infection within 2 years post-transplant. Survival at 10 years appeared worse in D+ transplants (P = 0.027). D-/R- lungs did not have significantly different survival across eras (P = 0.76), but survival of D-/R+, D+/R+, D+/R- lungs improved (P < 0.001). Cox regression revealed that transplantation in the valganciclovir era reduced risk of death in lung transplants by an estimated 52% (P < 0.001) compared to transplantation in the pre-ganciclovir era after controlling for age at transplant, D/R CMV serostatus and CMV infection. Age at transplant and CMV infection were also significant predictors of mortality in lung transplants (P < 0.001 and 0.033 respectively). CONCLUSION Our review of the impact of CMV managed differently across eras suggests in lung transplantation there is no independent influence of D/R CMV serostatus on 10-year survival.
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Affiliation(s)
- Curtis Mabilangan
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jutta Preiksaitis
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Carlos Cervera
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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21
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Jaamei N, Koutsokera A, Pasquier J, Mombelli M, Meylan P, Pascual M, Aubert JD, Manuel O. Clinical significance of post-prophylaxis cytomegalovirus infection in lung transplant recipients. Transpl Infect Dis 2018; 20:e12893. [PMID: 29603543 DOI: 10.1111/tid.12893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 12/16/2022]
Abstract
Cytomegalovirus (CMV) disease has been associated with the development of chronic lung allograft dysfunction (CLAD) after transplantation. However, the relevance of CMV replication occurring after the discontinuation of antiviral prophylaxis on the development of CLAD has not been fully established. Patients who underwent lung transplantation during 2004-2014 were included. All patients received antiviral prophylaxis for 3-6 months, followed by monitoring of CMV replication during the first year post-transplantation (preemptive therapy). Risk factors for the development of CLAD were assessed by Cox models. A linear regression model with an interaction coefficient between time and CMV infection was used to evaluate the influence of CMV infection on the evolution of FEV1 . Overall, 69 patients were included, 30/69 (43%) patients developed at least 1 episode of significant CMV infection, and 8/69 (11.5%) patients developed CMV disease. After a median follow-up of 3.67 years, 25/69 (36%) patients developed CLAD and 14/69 (20%) patients died. In the univariate Cox analysis, significant CMV infection (HR 1.177, P = .698), CMV disease (HR 1.001, P = .998), and duration of CMV replication (HR 1.004, P = .758) were not associated with CLAD. Only bacterial pneumonia tended to be associated with CLAD in the multivariate model (HR 2.579, P = .062). We did not observe a significant interaction between CMV replication and evolution FEV1 (interaction coefficient 0.006, CI 95% [-0.084 to 0.096], P = .890). In this cohort of lung transplant recipients receiving antiviral prophylaxis and monitored by preemptive therapy post-prophylaxis, CMV infection did not have impact on long-term allograft lung function.
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Affiliation(s)
- Nikta Jaamei
- Transplantation Center, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Angela Koutsokera
- Division of Pneumology, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jérôme Pasquier
- Institute for Social and Preventive Medicine, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Matteo Mombelli
- Transplantation Center, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland.,Infectious Diseases Service, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Pascal Meylan
- Infectious Diseases Service, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Manuel Pascual
- Transplantation Center, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - John-David Aubert
- Transplantation Center, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland.,Division of Pneumology, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Oriol Manuel
- Transplantation Center, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland.,Infectious Diseases Service, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
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22
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Liang X, Famure O, Li Y, Kim SJ. Incidence and Risk Factors for Leukopenia in Kidney Transplant Recipients Receiving Valganciclovir for Cytomegalovirus Prophylaxis. Prog Transplant 2018; 28:124-133. [DOI: 10.1177/1526924818765798] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Context: Valganciclovir is used not only for cytomegalovirus prophylaxis after kidney transplantation but can also induce leukopenia, thereby making patients more susceptible to other infections. The epidemiology of leukopenia in patients on valganciclovir remains poorly understood. Objective: To determine the incidence and risk factors for leukopenia in patients receiving valganciclovir for cytomegalovirus prophylaxis after kidney transplantation. Methods: In this single-center, retrospective, cohort study, we included kidney recipients transplanted from January 1, 2003, to December 31, 2010, to determine the incidence and risk factors for leukopenia in patients who received valganciclovir for cytomegalovirus prophylaxis. The Kaplan-Meier product limit method was used to graphically assess time to leukopenia, and risk factors were assessed using Cox proportional hazards models. Results: A total of 542 kidney transplant recipients were included in the study cohort. The cumulative incidence of leukopenia at 6 months posttransplant was 39.3% (11.0% for neutropenia). Low baseline white blood cell count (hazard ratio [HR] 2.34 [95% confidence interval [CI], 1.37-4.00]) and high baseline body mass index (HR 1.05 [95% CI, 1.02-1.09]) were independently associated with an increased risk of leukopenia, while higher Cockcroft-Gault creatinine clearance (HR 0.87 [95% CI, 0.78-0.97]) was significantly associated with a decreased risk of leukopenia. Conclusions: These data suggest that recipient baseline white blood cell count, baseline body mass index, and kidney function are clinical predictors of new-onset leukopenia after kidney transplantation. Our results may inform the approach to cytomegalovirus prophylaxis to reduce the risk of valganciclovir-induced leukopenia in kidney transplant recipients.
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Affiliation(s)
- Xinyun Liang
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Olusegun Famure
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Yanhong Li
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - S. Joseph Kim
- Multi-Organ Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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23
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Shnayder M, Nachshon A, Krishna B, Poole E, Boshkov A, Binyamin A, Maza I, Sinclair J, Schwartz M, Stern-Ginossar N. Defining the Transcriptional Landscape during Cytomegalovirus Latency with Single-Cell RNA Sequencing. mBio 2018; 9:e00013-18. [PMID: 29535194 PMCID: PMC5850328 DOI: 10.1128/mbio.00013-18] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 02/13/2018] [Indexed: 12/17/2022] Open
Abstract
Primary infection with human cytomegalovirus (HCMV) results in a lifelong infection due to its ability to establish latent infection, with one characterized viral reservoir being hematopoietic cells. Although reactivation from latency causes serious disease in immunocompromised individuals, our molecular understanding of latency is limited. Here, we delineate viral gene expression during natural HCMV persistent infection by analyzing the massive transcriptome RNA sequencing (RNA-seq) atlas generated by the Genotype-Tissue Expression (GTEx) project. This systematic analysis reveals that HCMV persistence in vivo is prevalent in diverse tissues. Notably, we find only viral transcripts that resemble gene expression during various stages of lytic infection with no evidence of any highly restricted latency-associated viral gene expression program. To further define the transcriptional landscape during HCMV latent infection, we also used single-cell RNA-seq and a tractable experimental latency model. In contrast to some current views on latency, we also find no evidence for any highly restricted latency-associated viral gene expression program. Instead, we reveal that latency-associated gene expression largely mirrors a late lytic viral program, albeit at much lower levels of expression. Overall, our work has the potential to revolutionize our understanding of HCMV persistence and suggests that latency is governed mainly by quantitative changes, with a limited number of qualitative changes, in viral gene expression.IMPORTANCE Human cytomegalovirus is a prevalent pathogen, infecting most of the population worldwide and establishing lifelong latency in its hosts. Although reactivation from latency causes significant morbidity and mortality in immunocompromised hosts, our molecular understanding of the latent state remains limited. Here, we examine the viral gene expression during natural and experimental latent HCMV infection on a transcriptome-wide level. In contrast to the classical views on herpesvirus latency, we find no evidence for a restricted latency-associated viral gene expression program. Instead, we reveal that latency gene expression largely resembles a late lytic viral profile, albeit at much lower levels of expression. Taken together, our data transform the current view of HCMV persistence and suggest that latency is mainly governed by quantitative rather than qualitative changes in viral gene expression.
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Affiliation(s)
- Miri Shnayder
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot, Israel
| | - Aharon Nachshon
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot, Israel
| | - Benjamin Krishna
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Emma Poole
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Alina Boshkov
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot, Israel
| | - Amit Binyamin
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot, Israel
| | - Itay Maza
- Department of Gastroenterology, Rambam Health Care Campus and Bruce Rappaport School of Medicine, Technion, Institute of Technology, Haifa, Israel
| | - John Sinclair
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Michal Schwartz
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot, Israel
| | - Noam Stern-Ginossar
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot, Israel
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25
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Hakimi Z, Aballéa S, Ferchichi S, Scharn M, Odeyemi IA, Toumi M, Saliba F. Burden of cytomegalovirus disease in solid organ transplant recipients: a national matched cohort study in an inpatient setting. Transpl Infect Dis 2017; 19. [PMID: 28599091 DOI: 10.1111/tid.12732] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 03/09/2017] [Accepted: 03/19/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND We investigated the impact of early- (E-CMV) and late onset (L-CMV) cytomegalovirus disease on the probability of graft rejection, graft failure, mortality, and healthcare resource use, following solid organ transplantation (SOT) in France. METHODS A retrospective analysis of data from the French 'Programme de Médicalisation des Systèmes d'Information' database (2007-2011) was conducted to identify SOT recipients who developed CMV disease in an inpatient setting. Recipients were stratified by time to CMV disease onset: E-CMV (≤3 months), L-CMV-3M (>3-24 months), and L-CMV-6M (>6-24 months). Data were analyzed by comparing recipients with CMV disease or without (controls) in a 1:2 ratio, matched according to age, gender, target organ, and previous/simultaneous occurrence of graft rejection. Graft failure, graft rejection, all-cause in-hospital mortality, and resource utilization (including hospitalization costs) were assessed over 12 months following CMV disease diagnosis. RESULTS Among 20 473 SOT recipients, 2430 (11.86%) were reported to have CMV disease within 24 months after transplantation. CMV disease was significantly associated with an increased risk of graft rejection and mortality, as indicated by logistic regression analysis. Odd ratios (ORs) for the risk of graft rejection were E-CMV=1.43, L-CMV-3M=1.50, and L-CMV-6M=1.61 (all P<.05), while ORs for mortality were E-CMV=2.85, L-CMV-3M=4.22, and L-CMV-6M=4.77 (all P<.0001). Only L-CMV was significantly correlated with a higher risk of graft failure: E-CMV=1.18 (P=.1906), L-CMV-3M=1.77 (P=.0013), and L-CMV-6M=3.12 (P<.0001). Hospitalization costs increased by €7078 (range €6270-€22 111), €6523 (range €5328-€10 295), and €6311 (range €5295-€9184) in recipients with E-CMV, L-CMV-3M, and L-CMV-6-M, respectively. CONCLUSION This study, based on French national data, demonstrates the considerable burden of CMV disease in SOT recipients and highlights the importance of developing new strategies to prevent and manage CMV disease and improve clinical outcomes for SOT patients.
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Affiliation(s)
- Zalmai Hakimi
- HEOR, Astellas Pharma Global Development, Leiden, The Netherlands
| | | | | | - Micky Scharn
- HEOR, Astellas Pharma Global Development, Leiden, The Netherlands
| | | | - Mondher Toumi
- Research Unit 3279, Aix-Marseille University, Marseille, France
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse - Centre Hépato-Biliaire, Villejuif, France
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26
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Almaghrabi RS, Omrani AS, Memish ZA. Cytomegalovirus infection in lung transplant recipients. Expert Rev Respir Med 2017; 11:377-383. [PMID: 28388307 DOI: 10.1080/17476348.2017.1317596] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality in solid organ transplant (SOT) patients. Lung transplant recipients are particularly at risk given the intense immunosuppression required. Areas covered: The Detailed review of the literature related to CMV infection, its direct and indirect effect on lung allograft function, as well as diagnosis, immune monitoring, treatment options and prevention strategies. Expert commentary: In lung transplant recipients, CMV infection is associated with pro-inflammatory and immune inhibitory effects that increase the risk of graft dysfunction and loss. Diagnosis of CMV infection remains challenging. Treatment options remain relatively limited.
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Affiliation(s)
- Reem S Almaghrabi
- a Section of Infectious Diseases, Department of Medicine , King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia
| | - Ali S Omrani
- a Section of Infectious Diseases, Department of Medicine , King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia
| | - Ziad A Memish
- b Director Research Department , Prince Mohammed Bin Abdulaziz Hospital, Ministry of Health , Riyadh , Saudi Arabia.,c College of Medicine, Alfaisal University , Riyadh , Saudi Arabia.,d Hubert Department of Global Health, Rollins School of Public Health , Emory University , Atlanta , USA
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27
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Gordon CL, Miron M, Thome JJC, Matsuoka N, Weiner J, Rak MA, Igarashi S, Granot T, Lerner H, Goodrum F, Farber DL. Tissue reservoirs of antiviral T cell immunity in persistent human CMV infection. J Exp Med 2017; 214:651-667. [PMID: 28130404 PMCID: PMC5339671 DOI: 10.1084/jem.20160758] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/29/2016] [Accepted: 12/15/2016] [Indexed: 01/22/2023] Open
Abstract
T cell responses to viruses are initiated and maintained in tissue sites; however, knowledge of human antiviral T cells is largely derived from blood. Cytomegalovirus (CMV) persists in most humans, requires T cell immunity to control, yet tissue immune responses remain undefined. Here, we investigated human CMV-specific T cells, virus persistence and CMV-associated T cell homeostasis in blood, lymphoid, mucosal and secretory tissues of 44 CMV seropositive and 28 seronegative donors. CMV-specific T cells were maintained in distinct distribution patterns, highest in blood, bone marrow (BM), or lymph nodes (LN), with the frequency and function in blood distinct from tissues. CMV genomes were detected predominantly in lung and also in spleen, BM, blood and LN. High frequencies of activated CMV-specific T cells were found in blood and BM samples with low virus detection, whereas in lung, CMV-specific T cells were present along with detectable virus. In LNs, CMV-specific T cells exhibited quiescent phenotypes independent of virus. Overall, T cell differentiation was enhanced in sites of viral persistence with age. Together, our results suggest tissue T cell reservoirs for CMV control shaped by both viral and tissue-intrinsic factors, with global effects on homeostasis of tissue T cells over the lifespan.
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Affiliation(s)
- Claire L Gordon
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032.,Department of Medicine, Columbia University Medical Center, New York, NY 10032
| | - Michelle Miron
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032.,Department of Microbiology and Immunology, Columbia University Medical Center, New York, NY 10032
| | - Joseph J C Thome
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032.,Department of Microbiology and Immunology, Columbia University Medical Center, New York, NY 10032
| | - Nobuhide Matsuoka
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032
| | - Joshua Weiner
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032
| | - Michael A Rak
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721
| | - Suzu Igarashi
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721
| | - Tomer Granot
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032
| | | | - Felicia Goodrum
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721
| | - Donna L Farber
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY 10032 .,Department of Microbiology and Immunology, Columbia University Medical Center, New York, NY 10032.,Department of Surgery, Columbia University Medical Center, New York, NY 10032
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28
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Bontà J, Zeitz J, Frei P, Biedermann L, Sulz MC, Vavricka SR, Scharl S, Fried M, Rogler G, Scharl M. Cytomegalovirus disease in inflammatory bowel disease: epidemiology and disease characteristics in a large single-centre experience. Eur J Gastroenterol Hepatol 2016; 28:1329-34. [PMID: 27482785 DOI: 10.1097/meg.0000000000000716] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) show an increased risk of developing cytomegalovirus (CMV) disease because of immunosuppressive medication and malnutrition. Here, we aimed to investigate the prevalence and clinical characteristics of CMV disease in our cohort of IBD patients. PATIENTS AND METHODS We carried out a retrospective analysis of 1023 IBD patients treated at our IBD clinic at the University Hospital Zurich between 2007 and 2014. CMV disease was defined as a positive immunohistochemistry for CMV and 14 patients were identified. RESULTS The prevalence of CMV disease in our IBD cohort was 1.37%. Twelve patients had ulcerative colitis and two had Crohn's disease with colonic involvement. All patients who developed CMV disease received immunosuppressive medication or, as in one case, had HIV infection. The most used immunosuppressive medications were steroids and azathioprine. The most common therapeutic strategy was the consecutive use of ganciclovir and valganciclovir. Ten patients recovered and two were treatment refractory; among these, one required colectomy and two had a relapse. CONCLUSION CMV disease may influence the clinical course of IBD. There is probably an association between CMV disease and IBD-specific medication. Risk factors, epidemiology and therapeutic strategy need to be further investigated.
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Affiliation(s)
- Jonas Bontà
- aDivision of Gastroenterology and Hepatology, University Hospital Zurich bZurich Center for Integrative Human Physiology, University of Zurich cDivision of Gastroenterology and Hepatology, Triemli Hospital dDivision of Gastroenterology and Hepatology, Clinic Bethanien, Zurich eDivision of Gastroenterology and Hepatology, Kantonsspital St Gallen, Switzerland
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29
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Kaminski H, Couzi L, Garrigue I, Moreau JF, Déchanet-Merville J, Merville P. Easier Control of Late-Onset Cytomegalovirus Disease Following Universal Prophylaxis Through an Early Antiviral Immune Response in Donor-Positive, Recipient-Negative Kidney Transplants. Am J Transplant 2016; 16:2384-94. [PMID: 26953216 DOI: 10.1111/ajt.13781] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 02/07/2016] [Accepted: 02/25/2016] [Indexed: 01/25/2023]
Abstract
Universal prophylaxis for cytomegalovirus (CMV) prevention is viable but, compared with a preemptive strategy, leads to higher incidence of late-onset disease (LOD) associated with poor patient and graft survival. The purpose of this study was to compare LOD with early onset disease (EOD), with a focus on the highest risk kidney transplant recipients (KTRs): CMV seronegative recipients transplanted from seropositive donors (D+R-). Since CMV control depends on both antiviral treatment and specific immune response, we also compared Vδ2-negative (Vδ2(neg) ) γδ T cell expansion involved in CMV infection resolution. EOD was defined as occurring <3 mo and LOD as occurring >3 mo after transplantation. Depending on the period, universal prophylaxis or preemptive treatment was used. Overall, 168 D+R- KTRs were included between 2003 and 2011. LOD was associated with a lower peak DNAemia (p = 0.04), fewer recurrences (odds ratio 0.16; 95% confidence interval 0.05-0.55; p = 0.01) and shorter anti-CMV curative treatment (40 vs. 60 days, p < 0.0001). As a corollary, we found that Vδ2(neg) γδ T cell expansion was faster in LOD than in EOD (31 vs. 168 days after the beginning of CMV disease, p < 0.0001). In D+R- KTRs, universal prophylaxis is associated with more LOD, which had better infection management and a faster immune response. These results support the use of universal prophylaxis over a preemptive strategy and reappraise outcomes of LOD.
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Affiliation(s)
- H Kaminski
- Department of Nephrology, Transplantation and Dialysis, Bordeaux, France
| | - L Couzi
- Department of Nephrology, Transplantation and Dialysis, Bordeaux, France.,National Center of Scientific Research (CNRS), Research Unit 5234, Bordeaux, France
| | - I Garrigue
- Virology Laboratory, Bordeaux, France.,National Center of Scientific Research, Mix Unit of Research 5164, Bordeaux, France
| | - J-F Moreau
- National Center of Scientific Research (CNRS), Research Unit 5234, Bordeaux, France.,Immunology Laboratory, Pellegrin Hospital, Bordeaux, France
| | - J Déchanet-Merville
- National Center of Scientific Research (CNRS), Research Unit 5234, Bordeaux, France
| | - P Merville
- Department of Nephrology, Transplantation and Dialysis, Bordeaux, France.,National Center of Scientific Research (CNRS), Research Unit 5234, Bordeaux, France
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30
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Tejwani V, Panchabhai TS, Kotloff RM, Mehta AC. Complications of Lung Transplantation. Chest 2016; 149:1535-45. [DOI: 10.1016/j.chest.2015.12.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 11/16/2015] [Accepted: 12/11/2015] [Indexed: 01/30/2023] Open
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