1
|
Aoki Y, Hamasaki Y, Hashimoto J, Zaitsu A, Suda S, Itabashi Y, Muramatsu M, Kawamura T, Shishido S, Sakai K. Comparison of preemptive and non-preemptive kidney transplantation outcomes in children aged <6 years. Medicine (Baltimore) 2024; 103:e38649. [PMID: 38905378 PMCID: PMC11191949 DOI: 10.1097/md.0000000000038649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/30/2024] [Indexed: 06/23/2024] Open
Abstract
We aimed to compare the outcomes of pediatric kidney transplantation (KT) between preemptive KT (PEKT) and non-PEKT in children aged < 6 years. Seventy-four pediatric recipients aged < 6 years who underwent KT were divided into the PEKT and non-PEKT groups. They were retrospectively evaluated for patient and graft survival, graft function, growth, and cytomegalovirus (CMV) infection. Comparison of the groups (PEKT, n = 14; non-PEKT, n = 60) revealed no significant differences between them in terms of distribution of sex, age, weight, primary disease, or population of pre-transplant CMV immunoglobulin G-positive patients. The median estimated glomerular filtration rate before KT in the PEKT and non-PEKT groups was 11.4 and 7.3 (mL/min/1.73 m2) (P < .001), respectively, and the median duration of dialysis was 2.7 years in the non-PEKT group. Graft survival at 5 years was 100% and 95% in the PEKT and non-PEKT groups, respectively (P = .634). One patient in the non-PEKT group had vascular complications, with subsequent early graft loss. Incidence of CMV infection was significantly lower in the PEKT group (P = .044). There were no significant differences in post-transplant estimated glomerular filtration rate, acute rejection, or growth. The height standard deviation score showed catch-up growth after KT in both groups. There was no significant difference in transplant outcomes in recipients aged < 6 years, with or without pre-transplant dialysis, except for the incidence of CMV infection. Therefore, PEKT in younger children should be performed aggressively by experienced multi-disciplinary teams.
Collapse
Affiliation(s)
- Yujiro Aoki
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Junya Hashimoto
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Ayuko Zaitsu
- Department of Pediatrics, Public Yame General Hospital, Fukuoka, Japan
| | - Shiho Suda
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yoshihiro Itabashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Masaki Muramatsu
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Takeshi Kawamura
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| |
Collapse
|
2
|
Kotton CN, Kamar N, Wojciechowski D, Eder M, Hopfer H, Randhawa P, Sester M, Comoli P, Tedesco Silva H, Knoll G, Brennan DC, Trofe-Clark J, Pape L, Axelrod D, Kiberd B, Wong G, Hirsch HH. The Second International Consensus Guidelines on the Management of BK Polyomavirus in Kidney Transplantation. Transplantation 2024:00007890-990000000-00727. [PMID: 38605438 DOI: 10.1097/tp.0000000000004976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
BK polyomavirus (BKPyV) remains a significant challenge after kidney transplantation. International experts reviewed current evidence and updated recommendations according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Risk factors for BKPyV-DNAemia and biopsy-proven BKPyV-nephropathy include recipient older age, male sex, donor BKPyV-viruria, BKPyV-seropositive donor/-seronegative recipient, tacrolimus, acute rejection, and higher steroid exposure. To facilitate early intervention with limited allograft damage, all kidney transplant recipients should be screened monthly for plasma BKPyV-DNAemia loads until month 9, then every 3 mo until 2 y posttransplant (3 y for children). In resource-limited settings, urine cytology screening at similar time points can exclude BKPyV-nephropathy, and testing for plasma BKPyV-DNAemia when decoy cells are detectable. For patients with BKPyV-DNAemia loads persisting >1000 copies/mL, or exceeding 10 000 copies/mL (or equivalent), or with biopsy-proven BKPyV-nephropathy, immunosuppression should be reduced according to predefined steps targeting antiproliferative drugs, calcineurin inhibitors, or both. In adults without graft dysfunction, kidney allograft biopsy is not required unless the immunological risk is high. For children with persisting BKPyV-DNAemia, allograft biopsy may be considered even without graft dysfunction. Allograft biopsies should be interpreted in the context of all clinical and laboratory findings, including plasma BKPyV-DNAemia. Immunohistochemistry is preferred for diagnosing biopsy-proven BKPyV-nephropathy. Routine screening using the proposed strategies is cost-effective, improves clinical outcomes and quality of life. Kidney retransplantation subsequent to BKPyV-nephropathy is feasible in otherwise eligible recipients if BKPyV-DNAemia is undetectable; routine graft nephrectomy is not recommended. Current studies do not support the usage of leflunomide, cidofovir, quinolones, or IVIGs. Patients considered for experimental treatments (antivirals, vaccines, neutralizing antibodies, and adoptive T cells) should be enrolled in clinical trials.
Collapse
Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases Unit, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University Paul Sabatier, Toulouse, France
| | - David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Helmut Hopfer
- Division of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Parmjeet Randhawa
- Division of Transplantation Pathology, The Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Patrizia Comoli
- Cell Factory and Pediatric Hematology/Oncology Unit, Department of Mother and Child Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Helio Tedesco Silva
- Division of Nephrology, Hospital do Rim, Fundação Oswaldo Ramos, Paulista School of Medicine, Federal University of São Paulo, Brazil
| | - Greg Knoll
- Department of Medicine (Nephrology), University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Jennifer Trofe-Clark
- Renal-Electrolyte Hypertension Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
- Transplantation Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Lars Pape
- Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - David Axelrod
- Kidney, Pancreas, and Living Donor Transplant Programs at University of Iowa, Iowa City, IA
| | - Bryce Kiberd
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Hans H Hirsch
- Division of Transplantation and Clinical Virology, Department of Biomedicine, Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
3
|
Valencia Deray KG, Danziger-Isakov LA, Downes KJ. Current and Emerging Antiviral Agents in the Prevention and Treatment of Cytomegalovirus in Pediatric Transplant Recipients. J Pediatric Infect Dis Soc 2024; 13:S14-S21. [PMID: 38417084 PMCID: PMC10901473 DOI: 10.1093/jpids/piad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/16/2023] [Indexed: 03/01/2024]
Abstract
Despite current prophylaxis regimens, cytomegalovirus (CMV) is common in hematopoietic cell transplantation (HCT) and solid organ transplantation (SOT) and remains a significant cause of morbidity and mortality. Newer antiviral medications are reshaping the landscape for prevention and treatment of CMV DNAemia, infection, and disease. Letermovir is approved for CMV prevention in adult HCT patients and is attractive due to the absence of marrow suppression seen with ganciclovir/valganciclovir. Letermovir should not be routinely used for CMV treatment due to its low threshold for resistance. Maribavir is approved for the treatment of refractory or resistant CMV disease in HCT and SOT recipients ≥12 years of age, though it has no current role in CMV prevention. More research is needed to fully elucidate the roles, efficacy, and safety of these newer agents in prevention and treatment of CMV in pediatric transplant recipients.
Collapse
Affiliation(s)
- Kristen G Valencia Deray
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Lara A Danziger-Isakov
- Division of Infectious Disease, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kevin J Downes
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Vo HD, Mackie F, McCulloch M, Reding R. International pediatric transplant association (IPTA) guidance on developing and/or expanding pediatric solid organ transplantation programs in low- and middle-income countries. Pediatr Transplant 2024; 28:e14346. [PMID: 36468319 DOI: 10.1111/petr.14346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 06/11/2022] [Indexed: 12/11/2022]
Abstract
Pediatric solid organ transplantation (SOT) is a preferred treatment for medically suitable children with end-stage organ failure. Still, many of them have no access to transplantation owing to socioeconomic constraints or lack of transplant facilities in low- and middle-income countries (LMIC). Establishing pediatric SOT programs in LMIC offers children the opportunities to receive transplant care in more familiar home environments as well as help curtail transplant tourism and improve transplant outcomes as pediatric transplantation would be performed ethically and legally. The International Pediatric Transplant Association (IPTA) is a professional organization aiming to promote safe, ethical, and high-quality pediatric transplantation worldwide. This society paper describes major obstacles to pediatric SOT in LMIC and provides guidance on developing and/or expanding pediatric SOT programs in such countries. We also summarize available resources from the IPTA Outreach Program to help establish and support pediatric SOT programs in LMIC.
Collapse
Affiliation(s)
- Hanh D Vo
- Pediatric Gastroenterology, Hepatology, and Nutrition, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Fiona Mackie
- Paediatric Nephrology, Sydney Children's Hospital Randwick, University of New South Wales, Sydney, New South Wales, Australia
| | - Mignon McCulloch
- Pediatric Renal and Solid Organ Transplant Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Raymond Reding
- Pediatric Liver Transplant Program, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| |
Collapse
|
5
|
Moghadamnia M, Eshaghi H, Alimadadi H, Dashti-Khavidaki S. A quick algorithmic review on management of viral infectious diseases in pediatric solid organ transplant recipients. Front Pediatr 2023; 11:1252495. [PMID: 37732007 PMCID: PMC10507262 DOI: 10.3389/fped.2023.1252495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023] Open
Abstract
Pediatric solid organ transplant is a life-saving procedure for children with end-stage organ failure. Viral infections are a common complication following pediatric solid organ transplantation (SOT), which can lead to increased morbidity and mortality. Pediatric solid organ transplant recipients are at an increased risk of viral infections due to their immunosuppressed state. The most commonly encountered viruses include cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus (HSV), varicella-zoster virus (VZV), adenoviruses, and BK polyomavirus. Prevention strategies include vaccination prior to transplantation, post-transplant prophylaxis with antiviral agents, and preemptive therapy. Treatment options vary depending on the virus and may include antiviral therapy and sometimes immunosuppression modification. This review provides a Quick Algorithmic overview of prevention and treatment strategies for viral infectious diseases in pediatric solid organ transplant recipient.
Collapse
Affiliation(s)
- Marjan Moghadamnia
- Department of Pharmacotherapy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Eshaghi
- Department of Infectious Diseases, Pediatrics’ Center of Excellence, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosein Alimadadi
- Department of Gastroenterology, Children’s Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Simin Dashti-Khavidaki
- Department of Pharmacotherapy, Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
6
|
Li QY, van den Anker J, Wu YE, Hao GX, Zhao W. Optimizing ganciclovir and valganciclovir dosing regimens in pediatric patients with cytomegalovirus infection: a spotlight on therapeutic drug monitoring. Expert Rev Clin Pharmacol 2023; 16:727-739. [PMID: 36794592 DOI: 10.1080/17512433.2023.2181161] [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: 12/12/2022] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Infants and immunocompromised children with cytomegalovirus (CMV) infection have significant morbidity and mortality. Ganciclovir (GCV) and its oral prodrug valganciclovir (VGCV) are the major antiviral options of choice for the prophylaxis and treatment of CMV infection. However, with the currently recommended dosing regimens used in pediatric patients, large intra- and inter-individual variability of pharmacokinetic (PK) parameters and exposure are observed. AREAS COVERED This review describes the PK and pharmacodynamic (PD) characteristics of GCV and VGCV in pediatrics. Moreover, the role of therapeutic drug monitoring (TDM) and current clinical practice for GCV and VGCV dosing regimens optimization in pediatrics are discussed. EXPERT OPINION GCV/VGCV TDM has shown the potential value to improve the benefit/risk ratio in pediatrics when using the therapeutic ranges derived from adults. However, well-designed studies are required to evaluate the relationship of TDM with clinical outcomes. Furthermore, studies to explore the children-specific dose-response-effect relationships will be helpful to facilitate the TDM practice. In the clinical setting, optimal sampling methods such as limited sampling strategies for pediatrics can be used in TDM and intracellular ganciclovir triphosphate may be used as an alternative TDM marker.
Collapse
Affiliation(s)
- Qiu-Yue Li
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA
- Departments of Pediatrics, Pharmacology & Physiology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
- NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, Qilu Hospital of Shandong University, Shandong University, Jinan, China
| |
Collapse
|
7
|
Dulek DE, Ardura MI. "Weight-ing" for an answer on optimal valganciclovir prophylaxis dosing in pediatric solid organ transplantation recipients. Pediatr Transplant 2023; 27:e14494. [PMID: 36945839 DOI: 10.1111/petr.14494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/17/2023] [Indexed: 03/23/2023]
Affiliation(s)
- D E Dulek
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Tennessee, Nashville, USA
| | - M I Ardura
- Department of Pediatrics, Division of Infectious Diseases & Host Defense, Nationwide Children's Hospital & The Ohio State University College of Medicine, Ohio, Columbus, USA
| |
Collapse
|
8
|
Liverman R, Serluco A, Nance G, George R, Rodriguez DS, Deshpande S, Mao C, Garro R, Yildirim I. Incidence of cytomegalovirus DNAemia in pediatric kidney, liver, and heart transplant recipients: Efficacy and risk factors associated with failure of weight-based dosed valganciclovir prophylaxis. Pediatr Transplant 2023; 27:e14493. [PMID: 36945819 DOI: 10.1111/petr.14493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 01/03/2023] [Accepted: 01/17/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) is associated with morbidity and mortality in solid organ transplant recipients (SOTR). Valganciclovir (VGC) is extensively used for prophylaxis. Optimal dosing in children, risk factors for failure, and the impact of dose adjustments on CMV DNAemia is not well established. METHODS This retrospective cohort study of pediatric SOTR transplanted between 2010-2018 evaluated the epidemiology of CMV DNAemia and used Cox-regression to assess the risk factors for CMV DNAemia within one-year following SOTR. RESULTS In 393 pediatric SOTR (heart [96, 24.4%], kidney [180, 45.6%], liver [117, 29.8%]; median age 9.5 ± 0.3 years), overall CMV DNAemia incidence was 6.6/10 000 days (95%CI 5.1/10 000-7.9/10 000) and varied by organ groups: heart 8.2/10 000 days (95%CI 4.9/10 000-11.4/10 000), kidney 5.8/10 000 days (95%CI 3.9/10 000-7.8/10 000), liver 6.2/10 000 days (95%CI 3.7/10 000-8.7/10 000). CMV DNAemia was detected in 75 of 275 (27.2%) patients who received prophylaxis (40 cases occurred during prophylaxis and 35 occurred after completion of prophylaxis). The median VGC dose given according to institutional weight-based algorithm was approximately 1.5-fold lower than the manufacturer-recommended dose. This discordance was more prominent at younger age groups (3.2-fold lower in <2-year-old [100 mg versus 325 mg], 2.5-fold lower in <6-year-old [200 mg versus 447 mg]). Dose reduction due to adverse events was an independent risk factor for breakthrough CMV DNAemia (hazard ratio 2.2, 95%CI 1.2-3.8) among patients with similar age, CMV risk stratification, starting VGC dose, immunosuppressive therapy, and organ group. CONCLUSION CMV events occurred while on VGC prophylaxis. Weight-based VGC may prevent supratherapeutic VGC exposure especially in younger children. Dose reduction of VGC prophylaxis for adverse event management places patients at an increased risk for CMV DNAemia suggesting other agents with fewer adverse effects should be considered and need to be studied in children.
Collapse
Affiliation(s)
| | | | - Gwen Nance
- Joe DiMaggio Children's Hospital, Florida, Hollywood, USA
| | - Roshan George
- Children's Healthcare of Atlanta, Georgia, Atlanta, USA
- Division of Pediatric Nephrology, Emory University School of Medicine, Georgia, Atlanta, USA
| | - Dellys Soler Rodriguez
- Children's Healthcare of Atlanta, Georgia, Atlanta, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Georgia, Atlanta, USA
| | - Shriprasad Deshpande
- Division of Pediatric Cardiology, Children's National Hospital, DC, Washington, USA
| | - Chad Mao
- Division of Pediatric Cardiology, Emory University School of Medicine, Georgia, Atlanta, USA
- Sibley Heart Center Cardiology, Georgia, Atlanta, USA
| | - Rouba Garro
- Children's Healthcare of Atlanta, Georgia, Atlanta, USA
- Division of Pediatric Nephrology, Emory University School of Medicine, Georgia, Atlanta, USA
| | - Inci Yildirim
- Department of Pediatrics, Section of Infectious Diseases, Yale University, School of Medicine, Connecticut, New Haven, USA
- Department of Epidemiology of Microbial Diseases, Yale University, School of Public Health, Connecticut, New Haven, USA
- Yale Institute of Global Health, Connecticut, New Haven, USA
- Yale Center for Infection and Immunity, Connecticut, New Haven, USA
| |
Collapse
|
9
|
Balani SS, Sadiq S, Jensen CJ, Kizilbash SJ. Prevention and management of CMV infection in pediatric solid organ transplant recipients. Front Pediatr 2023; 11:1098434. [PMID: 36891229 PMCID: PMC9986459 DOI: 10.3389/fped.2023.1098434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/31/2023] [Indexed: 02/22/2023] Open
Abstract
Human cytomegalovirus (CMV) remains one of the most common opportunistic infections following solid organ transplantation in children. CMV causes morbidity and mortality through direct tissue-invasive disease and indirect immunomodulatory effects. In recent years, several new agents have emerged for the prevention and treatment of CMV disease in solid organ transplant recipients. However, pediatric data remain scarce, and many of the treatments are extrapolated from the adult literature. Controversies exist about the type and duration of prophylactic therapies and the optimal dosing of antiviral agents. This review provides an up-to-date overview of treatment modalities used to prevent and treat CMV disease in solid organ transplant (SOT) recipients.
Collapse
Affiliation(s)
- Shanthi S Balani
- Division of Nephrology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Sanober Sadiq
- Division of Nephrology, Department of Pediatrics, University of California, San Francisco, CA, United States
| | - Chelsey J Jensen
- Department of Solid Organ Transplant, University of Minnesota, Minneapolis, MN, United States
| | - Sarah J Kizilbash
- Division of Nephrology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| |
Collapse
|
10
|
Downes KJ, Sharova A, Boge CLK, Vader D, Mitrou M, Hayes M, Galetaki DM, Gianchetti L, Vella LA, Li Y. CMV infection and management among pediatric solid organ transplant recipients. Pediatr Transplant 2022; 26:e14220. [PMID: 34994041 DOI: 10.1111/petr.14220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/29/2021] [Accepted: 12/26/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is an important cause of morbidity and mortality in pediatric solid organ transplant (SOT) recipients. However, the impact of asymptomatic CMV infections (ie, DNAemia) on clinical outcomes is not well established. METHODS We performed a retrospective cohort study of children undergoing first SOT at our institution from January 2012 to June 2018. We evaluated the epidemiology of CMV infections and performed multivariable Cox regression to assess the association between CMV DNAemia without disease or CMV disease (syndrome or end-organ disease) on negative outcomes (death, re-transplantation, or moderate/severe rejection) within the first year after SOT. RESULTS Among 271 individuals, 43 (15.9%) developed ≥1 CMV infection during the first year after SOT. There were 56 unique CMV infections including 14 episodes of CMV disease. In 167 patients offered CMV prophylaxis, only 8 (4.8%) developed their first CMV DNAemia episode while on prophylaxis 32 developed CMV DNAemia after prophylaxis completion; only 1 episode of CMV disease occurred while on antiviral prophylaxis. When accounting for receipt of ATG, oral steroids, and number of immunosuppressives on a given day, CMV disease was more strongly associated with negative outcomes (Hazard Ratio (HR): 3.28, 95% CI: 0.73-14.64; p = .12) than CMV DNAemia without disease (HR 1.42, 95% CI: 0.19- 10.79; p = .74), although not to a statistically significant degree. CONCLUSIONS Most CMV infections occurred after completion of antiviral prophylaxis. CMV disease was more strongly associated with negative outcomes than asymptomatic CMV DNAemia and should be the focus of CMV prevention practices.
Collapse
Affiliation(s)
- Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna Sharova
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Craig L K Boge
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniel Vader
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marina Mitrou
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Molly Hayes
- Antimicrobial Stewardship Program, Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Despoina M Galetaki
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lauren Gianchetti
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Laura A Vella
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yun Li
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
11
|
Levi S, Davidovits M, Alfandari H, Dagan A, Borovitz Y, Bilavsky E, Landau D, Haskin O. EBV, CMV, and BK viral infections in pediatric kidney transplantation: Frequency, risk factors, treatment, and outcomes. Pediatr Transplant 2022; 26:e14199. [PMID: 34817112 DOI: 10.1111/petr.14199] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/26/2021] [Accepted: 11/06/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Improved short- and long-term outcomes of kidney transplantation have been achieved over the past decades due to improved immunosuppression. This may have increased the risk for infections and, particularly, for the viral infections: cytomegalovirus (CMV), Epstein-Barr virus (EBV), and polyoma BK virus (BKV). METHODS A retrospective review of viremic CMV, EBV, and BKV infections in pediatric renal transplant recipients treated and followed by a national referral center over a 10-year period. RESULTS Sixty-seven patients (68% males) received 68 kidney grafts (62% from living donors) during the study period; the mean follow-up period was 5.2 ± 2.4 years. Twenty-seven viremic episodes were documented (CMV: 13, EBV: 6, BKV: 8) in 24 patients (35.2%). The median time (interquartile range) to viremia post-transplant was 11 (4-38) months. The viral infection rate was significantly higher in the years 2014-2015 than in previous years (61% vs. 29%, p = .017). Compared to patients who did not develop viremia, patients with viremias were younger at the time of transplantation, were more likely to receive thymoglobulin induction pre-transplant and to develop an acute rejection. Multiple logistic regression modeling identified transplant year and recipient's age as significant risk factors for viremia. Graft outcome and eGFR at the last follow-up was similar between patients who did and did not develop viremia. CONCLUSIONS Viral infections continue to be a major cause of morbidity in pediatric kidney transplant recipients. However, with close monitoring and prompt intervention, patient and renal outcomes remain favorable.
Collapse
Affiliation(s)
- Shelly Levi
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Miriam Davidovits
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadas Alfandari
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Dagan
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Borovitz
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efraim Bilavsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pediatrics C, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Daniel Landau
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Haskin
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
12
|
Thomas AN, Nguyen PB, Miller JL, Neely SB, Lewis TV. Incidence of Cytomegalovirus DNAemia in Pediatric Post–Renal Transplant Patients Receiving Weight-Based vs Body Surface Area–Based Valganciclovir Chemoprophylaxis. J Pediatr Pharmacol Ther 2022; 27:164-171. [DOI: 10.5863/1551-6776-27.2.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
To determine the incidence of cytomegalovirus (CMV) DNAemia and disease, identify potential risk factors, and assess the safety and efficacy of weight-based valganciclovir dosing in pediatric post–renal transplant patients.
METHODS
This single-center, retrospective study included patients ≤21 years who received a kidney transplant between January 1, 2011, and November 1, 2019, with 3 to 24 months of follow-up data. Demographics and clinical characteristics were collected to assess for potential risk factors. Descriptive statistics and logistic regressions were used to determine rates of CMV DNAemia considering clinical characteristics and chemoprophylaxis.
RESULTS
Fifty-seven patients were included. The incidence of CMV DNAemia was 43.9%. Cytomegalovirus seropositive status was associated with increased risk of CMV DNAemia. Patients receiving valganciclovir for <150 days had 8.33 (95% CI, 1.68–41.29) greater odds of developing CMV DNAemia than patients receiving valganciclovir for 180 ± 30 days, p = 0.01. The median time to detectable CMV PCR after transplant was 140 days (range, 12–511 days). Cytomegalovirus DNAemia was not statistically different between those receiving weight-based vs FDA-approved valganciclovir dosing; however, patients receiving the FDA-approved dosing were more likely to develop neutropenia. Among the intermediate-risk group, the adjusted relative risk of CMV DNAemia was 0.62 (95% CI, 0.36–1.09) for those not receiving chemoprophylaxis compared with those who did.
CONCLUSIONS
Risk of CMV DNAemia is higher among patients receiving valganciclovir for <150 days. Further exploration of weight-based valganciclovir dosing for CMV chemoprophylaxis in high- and intermediate-risk post–renal transplant patients is needed to minimize adverse drug effects while maintaining efficacy.
Collapse
Affiliation(s)
- Amber N. Thomas
- Office of Experiential Education (ANT), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Phu B. Nguyen
- Pharmacy Department (PBN), OU Health, Oklahoma City, OK
| | - Jamie L. Miller
- Department of Pharmacy: Clinical and Administrative Sciences (JLM, TVL), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Stephen B. Neely
- Office of Instructional Science and Assessment (SBN), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Teresa V. Lewis
- Department of Pharmacy: Clinical and Administrative Sciences (JLM, TVL), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| |
Collapse
|
13
|
Madden I, Baudouin V, Charbit M, Ranchin B, Roussey G, Novo R, Garaix F, Decramer S, Fila M, Merieau E, Vrillon I, Zaloszyc A, Hogan J, Harambat J. National survey of prevention and management of CMV infection in pediatric kidney transplantation in comparison to clinical practice guidelines. Front Pediatr 2022; 10:1057352. [PMID: 36589153 PMCID: PMC9800817 DOI: 10.3389/fped.2022.1057352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) is one of the most frequent opportunistic infections in kidney transplant (KT) recipients and is a risk factor for patient and graft survival after KT. Center-to-center variation, optimal prevention and treatment strategies in pediatric KT are currently unknown. This survey aimed to assess current CMV prevention and treatment strategies used among French pediatric KT centers. METHODS A web-based survey was sent to all 13 French pediatric kidney transplantation centers. RESULTS Twelve (92%) centers responded to the survey. All centers used prophylaxis for the donor-positive/recipient-negative (D+/R-) group. For R + patients, 54% used prophylaxis, 37% used a pre-emptive strategy. In the low-risk group, D-/R-, 50% used a pre-emptive approach and 50% had no specific prevention strategy. The antiviral used by all centers for prophylaxis was valganciclovir (VGCV). The duration of prophylaxis varied from 3 to 7 months and the duration of viral load monitoring varied from 6 months to indefinitely. No center used a hybrid/sequential approach. For the treatment of CMV DNAemia, VGCV or intravenous GCV were used. Therapeutic drug monitoring of VGCV was performed in 5 centers (42%). Five centers reported drug resistance. Eight centers (67%) administered VGCV during the treatment of acute graft rejection. CONCLUSIONS There is uniformity in CMV management in some areas among pediatric KT centers in France but not in others which remain diverse and are not up to date with current guidelines, suggesting unnecessary variation which could be reduced with better evidence to inform practice.
Collapse
Affiliation(s)
- Iona Madden
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | | | - Marina Charbit
- Pediatric Nephrology Unit, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - Bruno Ranchin
- Pediatric Nephrology Unit, Hospices Civils de Lyon, Lyon, France
| | - Gwenaëlle Roussey
- Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
| | - Robert Novo
- Pediatric Nephrology Unit, Lille University Hospital, Lille, France
| | - Florentine Garaix
- Pediatric Nephrology Unit, AP-Hôpitaux de Marseille, Marseille, France
| | - Stéphane Decramer
- Pediatric Nephrology Unit, Toulouse University Hospital, Toulouse, France
| | - Marc Fila
- Pediatric Nephrology Unit, Montpellier University Hospital, Montpellier, France
| | - Elodie Merieau
- Pediatric Nephrology Unit, Tours University Hospital, Tours, France
| | - Isabelle Vrillon
- Pediatric Nephrology Unit, Nancy University Hospital, Nancy, France
| | - Ariane Zaloszyc
- Pediatric Nephrology Unit, Strasbourg University Hospital, Strasbourg, France
| | - Julien Hogan
- Pediatric Nephrology Unit, Robert Debré Hospital, APHP, Paris, France
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| |
Collapse
|
14
|
Valencia Deray KG, Hosek KE, Chilukuri D, Dunson JR, Spielberg DR, Swartz SJ, Spinner JA, Leung DH, Moulton EA, Munoz FM, Demmler-Harrison GJ, Bocchini CE. Epidemiology and long-term outcomes of cytomegalovirus DNAemia and disease in pediatric solid organ transplant recipients. Am J Transplant 2022; 22:187-198. [PMID: 34467658 DOI: 10.1111/ajt.16822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/08/2021] [Accepted: 08/28/2021] [Indexed: 01/25/2023]
Abstract
Despite prevention strategies, cytomegalovirus (CMV) remains a common infection in pediatric solid organ transplant recipients (SOTR). We sought to determine the frequency, associations with, and long-term outcomes of CMV DNAemia in pediatric SOTR. We performed a single-center retrospective cohort study, including 687 first time SOTR ≤21 years receiving universal prophylaxis from 2011 to 2018. Overall, 159 (23%) developed CMV DNAemia, the majority occurring after completing primary prophylaxis. CMV disease occurred in 33 (5%) SOTR, 25 (4%) with CMV syndrome and 10 (1%) with proven/probable tissue-invasive disease. CMV contributed to the death of three (0.4%) patients (all lung). High-risk (OR 6.86 [95% CI, 3.6-12.9]) and intermediate-risk (4.36 [2.3-8.2]) CMV status and lung transplantation (4.63 [2.33-9.2]) were associated with DNAemia on multivariable analysis. DNAemia was associated with rejection in liver transplant recipients (p < .01). DNAemia was not associated with an increase in graft failure, all-cause mortality, or other organ-specific poor outcomes. We report one of the lowest rates of CMV disease after SOTR, showing that universal prophylaxis is effective and should be continued. However, we observed CMV morbidity and mortality in a subset of patients, highlighting the need for research on optimal prevention strategies. This study was IRB approved.
Collapse
Affiliation(s)
- Kristen G Valencia Deray
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Kathleen E Hosek
- Department of Pediatrics, Section of Quality, Texas Children's Hospital, Houston, Texas, USA
| | - Divya Chilukuri
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jordan R Dunson
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - David R Spielberg
- Department of Pediatrics, Section of Pulmonology, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph A Spinner
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel H Leung
- Department of Pediatrics, Section of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Elizabeth A Moulton
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Flor M Munoz
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Gail J Demmler-Harrison
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Claire E Bocchini
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
15
|
Pizzo H, Shin B, Garrison J, Huang E, Malekzadeh M, Jordan SC, Puliyanda D, Toyoda M. Development of CMV-specific cytotoxic T cells (CMV-Tc) in pediatric renal transplant recipients with CMV viremia. Pediatr Transplant 2021; 25:e14119. [PMID: 34390094 DOI: 10.1111/petr.14119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/09/2021] [Accepted: 08/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Viral infections are controlled primarily by viral-specific T cells, raising concern for adequate T-cell response to clear CMV infection in transplant recipients receiving lymphocyte-depleting agents (LDA). We examined the rates of CMV viremia and clearance, seroconversion, and CMV-specific CD8+ T cell (CMV-Tc) activity with class of induction agent received. METHODS Retrospective review of 45 pediatric renal transplant recipients who received induction with LDA (n = 31) or non-LDA (NLDA; n = 14) received valganciclovir prophylaxis for 6 months post-transplant and CMV-PCR monitoring. CMV-Tc was measured by intracellular IFNγ flow cytometry, when possible, at baseline, 1 month after CMV viremia (>5 copies/PCR) and serially until CMV-Tc was positive (≥0.2%). RESULTS Viremia rates at 1, 2, and 4 years post-transplant were higher in LDA vs. NLDA (46.3% vs. 7.2%, 64.2% vs. 7.2%, and 64.2% vs. 7.2%, respectively; p = .002). Viremia rates at these time points in seronegative LDA (50.3%, 71.6%, 71.6%) were significantly or near significantly higher than seronegative NLDA (9.1%, 9.1%, 9.1%; p = .004), seropositive-LDA (22.3%, 22.3%, 22.3%; p = .07), or seropositive NLDA (0%, 0%, 0%; p = .07). Eleven of 17 (64.7%) viremic subjects required valganciclovir dose reduction during the prophylaxis period for leukopenia. All viremic LDA patients developed CMV-Tc. One viremic NLDA patient did not develop CMV-Tc. No patients developed CMV disease. CONCLUSION CMV seronegative pediatric renal transplant patients receiving LDA are more likely to have valganciclovir prophylaxis dose reduction and develop subclinical CMV viremia; however, all developed CMV-Tc. Larger prospective studies are needed to further understand the effects of induction agents on CMV-Tc and CMV-Tc's role post-transplant.
Collapse
Affiliation(s)
- Helen Pizzo
- Pediatric Nephrology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bongha Shin
- Transplant Immunology Laboratory and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jon Garrison
- Transplant Immunology Laboratory and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edmund Huang
- Transplant Immunology Laboratory and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mohammad Malekzadeh
- Pediatric Nephrology, University of California Los Angeles, Los Angeles, CA, USA
| | - Stanley C Jordan
- Transplant Immunology Laboratory and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dechu Puliyanda
- Pediatric Nephrology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mieko Toyoda
- Transplant Immunology Laboratory and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
16
|
Gajardo M, Delucchi A, Pérez D, Cancino JM, Gálvez C, Ledezma X, Ceballos ML, Lillo AM, Cano F, Guerrero JL, Rojo A, Azócar M, González G, Pinilla C, Correa R, Toro L. Long-term outcome of early steroid withdrawal in pediatric renal transplantation. Pediatr Transplant 2021; 25:e14096. [PMID: 34327777 DOI: 10.1111/petr.14096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/15/2021] [Accepted: 07/08/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Steroid use in renal transplant is related to multiple adverse effects. Long-term effects of early withdrawal steroids in pediatric renal transplant were assessed. METHODS Renal transplant children with low immunological risk treated on basiliximab, tacrolimus, and mycophenolate with steroid withdrawal or steroid control were evaluated between 2003 and 2019. Clinical variables, treatment adherence, acute rejection, graft loss, and death were analyzed through hazard ratios, and Kaplan-Meier and multivariate analyses. RESULTS The study included 152 patients, 71.1% steroid withdrawal, mean follow-up 8.5 years, 64.5% structural abnormalities, and 81.6% deceased donor. At 12 years of transplant, event-free survival analysis for graft loss or death showed no significant difference between steroid withdrawal and control steroid treatment (85.9% vs. 80.4%, p = .36) nor in acute rejection at 10 years (18.5% vs. 20.5%, p = .78) or in donor-specific antibody appearance (19.6% vs. 21.4%, p = .98). Delta height Z-score was increased in the steroid withdrawal group (p < .01). The main predictor of graft loss or death was non-adherence to treatment (p = .001; OR: 17.5 [3.3-90.9]). CONCLUSIONS Steroid withdrawal therapy was effective and safe for low-risk pediatric renal transplant in long-term evaluation. Non-adherence was the main predictor of graft loss or death.
Collapse
Affiliation(s)
- Macarena Gajardo
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile.,Division of Nephrology, Hospital Roberto del Río, Santiago, Chile
| | - Angela Delucchi
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile.,Division of Nephrology, Clínica Alemana, Santiago, Chile
| | - Diego Pérez
- Department of Pediatric, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - José M Cancino
- Division of Nephrology, Hospital del Salvador, Santiago, Chile
| | - Carla Gálvez
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Ximena Ledezma
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - María L Ceballos
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile
| | - Ana M Lillo
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Francisco Cano
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile
| | - José L Guerrero
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Angélica Rojo
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Marta Azócar
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile
| | - Gloria González
- Renal transplant program, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Cesar Pinilla
- Renal transplant program, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Ramón Correa
- Renal transplant program, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada, Hospital Clinico Universidad de Chile, Santiago, Chile.,Critical Care Center, Clínica Las Condes, Santiago, Chile
| |
Collapse
|
17
|
CMV, EBV, JCV and BKV infection and outcome following kidney transplantation in children initiated on a corticosteroid-minimisation immunosuppressive regimen. Pediatr Nephrol 2021; 36:3229-3240. [PMID: 33825043 DOI: 10.1007/s00467-021-05047-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Modern immunosuppressive regimens in paediatric kidney transplant recipients have contributed to improved long-term allograft survival, but at the expense of an increased incidence of viral infections. Here, we describe, for the first time, the incidence, risk factors and clinical outcome of CMV, EBV, BKV and JCV viraemia in a cohort of paediatric allograft recipients treated with a corticosteroid-minimisation immunosuppressive regimen (CMR). METHODS We retrospectively analysed 98 children treated with a CMR (basiliximab induction, corticosteroids until day 4, long-term tacrolimus and mycophenolate mofetil), who received a kidney transplant in our centre between 2009 and 2019. RESULTS Over the first 4 years post-transplant, the incidences of viraemia were as follows: CMV, 25.5%; EBV, 52.0%; JCV, 16.3%; BKV, 26.5%. Younger children at time of transplant were more likely to develop EBV and BKV viraemia. EBV viraemia was also associated with a regimen involving corticosteroids, but lacking MMF. Recipient CMV serology predicted the development of EBV, BKV and CMV viraemia. Fifty-six percent of CMV viraemia episodes in high-risk patients occurred whilst the graft recipients were still receiving anti-viral prophylaxis or within 3 months of cessation. There was no difference in graft function at latest follow-up between those with and without viraemia. CONCLUSIONS Judicious monitoring of viraemia, coupled with timely clinical intervention, can result in similar long-term outcomes for graft recipients compared to controls. The high incidence of CMV viraemia observed within a short period of cessation of anti-viral prophylaxis supports an extension of the length of prophylactic treatment in high-risk allograft recipients.
Collapse
|
18
|
Mohapatra A, Valson AT, Annapandian VM, David VG, Alexander S, Jacob S, Kakde S, Kumar S, Devasia A, Vijayakumar TS, Tamilarasi V, Jacob CK, Basu G, John GT, Varughese S. Post-transplant complications, patient, and graft survival in pediatric and adolescent kidney transplant recipients at a tropical tertiary care center across two immunosuppression eras. Pediatr Transplant 2021; 25:e13973. [PMID: 33463876 PMCID: PMC7615901 DOI: 10.1111/petr.13973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND We report pediatric PAKT patient and graft outcomes at a large tropical tertiary center spanning two transplant eras. METHODS In this retrospective cohort study, all children ≤18 years who underwent kidney transplantation at our center between 1991 and 2016 were included. Data pertaining to their baseline characteristics, post-transplant events, and outcome were retrieved from transplant records and compared between transplant eras (1991-2005 and 2006-2016). RESULTS A total of 139 children (mean age 15.2 ± 2.9 years) underwent PAKT during this period. The incidence of UTIs, CMV disease, BKVN, invasive fungal infections, new-onset diabetes after transplant, leucopenia, and recurrent NKD was higher in the 2006-2016 era (P < .001 for all), while 1-year cumulative BPAR was comparable (P = .100). Five-year graft and patient survival in the two eras were 89.9% and 94.2% (P = .365) and 92.1% and 95.3% (P = .739), respectively. Incidence of CMV disease, BKVN, graft loss, and death was lower in the calcineurin withdrawal group. Non-adherence accounted for 36% of graft loss; infections caused 43.7% of deaths. On multivariate Cox proportional hazards analysis, independent predictors for graft loss were UTIs and blood transfusion naïve status and for death were serious infections and glomerular NKD. CONCLUSIONS PAKT in India has excellent long-term graft outcomes, though patient outcomes remain suboptimal owing to a high burden of infections. Current immunosuppression protocols need to be re-examined to balance infection risk, graft, and patient survival.
Collapse
Affiliation(s)
- Anjali Mohapatra
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Anna T. Valson
- Department of Nephrology, Christian Medical College, Vellore, India
| | | | | | | | - Shibu Jacob
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Shailesh Kakde
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Santosh Kumar
- Department of Urology, Christian Medical College, Vellore, India
| | - Antony Devasia
- Department of Urology, Christian Medical College, Vellore, India
| | | | | | | | - Gopal Basu
- Department of Nephrology, Christian Medical College, Vellore, India
| | | | | |
Collapse
|
19
|
Ahlenstiel-Grunow T, Pape L. Novel ways to monitor immunosuppression in pediatric kidney transplant recipients-underlying concepts and emerging data. Mol Cell Pediatr 2021; 8:8. [PMID: 34309698 PMCID: PMC8313639 DOI: 10.1186/s40348-021-00118-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022] Open
Abstract
After pediatric kidney transplantation, immunosuppressive therapy is given to avoid acute and chronic rejections. However, the immunosuppression causes an increased risk of severe viral complications and bacterial infections and is associated with serious side effects. It is therefore crucial to achieve the optimal individual balance between over- and under-immunosuppression and thereby avoid unnecessary exposure to immunosuppressive drugs. In routine use, steering of immunosuppressants is performed primarily by monitoring of trough levels that mirror pharmacokinetics (although not, however, pharmacodynamics). Other diagnostic and prognostic markers to assess the individual intensity of immunosuppression are missing. Potential methods to determine immune function and grade of immunosuppression, such as analysis of the torque teno virus (TTV) load, QuantiFERON Monitor®, and ImmuKnow® as well as virus-specific T cells (Tvis), are currently being evaluated. In some studies TTV load, QuantiFERON Monitor® and ImmuKnow® were associated with the risk for post-transplant rejections and infections, but randomized controlled trials after pediatric kidney transplantation are not available. Post-transplant monitoring of Tvis levels seem to be promising because Tvis control virus replication and have been shown to correlate with virus-specific as well as general cellular immune defense, which represents the individual’s susceptibility to infections. Additional Tvis-monitoring provides an innovative opportunity to personalize the antiviral management and the dosing of the immunosuppressive therapy after pediatric kidney transplantation to avoid unnecessary therapeutic interventions and identify over-immunosuppression.
Collapse
Affiliation(s)
- Thurid Ahlenstiel-Grunow
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Pape
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Hufelandstraße 55, 45147, Essen, Germany.
| |
Collapse
|
20
|
Iida T, Miura K, Ban H, Ando T, Shirai Y, Ishiwa S, Shiratori A, Kaneko N, Yabuuchi T, Ishizuka K, Takaiwa M, Suyama K, Hisano M, Hattori M. Valganciclovir prophylaxis for cytomegalovirus infection in pediatric kidney transplant recipients: a single-center experience. Clin Exp Nephrol 2021; 25:531-536. [PMID: 33506359 DOI: 10.1007/s10157-021-02020-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are two approaches for treating cytomegalovirus (CMV) infection occurring after kidney transplantation (KTx). One is preemptive therapy in which treatment is started after confirming positive CMV antigenemia using periodic antigenemia assay. The other approach is prophylactic therapy in which oral valganciclovir (VGCV) is started within 10 days after KTx and continued for 200 days. The Transplantation Society guidelines recommend prophylactic therapy for high-risk (donor's CMV-IgG antibody positive and recipient's negative) pediatric recipients. However, the adequate dose and side effects of VGCV are not clear in children, and there is no sufficient information about prophylaxis for Japanese pediatric recipients. METHODS A single-center retrospective analysis was conducted on case series of high-risk pediatric patients who underwent KTx and received oral VGCV prophylaxis at the Department of Pediatric Nephrology, Tokyo Women's Medical University, between August 2018 and March 2019. Data were collected using medical records. RESULTS The dose of administration was 450 mg in all the study patients (n = 5). Reduction or discontinuation was required in four of five patients due to adverse events, which included neutropenia in one patient, anemia in two patients, and neutropenia and digestive symptoms in one patient. Late-onset CMV disease occurred in all patients. No seroconversion was observed during prophylaxis. CONCLUSIONS Our preliminary study suggests that the dosage endorsed by The Transplantation Society may be an overdose for Japanese pediatric recipients. Further studies are required to examine the safety and efficacy of VGCV prophylaxis in Japanese pediatric recipients.
Collapse
Affiliation(s)
- Takaya Iida
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kenichiro Miura
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hideki Ban
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Taro Ando
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yoko Shirai
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Sho Ishiwa
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Atsutoshi Shiratori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Naoto Kaneko
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Tomoo Yabuuchi
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kiyonobu Ishizuka
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masanori Takaiwa
- Department of Pediatrics, Matsuyama Red Cross Hospital, Ehime, Japan
| | - Kazuhide Suyama
- Department of Pediatrics, Fukushima Medical University, Fukushima, Japan
| | - Masataka Hisano
- Department of Nephrology, Chiba Children's Hospital, Chiba, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| |
Collapse
|
21
|
Virus-specific T cells in pediatric renal transplantation. Pediatr Nephrol 2021; 36:789-796. [PMID: 32221706 PMCID: PMC7910244 DOI: 10.1007/s00467-020-04522-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 12/15/2022]
Abstract
After pediatric kidney transplantation, immunosuppressive therapy causes an increased risk of severe viral complications, especially from cytomegalovirus (CMV), BK polyomavirus (BKPyV) or Epstein-Barr virus (EBV), and less frequent from adenovirus (ADV). However, suitable predictive markers for the individual outcome of viral infections are missing and the therapeutic management remains a challenge to the success of pediatric kidney transplantation. Virus-specific T cells are known for controlling viral replication and there is growing evidence that virus-specific T cells may serve as a prognostic marker to identify patients at risk for viral complications. This review provides an overview of the usability of virus-specific T cells for improving diagnostic and therapeutic management of viral infections with reference to the necessity of antiviral prophylaxis, timing of pre-emptive therapy, and dosing of immunosuppressive medication after pediatric kidney transplantation. Several studies demonstrated that high levels of virus-specific T cells are associated with decrease of virus load and favorable outcome, whereas lack of virus-specific T cells coincided with virus-induced complications. Accordingly, the additional monitoring of virus-specific T cells aims to personalize the management of antiviral therapy, identify overimmunosuppression, and avoid unnecessary therapeutic interventions. Prospective randomized trials in pediatric kidney recipients comparing standard antiviral and immunosuppressive regimens with T cell-guided therapeutic interventions are needed, before monitoring of virus-specific T cells is implemented in the routine care of pediatric kidney graft recipients.
Collapse
|
22
|
Keskinoglu A, Bulut İK, Taner S, Turkes AZ, Kabasakal C. Cytomegalovirus Experience in Pediatric Kidney Transplantation in 26 Years' Time. Transplant Proc 2020; 52:3186-3191. [PMID: 32646585 DOI: 10.1016/j.transproceed.2020.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/22/2020] [Accepted: 03/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In this study,we investigated the presence of cytomegalovirus (CMV) infection in kidney transplanted children and its effect on kidney dysfunction. MATERIAL AND METHODS One hundred thirty-five pediatric renal transplant patients were included in this study. The presence of CMV infection, CMV risk status, and other clinical features of the patients were evaluated retrospectively. RESULTS Fifty-three percent of all patients and 68.8% of patients with CMV were male. The mean age was 12 years in all patients and CMV groups. According to the CMV risk classification, 40.9% of the patients with CMV infection/disease were in the high-risk group (CMV D+R-). In CMV risk groups, the presence of CMV infection/disease was similar. Cold ischemia time, male sex (patients and donors), deceased donor, higher HLA-mismatches, and cumulative antithymocyte globulin dose were found as risk factors for CMV infection/disease. Acute rejection/graft failure was observed in 27% of all patients. CMV infection has no effect on rejection/graft failure and survival. DISCUSSION The frequency and risk factors of CMV in renal transplant children in our study were consistent with the literature. CONCLUSIONS CMV infection was found in one-fifth of our patients and the majority (71.9%) of them developed infection in the first 6 months. In one-third of our patients acute rejection/graft failure was observed. There was no effect of CMV infection on rejection/graft failure and survival in pediatric patients with proper and effective treatment.
Collapse
Affiliation(s)
- Ahmet Keskinoglu
- Department of Pediatric Nephrology, Ege University Faculty of Medicine Children's Hospital, Bornova-İzmir, Turkey.
| | - İpek Kaplan Bulut
- Department of Pediatric Nephrology, Ege University Faculty of Medicine Children's Hospital, Bornova-İzmir, Turkey
| | - Sevgin Taner
- Department of Pediatric Nephrology, Ege University Faculty of Medicine Children's Hospital, Bornova-İzmir, Turkey
| | - Ayşın Zeytinoglu Turkes
- Department of Medical Microbiology, Ege University Faculty of Medicine, Bornova-İzmir, Turkey
| | - Caner Kabasakal
- Department of Pediatric Nephrology, Ege University Faculty of Medicine Children's Hospital, Bornova-İzmir, Turkey
| |
Collapse
|
23
|
Efficacy and Safety of a Weight-based Dosing Regimen of Valganciclovir for Cytomegalovirus Prophylaxis in Pediatric Solid-organ Transplant Recipients. Transplantation 2020; 103:1730-1735. [PMID: 31343571 DOI: 10.1097/tp.0000000000002632] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Valganciclovir has been widely used for cytomegalovirus (CMV) prophylaxis in solid-organ transplant recipients. However, the optimal dosing protocol and target exposure in children are still unclear. Specific data as to the efficacy and safety of low-dose/low-exposure regimens are lacking and urgently needed. METHODS During 2010 to 2015, the clinical efficacy and safety of a weight-based regimen of valganciclovir of 17 mg/kg/day, with a stratified dose reduction for impaired creatinine clearance, given as a CMV prophylaxis for 3 to 6 months, was retrospectively evaluated among pediatric kidney and liver transplant recipients, 12 months posttransplantation. Incidence of CMV infection was assessed by periodic measurements of viral load; adverse events were evaluated. RESULTS Eighty-three children who had undergone 86 transplantations and were treated with 17 mg/kg of valganciclovir were included. Median age was 9.77 years (range, 0.6 to 18.9). Twelve (14%) developed CMV infection: 1 during prophylaxis and 11 during follow-up. These events comprised 6 cases of asymptomatic viremia and 6 cases of a clinically significant disease without occurrences of tissue-invasive disease. Treatment-related adverse effects occurred in 7 patients (8%), mostly hematological, resulting in premature drug cessation. CONCLUSIONS Our results support the use of 17 mg/kg of valganciclovir for CMV prophylaxis in liver and kidney transplanted children as it showed satisfactory long-term efficacy and a good safety profile.
Collapse
|
24
|
Höcker B, Schneble L, Murer L, Carraro A, Pape L, Kranz B, Oh J, Zirngibl M, Dello Strologo L, Büscher A, Weber LT, Awan A, Pohl M, Bald M, Printza N, Rusai K, Peruzzi L, Topaloglu R, Fichtner A, Krupka K, Köster L, Bruckner T, Schnitzler P, Hirsch HH, Tönshoff B. Epidemiology of and Risk Factors for BK Polyomavirus Replication and Nephropathy in Pediatric Renal Transplant Recipients: An International CERTAIN Registry Study. Transplantation 2020; 103:1224-1233. [PMID: 30130322 DOI: 10.1097/tp.0000000000002414] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND BK polyomavirus-associated nephropathy (BKPyVAN) constitutes a serious cause of kidney allograft failure, but large-scale data in pediatric renal transplant recipients and a comprehensive analysis of specific risk factors are lacking. METHODS We analyzed the data of 313 patients in the Cooperative European Pediatric Renal Transplant Initiative Registry, with an observation period of 3.3 years (range, 1-5). The net state of immunosuppressive therapy was assessed by the modified Vasudev score. RESULTS Presumptive BKPyVAN (defined as sustained [>3 wk] high-level BK viremia >10 copies/mL) within 5 years posttransplant occurred in 49 (15.8%) of 311 patients, and biopsy-proven BKPyVAN in 14 (4.5%) of 313. BKPyV viremia was observed in 115 (36.7%) of 311 patients, of whom 11 (9.6%) of 115 developed viremia late, that is, after the second year posttransplant. In 6 (12.5%) of 48 patients with high-level viremia and in 3 (21.4%) of 14 with BKPyVAN, this respective event occurred late. According to multivariable analysis, BKPyV viremia and/or BKPyVAN were associated not only with a higher net state of immunosuppression (odds ratio [OR], 1.3; P < 0.01) and with tacrolimus-based versus ciclosporin-based immunosuppression (OR, 3.6; P < 0.01) but also with younger recipient age (OR, 1.1 per y younger; P < 0.001) and obstructive uropathy (OR, 12.4; P < 0.01) as primary renal disease. CONCLUSIONS Uncontrolled BKPyV replication affects a significant proportion of pediatric renal transplant recipients and is associated with unique features of epidemiology and risk factors, such as young recipient age, obstructive uropathy, and overall intensity of immunosuppressive therapy. BKPyV surveillance should be considered beyond 2 years posttransplant in pediatric patients at higher risk.
Collapse
Affiliation(s)
- Britta Höcker
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Lukas Schneble
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
| | - Andrea Carraro
- Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
| | - Lars Pape
- Hanover Medical School, Hanover, Germany
| | - Birgitta Kranz
- Department of General Pediatrics, University Children's Hospital Münster, Münster, Germany
| | - Jun Oh
- Department of Pediatric Nephrology, University Children's Hospital, Hamburg, Germany
| | | | - Luca Dello Strologo
- Pediatric Nephrology and Renal Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Anja Büscher
- Pediatric Nephrology, Pediatrics II, University Children's Hospital Essen, Essen, Germany
| | - Lutz T Weber
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Cologne, Germany
| | - Atif Awan
- Temple Street Children's University Hospital, Dublin, Ireland
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Bald
- Olga Children's Hospital, Clinic of Stuttgart, Stuttgart, Germany
| | - Nikoleta Printza
- 1st Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Krisztina Rusai
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Rezan Topaloglu
- Hacettepe University Faculty of Medicine, Department of Pediatric Nephrology, Ankara, Turkey
| | - Alexander Fichtner
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Kai Krupka
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Lennart Köster
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany.,Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, Virology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| |
Collapse
|
25
|
Gotoh Y, Shishido S, Hamasaki Y, Watarai Y, Hattori M, Miura K, Ishizuka K, Fujita N, Saito K, Nakagawa Y, Hotta K, Hataya H, Hamada R, Sato H, Kitayama H, Ishikura K, Honda M, Uemura O. Kidney function of Japanese children undergoing kidney transplant with preemptive therapy for cytomegalovirus infection. Transpl Infect Dis 2020; 22:e13271. [DOI: 10.1111/tid.13271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 02/08/2020] [Accepted: 02/24/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Yoshimitsu Gotoh
- Department of Pediatric Nephrology Japanese Red Cross Nagoya Daini Hospital Aichi Japan
| | - Seiichiro Shishido
- Department of Nephrology Toho University Faculty of Medicine Tokyo Japan
| | - Yuko Hamasaki
- Department of Nephrology Toho University Faculty of Medicine Tokyo Japan
| | - Yoshihiko Watarai
- Department of Transplantation Surgery, Nephrology Japanese Red Cross Nagoya Daini Hospital Aichi Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology Kidney Center Tokyo Women’s Medical University Tokyo Japan
| | - Kenichiro Miura
- Department of Pediatric Nephrology Kidney Center Tokyo Women’s Medical University Tokyo Japan
| | - Kiyonobu Ishizuka
- Department of Pediatric Nephrology Kidney Center Tokyo Women’s Medical University Tokyo Japan
| | - Naoya Fujita
- Department of Nephrology Aichi Children’s Health and Medical Center Aichi Japan
| | - Kazuhide Saito
- Department of Urology Niigata University School of Medicine Niigata Japan
| | - Yuki Nakagawa
- Department of Urology Niigata University School of Medicine Niigata Japan
- Department of Urology Juntendo University Tokyo Japan
| | - Kiyohiko Hotta
- Department of Urology Hokkaido University Hospital Hokkaido Japan
| | - Hiroshi Hataya
- Department of Nephrology Tokyo Metropolitan Children’s Medical Center Tokyo Japan
| | - Riku Hamada
- Department of Nephrology Tokyo Metropolitan Children’s Medical Center Tokyo Japan
| | - Hiroyuki Sato
- Department of Urology Tokyo Metropolitan Children’s Center Tokyo Japan
| | - Hirotsugu Kitayama
- Department of Pediatric Nephrology Shizuoka Children’s Hospital Shizuoka Japan
| | - Kenji Ishikura
- Department of Pediatrics Kitasato University Hospital Tokyo Japan
| | - Masataka Honda
- Department of Nephrology Tokyo Metropolitan Children’s Medical Center Tokyo Japan
| | - Osamu Uemura
- Ichinomiya Medical Treatment and Habilitation Center Aichi Japan
| |
Collapse
|
26
|
Mehta K, Al-Yabes O, Allen A, Williams A, Petrich A, Langlois V, Hébert D, Allen U. Burden of cytomegalovirus DNAemia among pediatric renal transplant patients on antiviral prophylaxis: A hospital-based analysis. Pediatr Transplant 2020; 24:e13650. [PMID: 31891234 DOI: 10.1111/petr.13650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 11/02/2019] [Accepted: 11/24/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We examined the burden of CMV DNAemia and time to such events among renal transplant patients receiving CMV prophylaxis. We targeted the first year after transplantation, with the primary focus being on the first 3 months. METHODS We conducted a retrospective review of renal transplant patients (<18 years) who were transplanted and followed at our center between January 2007, and December 2017. Clinical and laboratory data were obtained from the medical records and laboratory databases. RESULTS Among 141 patients, the median age at transplant was 12.7 years (range 0.87-17.83 years). CMV DNAemia was detected in 33 of 77 patients eligible for prophylaxis (42.9%; 95% CI 31.6-54.6) during the first post-transplant year. Proportionately more D+R- patients were present among patients with DNAemia compared with those without DNAemia (15/38, 39.5% vs 16/103, 15.5%, P = .005). Median time to first positivity was 134 days (range 0-304 days). Eight patients had a positive PCR during the first 3 months (5.7% of all patients). Among those eligible for prophylaxis, 6.5% had DNAemia during the first 3 months while on prophylaxis. Among patients whose first positive PCR was after 3 months post-transplant, the median time to positivity was 52 days (range 13-214 days) after the end of prophylaxis. CONCLUSIONS Breakthrough CMV DNAemia was documented among children receiving antiviral prophylaxis. While routine monitoring while on prophylaxis might not be warranted for the majority of patients, studies are needed to determine the optimal indications for CMV PCR testing while on prophylaxis.
Collapse
Affiliation(s)
- Kayur Mehta
- Division of Infectious, Hospital for Sick Children, Toronto, ON, Canada
| | - Ohoud Al-Yabes
- Division of Infectious, Hospital for Sick Children, Toronto, ON, Canada
| | - Andrew Allen
- Division of Infectious, Hospital for Sick Children, Toronto, ON, Canada
| | - Angela Williams
- Division of Nephrology, Hospital for Sick Children, Toronto, ON, Canada.,The Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, ON, Canada
| | - Astrid Petrich
- Deaprtment of Pediatric Laboratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Valerie Langlois
- Division of Nephrology, Hospital for Sick Children, Toronto, ON, Canada.,The Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, ON, Canada
| | - Diane Hébert
- Division of Nephrology, Hospital for Sick Children, Toronto, ON, Canada.,The Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, ON, Canada
| | - Upton Allen
- Division of Infectious, Hospital for Sick Children, Toronto, ON, Canada.,The Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
27
|
Pangonis S, Paulsen G, Andersen H, Flores F, Miethke A, Peters A, Kocoshis S, Lazear D, Garr B, Schecter M, Chin C, Hemmelgarn T, Danziger-Isakov L. Evaluation of a change in cytomegalovirus prevention strategy following pediatric solid organ transplantation. Transpl Infect Dis 2019; 22:e13232. [PMID: 31840369 DOI: 10.1111/tid.13232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/09/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND An optimal cytomegalovirus (CMV) prevention strategy following solid organ transplantation (SOT) remains uncertain. This study reports on the rates of CMV events following a change in a local prevention guideline involving increased surveillance, earlier transition to oral valganciclovir, and decreased CMV-immunoglobulin use. METHODS A retrospective cohort study utilizing historical controls evaluated the rates of CMV invasive disease pre- and post-intervention among pediatric heart, liver, and kidney recipients. Outcomes were recorded for the 4 years pre- and post-intervention, 9/2009-10/2017. Logistic regression was used to estimate the risk of a CMV event. RESULTS There was no difference in the rates of CMV invasive disease between the two study groups (P = 1). An increase in the detection of CMV events occurred (P = .04), predominantly asymptomatic CMV infection. This increase was independently associated with increased surveillance testing among high-risk heart and liver recipients, aOR 1.08 (1.06-1.12). Surprisingly, 28.9% of CMV events occurred during antiviral prophylaxis. CONCLUSIONS Modification of the local CMV prevention guideline did not result in an increase in CMV invasive disease. CMV events occurred while on prophylaxis, highlighting a potential difference from adult solid organ transplant (SOT) and emphasizing the potential need for monitoring on prophylaxis in the pediatric population.
Collapse
Affiliation(s)
- Scott Pangonis
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Grant Paulsen
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Heidi Andersen
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Francisco Flores
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Alexander Miethke
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Anna Peters
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Samuel Kocoshis
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Danielle Lazear
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - BreAnn Garr
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Marc Schecter
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Clifford Chin
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Trina Hemmelgarn
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| |
Collapse
|
28
|
Ganapathi L, Blumenthal J, Alawdah L, Lewis L, Gilarde J, Jones S, Milliren C, Kim HB, Sharma TS. Impact of standardized protocols for cytomegalovirus disease prevention in pediatric solid organ transplant recipients. Pediatr Transplant 2019; 23:e13568. [PMID: 31515909 PMCID: PMC6824938 DOI: 10.1111/petr.13568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 04/30/2019] [Accepted: 07/15/2019] [Indexed: 12/15/2022]
Abstract
End-organ disease caused by CMV is a significant cause of morbidity and mortality in pediatric SOT recipients. Pediatric transplant centers have adopted various approaches for CMV disease prevention in this patient population. We observed significant practice variation in CMV testing, prophylaxis, and surveillance across SOT groups in our center. To address this, we implemented evidence-based standardized protocols and measured outcomes pre- and post-implementation of these protocols. We performed retrospective chart review for SOT recipients from 2009 to 2014 at Boston Children's Hospital. Using descriptive statistics, we measured practice improvement in provision of appropriate prophylaxis, occurrence of neutropenia and associated complications, and occurrence of CMV DNAemia and CMV disease pre- and post-intervention. The pre- and post-intervention periods included 141 and 109 patients, respectively. With the exception of kidney transplant recipients, provision of appropriate valganciclovir prophylaxis improved across SOT groups post-intervention (P < .01). Occurrence of >1 episode of neutropenia was greater in the preintervention period (30% vs 10%, P < .001). In both periods, neutropenia was associated with few episodes of invasive infections. The occurrence of CMV disease did not differ and was overall low. However, due to routine surveillance a significantly greater number of asymptomatic CMV DNAemia episodes were identified and treated in the post-intervention period. Implementation of standardized prevention protocols helped to improve the provision of appropriate prophylaxis to patients at risk for CMV acquisition, increased the diagnosis and treatment of asymptomatic CMV DNAemia, and decreased episodes of recurrent neutropenia in patients receiving prophylaxis.
Collapse
Affiliation(s)
- Lakshmi Ganapathi
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA
| | - Jennifer Blumenthal
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA
- Division of Critical Care Medicine, Boston Children’s Hospital, Boston, MA
| | - Laila Alawdah
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA
| | - Lynne Lewis
- International Medical Service, Boston Children’s Hospital, Boston, MA
| | | | - Sarah Jones
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA
- Division of Pharmacy, Boston Children’s Hospital, Boston, MA
| | - Carly Milliren
- Program for Patient Quality and Safety, Boston Children’s Hospital, Boston, MA
| | - Heung Bae Kim
- Department of Surgery, Boston Children’s Hospital, Boston, MA
| | - Tanvi S. Sharma
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA
| |
Collapse
|
29
|
Chatani B, Glaberson W, Nemeth Z, Tamariz L, Gonzalez IA. GCV/VCVG prophylaxis against CMV DNAemia in pediatric renal transplant patients: A systematic review and meta-analysis. Pediatr Transplant 2019; 23:e13514. [PMID: 31210393 DOI: 10.1111/petr.13514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 02/27/2019] [Accepted: 05/06/2019] [Indexed: 12/26/2022]
Abstract
CMV disease continues to stand as a significant threat to the longevity of renal transplants in children. More pediatric recipients are CMV-negative with CMV-positive donor serologies resulting in a HR mismatch. The length of prophylaxis with GCV or VGCV required to optimally prevent recurrence of CMVDNAemia remains unknown. This study is a meta-analysis comparing GCV/VGCV prophylaxis regimens provided for <6 months, from 6 to <12 months, and ≥12 months after transplant in order to prevent CMVDNAemia. The search conducted involved PubMed, EMBASE, ISI Web of Science, and Cochrane Central Register from inception through December 2017. Search terms Kidney Transplantation, CMV, GCV, and VGCV provided 204 studies for abstract review. Studies excluded were those which did not itemize pediatric data separately, single case reports, and duplicate studies. Pooled analysis of five retrospective studies and one prospective study identified that there is no statistically significant difference in the incidence of CMV DNAemia when comparing <6 months of prophylaxis and >12 months of prophylaxis (23% and 15%, respectively, P = 0.23). Regardless of the length of prophylaxis, there was no statistical difference in the incidence of CMV DNAemia in the HR patients (6 to <12 months vs <6 months, P = 0.62; 6 to <12 months vs ≥12 months, P = 0.78; ≥12 months vs <6 months, P = 0.83). This study identifies no optimal length of prophylaxis for HR mismatch pediatric renal transplant patients as many develop CMV DNAemia.
Collapse
Affiliation(s)
- Brandon Chatani
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Wendy Glaberson
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Zsuzsanna Nemeth
- Department of Health Informatics, University of Miami Miller School of Medicine, Miami, Florida
| | - Leonardo Tamariz
- Department of Population Health and Computation Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Ivan A Gonzalez
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, Florida
| |
Collapse
|
30
|
Infectious disease risks in pediatric renal transplantation. Pediatr Nephrol 2019; 34:1155-1166. [PMID: 29626241 DOI: 10.1007/s00467-018-3951-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 02/19/2018] [Accepted: 03/19/2018] [Indexed: 02/06/2023]
Abstract
Renal transplantation is a vital treatment option in children with ESRD with more than 10,000 pediatric kidney transplants and survival rates of greater than 80% at 10 years post-transplant in the USA alone. Despite these advances, infection remains a significant cause of morbidity in pediatric recipients. Screening potential organ donors and recipients is imperative to identify and mitigate infectious risks in the transplant patient. Despite the unique risks of each patient, the timing of many infections post-transplant is predictable. In early post-transplant infections (within 30 days), bacterial and fungal pathogens predominate with donor-derived events and nosocomial infections. In the intermediate period (31-180 days after transplant), latent infections from donor organs, such as EBV and CMV, develop. Late infections occurring > 180 days after the transplant can be due to latent pathogens or community-acquired organisms. Approaching an infectious evaluation in a pediatric kidney recipient requires finesse to diagnose and treat this vulnerable population in a timely manner. The following article highlights the most relevant and common infections including clinical manifestations, risk factors, diagnostic techniques, and treatment options.
Collapse
|
31
|
Paulsen G, Cumagun P, Mixon E, Fowler K, Feig D, Shimamura M. Cytomegalovirus and Epstein-Barr virus infections among pediatric kidney transplant recipients at a center using universal Valganciclovir Prophylaxis. Pediatr Transplant 2019; 23:e13382. [PMID: 30786115 PMCID: PMC6650320 DOI: 10.1111/petr.13382] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/03/2018] [Accepted: 01/16/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND CMV is associated with adverse effects in renal transplant recipients. The objective of this study was to characterize the incidence and timing of CMV and EBV infections in relation to valGCV prophylaxis in a pediatric renal transplant cohort. METHODS Retrospective cohort of pediatric renal transplant patients given universal valGCV prophylaxis and universal viral surveillance was evaluated. Demographics, prophylaxis, acute rejection, and CMV and EBV infections were abstracted. RESULTS A total of 92 pediatric renal allograft recipients, 2008-2013, were included. One or more viral infections developed in 77/92 (83.7%) of the patients. EBV was the most common in 62/92 (67%) patients, irrespective of valGCV (82% of episodes occurring on valGCV). CMV DNAemia occurred in 30/92 (33%) patients, 14 episodes (47%) occurring on valGCV. Incidence of breakthrough CMV on prophylaxis was 15% and was associated with persistent DNAemia (OR 7.8, CI:1.6-32.9, P < 0.02). CMV tissue-invasive disease was not seen. CMV syndrome occurred in 10% of the cohort, only in CMV D+ patients, and only one symptomatic breakthrough infection required treatment. Out of 92, 21 (23%) had simultaneous co-infections with 2-3 viruses. CONCLUSIONS Viral infections in pediatric renal transplant recipients receiving universal valGCV prophylaxis were common. EBV infections were not reduced by valGCV prophylaxis, and nearly half of CMV infections occurred on valGCV. Symptomatic CMV infection while on prophylaxis was rare. valGCV prophylaxis may prevent symptomatic CMV infection but not EBV infection, and frequent CMV surveillance in pediatric renal transplant recipients on prophylaxis may not be necessary.
Collapse
Affiliation(s)
- Grant Paulsen
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati OH,Division of Pediatric Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati OH,Corresponding author: Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 7017, Cincinnati OH 45229, , Phone: (513) 636-4578
| | - Pia Cumagun
- University of Alabama School of Medicine, Birmingham AL,Current Affiliations: Princeton Baptist Medical Center, Birmingham AL
| | - Emily Mixon
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham AL
| | - Karen Fowler
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham AL,Division of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham AL
| | - Daniel Feig
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham AL
| | - Masako Shimamura
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children’s Hospital, Columbus OH,Division of Pediatric Infectious Diseases, Department of Pediatrics, The Ohio State University, Columbus OH
| |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW Infections represent a significant source of morbidity and mortality after kidney transplantation in children. We review recent advances in epidemiology, assessment, prevention and treatment for several different infections. RECENT FINDINGS Infections, such as bacterial urinary tract infection or opportunistic viral infection remain common, may be increasing and represent a large proportion of hospitalization. Extended antiviral agent use reduces the incidence of cytomegalovirus disease but its efficacy to reduce Epstein-Barr virus disease remains controversial. Human herpesvirus-6 and hepatitis E virus represent new infections to keep in mind. Ureteral stenting increases the rate of early UTI. Several new vaccines are now available, but rates of complete vaccination pretransplant are low. SUMMARY Infections remain a critical posttransplant issue associated with significant medical burdens. Emerging data on associated risk factors, assessment of and treatment for infections provide clinicians with new knowledge.
Collapse
|
33
|
Pape L. State-of-the-art immunosuppression protocols for pediatric renal transplant recipients. Pediatr Nephrol 2019; 34:187-194. [PMID: 29067527 DOI: 10.1007/s00467-017-3826-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 09/08/2017] [Accepted: 10/06/2017] [Indexed: 01/28/2023]
Abstract
Immunosuppressive protocols used in pediatric kidney transplantation have changed substantially within the last decade. Many transplant centers now focus on the use of tacrolimus and mycophenolate mofetil in combination with early steroid withdrawal, frequently combined with antibody induction therapy. However, this approach is mainly based on treatment efficacy and-compared to other immunosuppressive regimens used in this context-leads to higher rates of viral infections in patients. In this review I assess data from prospective, interventional trials of immunosuppressive therapy in pediatric kidney transplantation. However, since there is a paucity of randomized controlled trials, I also describe the results of studies with weaker designs. The advantages and disadvantages of different immunosuppressive strategies are discussed. Within this framework I suggest ideas for individualized immunosuppressive regimens based on different stratificators that could effect a change from a 'one size fits all' to a tailored approach for initial and maintenance immunosuppressive therapy after renal transplantation in the pediatric setting.
Collapse
Affiliation(s)
- Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany.
| |
Collapse
|
34
|
The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. Transplantation 2019; 102:900-931. [PMID: 29596116 DOI: 10.1097/tp.0000000000002191] [Citation(s) in RCA: 691] [Impact Index Per Article: 138.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite recent advances, cytomegalovirus (CMV) infections remain one of the most common complications affecting solid organ transplant recipients, conveying higher risks of complications, graft loss, morbidity, and mortality. Research in the field and development of prior consensus guidelines supported by The Transplantation Society has allowed a more standardized approach to CMV management. An international multidisciplinary panel of experts was convened to expand and revise evidence and expert opinion-based consensus guidelines on CMV management including prevention, treatment, diagnostics, immunology, drug resistance, and pediatric issues. Highlights include advances in molecular and immunologic diagnostics, improved understanding of diagnostic thresholds, optimized methods of prevention, advances in the use of novel antiviral therapies and certain immunosuppressive agents, and more savvy approaches to treatment resistant/refractory disease. The following report summarizes the updated recommendations.
Collapse
|
35
|
Höcker B, Tabatabai J, Schneble L, Oh J, Thiel F, Pape L, Rusai K, Topaloglu R, Kranz B, Klaus G, Printza N, Yavascan O, Fichtner A, Krupka K, Bruckner T, Waldherr R, Pawlita M, Schnitzler P, Hirsch HH, Tönshoff B. JC polyomavirus replication and associated disease in pediatric renal transplantation: an international CERTAIN Registry study. Pediatr Nephrol 2018; 33:2343-2352. [PMID: 30058047 DOI: 10.1007/s00467-018-4029-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/16/2018] [Accepted: 07/19/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND JC polyomavirus (JCPyV)-associated nephropathy (JCPyVAN) is a severe, but rare complication in adult renal transplant (RTx) recipients. Related data in pediatric patients are scarce. METHODS Based on the CERTAIN Registry, we therefore performed a multi-center, retrospective study on the JCPyV antibody status, prevalence of JCPyV replication, and its associated disease in 139 pediatric RTx recipients (mean age, 8.5 ± 5.3 years). JCPyV DNA in plasma and/or urine was measured by quantitative PCR at a median time of 3.2 (IQR, 0.3-8.1) years post-transplant. RESULTS 53.2% of patients were JCPyV-seronegative prior to transplantation; younger age was associated with JCPyV seronegativity. 34/139 (24.5%) patients post-transplant showed active JCPyV replication in either urine (22.0%), plasma (13.4%), or both (7.6%). JCPyV viremia occurred significantly (p < 0.001) more often in patients with viruria (34.6%) than in those without (7.6%), but 7/118 (5.9%) had isolated viremia. High-level viruria (> 107 copies/mL) was found in 29.6% of viruric patients. A higher net state of immunosuppression constituted an independent risk factor for JCPyV replication both in urine and plasma (OR 1.2, p < 0.02). Male patients tended to have a higher risk of JCPyV viremia than females (OR 4.3, p = 0.057). There was one male patient (0.7%) with JCPyVAN 7 years post-transplant, which resolved after reduction of immunosuppressive therapy. No patient exhibited progressive multifocal leukoencephalopathy. CONCLUSIONS This first multi-center study on JCPyV in pediatric renal transplant recipients shows that JCPyV replication is common (24.5%), with strong immunosuppression being a significant risk factor, but associated nephropathy is rare.
Collapse
Affiliation(s)
- Britta Höcker
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany.
| | - Julia Tabatabai
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
- German Center for Infection Research, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
- Department of Infectious Diseases, Virology, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - Lukas Schneble
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Jun Oh
- Department of Pediatric Nephrology, University Children's Hospital, Martinistr. 52, 20246, Hamburg, Germany
| | - Florian Thiel
- Department of Pediatric Nephrology, University Children's Hospital, Martinistr. 52, 20246, Hamburg, Germany
| | - Lars Pape
- Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hanover, Germany
| | - Krisztina Rusai
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Rezan Topaloglu
- Faculty of Medicine, Department of Pediatric Nephrology, Hacettepe University, Ankara, Turkey
| | - Birgitta Kranz
- Department of General Pediatrics, University Children's Hospital Münster, Waldeyerstraße 22, 48149, Münster, Germany
| | - Günter Klaus
- Department of Pediatric Nephrology, University Children's Hospital Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Nikoleta Printza
- 1st Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Onder Yavascan
- Department of Pediatric Nephrology, Tepecik Teaching and Research Hospital, 1140/1 Sk No: 1, 35180 Yenisehir, İzmir, Turkey
| | - Alexander Fichtner
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Kai Krupka
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Rüdiger Waldherr
- Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Michael Pawlita
- Division of Molecular Diagnostics of Oncogenic Infections, German Cancer Research Center, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Paul Schnitzler
- Department of Infectious Diseases, Virology, University Hospital Heidelberg, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - Hans H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine, University of Basel, Petersplatz 10, 4009, Basel, Switzerland
- Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| |
Collapse
|
36
|
Pellett Madan R, Allen UD, Green M, Höcker B, Michaels MG, Varela-Fascinetto G, Danziger-Isakov L. Pediatric transplantation case conference: Update on cytomegalovirus. Pediatr Transplant 2018; 22:e13276. [PMID: 30203626 DOI: 10.1111/petr.13276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/25/2018] [Accepted: 07/06/2018] [Indexed: 12/24/2022]
Abstract
The prevention and management of cytomegalovirus (CMV) remain challenging in children who have undergone solid organ transplantation, despite the availability of effective antiviral medications and sensitive diagnostic assays. The primary objective of this invited commentary is to provide an updated and multidisciplinary approach to persistently challenging CMV cases that commonly occur in pediatric transplantation candidates and recipients, including cases for which published data are frequently lacking.
Collapse
Affiliation(s)
- Rebecca Pellett Madan
- Department of Pediatrics, New York University School of Medicine, New York, New York
| | - Upton D Allen
- Department of Paediatrics and the Transplant and Regenerative Medicine Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michael Green
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Britta Höcker
- Department of Pediatrics, University Children's Hospital, Heidelberg, Germany
| | - Marian G Michaels
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | | | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | |
Collapse
|
37
|
Incidence of Cytomegalovirus DNAemia in Pediatric Kidney Transplant Recipients After Cessation of Antiviral Prophylaxis. Transplantation 2018; 102:1391-1396. [DOI: 10.1097/tp.0000000000002115] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
38
|
Cytomegalovirus infection in the first year after pediatric kidney transplantation. Nephrol Ther 2018; 15:44-50. [PMID: 29887270 DOI: 10.1016/j.nephro.2018.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 03/30/2018] [Accepted: 04/01/2018] [Indexed: 11/20/2022]
Abstract
Cytomegalovirus is common in adult recipients (prevalence of 40-90%). Children are typically seronegative but immunosuppression may prone to primary-infection or viral reactivation, with potentially severe consequences. CMV infection incidence in pediatric kidney transplant recipients has seldom been investigated. The aim of our study was to evaluate the incidence and timing of CMV infection during the first year after renal transplantation. We assembled a retrospective cohort of 136 children who had received a kidney transplant between 2003 and 2014 with a year follow-up. The patients were classified regarding CMV infection as high risk (D+/R-), intermediate risk (R+) or low risk (D-/R-). CMV infection was defined by the viral replication remaining asymptomatic whereas CMV disease concerned viral replication with clinical and/or biological symptoms. Oral valganciclovir was used as prophylaxis for high-risk recipients. A total of 38 patients (27.9%) developed CMV infection, 13 (40.6%) of the 32 D+/R-, 24 (45.3%) of the 53 R+ and 1 (2.0%) of the 51 D-/R-. Of these 38 infected patients, 10 developed tissue-invasive disease. During the first year after kidney transplantation, 27.9% of recipients developed CMV infection. This study confirms the influence of donor and recipient CMV status on infection propensity and highlights the importance of adequate follow-up for intermediate risk patients.
Collapse
|
39
|
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.
Collapse
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
| |
Collapse
|
40
|
Noble J, Gatault P, Sautenet B, Gaudy-Graffin C, Beby-Defaux A, Thierry A, Essig M, Halimi JM, Munteanu E, Alain S, Buchler M. Predictive factors of spontaneous CMV DNAemia clearance in kidney transplantation. J Clin Virol 2018; 99-100:38-43. [DOI: 10.1016/j.jcv.2017.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/18/2017] [Accepted: 12/20/2017] [Indexed: 12/26/2022]
|
41
|
Suresh S, Lee BE, Robinson JL, Akinwumi MS, Preiksaitis JK. A risk-stratified approach to cytomegalovirus prevention in pediatric solid organ transplant recipients. Pediatr Transplant 2016; 20:970-980. [PMID: 27565955 DOI: 10.1111/petr.12786] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2016] [Indexed: 12/19/2022]
Abstract
Optimal strategies to prevent cytomegalovirus (CMV) disease following pediatric solid organ transplantation remain controversial. The purpose of this study was to review the outcomes of a risk-stratified strategy that uses a hybrid or prophylactic strategy for donor (D)+ recipient (R)- patients, a preemptive strategy for D+R+/D-R+, and clinical follow-up alone for D-R+ patients. A retrospective chart review was undertaken at the Stollery Children's Hospital in Edmonton, Alberta for pediatric solid organ transplants 2004 through 2010. Transplants were risk-stratified according to D/R CMV serostatus, organ group, and type of induction or rejection immunosuppression. The incidence of DNAemia and CMV disease and adverse effects from prophylaxis were analyzed. The study included 197 recipients. CMV DNAemia was detected in 49 of 197 recipients (24.8%), and CMV disease occurred in eight of 197 (4%) of which all but one were D+R-. All recovered. Seventeen of 142 recipients who received prophylaxis (12%) had hematologic toxicity. No other toxicities were identified. In conclusion, A risk-stratified approach resulted in very low rates of CMV disease with minimal adverse effects. Lowering the dosage rather than stopping antivirals in the face of neutropenia has the potential to further lower the rate of CMV disease.
Collapse
Affiliation(s)
- Sneha Suresh
- Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| | - Bonita E Lee
- Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| | - Joan L Robinson
- Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada.
| | - Michael S Akinwumi
- Department of Mathematical and Statistical Sciences, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| | - Jutta K Preiksaitis
- Department of Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
42
|
Torre-Cisneros J, Aguado J, Caston J, Almenar L, Alonso A, Cantisán S, Carratalá J, Cervera C, Cordero E, Fariñas M, Fernández-Ruiz M, Fortún J, Frauca E, Gavaldá J, Hernández D, Herrero I, Len O, Lopez-Medrano F, Manito N, Marcos M, Martín-Dávila P, Monforte V, Montejo M, Moreno A, Muñoz P, Navarro D, Pérez-Romero P, Rodriguez-Bernot A, Rumbao J, San Juan R, Vaquero J, Vidal E. Management of cytomegalovirus infection in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations. Transplant Rev (Orlando) 2016; 30:119-43. [DOI: 10.1016/j.trre.2016.04.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 04/02/2016] [Accepted: 04/04/2016] [Indexed: 02/06/2023]
|
43
|
Höcker B, Zencke S, Pape L, Krupka K, Köster L, Fichtner A, Dello Strologo L, Guzzo I, Topaloglu R, Kranz B, König J, Bald M, Webb NJA, Noyan A, Dursun H, Marks S, Ozcakar ZB, Thiel F, Billing H, Pohl M, Fehrenbach H, Schnitzler P, Bruckner T, Ahlenstiel-Grunow T, Tönshoff B. Impact of Everolimus and Low-Dose Cyclosporin on Cytomegalovirus Replication and Disease in Pediatric Renal Transplantation. Am J Transplant 2016; 16:921-9. [PMID: 26613840 DOI: 10.1111/ajt.13649] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 11/16/2015] [Accepted: 11/20/2015] [Indexed: 01/25/2023]
Abstract
In order to investigate the hypothesis that the mammalian target of rapamycin inhibitor everolimus (EVR) shows anticytomegalovirus (CMV) activity in pediatric patients, we analyzed the impact of EVR-based immunosuppressive therapy on CMV replication and disease in a large cohort (n = 301) of pediatric kidney allograft recipients. The EVR cohort (n = 59), who also received low-dose cyclosporin, was compared with a control cohort (n = 242), who was administered standard-dose cyclosporin or tacrolimus and an antimetabolite, mostly mycophenolate mofetil (91.7%). Multivariate analysis revealed an 83% lower risk of CMV replication in the EVR cohort than in the control cohort (p = 0.005). In CMV high-risk (donor+/recipient-) patients (n = 88), the EVR-based regimen was associated with a significantly lower rate of CMV disease (0% vs. 14.3%, p = 0.046) than the standard regimen. In patients who had received chemoprophylaxis with (val-)ganciclovir (n = 63), the CMV-free survival rates at 1 year and 3 years posttransplant (100%) were significantly (p = 0.015) higher in the EVR cohort (n = 15) than in the control cohort (n = 48; 1 year, 75.0%; 3 years, 63.3%). Our data suggest that in pediatric patients at high risk of CMV, an EVR-based immunosuppressive regimen is associated with a lower risk of CMV disease than a standard-dose calcineurin inhibitor-based regimen.
Collapse
Affiliation(s)
- B Höcker
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - S Zencke
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - L Pape
- Hanover Medical School, Hanover, Germany
| | - K Krupka
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - L Köster
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany.,Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - A Fichtner
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | | | - I Guzzo
- IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - R Topaloglu
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - B Kranz
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital, Münster, Germany
| | - J König
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital, Münster, Germany
| | - M Bald
- Olga Children's Hospital, Clinic of Stuttgart, Stuttgart, Germany
| | - N J A Webb
- Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Center, Manchester, UK
| | - A Noyan
- Department of Pediatric Nephrology, Adana Teaching and Research Center, Baskent University, Adana, Turkey
| | - H Dursun
- Department of Pediatric Nephrology, Adana Teaching and Research Center, Baskent University, Adana, Turkey
| | - S Marks
- Great Ormond Street Hospital, London, UK
| | - Z B Ozcakar
- Ankara University Faculty of Medicine, Ankara, Turkey
| | - F Thiel
- University Children's Hospital, Hamburg, Germany
| | - H Billing
- University Children's Hospital, Tübingen, Germany
| | - M Pohl
- University Children's Hospital, Freiburg, Germany
| | | | - P Schnitzler
- Department of Infectious Diseases, Virology, University Hospital Heidelberg, Heidelberg, Germany
| | - T Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | | | - B Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| |
Collapse
|
44
|
Tsai KC, Danziger-Isakov LA, Banach DB. Cytomegalovirus Infection in Pediatric Solid Organ Transplant Recipients: a Focus on Prevention. Curr Infect Dis Rep 2016; 18:5. [DOI: 10.1007/s11908-015-0511-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
45
|
|