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Shirini K, Kamberi S, Drachenberg C, Haririan A, Saharia K, Meier RPH. Renal transplantation using kidneys from a donor with high grade cytomegalovirus viraemia: case report and literature review. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00359-1. [PMID: 38991589 DOI: 10.1016/s1473-3099(24)00359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 07/13/2024]
Abstract
Transplanting organs from cytomegalovirus-seropositive donors into cytomegalovirus-seronegative recipients is an accepted practice. However, outcomes following transplantation of organs from donors with active cytomegalovirus disease are unknown. We present a case involving a patient aged 61 years with end-stage renal disease, seropositive for cytomegalovirus, who underwent dual kidney transplant from a donor with high-grade cytomegalovirus viraemia. The donor was on immunosuppressive therapy for systemic lupus erythematosus and interstitial lung disease and had been admitted with respiratory failure. The donor had high-grade cytomegalovirus viraemia with probable cytomegalovirus pneumonitis (cytomegalovirus viral load >100 000 international units [IU]/mL in plasma and 319 000 IU/mL in bronchoalveolar lavage). Renal biopsy at organ procurement showed the absence of cytomegalovirus inclusions. Following transplantation, the recipient had delayed graft function, with renal recovery after 1 week. The patient received basiliximab induction and standard tacrolimus-based maintenance immunosuppression. He received ganciclovir and valganciclovir treatment for 1 month, followed by valganciclovir prophylaxis (or viral load monitoring, when prophylaxis had to be paused) for 2 additional months to prevent donor-derived cytomegalovirus infection. Transient cytomegalovirus viraemia (peaking at 4480 IU/mL) developed at 4 months and resolved with 1 month of valganciclovir treatment. The patient is doing well 1 year after transplantation, with adequate kidney function. This case highlights the successful and safe transplantation of kidneys from a donor with cytomegalovirus disease into a cytomegalovirus-seropositive recipient. Further research is needed to confirm our findings and define post-transplantation management.
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Affiliation(s)
- Kasra Shirini
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shani Kamberi
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cynthia Drachenberg
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abdolreza Haririan
- Division of Nephrology, Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kapil Saharia
- Institute of Human Virology, Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raphael P H Meier
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
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2
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Danger R, Le Berre L, Cadoux M, Kerleau C, Papuchon E, Mai HL, Nguyen TVH, Guérif P, Morelon E, Thaunat O, Legendre C, Anglicheau D, Lefaucheur C, Couzi L, Del Bello A, Kamar N, Le Quintrec M, Goutaudier V, Renaudin K, Giral M, Brouard S. Subclinical rejection-free diagnostic after kidney transplantation using blood gene expression. Kidney Int 2023; 103:1167-1179. [PMID: 36990211 DOI: 10.1016/j.kint.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 02/16/2023] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
We previously established a six-gene-based blood score associated with operational tolerance in kidney transplantation which was decreased in patients developing anti-HLA donor-specific antibodies (DSA). Herein, we aimed to confirm that this score is associated with immunological events and risk of rejection. We measured this using quantitative PCR (qPCR) and NanoString methods from an independent multicenter cohort of 588 kidney transplant recipients with paired blood samples and biopsies at one year after transplantation validating its association with pre-existing and de novo DSA. From 441 patients with protocol biopsy, there was a significant decrease of the score of tolerance in 45 patients with biopsy-proven subclinical rejection (SCR), a major threat associated with pejorative allograft outcomes that prompted an SCR score refinement. This refinement used only two genes, AKR1C3 and TCL1A, and four clinical parameters (previous experience of rejection, previous transplantation, sex of recipient and tacrolimus uptake). This refined SCR score was able to identify patients unlikely to develop SCR with a C-statistic of 0.864 and a negative predictive value of 98.3%. The SCR score was validated in an external laboratory, with two methods (qPCR and NanoString), and on 447 patients from an independent and multicenter cohort. Moreover, this score allowed reclassifying patients with discrepancies between the DSA presence and the histological diagnosis of antibody mediated rejection unlike kidney function. Thus, our refined SCR score could improve detection of SCR for closer and noninvasive monitoring, allowing early treatment of SCR lesions notably for patients DSA-positive and during lowering of immunosuppressive treatment.
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Affiliation(s)
- Richard Danger
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France.
| | - Ludmilla Le Berre
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Marion Cadoux
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Clarisse Kerleau
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Emmanuelle Papuchon
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), CHU Nantes, Nantes, France
| | - Hoa Le Mai
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Thi-Van-Ha Nguyen
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Pierrick Guérif
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France
| | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, INSERM Unit 1111, Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, INSERM Unit 1111, Lyon-Est Medical Faculty, Claude Bernard University (Lyon 1), Lyon, France
| | - Christophe Legendre
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Necker-Enfants Malades Institute, INSERM, Paris University, Paris, France
| | - Dany Anglicheau
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Necker-Enfants Malades Institute, INSERM, Paris University, Paris, France
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, INSERM UMR S970, Université Paris Cité, Kidney Transplant Department, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis, and Apheresis, CHU Bordeaux, Bordeaux, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire de Toulouse, INSERM UMR1291 - Université Toulouse III, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Toulouse, Université Toulouse III Paul Sabatier, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire de Toulouse, INSERM UMR1291 - Université Toulouse III, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Toulouse, Université Toulouse III Paul Sabatier, Toulouse, France
| | - Moglie Le Quintrec
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Lapeyronie, Montpellier, France
| | - Valentin Goutaudier
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Necker-Enfants Malades Institute, INSERM, Paris University, Paris, France; Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, Paris, France
| | - Karine Renaudin
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; CHU Nantes, Service d'Anatomie et Cytologie Pathologiques, Nantes, France
| | - Magali Giral
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), CHU Nantes, Nantes, France; LabEx IGO "Immunotherapy, Graft, Oncology", Nantes Université, Nantes, France
| | - Sophie Brouard
- CHU Nantes, Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology (CR2TI), UMR 1064, ITUN, Nantes, France; Centre d'Investigation Clinique en Biothérapie, Centre de Ressources Biologiques (CRB), CHU Nantes, Nantes, France; LabEx IGO "Immunotherapy, Graft, Oncology", Nantes Université, Nantes, France.
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Parhizgari N, Zarei Ghobadi M, Rezaei F, Maraashi SM, Khatami MR, Mokhtari-Azad T. Transcriptomic analysis of human cytomegalovirus to survey the indirect effects on renal transplant recipients. Transpl Immunol 2023; 78:101746. [PMID: 36796459 DOI: 10.1016/j.trim.2022.101746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/02/2022] [Accepted: 11/13/2022] [Indexed: 02/17/2023]
Abstract
Post-transplant human cytomegalovirus (HCMV) viremia has been linked to adverse "indirect effects" among transplant patients. HCMV-created immunomodulatory mechanisms could be associated with the indirect effects. OBJECTIVE In the present study, the RNA-Seq whole transcriptome of renal transplant (RT) patients was analyzed to seek the underlying pathobiologic pathways associated with the long-term indirect effects of HCMV. METHODS To investigate the activated biological pathways in HCMV infection, total RNA was extracted from PBMCs of 2 RT patients with active HCMV and 2 RT patients without infection and then were sequenced using RNA-Seq. The resulted raw data were analyzed by conventional RNA-Seq software to determine the Differentially Expressed Genes (DEGs). Afterward, Gene Ontology (GO) and pathway enrichment analyses were conducted to determine the enriched pathways and biological processes by DEGs. Eventually, the relative expressions of some significant genes were validated in the twenty external RT patients. RESULT The analysis of RNA-Seq data related to RT patients with HCMV active viremia led to the identification of 140 up-regulated and 100 down-regulated DEGs. KEGG pathway analysis revealed the enrichment of DEGs in IL18 signaling, AGE-RAGE signaling pathway in diabetic complications, signaling by GPCR, Platelet activation, signaling and aggregation, Estrogen signaling pathway and signaling by Wnt due to HCMV infection. The expression levels of six genes involved in enriched pathways including F3, PTX3, ADRA2B, GNG11, GP9, HBEGF were then verified using RT-qPCR. The results were in consistent with RNA-Seq resultsoutcomes. CONCLUSION This study specifies some pathobiological pathways which are activated in HCMV active infection and could be linked to the adverse indirect effects caused by HCMV infection in transplant patients.
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Affiliation(s)
- Najmeh Parhizgari
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohadeseh Zarei Ghobadi
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Department of Cell and Molecular Biology and Microbiology, Faculty of Biological Science and Technology, University of Isfahan, Isfahan, Iran
| | - Farhad Rezaei
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Seyed Mahdi Maraashi
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Talat Mokhtari-Azad
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
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Diena D, Allesina A, Fop F, Mella A, Cavallo R, Costa C, Dolla C, Gallo E, De Rosa FG, Lavacca A, Giraudi R, Mariano F, Biancone L. Relationship between Cytomegalovirus Viremia and Long-Term Outcomes in Kidney Transplant Recipients with Different Donor Ages. Microorganisms 2023; 11:microorganisms11020458. [PMID: 36838423 PMCID: PMC9961719 DOI: 10.3390/microorganisms11020458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
OBJECTIVES To explore the Cytomegalovirus (CMV) burden on the long-term post-transplant course in different donor ages, we evaluated the incidence and risk factors for CMV in our kidney-transplanted patients (KTs) with extensive adoption of expanded-criteria donors (ECDs). METHODS Retrospective evaluation of 929 consecutive first KTs (49.5% receiving an organ from a donor ≥ 60 years) performed between 01-2003 and 12-2013. Overall survival was estimated using Kaplan-Meier curves; cumulative incidence function was additionally analyzed to consider the potential role of death with a functioning graft as a competitive event with graft dysfunction and to avoid overestimation. Apart from regular DNAemia monitoring in all patients, prophylaxis was adopted in high-risk groups (D+/R- or recipients of anti-thymocyte globulin induction), with pre-emptive therapy in the remaining groups. RESULTS CMV incidence was 19.5% (4-34.9% according to serostatus combination: D-/R-, D-/R+, D+/R+, D+/R-). Donor and recipient age, recipient pre-transplant hypertension, DR antigen compatibility, cold ischemia time, and post-transplant early complications, including rejection, urologic and renal artery stenosis, and lower renal function and proteinuria ≥ 0.5 g/day at one year after KT were associated with CMV. CMV determined lower death-censored graft survival (DCGS) (p < 0.01), with a prominent effect in R+ (p < 0.01) and without impact in R- (p = 0.32 in D-/R- and p = 0.006 in D+/R-). Interestingly, CMV occurrence influenced DCGS only in KTs who received grafts from donors < 50 or 50-69 years old (p < 0.01), while it was not significant with older donors (p = 0.07). The analysis of the cumulative incidence of graft loss accounting for death as a competing risk confirmed all these findings. In multivariate analysis, CMV replication/disease in the first year was an independent predictor for DCGS (HR 1.73 [1.3-2.3]). CONCLUSIONS In a large population with extensive ECD adoption, CMV viremia in the first year demonstrates its harmful effect with an independent role for graft loss and significant impact among R+ recipients and KTs with donors < 70 years.
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Affiliation(s)
- Davide Diena
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
- Renal Unit, Santa Croce e Carle Hospital, 12100 Cuneo, Italy
| | - Anna Allesina
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Fabrizio Fop
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Alberto Mella
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Rossana Cavallo
- Microbiology and Virology Unit, University of Turin, 10126 Turin, Italy
| | - Cristina Costa
- Microbiology and Virology Unit, University of Turin, 10126 Turin, Italy
| | - Caterina Dolla
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Ester Gallo
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, A.O.U. Città Della Salute e Della Scienza di Torino, 10126 Turin, Italy
| | - Antonio Lavacca
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Roberta Giraudi
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Filippo Mariano
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Luigi Biancone
- Renal Transplant Center “A. Vercellone”, Nephrology, Dialysis, and Renal Transplant Division, “Città Della Salute e Della Scienza” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
- Correspondence: ; Tel.: +39-011-6336797
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5
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Montero C, Yomayusa N, Torres R, Cortes J, Alvarez C, Gallo J, Aldana G, Acevedo A, Rios M, Echeverri J, Yepes Z, Silva A, Gayon D, Perez J, Ibanez M. Low dose thymoglobulin versus basiliximab in cytomegalovirus positive kidney transplant recipients: Effectiveness of preemptive cytomegalovirus modified strategy. Nefrologia 2022:S2013-2514(22)00143-2. [PMID: 36437203 DOI: 10.1016/j.nefroe.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 10/06/2021] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND We performed a retrospective trial to determine asymptomatic CMV reactivation and CMV disease in kidney allograft recipients with positive CMV serostatus. METHODS Preemptive modified strategy under low dose thymoglobulin versus basiliximab induction was evaluated. Patients were monitored by CMV-polymerase chain reaction (PCR); if the viral load was >4000copies/μl, they received valganciclovir adjusted for their renal function. RESULTS 132 recipients were included in the study, 84 and 48 receiving basiliximab and thymoglobulin induction respectively, and followed up for 12 months. Asymptomatic CMV reactivation was significantly higher for thymoglobulin (77.1% vs. 16.7%, p<0.001). Treatment groups had similar rates of CMV disease (3.6% vs. 2.1%, p 0.538). The significant difference in asymptomatic CMV reactivation between two treatment groups did not have any impact on 1 year graft function (71±26ml/min vs. 74±19ml/min; p=0.475) and no histological differences in protocol biopsies were observed among patients with asymptomatic CMV reactivation vs those without CMV reactivation. CONCLUSIONS Due to the high asymptomatic CMV reactivation incidence in patients who received thymoglobulin induction, our results suggest that valganciclovir prophylaxis may be advantageous in CMV seropositive renal transplant recipients after low dose thymoglobulin induction. A preemptive strategy appeared to significantly reduce the likelihood of CMV disease in both groups. Rejection risk and negative impact in renal function associated with asymptomatic CMV reactivation was not found in our series.
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Affiliation(s)
- Camilo Montero
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia; Translational Investigation Group, Sanitas University, Clinica Colsanitas, Bogota, Colombia.
| | - Nancy Yomayusa
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia; Translational Investigation Group, Sanitas University, Clinica Colsanitas, Bogota, Colombia; Infectious Diseases Department, Clinica Colsanitas, Bogota, Colombia
| | - Rodolfo Torres
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia; Translational Investigation Group, Sanitas University, Clinica Colsanitas, Bogota, Colombia
| | - Jorge Cortes
- Facultad de Medicina, Universidad Nacional de Colombia
| | - Carlos Alvarez
- Translational Investigation Group, Sanitas University, Clinica Colsanitas, Bogota, Colombia; Infectious Diseases Department, Clinica Colsanitas, Bogota, Colombia
| | - Juan Gallo
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia
| | - Guillermo Aldana
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia
| | - Andres Acevedo
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia; Translational Investigation Group, Sanitas University, Clinica Colsanitas, Bogota, Colombia
| | - Maria Rios
- Molecular Biology and Immunology Laboratory, Clinica Colsanitas, Bogota, Colombia
| | - Johana Echeverri
- Molecular Biology and Immunology Laboratory, Clinica Colsanitas, Bogota, Colombia
| | - Zuly Yepes
- Molecular Biology and Immunology Laboratory, Clinica Colsanitas, Bogota, Colombia
| | - Adriana Silva
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia
| | - Diana Gayon
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia
| | - Jorge Perez
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia; Translational Investigation Group, Sanitas University, Clinica Colsanitas, Bogota, Colombia; Infectious Diseases Department, Clinica Colsanitas, Bogota, Colombia; Molecular Biology and Immunology Laboratory, Clinica Colsanitas, Bogota, Colombia
| | - Milciades Ibanez
- Renal Transplantation Group, Clinica Reina Sofia, University Clinic, Bogota, Colombia; Translational Investigation Group, Sanitas University, Clinica Colsanitas, Bogota, Colombia
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Rodríguez-Goncer I, Ruiz-Ruigómez M, López-Medrano F, Trujillo H, González E, Polanco N, Gutiérrez E, San Juan R, Corbella L, Ruiz-Merlo T, Parra P, Folgueira MD, Andrés A, Aguado JM, Fernández-Ruiz M. Cytomegalovirus Exposure and the Risk of Overall Infection After Kidney Transplantation: A Cohort Study on the Indirect Effects Attributable to Viral Replication. Transpl Int 2022; 35:10273. [PMID: 35185374 PMCID: PMC8842254 DOI: 10.3389/ti.2021.10273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/22/2021] [Indexed: 11/13/2022]
Abstract
Previous reports hypothesized that cytomegalovirus (CMV) may predispose to non-CMV infection after kidney transplantation (KT). We analysed the incidence of non-CMV infection (overall, bacterial and opportunistic) in 291 KT recipients according to the previous development of any level or high-level (≥1,000 IU/ml) CMV viremia. Exposure to CMV replication was assessed throughout fixed intervals covering first the 30, 90, 180 and 360 post-transplant days (cumulative exposure) and non-overlapping preceding periods (recent exposure). Adjusted Cox models were constructed for each landmark analysis. Overall, 67.7 and 50.5% patients experienced non-CMV and CMV infection, respectively. Patients with cumulative CMV exposure had higher incidence of non-CMV infection beyond days 30 (p-value = 0.002) and 90 (p-value = 0.068), although these associations did not remain after multivariable adjustment. No significant associations were observed for the remaining landmark models (including those based on high-level viremia or recent CMV exposure), or when bacterial and opportunistic infection were separately analysed. There were no differences in viral kinetics (peak CMV viremia and area under curve of CMV viral load) either. Our findings do not support the existence of an independent association between previous CMV exposure and the overall risk of post-transplant infection, although results might be affected by power limitations.
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Affiliation(s)
- Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Madrid, Spain
- *Correspondence: Isabel Rodríguez-Goncer,
| | - María Ruiz-Ruigómez
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
| | - Hernando Trujillo
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Esther González
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
| | - Laura Corbella
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Madrid, Spain
| | - Patricia Parra
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Madrid, Spain
| | - María Dolores Folgueira
- School of Medicine, Universidad Complutense, Madrid, Spain
- Department of Microbiology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - Amado Andrés
- School of Medicine, Universidad Complutense, Madrid, Spain
- Department of Nephrology, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Sanitaria Hospital “12 de Octubre” (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
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7
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Requião-Moura LR. Local evidence on the cytomegalovirus viral load threshold for preemptive treatment is welcome, and a comment on indirect effects. J Bras Nefrol 2021; 43:457-459. [PMID: 34747434 PMCID: PMC8940103 DOI: 10.1590/2175-8239-jbn-2021-e009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Lúcio R Requião-Moura
- Universidade Federal de São Paulo, Departamento de Medicina, Disciplina de Nefrologia, São Paulo, SP, Brasil.,Hospital Israelita Albert Einstein, Unidade de Transplante Renal, São Paulo, SP, Brasil
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8
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Low dose thymoglobulin versus basiliximab in cytomegalovirus positive kidney transplant recipients: Effectiveness of preemptive cytomegalovirus modified strategy. Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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9
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Räihä J, Ortiz F, Mannonen L, Loginov R, Lempinen M, Lautenschlager I, Helanterä I. The burden of cytomegalovirus infection remains high in high-risk kidney transplant recipients despite six-month valganciclovir prophylaxis. Transpl Infect Dis 2021; 23:e13577. [PMID: 33527660 DOI: 10.1111/tid.13577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 01/09/2021] [Accepted: 01/17/2021] [Indexed: 12/28/2022]
Abstract
Cytomegalovirus continues to be a concern after transplantation despite prophylaxis regimens. Our aim was to analyse post-prophylaxis primary cytomegalovirus infections among kidney transplant recipients after 6-month valganciclovir prophylaxis and to determine the usefulness of surveillance after prophylaxis. Data from all cytomegalovirus D+/R- kidney transplant recipients from January 2004 to October 2018 at our center who received 6-month prophylaxis with valganciclovir were retrospectively analysed (N = 481). Detailed analyses were performed for 136 patients who were monitored every 2-4 weeks for DNAemia after the discontinuation of prophylaxis. Post-prophylaxis primary cytomegalovirus infection occurred in 182/481 (38%) patients median 264 days after transplantation (IQR: 226-367) and median 84 days after the end of prophylaxis (IQR: 46-187). In 49% patients, cytomegalovirus infection occurred over 3 months after the end of prophylaxis. Cytomegalovirus infection was not associated with lower patient or graft survival and no independent risk factors for infection were found. From patients monitored closely, 71/136 (52%) patients developed post-prophylaxis primary cytomegalovirus infection. Altogether, 52/136 (38%) patients were diagnosed with probable post-prophylaxis cytomegalovirus disease and 19/136 (14%) patients had asymptomatic CMV infection. Recurrent infection occurred in 38/71 (39%) patients. The incidence of post-prophylaxis primary cytomegalovirus infection among D+/R- kidney transplant recipients remains high despite 6-month prophylaxis. Surveillance after prophylaxis was challenging as a considerable portion of the infections occurred late and already symptomatic.
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Affiliation(s)
- Juulia Räihä
- Abdominal Center, Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Fernanda Ortiz
- Abdominal Center, Department of Nephrology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Laura Mannonen
- Department of Virology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Raisa Loginov
- Department of Virology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marko Lempinen
- Abdominal Center, Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Irmeli Lautenschlager
- Department of Virology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Abdominal Center, Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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10
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Singh R, Peters-Sengers H, Remmerswaal EBM, Yapici U, van der Pant KAMI, van der Weerd NC, Roelofs JJTH, van Lier RAW, Bemelman FJ, Florquin S, Ten Berge IJM. Clinical consequences of primary CMV infection after renal transplantation: a case-control study. Transpl Int 2020; 33:1116-1127. [PMID: 32480425 PMCID: PMC7540315 DOI: 10.1111/tri.13667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/11/2020] [Accepted: 05/25/2020] [Indexed: 12/15/2022]
Abstract
The impact of primary cytomegalovirus infection (pCMV) on renal allograft function and histology is controversial. We evaluated the influence on incidence of acute rejection, allograft loss, allograft function and interstitial fibrosis/tubular atrophy (IF/TA). Retrospective case-control study, recipients transplanted between 2000 and 2014. Risk of acute rejection and allograft loss for those who experienced pCMV infection compared with those who did not, within an exposure period of two months after transplantation. Besides, its influence on allograft function and histology at one to three years after transplantation. Of 113 recipients experienced pCMV infection, 306 remained CMV seronegative. pCMV infection in the exposure period could not be proven as increasing the risk for acute rejection [HR = 2.18 (95% CI 0.80-5.97) P = 0.13] or allograft loss [HR = 1.11 (95%CI 0.33-3.72) P = 0.87]. Combination of pCMV infection and acute rejection posed higher hazard for allograft loss than acute rejection alone [HR = 3.69 (95% CI 1.21-11.29) P = 0.02]. eGFR(MDRD) values did not significantly differ at years one [46 vs. 50], two [46 vs. 51] and three [46 vs. 52]. No association between pCMV infection and IF/TA could be demonstrated [OR = 2.15 (95%CI 0.73-6.29) P = 0.16]. pCMV infection was not proven to increase the risk for acute rejection or allograft loss. However, it increased the risk for rejection-associated allograft loss. In remaining functioning allografts, it was not significantly associated with decline in function nor with presence of IF/TA.
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Affiliation(s)
- Ramandeep Singh
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Hessel Peters-Sengers
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Center for Experimental Molecular Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Ester B M Remmerswaal
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Department of Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands
| | - Unsal Yapici
- Department of Pathology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Karlijn A M I van der Pant
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Neelke C van der Weerd
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - René A W van Lier
- Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Fréderike J Bemelman
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Sandrine Florquin
- Department of Pathology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Ineke J M Ten Berge
- Renal Transplant Unit, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
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11
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The development and implementation of stewardship initiatives to optimize the prevention and treatment of cytomegalovirus infection in solid-organ transplant recipients. Infect Control Hosp Epidemiol 2020; 41:1068-1074. [DOI: 10.1017/ice.2020.203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AbstractClassical stewardship efforts have targeted immunocompetent patients; however, appropriate use of antimicrobials in the immunocompromised host has become a target of interest. Cytomegalovirus (CMV) infection is one of the most common and significant complications after solid-organ transplant (SOT). The treatment of CMV requires a dual approach of antiviral drug therapy and reduction of immunosuppression for optimal outcomes. This dual approach to CMV management increases complexity and requires individualization of therapy to balance antiviral efficacy with the risk of allograft rejection. In this review, we focus on the development and implementation of CMV stewardship initiatives, as a component of antimicrobial stewardship in the immunocompromised host, to optimize the management of prevention and treatment of CMV in SOT recipients. These initiatives have the potential not only to improve judicious use of antivirals and prevent resistance but also to improve patient and graft survival given the interconnection between CMV infection and allograft function.
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12
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Development of a Predictive Model Using Endoscopic Features for Gastric Cytomegalovirus Infection in Renal Transplant Patients. Transplantation 2018; 103:998-1004. [PMID: 30507742 DOI: 10.1097/tp.0000000000002554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a common viral pathogen in transplant patients which often targets the stomach. However, the endoscopic characteristics of gastric CMV infection are not well established. We aimed to develop a predictive model using endoscopic findings for gastric CMV infection in renal transplant patients. METHODS A retrospective study of 287 kidney transplant recipients who underwent endoscopy with biopsy for suspected CMV infection from January 2006 to November 2015 at a tertiary referral hospital was performed. CMV infection was defined based on inclusion bodies in hematoxylin and eosin and immunohistochemical staining. Endoscopic and clinical parameters related to gastric CMV infection were selected by univariate analyses. Multivariate logistic regression was used to create a predictive model from β-coefficients. RESULTS CMV was present in 107 (37.7%) of the 287 patients. Multivariate analysis found age (odds ratio [OR], 0.964; 95% confidence interval [CI], 0.938-0.99; P = 0.008), erosions with surface exudate (OR, 5.34; 95% CI, 2.687-10.612; P < 0.001), raised shape of erosions (OR, 3.957; 95% CI, 1.937-8.083; P < 0.001), and antral location of ulcers (OR, 15.018; 95% CI, 5.728-39.371; P < 0.001) as independent predictive factors for gastric CMV infection. Using the predictive model created from this analysis, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 71.03%, 85.56%, 74.51%, 83.24%, and 80.14%, respectively. The area under the receiver operating characteristic curve of this model for detecting CMV infection was 0.850 (95% CI, 0.803-0.889; P < 0.001). CONCLUSIONS The predictive model with typical endoscopic findings may be useful for detecting gastric CMV infection in renal transplant patients.
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13
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Reischig T, Kacer M, Hruba P, Hermanova H, Hes O, Lysak D, Kormunda S, Bouda M. Less renal allograft fibrosis with valganciclovir prophylaxis for cytomegalovirus compared to high-dose valacyclovir: a parallel group, open-label, randomized controlled trial. BMC Infect Dis 2018; 18:573. [PMID: 30442095 PMCID: PMC6238264 DOI: 10.1186/s12879-018-3493-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 11/01/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) prophylaxis may prevent CMV indirect effects in renal transplant recipients. This study aimed to compare the efficacy of valganciclovir and valacyclovir prophylaxis for CMV after renal transplantation with the focus on chronic histologic damage within the graft. METHODS From November 2007 through April 2012, adult renal transplant recipients were randomized, in an open-label, single-center study, at a 1:1 ratio to 3-month prophylaxis with valganciclovir (n = 60) or valacyclovir (n = 59). The primary endpoint was moderate-to-severe interstitial fibrosis and tubular atrophy assessed by protocol biopsy at 3 years evaluated by a single pathologist blinded to the study group. The analysis was conducted in an intention-to-treat population. RESULTS Among the 101 patients who had a protocol biopsy specimen available, the risk of moderate-to-severe interstitial fibrosis and tubular atrophy was significantly lower in those treated with valganciclovir (22% versus 34%; adjusted odds ratio, 0.31; 95% confidence interval, 0.11-0.90; P = 0.032 by multivariate logistic regression). The incidence of CMV disease (9% versus 2%; P = 0.115) and CMV DNAemia (36% versus 42%; P = 0.361) were not different at 3 years. CONCLUSIONS Valganciclovir prophylaxis, as compared with valacyclovir, was associated with a reduced risk of moderate-to-severe interstitial fibrosis and tubular atrophy in patients after renal transplantation. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ( ACTRN12610000016033 ). Registered on September 26, 2007.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic. .,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.
| | - Martin Kacer
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic
| | - Petra Hruba
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Transplant Laboratory, Institute for Clinical and Experimental Medicine, 14021, Prague, Czech Republic
| | - Hana Hermanova
- Department of Hemato-oncology, Teaching Hospital, 30460, Pilsen, Czech Republic
| | - Ondrej Hes
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Department of Pathology, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic
| | - Daniel Lysak
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Department of Hemato-oncology, Teaching Hospital, 30460, Pilsen, Czech Republic
| | - Stanislav Kormunda
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Division of Information Technologies and Statistics, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic
| | - Mirko Bouda
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic
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14
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A high level of urinary retinol-binding protein is associated with cytomegalovirus infection in kidney transplantation. Clin Sci (Lond) 2018; 132:2059-2069. [PMID: 30171051 DOI: 10.1042/cs20180390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/23/2018] [Accepted: 08/28/2018] [Indexed: 11/17/2022]
Abstract
The indirect effects of cytomegalovirus (CMV) viremia can be related to chronic changes in renal allograft structure, but its real impact in early and late graft function remains speculative. A total of 159 patients undergoing renal transplantation using a preemptive therapeutic strategy to prevent CMV disease were included in the present study. The patients were prospectively followed, with serial measurements of urinary retinol-binding protein (uRBP), a marker of proximal tubule injury. uRBP levels and their dynamic performance were compared according to CMV viremia and the 5-year estimated glomerular filtration rate (eGFR), as measured with the modification of diet in renal disease (MDRD) equation. CMV viremia was detected in 79.9% of the patients, with high uRBP levels being detected in 76.0% of these patients (compared with 40.7% in CMV-, P=0.005). High uRBP was associated with male recipients (P=0.02), the number of mismatches (P=0.02) and CMV infection (P=0.001). Five-year eGFR was worse in patients with high uRBP levels (50.3 ± 25.8 compared with 59.8 ± 26.4 ml/min, P=0.04). In a multivariate model, eGFR <60 ml/min was associated with donor age (P<0.001), the number of mismatches (P=0.04), thymoglobulin dose (P=0.02), the presence of and time with delayed graft function (DGF) (P=0.005 and P=0.04), 1-month tacrolimus levels (P=0.03), and uRBP levels after CMV treatment (P=0.01). Patients with CMV viremia in whom uRBP levels were normalized up to 3 months after treatment showed significantly better 5-year eGFR than those in whom uRBP remained high: 61.0 ± 24.2 compared with 42.3 ± 23.9 ml/min, P<0.001. CMV viremia was associated with high uRBP levels, which represent a profile of proximal tubule injury, and the dynamic performance of uRBP after treatment was associated with long-term kidney graft function.
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15
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Britt WJ, Prichard MN. New therapies for human cytomegalovirus infections. Antiviral Res 2018; 159:153-174. [PMID: 30227153 DOI: 10.1016/j.antiviral.2018.09.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/28/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
Abstract
The recent approval of letermovir marks a new era of therapy for human cytomegalovirus (HCMV) infections, particularly for the prevention of HCMV disease in hematopoietic stem cell transplant recipients. For almost 30 years ganciclovir has been the therapy of choice for these infections and by today's standards this drug exhibits only modest antiviral activity that is often insufficient to completely suppress viral replication, and drives the selection of drug-resistant variants that continue to replicate and contribute to disease. While ganciclovir remains the therapy of choice, additional drugs that inhibit novel molecular targets, such as letermovir, will be required as highly effective combination therapies are developed not only for the treatment of immunocompromised hosts, but also for congenitally infected infants. Sustained efforts, largely in the biotech industry and academia, have identified additional highly active lead compounds that have progressed into clinical studies with varying levels of success and at least two have the potential to be approved in the near future. Some of the new drugs in the pipeline inhibit new molecular targets, remain effective against isolates that have developed resistance to existing therapies, and promise to augment existing therapeutic regimens. Here, we will describe some of the unique features of HCMV biology and discuss their effect on therapeutic needs. Existing drugs will also be discussed and some of the more promising candidates will be reviewed with an emphasis on those progressing through clinical studies. The in vitro and in vivo antiviral activity, spectrum of antiviral activity, and mechanism of action of new compounds will be reviewed to provide an update on potential new therapies for HCMV infections that have progressed significantly in recent years.
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Affiliation(s)
- William J Britt
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham AL 35233-1711, USA
| | - Mark N Prichard
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham AL 35233-1711, USA.
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16
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Lollinga WT, Rurenga-Gard L, van Doesum W, van Bergen R, Diepstra A, Vonk JM, Riezebos-Brilman A, Niesters HGM, van Son WJ, van den Born J, Sanders JS. High human cytomegalovirus DNAemia early post-transplantation associates with irreversible and progressive loss of renal function - a retrospective study. Transpl Int 2017; 30:817-826. [DOI: 10.1111/tri.12972] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/02/2016] [Accepted: 04/18/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Wouter T. Lollinga
- Division of Nephrology; Department of Internal Medicine; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Lilli Rurenga-Gard
- Department of Medical Microbiology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Willem van Doesum
- Division of Nephrology; Department of Internal Medicine; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Rik van Bergen
- Division of Nephrology; Department of Internal Medicine; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Arjan Diepstra
- Division of Pathology; Department of Pathology and Medical Biology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Judith M. Vonk
- Department of Epidemiology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Annelies Riezebos-Brilman
- Department of Medical Microbiology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - H. G. M. Niesters
- Department of Medical Microbiology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Willem J. van Son
- Division of Nephrology; Department of Internal Medicine; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Jacob van den Born
- Division of Nephrology; Department of Internal Medicine; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Jan-Stephan Sanders
- Division of Nephrology; Department of Internal Medicine; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
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17
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Kotton CN, Huprikar S, Kumar D. Transplant Infectious Diseases: A Review of the Scientific Registry of Transplant Recipients Published Data. Am J Transplant 2017; 17:1439-1446. [PMID: 28066999 DOI: 10.1111/ajt.14195] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 12/01/2016] [Accepted: 12/26/2016] [Indexed: 01/25/2023]
Abstract
The Scientific Registry of Transplant Recipients (SRTR) serves to collect data on organ transplants performed in the United States. Although the infectious diseases data are limited and include mostly pretransplant serologies and other nonspecific infection-related outcomes, this multicenter data collection allows for insightful national data and the ability to monitor trends over time. We reviewed the published concise reports for each organ type in SRTR reports containing data from 2005 to 2014, and summarized our findings with respect to cytomegalovirus (CMV), Epstein-Barr virus, posttransplant lymphoproliferative disorder (PTLD), hepatitis B virus (HBV), hepatitis C virus (HCV), HIV, general infection, and prophylaxis. Our review highlights a few developments. While rates of donor-recipient CMV serology combinations remain fairly constant over time, there are generally more seronegative donors and recipients among living donor transplants. There has been a reduction in PTLD for pediatric transplant recipients. There has also been a slight reduction in anti-HBV core antibody-positive donor organs and stable reporting of HCV-positive donor organs and HIV-positive recipients.
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Affiliation(s)
- C N Kotton
- Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - S Huprikar
- Ichan School of Medicine at Mount Sinai, New York, NY
| | - D Kumar
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
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18
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Kır O, Zeytinoğlu A, Arda B, Yılmaz M, Aşçı G, Töz H. Impact of Prophylaxis vs Pre-emptive Approach for Cytomegalovirus Infection in Kidney Transplant Recipients. Transplant Proc 2017; 49:537-540. [PMID: 28340829 DOI: 10.1016/j.transproceed.2017.01.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cytomegalovirus (CMV) is the most common viral infection during the post-transplant period, and it is one of the major causes of morbidity and mortality in kidney transplantation. In this study, the incidence and impact of pre-emptive and prophylactic approaches and long-term effects on graft and patient survival of CMV infection were investigated. Among 493 adult kidney transplant recipients, pretransplant CMV IgG-negative patients and patients with a follow-up shorter than a month were excluded. The patients were divided into 2 groups: pre-emptive group (n = 187, regular screening and acyclovir 400 mg twice daily for 6 months), and prophylaxis group (n = 275, valganciclovir 450 mg/d for 3 months). The pre-emptive group was screened for CMV with either pp65 antigenemia or CMV DNA. There were 462 patients, and mean follow-up was 37.7 months. There were more CMV infections in the pre-emptive group than in the prophylaxis group (n = 56, 30.1% vs n = 12, 4.4%, respectively; P < .001). Late CMV infections were significantly more frequent in the prophylaxis group (10 of 12, 83.3%) than in the pre-emptive group (8 of 56, 14.3%, P < .001). In multivariate analysis, valganciclovir prophylaxis was associated with a lower CMV infection (relative risk [RR]: 0.18, 95% confidence interval [CI] 0.08 to 0.39, P < .001). Delayed graft function was the only independent risk factor for graft loss during the follow-up on multivariate Cox regression analysis (RR: 2.66, 95% GA 1.17 to 6.04, P = .02). Valganciclovir prophylaxis was more protective against CMV infection than the pre-emptive approach. Neither prophylaxis/pre-emptive approaches nor CMV infection had negative effect on graft and patient survival.
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Affiliation(s)
- O Kır
- Department of Internal Medicine, Ege University Medical School, Izmir, Turkey
| | - A Zeytinoğlu
- Department of Microbiology, Ege University Medical School, Izmir, Turkey
| | - B Arda
- Department of Infectious Disease, Ege University Medical School, Izmir, Turkey
| | - M Yılmaz
- Division of Nephrology, Ege University Medical School, Izmir, Turkey.
| | - G Aşçı
- Division of Nephrology, Ege University Medical School, Izmir, Turkey
| | - H Töz
- Division of Nephrology, Ege University Medical School, Izmir, Turkey
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19
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Feng S, Yang J, Wang W, Hu X, Liu H, Qian X, Feng D, Zhang X. Incidence and Risk Factors for Cytomegalovirus Infection in Patients With Kidney Transplantation: A Single-Center Experience. Transplant Proc 2017; 48:2695-2699. [PMID: 27788803 DOI: 10.1016/j.transproceed.2016.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/03/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is deemed to be a major cause of morbidity and mortality in patients after kidney transplantation. The purpose of this study was to analyze the incidence of CMV infection and risk factors for CMV infection in our center, to help in determination of its impact on the kidney function in this patient population, and to provide new ideas for the prevention and treatment of CMV infection. METHODS A total of 319 kidney transplant recipients from our center were studied between January 2000 and December 2015. The CMV viral load in each kidney transplant patients was monitored with the use of CMV quantitative nucleic acid testing (CMV-QNAT). Laboratory data and other medical records were also collected. RESULTS The incidence of CMV infection was 8.8% in our studied patients. The patients within 3 to 6 months and 5 to 10 years after transplantation had a higher risk of CMV infection. CMV infection was probably correlated with lower white blood cell counts but elevated hemoglobin, serum creatinine, blood urea nitrogen, potassium, and estimated glomerular filtration rate (eGFR). Anti-CMV immunoglobulin (Ig)G and history of allograft rejection were also associated with CMV infection. In multivariate regression analysis, white blood cells, eGFR, anti-CMV IgG, and history of allograft rejection were the independent risk factors associated with CMV infection in kidney transplantation patients. CONCLUSIONS CMV infection was an important complication after kidney transplantation, particularly in these patients with allograft impairment.
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Affiliation(s)
- S Feng
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - J Yang
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - W Wang
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - X Hu
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - H Liu
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - X Qian
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - D Feng
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - X Zhang
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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20
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Vanhove T, Goldschmeding R, Kuypers D. Kidney Fibrosis: Origins and Interventions. Transplantation 2017; 101:713-726. [PMID: 27941433 PMCID: PMC7228593 DOI: 10.1097/tp.0000000000001608] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/24/2016] [Accepted: 11/10/2016] [Indexed: 02/06/2023]
Abstract
All causes of renal allograft injury, when severe and/or sustained, can result in chronic histological damage of which interstitial fibrosis and tubular atrophy are dominant features. Unless a specific disease process can be identified, what drives interstitial fibrosis and tubular atrophy progression in individual patients is often unclear. In general, clinicopathological factors known to predict and drive allograft fibrosis include graft quality, inflammation (whether "nonspecific" or related to a specific diagnosis), infections, such as polyomavirus-associated nephropathy, calcineurin inhibitors (CNI), and genetic factors. The incidence and severity of chronic histological damage have decreased substantially over the last 3 decades, but it is difficult to disentangle what effects individual innovations (eg, better matching and preservation techniques, lower CNI dosing, BK viremia screening) may have had. There is little evidence that CNI-sparing/minimization strategies, steroid minimization or renin-angiotensin-aldosterone system blockade result in better preservation of intermediate-term histology. Treatment of subclinical rejections has only proven beneficial to histological and functional outcome in studies in which the rate of subclinical rejection in the first 3 months was greater than 10% to 15%. Potential novel antifibrotic strategies include antagonists of transforming growth factor-β, connective tissue growth factor, several tyrosine kinase ligands (epidermal growth factor, platelet-derived growth factor, vascular endothelial growth factor), endothelin and inhibitors of chemotaxis. Although many of these drugs are mainly being developed and marketed for oncological indications and diseases, such as idiopathic pulmonary fibrosis, a number may hold promise in the treatment of diabetic nephropathy, which could eventually lead to applications in renal transplantation.
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Affiliation(s)
- Thomas Vanhove
- 1 Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium. 2 Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium. 3 Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
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21
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Sayin B, Canver B, Gurlek Demirci B, Colak T, Ozdemir BH, Haberal M. Renin-Angiotensin System Blockage and Avoiding High Doses of Calcineurin Inhibitors Prevent Interstitial Fibrosis and Tubular Atrophy in Kidney Transplant Recipients. EXP CLIN TRANSPLANT 2017; 15:32-36. [PMID: 28260428 DOI: 10.6002/ect.mesot2016.o19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Chronic allograft dysfunction is a complex and multifactorial process characterized by progressive interstitial fibrosis and tubular atrophy. The finding of interstitial fibrosis and tubular atrophy is prevalent among kidney transplant patients receiving a calcineurin inhibitor-based immunosuppressive regimen and may be considered as a surrogate of allograft survival. Both immune (acute rejection episodes, sensitization, and HLA incompatibility) and nonimmune (donor age, delayed graft function, calcineurin inhibitor toxicity, infections, and hypertension) mechanisms play a role in chronic allograft dysfunction, and different causes all lead to similar histologic and clinical final pathways, with the end result of graft loss. In our study, we aimed to compare the outcomes of kidney transplant recipients with or without interstitial fibrosis and tubular atrophy in protocol biopsies to determine the conditions that may affect allograft survival. MATERIALS AND METHODS We divided 192 kidney transplant recipients into 2 groups (96 patients with interstitial fibrosis and tubular atrophy; 96 patients without interstitial fibrosis and tubular atrophy) according to protocol biopsy at 6 months. Patient groups were compared according to their risk factors for chronic allograft dysfunction (cold ischemia time, delayed graft function, donor age, infections, mean blood calcineurin levels, and hypertension). RESULTS Cold ischemia time, delayed graft function, high 24-hour proteinuria levels, and higher mean blood calcineurin levels were found to be major risk factors for poor graft function in kidney transplant recipients with interstitial fibrosis and tubular atrophy. Renin-angiotensin system blockage with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was found to be preventive for interstitial fibrosis and tubular atrophy after kidney transplant. CONCLUSIONS Preventing prolongation of cold ischemia time, lowering blood cholesterol levels, angiotensin-converting enzyme inhibitors and angiotensin receptor blocker treatment even without existing proteinuria and avoiding higher doses of calcineurin inhibitors should be major approaches in kidney transplant recipients.
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Affiliation(s)
- Burak Sayin
- Department of Nephrology, Baskent University Faculty of Medicine, Ankara, Turkey
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22
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Han SH. Immunological Prediction of Cytomegalovirus (CMV) Replication Risk in Solid Organ Transplantation Recipients: Approaches for Regulating the Targeted Anti-CMV Prevention Strategies. Infect Chemother 2017; 49:161-175. [PMID: 29027383 PMCID: PMC5620383 DOI: 10.3947/ic.2017.49.3.161] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The current cytomegalovirus (CMV) prevention strategies in solid organ transplantation (SOT) recipients have contributed towards overcoming the detrimental effects caused by CMV lytic infection, and improving the long-term success rate of graft survival. Although the quantification of CMV in peripheral blood is the standard method, and an excellent end-point for diagnosing CMV replication and modulating the anti-CMV prevention strategies in SOT recipients, a novel biomarker mimicking the CMV control mechanism is required. CMV-specific immune monitoring can be employed as a basic tool predicting CMV infection or disease after SOT, since uncontrolled CMV replication mostly originates from the impairment of immune responses against CMV under immunosuppressive conditions in SOT recipients. Several studies conducted during the past few decades have indicated the possibility of measuring the CMV-specific cell-mediated immune response in clinical situations. Among several analytical assays, the most advancing standardized tool is the QuantiFERON®-CMV assay. The T-Track® CMV kit that uses the standardized enzyme-linked immunospot assay is also widely employed. In addition to these assays, immunophenotyping and intracellular cytokine analysis using flow cytometry (with fluorescence-labeled monoclonal antibodies or peptide-major histocompatibility complex multimers) needs to be adequately standardized and validated for potential clinical applications.
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Affiliation(s)
- Sang Hoon Han
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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23
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Reischig T, Kacer M, Hruba P, Jindra P, Hes O, Lysak D, Bouda M, Viklicky O. The impact of viral load and time to onset of cytomegalovirus replication on long-term graft survival after kidney transplantation. Antivir Ther 2017; 22:503-513. [DOI: 10.3851/imp3129] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
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24
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Forconi C, Gatault P, Miquelestorena-Standley E, Noble J, Al-Hajj S, Guillemain R, Stern M, Hoffmann T, Prat L, Suberbielle C, Masson E, Cesbron-Gautier A, Gaudy-Graffin C, Goudeau A, Thibault G, Ivanes F, Guibon R, Kazma I, Lebranchu Y, Büchler M, Magnan A, Halimi JM, Baron C. Polymorphism in programmed cell death 1 gene is strongly associated with lung and kidney allograft survival in recipients from CMV-positive donors. J Heart Lung Transplant 2016; 36:315-324. [PMID: 27751774 DOI: 10.1016/j.healun.2016.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/15/2016] [Accepted: 08/17/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) has a role in chronic rejection and graft loss in kidney transplant (KTx) and lung transplant (LTx) recipients. In addition, donor CMV seropositivity is an independent risk factor for renal graft loss. The anti-CMV response might modulate this risk. Expression of programmed cell death 1 (PD-1), a receptor involved in viral-specific T-cell exhaustion, is influenced by a single nucleotide polymorphism called PD-1.3 (wild-type allele G, variant allele A). METHODS We performed a retrospective study to assess the impact of PD-1.3 on graft outcome in donor CMV seropositive (D+) and donor CMV seronegative (D-) KTx and LTx. We also performed a case-control study to evaluate the anti-CMVpp65 response according to genotype. RESULTS PD-1.3 was determined in 1,119 KTx and 181 LTx. In 481 D+ KTx, A allele carriers (24%) experienced significantly less graft failure compared with GG carriers (p = 0.001). Multivariate analysis showed that this association was independent of donor and recipient age, acute rejection episodes, and number of human leukocyte antigen mismatches (hazard ratio, 0.381; 95% confidence interval, 0.209-0.696; p = 0.002). Analysis in 85 D+ LTx showed similar results: A allele carriers had better survival (hazard ratio, 0.302; 95% confidence interval, 0.128-0.716; p = 0.006) and greater 6-month forced expiratory volume (71% ± 17% vs 54% ± 16%, p = 0.001). In D- recipients, PD-1.3 did not affect KTx or LTx outcome. Finally, AA recipients had a stronger anti-CMVpp65 T-cell response than matched GG recipients (p = 0.003). CONCLUSIONS The A variant allele in PD-1.3 single nucleotide polymorphism improved graft survival in kidney and lung transplant recipients receiving grafts from CMV-positive donors.
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Affiliation(s)
- Catherine Forconi
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours
| | - Philippe Gatault
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours; Service de Néphrologie et Immunologie Clinique, CHRU Tours, Tours; Laboratory of Immunology, CHRU Tours, Tours.
| | | | - Johan Noble
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours; Service de Néphrologie et Immunologie Clinique, CHRU Tours, Tours
| | - Sally Al-Hajj
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours
| | - Romain Guillemain
- Department of Thoracic Surgery and Lung Transplant, HEGP Hospital, Paris
| | - Marc Stern
- Pneumology and Lung Transplant Unit, FOCH Hospital, Suresnes
| | - Thomas Hoffmann
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours
| | - Louis Prat
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours; Service de Néphrologie et Immunologie Clinique, CHRU Tours, Tours
| | - Caroline Suberbielle
- Laboratory of Immunology and Histocompatibility, Saint-Louis Hospital, APHP, Paris
| | - Emeline Masson
- Laboratory of Immunology and Histocompatibility, Saint-Louis Hospital, APHP, Paris
| | | | - Catherine Gaudy-Graffin
- Laboratory of Bacteriology and Virology, CHRU de Tours, Tours; INSERM U966, Tours University, Tours
| | - Alain Goudeau
- Laboratory of Bacteriology and Virology, CHRU de Tours, Tours; INSERM U966, Tours University, Tours
| | - Gilles Thibault
- Laboratory of Immunology, CHRU Tours, Tours; CNRS UMR 7292, Genetics, Immunotherapy, Chemistry and Cancer, Tours University, Tours
| | - Fabrice Ivanes
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours
| | - Roseline Guibon
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours
| | - Ihab Kazma
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours
| | - Yvon Lebranchu
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours; Service de Néphrologie et Immunologie Clinique, CHRU Tours, Tours
| | - Matthias Büchler
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours; Service de Néphrologie et Immunologie Clinique, CHRU Tours, Tours
| | - Antoine Magnan
- INSERM UMR 915, Institut du Thorax, IRT-UN, Nantes, France
| | - Jean-Michel Halimi
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours; Service de Néphrologie et Immunologie Clinique, CHRU Tours, Tours
| | - Christophe Baron
- EA4245 Cellules Dendritiques, Immunomodulation et Greffes, Université François-Rabelais, Tours
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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]
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26
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Erdbrügger U, Scheffner I, Mengel M, Schwarz A, Haller H, Gwinner W. Long-term impact of CMV infection on allografts and on patient survival in renal transplant patients with protocol biopsies. Am J Physiol Renal Physiol 2015; 309:F925-32. [DOI: 10.1152/ajprenal.00317.2015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 09/08/2015] [Indexed: 12/13/2022] Open
Abstract
Cytomegalovirus (CMV) infection is a frequent complication of early posttransplantation. This study examines its impact on chronic allograft changes, long-term graft loss, and patient survival. We studied 594 patients who had protocol biopsies at 6 wk, and 3 and 6 mo posttransplantation. Chronic allograft changes were evaluated according to the updated Banff classification [interstitial fibrosis/tubular atrophy (IF/TA), vascular and glomerular lesions]. Follow-up data were available for up to 10 yr. CMV infection was diagnosed in 153 of 594 patients (26%) in the first year after transplantation, mostly within the first 3 mo. Graft survival was reduced in patients with CMV ( P = 0.03) as well as the combined allograft/patient survival ( P = 0.008). Prevalence of IF/TA at 6 wk after transplantation was already threefold higher in patients who experienced CMV infection later on compared with patients without CMV ( P = 0.005). In multivariate analyses, CMV viremia or disease was not a significant factor for graft loss or death. In conclusion, patients with CMV infection posttransplantation show more chronic allograft changes early on, even before CMV infection, and development of IF/TA is not more prevalent in patients with CMV. Our data do not support a significant role of CMV in patient and graft outcomes.
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Affiliation(s)
- U. Erdbrügger
- Division of Nephrology and Hypertension, University of Virginia Health System, Charlottesville, Virginia
| | - I. Scheffner
- Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany; and
| | - M. Mengel
- Department of Laboratory Medicine and Pathology, University of Edmonton, Edmonton, Ontario, Canada
| | - A. Schwarz
- Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany; and
| | - H. Haller
- Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany; and
| | - W. Gwinner
- Division of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany; and
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27
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Choi BH, Cho HK, Jung JH, Choi JY, Shin S, Kim YH, Han DJ. How to reduce lethal infectious complications in ABO-incompatible kidney transplantation. Transplant Proc 2015; 47:653-9. [PMID: 25891705 DOI: 10.1016/j.transproceed.2014.11.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/12/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND ABO-incompatible organ transplants are good options for expanding the living donor pool; however, the necessary pre-conditioning to remove ABO antibodies before surgery can evoke critical infectious complications after surgery. METHODS Between February 2009 and July 2013, we performed ABO-incompatible kidney transplantation on 182 patients. We analyzed the first 85 patients for post-operative infectious complications in a cross-sectional cohort of patients (group 1, n = 85) who had received an ABO-incompatible kidney transplant and, in light of the results, amended the pre-conditioning (lower dose of rituximab, selective use of calcineurin inhibitors, anti-metabolite reduction, and prophylactic strategy) given to a prospective cohort (group 2, n = 97). RESULTS The characteristics of the two groups did not differ significantly. Infectious complications decreased significantly in group 2, including cytomegalovirus (anti-genemia 64.7% vs 27.8%, P < .001) and BK viremia (35.2% vs 18.6%, P = .008). The acute rejection rate and death-censored graft survival were similar in both groups. Notably, with the modified protocol, there were no deaths (8.2% vs 0.0%, P = .03). CONCLUSIONS Pre-conditioning for ABO-incompatible kidney transplantation is a prerequisite for successful outcome; its drawbacks can be limited with the use of a modified immunosuppressive strategy. If immunosuppression is modified according to host conditions, ABO-incompatible kidney transplantation can be performed safely with a successful graft outcome.
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Affiliation(s)
- B-H Choi
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - H K Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - J H Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - J Y Choi
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - S Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Y H Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - D J Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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28
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Boratyńska M, Wakulenko A, Klinger M, Szyber P. Chronic allograft dysfunction in kidney transplant recipients: long-term single-center study. Transplant Proc 2015; 46:2673-7. [PMID: 25380892 DOI: 10.1016/j.transproceed.2014.09.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of this study was to determine the prevalence and risk factors responsible for the occurrence and progression of chronic allograft dysfunction (CAD) among patients treated in our transplant center. MATERIAL AND METHODS Retrospective analysis included 637 kidney allograft recipients transplanted between 1990 and 2003 with functioning graft for at least 1 year. CAD was diagnosed based on increased creatinine concentration ≥ 2 mg/dL, occurrence of proteinuria, and worsening of arterial hypertension. In immunosuppressive treatment, 50% of patients received cyclosporine A (CsA), azathioprine, and prednisone; 25% received CsA, mycophenolate mofetil (MMF), and prednisone; whereas 20% received tacrolimus, MMF, and prednisone. The influence of immune and non-immune factors before and after transplantation on the occurrence and progression of CAD was analyzed. RESULTS CAD was diagnosed in 43.1% of patients within 10 years after kidney transplantation. CAD development considerably worsened the actual 10-year survival rate of patients (80% versus 92%) and the graft (42% versus 92%). The following factors had the greatest influence (as confirmed with multivariate regression analysis) on CAD progression: proteinuria (odds ratio [OR]: 11.3; P < .0001), serum creatinine concentration > 1.5 mg/dL at 12th month (OR: 3.5; P < .0001) and 24th month (OR: 6.69; P < .0001), cytomegalovirus (CMV) infections (OR: 3.15; P < .0001), and male gender of recipients (OR: 1.48; P < .04). In the CAD patients, acute rejection episodes, delayed graft function, urinary tract infections, and hepatitis C virus (HCV) infections were statistically significantly more often observed compared with the group of patients with stable renal function (reference group). Moreover, in the CAD group, donors were older and recipients younger. The CAD patients had higher arterial pressure and uric acid concentration. CONCLUSIONS During the 10-year follow-up, chronic renal allograft dysfunction developed in 43.1% of patients. Proteinuria, serum creatinine level >1.5 mg/dL at 12th and 24th month, and CMV infections were identified as the most significant CAD progression factors. CAD had detrimental effects both on graft and patient survival rates.
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Affiliation(s)
- M Boratyńska
- Department of Nephrology and Transplant Medicine, Wrocław Medical University, Wrocław, Poland.
| | - A Wakulenko
- Department of Nephrology and Transplant Medicine, Wrocław Medical University, Wrocław, Poland
| | - M Klinger
- Department of Nephrology and Transplant Medicine, Wrocław Medical University, Wrocław, Poland
| | - P Szyber
- Department of Surgery and Transplantation, Wrocław Medical University, Wrocław, Poland
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Requião-Moura LR, deMatos ACC, Pacheco-Silva A. Cytomegalovirus infection in renal transplantation: clinical aspects, management and the perspectives. EINSTEIN-SAO PAULO 2015; 13:142-8. [PMID: 25993081 PMCID: PMC4946822 DOI: 10.1590/s1679-45082015rw3175] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 02/26/2015] [Indexed: 12/29/2022] Open
Abstract
Cytomegalovirus infection is one of most frequent infectious complications after renal transplantation, and can be classified as primo-infection, when the transmission occurs through the graft, or reactivation, when the recipient is cytomegalovirus seropositive. After transplantation, cytomegalovirus can appear as an infection, when the patient presents with evidence of viral replication without symptoms or disease, which has two clinical spectra: typical viral syndrome or invasive disease, which is a less common form. Their effects can be classified as direct, while the disease is developed, or indirect, with an increase of acute rejection and chronic allograft dysfunction risks. Diagnosis must be made based on viremia by one of the standardized methods: antigenemia or PCR, which is more sensitive. The risk factors related to infection after transplantation are the serologic matching (positive donor and negative recipient) and anti-lymphocyte antibody drugs. One of the strategies to reduce risk of disease should be chosen for patients at high risk: preemptive treatment or universal prophylaxis. Recent clinical research has described ganciclovir resistance as an emergent problem in management of cytomegalovirus infection. Two types of mutation that cause resistance were described: UL97 (most frequent) and UL54. Today, sophisticated methods of immunologic monitoring to detect specific T-cell clones against cytomegalovirus are used in clinical practice to improve the management of high-risk patients after renal transplantation.
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30
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Reduced rate of cardiovascular death after cytomegalovirus prophylaxis in renal transplant recipients. Transplantation 2015; 99:1197-202. [PMID: 25606797 DOI: 10.1097/tp.0000000000000522] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unknown how death with a functioning graft (DWFG) is affected in renal transplant recipients who receive prophylaxis for cytomegalovirus (CMV) infection. METHODS Data from 61,927 adult recipients of a deceased donor kidney transplant in 1990 to 2012 registered with the Collaborative Transplant Study were analyzed. RESULTS Cytomegalovirus prophylaxis was administered in 18%, 75%, 27% and 34% of R-/D- (recipient-negative, donor-negative), R-/D+, R+/D- and R+/D+ transplants, respectively. Only in R-/D+ transplants was CMV prophylaxis associated with significantly improved patient survival versus no prophylaxis (P<0.001). Unexpectedly, in the R-/D+ subgroup, DWFG because of infection was not significantly affected by use of CMV prophylaxis (P=0.16) but death from cardiovascular disease was significantly lower (P<0.001). Cox regression analysis confirmed that the primary impact of CMV prophylaxis on DWFG in R-/D+ transplants was because of reduced cardiovascular death (hazard ratio, 0.66; 95% confidence interval, 0.51-0.85; P=0.002), an effect restricted to patients aged 40 years or older (hazard ratio, 0.61; 95% confidence interval, 0.46-0.81; P<0.001). CONCLUSION We conclude that CMV prophylaxis is associated with a significant benefit for risk of cardiovascular DWFG among R-/D+ kidney transplant patients aged ≥ 40 years. Cytomegalovirus prophylaxis appears particularly critical in this patient subpopulation.
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Kacer M, Kielberger L, Bouda M, Reischig T. Valganciclovir versus valacyclovir prophylaxis for prevention of cytomegalovirus: an economic perspective. Transpl Infect Dis 2015; 17:334-41. [DOI: 10.1111/tid.12383] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 01/30/2015] [Accepted: 02/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- M. Kacer
- Department of Internal Medicine I; Charles University Medical School and Teaching Hospital; Pilsen Czech Republic
- Biomedical Center; Faculty of Medicine in Pilsen; Charles University in Prague; Pilsen Czech Republic
| | - L. Kielberger
- Department of Internal Medicine I; Charles University Medical School and Teaching Hospital; Pilsen Czech Republic
- Biomedical Center; Faculty of Medicine in Pilsen; Charles University in Prague; Pilsen Czech Republic
| | - M. Bouda
- Department of Internal Medicine I; Charles University Medical School and Teaching Hospital; Pilsen Czech Republic
- Biomedical Center; Faculty of Medicine in Pilsen; Charles University in Prague; Pilsen Czech Republic
| | - T. Reischig
- Department of Internal Medicine I; Charles University Medical School and Teaching Hospital; Pilsen Czech Republic
- Biomedical Center; Faculty of Medicine in Pilsen; Charles University in Prague; Pilsen Czech Republic
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32
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Reischig T, Kacer M, Jindra P, Hes O, Lysak D, Bouda M. Randomized trial of valganciclovir versus valacyclovir prophylaxis for prevention of cytomegalovirus in renal transplantation. Clin J Am Soc Nephrol 2014; 10:294-304. [PMID: 25424991 DOI: 10.2215/cjn.07020714] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Both valganciclovir and high-dose valacyclovir are recommended for cytomegalovirus prophylaxis after renal transplantation. A head-to-head comparison of both regimens is lacking. The objective of the study was to compare valacyclovir prophylaxis with valganciclovir, which constituted the control group. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS In a randomized, open-label, single-center trial, recipients of renal transplants (recipient or donor cytomegalovirus-seropositive) were randomly allocated (1:1) to 3-month prophylaxis with valacyclovir (2 g four times daily) or valganciclovir (900 mg daily). Enrollment occurred from November of 2007 to April of 2012. The primary end points were cytomegalovirus DNAemia and biopsy-proven acute rejection at 12 months. Analysis was by intention to treat. RESULTS In total, 119 patients were assigned to valacyclovir (n=59) or valganciclovir prophylaxis (n=60). Cytomegalovirus DNAemia developed in 24 (43%) of 59 patients in the valacyclovir group and 18 (31%) of 60 patients in the valganciclovir group (adjusted hazard ratio, 1.35; 95% confidence interval, 0.71 to 2.54; P=0.36). The incidence of cytomegalovirus disease was 2% with valacyclovir and 5% with valganciclovir prophylaxis (adjusted hazard ratio, 0.21; 95% confidence interval, 0.01 to 5.90; P=0.36). Significantly more patients with valacyclovir prophylaxis developed biopsy-proven acute rejection (18 of 59 [31%] versus 10 of 60 [17%]; adjusted hazard ratio, 2.49; 95% confidence interval, 1.09 to 5.65; P=0.03). The incidence of polyomavirus viremia was higher in the valganciclovir group (18% versus 36%; adjusted hazard ratio, 0.43; 95% confidence interval, 0.19 to 0.96; P=0.04). CONCLUSIONS Valganciclovir shows no superior efficacy in cytomegalovirus DNAemia prevention compared with valacyclovir prophylaxis. However, the risk of biopsy-proven acute rejection is higher with valacyclovir.
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Affiliation(s)
- Tomas Reischig
- Departments of Internal Medicine I, Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Martin Kacer
- Departments of Internal Medicine I, Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Pavel Jindra
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic Hemato-oncology, and
| | - Ondrej Hes
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic Pathology, Charles University Medical School and Teaching Hospital, Pilsen, Czech Republic; and
| | - Daniel Lysak
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic Hemato-oncology, and
| | - Mirko Bouda
- Departments of Internal Medicine I, Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
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Reischig T, Kacer M. The efficacy and cost-effectiveness of valacyclovir in cytomegalovirus prevention in solid organ transplantation. Expert Rev Pharmacoecon Outcomes Res 2014; 14:771-9. [PMID: 25252996 DOI: 10.1586/14737167.2014.965157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Prevention of cytomegalovirus infection using antiviral prophylaxis or the pre-emptive therapy approach is an integral part of management of patients after solid organ transplantation. Regarding renal transplantation, valacyclovir is currently the only antiviral agent recommended for prophylaxis as an alternative to valganciclovir. This review article discusses studies documenting the efficacy and safety of valacyclovir prophylaxis as well as those comparing valacyclovir with other prophylactic regimens or with pre-emptive therapy. Also addressed are the economic aspects supporting the cost-effectiveness of valacyclovir prophylaxis and demonstrating lower costs compared with other cytomegalovirus preventive strategies.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Alej Svobody 80, 304 60 Pilsen, Czech Republic
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Exposure to Mycophenolic Acid Better Predicts Immunosuppressive Efficacy Than Exposure to Calcineurin Inhibitors in Renal Transplant Patients. Clin Pharmacol Ther 2014; 96:508-15. [DOI: 10.1038/clpt.2014.140] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 06/10/2014] [Indexed: 11/08/2022]
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Roman A, Manito N, Campistol JM, Cuervas-Mons V, Almenar L, Arias M, Casafont F, del Castillo D, Crespo-Leiro MG, Delgado JF, Herrero JI, Jara P, Morales JM, Navarro M, Oppenheimer F, Prieto M, Pulpón LA, Rimola A, Serón D, Ussetti P. The impact of the prevention strategies on the indirect effects of CMV infection in solid organ transplant recipients. Transplant Rev (Orlando) 2014; 28:84-91. [DOI: 10.1016/j.trre.2014.01.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/19/2014] [Indexed: 01/10/2023]
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Reischig T. Cytomegalovirus-associated renal allograft rejection: new challenges for antiviral preventive strategies. Expert Rev Anti Infect Ther 2014; 8:903-10. [DOI: 10.1586/eri.10.63] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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37
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Kotton CN, Kumar D, Caliendo AM, Asberg A, Chou S, Danziger-Isakov L, Humar A. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2013; 96:333-60. [PMID: 23896556 DOI: 10.1097/tp.0b013e31829df29d] [Citation(s) in RCA: 554] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cytomegalovirus (CMV) continues to be one of the most common infections after solid-organ transplantation, resulting in significant morbidity, graft loss, and adverse outcomes. Management of CMV varies considerably among transplant centers but has been become more standardized by publication of consensus guidelines by the Infectious Diseases Section of The Transplantation Society. An international panel of experts was reconvened in October 2012 to revise and expand evidence and expert opinion-based consensus guidelines on CMV management, including diagnostics, immunology, prevention, treatment, drug resistance, and pediatric issues. The following report summarizes the recommendations.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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Gatault P, Halimi JM, Forconi C, Thibault G, Barbet C, Mérieau E, Gaudy-Graffin C, Marlière JF, Goudeau A, Bruyère F, Lebranchu Y, Büchler M, Baron C. CMV infection in the donor and increased kidney graft loss: impact of full HLA-I mismatch and posttransplantation CD8(+) cell reduction. Am J Transplant 2013; 13:2119-29. [PMID: 23731368 DOI: 10.1111/ajt.12298] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/29/2013] [Accepted: 04/02/2013] [Indexed: 01/25/2023]
Abstract
Despite a large body of literature, the impact of chronic cytomegalovirus (CMV) infection in donor on long-term graft survival remains unclear, and factors modulating the effect of CMV infection on graft survival are presently unknown. In this retrospective study of 1279 kidney transplant patients, we analyzed long-term graft survival and evolution of CD8(+) cell population in donors and recipients by CMV serology and antigenemia status. A positive CMV serology in the donor was an independent risk factor for graft loss, especially among CMV-positive recipients (R(+) ). Antigenemia was not a risk factor for graft loss and kidneys from CMV-positive donors remained associated with poor graft survival among antigenemia-free recipients. Detrimental impact of donor's CMV seropositivity on graft survival was restricted to patients with full HLA-I mismatch, suggesting a role of CD8(+) cells. In R(+) patients with positive CMV antigenemia during the first year, CD8(+) cell count did not increase at 2 years posttransplantation, in contrast to R(-) recipients. In addition, marked CD8(+) -cell decrease was a risk factor of graft failure in these patients. This study identifies HLA-I full mismatch and a decrease of CD8(+) cell count at 2 years as important determinants of CMV-associated graft loss.
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Affiliation(s)
- P Gatault
- EA4245 Cellules Dendritiques et Greffes, Université François-Rabelais, Tours, France.
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Kotton CN. CMV: Prevention, Diagnosis and Therapy. Am J Transplant 2013; 13 Suppl 3:24-40; quiz 40. [PMID: 23347212 DOI: 10.1111/ajt.12006] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 07/05/2012] [Accepted: 07/25/2012] [Indexed: 01/25/2023]
Abstract
Cytomegalovirus (CMV) is the most common infection after organ transplantation and has a major impact on morbidity, mortality and graft survival. Optimal prevention, diagnosis and treatment of active CMV infection enhance transplant outcomes, and are the focus of this section. Methods to prevent CMV include universal prophylaxis and preemptive therapy; each has its merits, and will be compared and contrasted. Diagnostics have improved substantially in recent years, both in type and quality, allowing for more accurate and savvy treatment; advances in diagnostics include the development of an international standard, which should allow comparison of results across different methodologies, and assays for cellular immune function against CMV. Therapy primarily involves ganciclovir, now rendered more versatile by data suggesting oral therapy with valganciclovir is not inferior to intravenous therapy with ganciclovir. Treatment of resistant virus remains problematic, but is enhanced by the availability of multiple novel therapeutic agents.
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Affiliation(s)
- C N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Boston, MA, USA.
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San-Juan R, De Dios B, García-Reyne A, Fernández-Ruiz M, Lumbreras C, López-Medrano F, Morales JM, Hernando S, Folgueira D, Jiménez C, Aguado JM. Limited impact of cytomegalovirus infection in the long-term outcome of renal and liver transplant. J Clin Virol 2013; 56:316-22. [PMID: 23290883 DOI: 10.1016/j.jcv.2012.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 12/08/2012] [Accepted: 12/10/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND The strength of the assumed association of CMV and long term deleterious events in solid organ transplant recipients (SOT) is controversial. OBJECTIVES The aim of the present study was to evaluate whether viral replication dynamics during CMV infection or CMV disease may correlate not only with graft dysfunction and survival, but also with other potentially related late events in a long-term followed cohort of kidney (KT) and liver (LT) transplant recipients. STUDY DESIGN 162 SOT (104 kidney, 58 liver) at our institution (2003-2005) with survival over 180 days and a median follow-up of 71 months (9-86) were analyzed. Using a Cox proportional hazard model, CMV infection (including area under the curve of DNAemia[AUC]) and CMV disease in the first 180 days were evaluated as potential predictors of the following late events (>180 days): mortality, graft dysfunction (GD), graft loss (GL), cardiovascular events (CVE), malignant tumors (MT). RESULTS CMV infection occurred in 59% and CMV disease in 8%. Late death occurred in 17%, GD in 45.6%, GL in 14.2%, CVE in 10.5% and MT in 9.9%. We found no significant association between the intensity or duration of CMV viremia (AUC, persistent viremia or untreated CMV viremia) or CMV disease and the development of evaluated late events. According multivariate analysis neither CMV infection (hazard ratio [HR] 2.18 95% CI 0.949-5 p = 0.066) nor CMV disease (HR: 1.72; 95% CI 0.59-5 p = 0.31) were significantly correlated with late mortality. CONCLUSIONS Our data do not support that CMV infection or CMV disease contribute significantly to long-term deleterious events in SOT.
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Affiliation(s)
- R San-Juan
- Unit of Infectious Diseases, Instituto de Investigación Hospital 12 de Octubre (i+12), University Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain.
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Couzi L, Helou S, Bachelet T, Martin S, Moreau K, Morel D, Lafon M, Garrigue I, Merville P. Preemptive Therapy Versus Valgancyclovir Prophylaxis in Cytomegalovirus-positive Kidney Transplant Recipients Receiving Antithymocyte Globulin Induction. Transplant Proc 2012; 44:2809-13. [DOI: 10.1016/j.transproceed.2012.09.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Six-month low-dose valganciclovir prophylaxis in cytomegalovirus D+/R- kidney transplant patients receiving thymoglobulin induction. Transplant Proc 2012; 45:175-7. [PMID: 23267799 DOI: 10.1016/j.transproceed.2012.04.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 04/17/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND The use of T-cell-depleting antibody, such as thymoglobulin, is a risk factor for cytomegalovirus (CMV) infection. We studied the effectiveness of 6 months of low-dose valganciclovir prophylaxis in CMV-naive kidney transplant recipients of CMV-positive donor kidney (D+/R-) receiving thymoglobulin induction. METHODS We included all D+/R- kidney transplant patients between October 2005 and December 2010 who received valganciclovir 450 mg daily for 6 months as per center protocol. CMV infection was confirmed by positive viremia. Kaplan-Meier and multivariate Cox proportional regression analyses were employed to compare the risk of CMV infection between patients with and without the use of thymoglobulin induction. RESULTS Out of 170 D+/R- kidney transplant patients, 42 cases of CMV infection (24.6%) were diagnosed after a median follow-up of 3.2 years: six patients from the noninduction (9.4%) and 36 from the induction cohort (34.0%). The induction with thymoglobulin was associated with four times greater risk of developing CMV infection (adjusted hazard ratio: AHR 4.15, 95% 1.75, 9.86, P = .001). The use of thymoglobulin was associated with leukopenia but not neutropenia. CONCLUSIONS Additional measures are needed to reduce the elevated incidence of CMV infection in D+/R- kidney transplant patients receiving induction with thymoglobulin.
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Reischig T. Advances in cytomegalovirus-preventive strategies in solid organ transplantation: defending pre-emptive therapy. Expert Rev Anti Infect Ther 2012; 10:51-61. [PMID: 22149614 DOI: 10.1586/eri.11.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Prevention of cytomegalovirus (CMV) infection is an important part of clinical care provided to patients after solid organ transplantation. While the optimal preventive strategy has not been defined, most centers rely on universal prophylaxis or pre-emptive therapy. This article comments on recent studies designed to identify strategies that effectively reduce the incidence of late-onset CMV disease as the main problem associated with prophylaxis, and on recent data regarding the development of CMV-specific immunity depending on the CMV-preventive regimen used. Despite an apparent trend to prefer prophylaxis in clinical practice, this approach does not seem to be based on robust evidence.
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Affiliation(s)
- Tomáš Reischig
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Alej Svobody 80, 304 60 Pilsen, Czech Republic.
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Reischig T, Hribova P, Jindra P, Hes O, Bouda M, Treska V, Viklicky O. Long-term outcomes of pre-emptive valganciclovir compared with valacyclovir prophylaxis for prevention of cytomegalovirus in renal transplantation. J Am Soc Nephrol 2012; 23:1588-97. [PMID: 22917575 DOI: 10.1681/asn.2012010100] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Prevention of cytomegalovirus (CMV) is essential in organ transplantation. The two main strategies are pre-emptive therapy, in which one screens for and treats asymptomatic CMV viremia, and universal antiviral prophylaxis. We compared these strategies and examined long-term outcomes in a randomized, open-label, single-center trial. We randomly assigned 70 renal transplant recipients (CMV-seropositive recipient or donor) to 3-month prophylaxis with valacyclovir (n=34) or pre-emptive valganciclovir for significant CMV viremia detected at predefined assessments through month 12 (n=36). Among the 55 patients who had a protocol biopsy specimen available at 3 years to allow assessment of the primary outcome, 9 (38%) of 24 patients in the prophylaxis group and 6 (19%) of 31 patients in the pre-emptive therapy group had moderate to severe interstitial fibrosis and tubular atrophy (odds ratio, 2.50; 95% confidence interval, 0.74-8.43; P=0.22). The prophylaxis group had significantly higher intrarenal mRNA expression of genes involved in fibrogenesis. The occurrence of CMV disease was similar in both groups, but pre-emptive therapy improved 4-year graft survival (92% versus 74%; P=0.049) as a result of worse outcomes in patients with late-onset CMV viremia. In conclusion, compared with valacyclovir prophylaxis, pre-emptive valganciclovir therapy may lead to less severe interstitial fibrosis and tubular atrophy and to significantly better graft survival.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, alej Svobody 80, 304 60 Pilsen, Czech Republic.
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Kielberger L, Bouda M, Jindra P, Reischig T. Pharmacoeconomic Impact of Different Regimens to Prevent Cytomegalovirus Infection in Renal Transplant Recipients. Kidney Blood Press Res 2012; 35:407-16. [DOI: 10.1159/000335962] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 12/15/2011] [Indexed: 11/19/2022] Open
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Torre-Cisneros J, Fariñas MC, Castón JJ, Aguado JM, Cantisán S, Carratalá J, Cervera C, Cisneros JM, Cordero E, Crespo-Leiro MG, Fortún J, Frauca E, Gavaldá J, Gil-Vernet S, Gurguí M, Len O, Lumbreras C, Marcos MÁ, Martín-Dávila P, Monforte V, Montejo M, Moreno A, Muñoz P, Navarro D, Pahissa A, Pérez JL, Rodriguez-Bernot A, Rumbao J, San Juan R, Santos F, Varo E, Zurbano F. GESITRA-SEIMC/REIPI recommendations for the management of cytomegalovirus infection in solid-organ transplant patients. Enferm Infecc Microbiol Clin 2011; 29:735-58. [DOI: 10.1016/j.eimc.2011.05.022] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 05/30/2011] [Indexed: 12/31/2022]
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Brennan DC, Legendre C, Patel D, Mange K, Wiland A, McCague K, Shihab FS. Cytomegalovirus incidence between everolimus versus mycophenolate in de novo renal transplants: pooled analysis of three clinical trials. Am J Transplant 2011; 11:2453-62. [PMID: 21812923 DOI: 10.1111/j.1600-6143.2011.03674.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Everolimus (EVR) in heart and renal transplant (RTx) recipients may be associated with a decreased incidence of cytomegalovirus (CMV). A detailed analysis of the association between EVR versus mycophenolic acid (MPA) and CMV events has not been reported. CMV data from 2004 de novo RTx recipients from three-randomized, prospective, EVR studies A2309 (N = 833), B201 (N = 588) and B251 (N = 583) were retrospectively analyzed to identify differences between two EVR dosing groups and MPA. EVR groups received 1.5 mg/day, or 3 mg/day with either standard (SD-CsA) or reduced dose cyclosporine (RD-CsA). Controls received MPA with SD-CsA. CMV prophylaxis was as per center practice. CMV incidence (infection/syndrome, disease, viremia) was captured per local center evaluations. Kaplan-Meier analyses demonstrated that freedom from CMV viremia and infection/syndrome was significantly greater for EVR versus MPA for recipients without CMV prophylaxis. Among recipients who received prophylaxis, freedom from viremia was greater for EVR 3.0 mg; freedom from infection/syndrome was greater for EVR 3.0 and 1.5 mg. Although freedom from organ involvement was numerically greater for EVR, it was not statistically significant. This analysis documents significant reductions in the incidence of CMV infection/syndrome and viremia in EVR-treated de novo RTx recipients, especially those who did not receive CMV prophylaxis versus MPA.
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Affiliation(s)
- D C Brennan
- Washington University School of Medicine Barnes-Jewish Hospital, St. Louis, MO, USA.
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De Keyzer K, Van Laecke S, Peeters P, Vanholder R. Human cytomegalovirus and kidney transplantation: a clinician's update. Am J Kidney Dis 2011; 58:118-26. [PMID: 21684438 DOI: 10.1053/j.ajkd.2011.04.010] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 04/13/2011] [Indexed: 01/15/2023]
Abstract
Infection with human cytomegalovirus (CMV) is an important cause of morbidity and mortality in kidney transplant recipients. CMV disease is diagnosed based on the detection of viral replication by phosphoprotein 65 antigenemia or CMV DNA polymerase chain reaction in combination with typical signs and symptoms. Risk factors include CMV-seronegative recipients receiving a CMV-seropositive transplant, older donor age, exposure to cyclosporine and/or antilymphocyte antibody, rejection episodes, and impaired transplant function. Current preventive strategies in kidney transplant recipients include pre-emptive therapy with valganciclovir or intravenous ganciclovir and universal prophylaxis with valacyclovir, valganciclovir, or ganciclovir for 3-6 months after kidney transplantation and for 1-3 months after treatment with antilymphocyte antibody. Established disease should be treated using either intravenous ganciclovir or oral valganciclovir until CMV replication can no longer be detected. In addition to direct effects, CMV infection also induces a wide range of indirect effects, such as decreased transplant and recipient survival and susceptibility to rejection and opportunistic infections. In this review, we highlight the most relevant topics on CMV and kidney transplantation based on current evidence and guidelines.
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Factors increasing quantitative interstitial fibrosis from 0 hr to 1 year in living kidney transplant patients receiving tacrolimus. Transplantation 2011; 91:78-85. [PMID: 21452412 DOI: 10.1097/tp.0b013e3181ff4f7f] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND This study investigated the increase in interstitial fibrosis (IF) from 0 hr to 1 month and 1 year posttransplantation in biopsy sections and assessed the risk of developing IF in 118 living kidney recipients. METHODS A quantitative analysis of IF was performed using computer-assisted imaging. The percent IF (%IF) in the cortical region at 0 hr was defined as the baseline, and the increases in %IF at 1 month and 1 year were calculated. Demographics, higher (regimen 1) and lower (regimen 2) target trough concentrations of tacrolimus, and the cytochrome P450 (CYP) 3A5 polymorphism were tested as risk factors. RESULTS The mean %IF at 0 hr, 1 month, and 1 year was 10.3%+/-4.2%, 15.0%+/-5.8%, and 19.0%+/-7.7%, respectively. %IF increased 1.7- and 2.2-fold from 0 hr to 1 month and 1 year posttransplantation, respectively. At 1 year, the increase was higher in patients with the CYP3A5*3/*3 genotype (nonexpressers), those treated with regimen 1, and those with a lower estimated glomerular filtration rate and higher body mass index. In a multivariate analysis, CYP3A5 nonexpression correlated with the development of IF (odds ratio 2.63, P=0.018). Tacrolimus blood levels in the early stage posttransplantation were higher in nonexpressers than CYP3A5 expressers in both regimens 1 and 2, despite therapeutic drug monitoring. CONCLUSIONS The higher concentrations of tacrolimus, especially in the nonexpressers treated with regimen 1, might influence the development of IF. This study suggested that a new regimen with lower and narrow target trough levels of tacrolimus or a dosing strategy based on the CYP3A5 genotype is needed to reduce the risk of developing IF.
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