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Immohr MB, Oehler D, Jenkins FS, Kalampokas N, Hettlich VH, Sigetti D, Voß F, Dalyanoglu H, Aubin H, Akhyari P, Lichtenberg A, Boeken U. Evaluation of risk factors for cytomegalovirus DNAemia after end of regular prophylaxis after heart transplantation. Immun Inflamm Dis 2023; 11:e1075. [PMID: 38018580 PMCID: PMC10655632 DOI: 10.1002/iid3.1075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infections after heart transplantation (HTx) can cause cardiac allograft vasculopathy. Consequently, monitoring and prophylaxis for cytomegalovirus deoxyribonucleic acid (CMV-DNAemia) within the first weeks after HTx is recommended. METHODS All patients who underwent HTx between September 2010 and 2021 surviving the first 90 days (n = 196) were retrospectively reviewed. The patients were divided on the prevalence of CMV-DNAemia during the first postoperative year after the end of the prophylaxis. A total of n = 35 (20.1%) developed CMV-DNAemia (CMV group) and were compared to patients without CMV-DNAemia (controls, n = 139). The remaining patients (n = 22) were excluded due to incomplete data. RESULTS Positive donors and negative recipients (D+/R-) and negative donors and positive recipients (D-/R+) serology was significantly increased and D-/R- decreased in the CMV group (p < .01). Furthermore, the mean age was 57.7 ± 8.7 years but only 53.6 ± 10.0 years for controls (p = .03). Additionally, the intensive care unit (p = .02) and total hospital stay (p = .03) after HTx were approximately 50% longer. Interestingly, the incidence of CMV-DNAemia during prophylaxis was only numerically increased in the CMV group (5.7%, respectively, 0.7%, p = .10), the same effect was also observed for postoperative infections. Multivariate analyses confirmed that D+/R- and D-/R+ CMV immunoglobulin G match were independent risk factors for postprophylaxis CMV-DNAemia. CONCLUSION Our data should raise awareness of CMV-DNAemia after the termination of regular prophylaxis, as this affects one in five HTx patients. Especially old recipients as well as D+/R- and D-/R+ serology share an elevated risk of late CMV-DNAemia. For these patients, prolongation, or repetition of CMV prophylaxis, including antiviral drugs and CMV immunoglobulins, may be considered.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
- Department of Cardiac Surgery, Medical FacultyRWTH Aachen UniversityAachenGermany
| | - Daniel Oehler
- Division of Cardiology, Pulmonology and Angiology Medical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Freya Sophie Jenkins
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Nikolas Kalampokas
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Vincent Hendrik Hettlich
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Dennis Sigetti
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Fabian Voß
- Division of Cardiology, Pulmonology and Angiology Medical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Hannan Dalyanoglu
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Hug Aubin
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Payam Akhyari
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
- Department of Cardiac Surgery, Medical FacultyRWTH Aachen UniversityAachenGermany
| | - Artur Lichtenberg
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
| | - Udo Boeken
- Department of Cardiac SurgeryMedical Faculty and University Hospital Düsseldorf, Heinrich‐Heine‐University DüsseldorfDüsseldorfGermany
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Gardiner BJ, Bailey JP, Percival MA, Morgan BA, Warner VM, Lee SJ, Morrissey CO, Kaye DM, Peleg AY, Taylor AJ. Incidence and severity of cytomegalovirus infection in seropositive heart transplant recipients. Clin Transplant 2023; 37:e14982. [PMID: 36988473 PMCID: PMC10909407 DOI: 10.1111/ctr.14982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/07/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND The frequency and significance of cytomegalovirus (CMV) infection in seropositive (R+) heart transplant recipients (HTR) is unclear, with preventative recommendations mostly extrapolated from other groups. We evaluated the incidence and severity of CMV infection in R+ HTR, to identify risk factors and describe outcomes. METHODS R+ HTR from 2010 to 2019 were included. Antiviral prophylaxis was not routinely used, with clinically guided monitoring the local standard of care. The primary outcome was CMV infection within one-year post-transplant; secondary outcomes included other herpesvirus infections and mortality. RESULTS CMV infection occurred in 27/155 (17%) R+ HTR. Patients with CMV had a longer hospitalization (27 vs. 20 days, unadjusted HR 1.02, 95% CI 1.00-1.02, p = .01), higher rate of intensive care readmission (26% vs. 9%, unadjusted HR 3.46, 1.46-8.20, p = .005), and increased mortality (33% vs. 8%, unadjusted HR 10.60, 4.52-24.88, p < .001). The association between CMV and death persisted after adjusting for multiple confounders (HR 24.19, 95% CI 7.47-78.30, p < .001). Valganciclovir prophylaxis was used in 35/155 (23%) and was protective against CMV (infection rate 4% vs. 27%, adjusted HR .07, .01-.72, p = .025), even though those receiving it were more likely to have received thymoglobulin (adjusted OR 10.5, 95% CI 2.01-55.0, p = .005). CONCLUSIONS CMV infection is common in R+ HTR and is associated with a high burden of disease and increased mortality. Patients who received valganciclovir prophylaxis were less likely to develop CMV infection, despite being at higher risk. These findings support the routine use of antiviral prophylaxis following heart transplantation in all CMV R+ patients.
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Affiliation(s)
- Bradley J. Gardiner
- Department of Infectious DiseasesAlfred Health and Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | | | | | - Beth A. Morgan
- Department of Infectious DiseasesAlfred Health and Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - Victoria M. Warner
- Pharmacy DepartmentAlfred HealthMelbourneVictoriaAustralia
- Department of CardiologyAlfred HealthMelbourneVictoriaAustralia
| | - Sue J. Lee
- Department of Infectious DiseasesAlfred Health and Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - C. Orla Morrissey
- Department of Infectious DiseasesAlfred Health and Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - David M. Kaye
- Department of CardiologyAlfred HealthMelbourneVictoriaAustralia
- Department of MedicineMonash UniversityMelbourneAustralia
- Baker Heart & Diabetes InstituteMelbourneAustralia
| | - Anton Y. Peleg
- Department of Infectious DiseasesAlfred Health and Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
- Department of MicrobiologyBiomedicine Discovery InstituteMonash UniversityClaytonVictoriaAustralia
| | - Andrew J. Taylor
- Department of CardiologyAlfred HealthMelbourneVictoriaAustralia
- Department of MedicineMonash UniversityMelbourneAustralia
- Baker Heart & Diabetes InstituteMelbourneAustralia
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3
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Zang S, Zhang X, Niu J, Das BB. Impact of induction therapy on cytomegalovirus infection and post-transplant outcomes in pediatric heart transplant recipients receiving routine antiviral prophylaxis. Clin Transplant 2023; 37:e14836. [PMID: 36259556 DOI: 10.1111/ctr.14836] [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: 07/10/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Induction therapy has been increasingly used in pediatric heart transplantation. This study evaluated the impact of anti-thymocyte globulin (ATG) versus basiliximab as induction therapy on post-transplant cytomegalovirus (CMV) infection, rejection at 1 year, coronary allograft vasculopathy (CAV), and mortality in pediatric heart transplant recipients receiving antiviral prophylaxis. RESULTS Of the 96 patients (age < 18 years) analyzed, 46 (47.9%) patients received basiliximab, and 50 (52.1%) received ATG. Median follow-up was 3.0 (IQR, 1.7-4.9) years with 32.3% reporting CMV infection. The ATG group, as compared with the basiliximab group, had similar incidences of CMV infection (36% vs. 28.3%, p = .418), CMV viremia (22% vs. 19.6%, p = .769), and CMV-positive tissue biopsy (30% vs. 22%, p = .486). The ATG group had lower incidences of rejection at 1 year (16% vs. 36.9%, p = .022) and CAV (4% vs. 23.9%, p = .006) with no difference in mortality (8% vs. 15.2%, p = .343), compared with the basiliximab group. Multivariate analysis showed that induction with ATG was associated with a lower risk of rejection at 1 year (OR, .31; 95% CI, .09-.94; p = .039) with no impact on the incidences of CMV infection (HR, 2.06; 95% CI, .54-7.89; p = .292), CAV (HR, .30; 95% CI, .04-2.58; p = .275), and mortality (HR, .39; 95% CI, .09-1.82; p = .233) compared to basiliximab induction. DISCUSSION AND CONCLUSIONS In conclusion, induction with ATG was associated with reduction in risk of rejection at 1 year with no effects on CMV infection, CAV, and mortality in pediatric heart transplant recipients with universal antiviral prophylaxis compared with basiliximab induction therapy.
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Affiliation(s)
- Suhua Zang
- Department of Cardiac Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Zhang
- Department of Cardiac Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianli Niu
- Office of Human Research, Memorial Healthcare System, Hollywood, Florida, USA
| | - Bibhuti B Das
- Office of Human Research, Memorial Healthcare System, Hollywood, Florida, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Mississippi Children's Hospital, University of Mississippi Medical Center, Jackson, Mississippi, USA
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4
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A Retrospective Review of Calcineurin Inhibitors’ Impact on Cytomegalovirus Infections in Lung Transplant Recipients. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2040045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Immunosuppressive therapy reduces the risk for allograft rejection but leaves recipients susceptible to infections. Cytomegalovirus (CMV) is one of the most frequent causes for infection after transplantation and increases the risk for allograft rejection. As lung transplant recipients (LTRs) need to be under immunosuppression for life, they are a vulnerable group. To determine the potential association between the development of CMV infection and the calcineurin inhibitor (CNI) blood levels within previous 90 days, a retrospective review of LTRs was performed. Data from recipients who underwent a lung transplantation (LTx) at our center from January 2011 to December 2018 were collected. The studied recipients, after case/control matching, included 128 CMV-infection cases. The median time from the transplant to the first positive CMV viral load was 291.5 days. In our study, more patients were treated with tacrolimus (91.9%) than with cyclosporine (8.1%). Drug blood levels at selected timepoints showed no statistically significant difference between cases and controls. However, we found that CMV infection was more frequent in the donor-seropositive/recipient-seronegative group, interstitial lung disease (ILD) recipients, LTRs who underwent basiliximab induction, cyclosporine treated recipients, and LTRs with lymphopenia (at the time of CMV infection and 90 days before). In this review of LTRs, no association between the CNI blood level and CMV infection was seen, although other immunity-related factors were found to be influencing, i.e., basiliximab induction, cyclosporine treatment, and lymphopenia.
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5
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Méndez-Eirín E, Barge-Caballero E, Paniagua-Martín MJ, Barge-Caballero G, Couto-Mallón D, Grille-Cancela Z, Blanco-Canosa P, Cañizares-Castellanos A, González Barbeito M, Aller Fernández AV, Vázquez-Rodríguez JM, Crespo-Leiro MG. Incidencia, factores de riesgo e impacto pronóstico de la infección por citomegalovirus tras el trasplante cardiaco. Med Clin (Barc) 2020; 154:381-387. [DOI: 10.1016/j.medcli.2019.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 07/10/2019] [Accepted: 07/18/2019] [Indexed: 01/10/2023]
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6
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Scherger S, Mathur S, Bajrovic V, Johnson SC, Benamu E, Ramanan P, Wolfel G, Levi ME, Abidi MZ. Cytomegalovirus myocarditis in solid organ transplant recipients: A case series and review of literature. Transpl Infect Dis 2020; 22:e13282. [PMID: 32232951 DOI: 10.1111/tid.13282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/11/2020] [Accepted: 03/22/2020] [Indexed: 11/30/2022]
Abstract
Cytomegalovirus (CMV) is a DNA virus of the Herpesviridae family and is estimated to affect 15%-30% of high-risk solid organ transplant recipients. Typical manifestations of CMV end-organ disease in this population include colitis, esophagitis, and pneumonitis, and myocarditis is a rarely reported manifestation. We describe two cases of CMV myocarditis in solid organ transplant recipients and review the literature regarding previously published cases of CMV myocarditis.
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Affiliation(s)
- Sias Scherger
- Division of Infectious Disease, University of Colorado Denver, Aurora, CO, USA
| | - Swati Mathur
- Division of Infectious Disease, University of Colorado Denver, Aurora, CO, USA
| | - Valida Bajrovic
- Division of Infectious Disease, University of Colorado Denver, Aurora, CO, USA
| | - Steven C Johnson
- Division of Infectious Disease, University of Colorado Denver, Aurora, CO, USA
| | - Esther Benamu
- Division of Infectious Disease, University of Colorado Denver, Aurora, CO, USA
| | - Poornima Ramanan
- Division of Infectious Disease, University of Colorado Denver, Aurora, CO, USA
| | - Gene Wolfel
- Division of Cardiology, University of Colorado Denver, Aurora, CO, USA
| | - Marilyn E Levi
- Division of Infectious Disease, University of Colorado Denver, Aurora, CO, USA
| | - Maheen Z Abidi
- Division of Infectious Disease, University of Colorado Denver, Aurora, CO, USA
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7
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Pons S, Sonneville R, Bouadma L, Styfalova L, Ruckly S, Neuville M, Radjou A, Lebut J, Dilly MP, Mourvillier B, Dorent R, Nataf P, Wolff M, Timsit JF. Infectious complications following heart transplantation in the era of high-priority allocation and extracorporeal membrane oxygenation. Ann Intensive Care 2019; 9:17. [PMID: 30684052 PMCID: PMC6347647 DOI: 10.1186/s13613-019-0490-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 01/12/2019] [Indexed: 01/09/2023] Open
Abstract
Background Infectious complications are a major cause of morbidity and mortality after heart transplantation (HT). However, the epidemiology and outcomes of these infections in the recent population of adult heart transplant recipients have not been investigated. Methods We conducted a single-center retrospective study on infectious complications occurring within 180 days following HT on consecutive heart transplant recipients, from January 2011 to June 2015 at Bichat University Hospital in Paris, France. Risk factors for non-viral infections occurring within 8, 30 and 180 days after HT were investigated using competing risk analysis. Results Overall, 113 patients were included. Fifty-eight (51%) HTs were high-priority allocations. Twenty-eight (25%) patients had an extracorporeal membrane oxygenation (ECMO) support at the time of transplantation. Ninety-two (81%) patients developed at least one infection within 180 days after HT. Bacterial and fungal infections (n = 181 episodes) occurred in 80 (71%) patients. The most common bacterial and fungal infections were pneumonia (n = 95/181 episodes, 52%), followed by skin and soft tissue infections (n = 26/181, 14%). Multi-drug-resistant bacteria were responsible for infections in 21 (19%) patients. Viral infections were diagnosed in 44 (34%) patients, mostly Cytomegalovirus infection (n = 39, 34%). In multivariate subdistribution hazard model, prior cardiac surgery (subdistribution hazard ratio sHR = 2.7 [95% CI 1.5–4.6] p < 0.01) and epinephrine or norepinephrine at the time of HT (sHR = 2.3 [95% CI 1.1–5.2] p = 0.04) were significantly associated with non-viral infections within 8 days after HT. Prior cardiac surgery (sHR = 2.5 [95% CI 1.4–4.4] p < 0.01), recipient age over 60 years (sHR = 2.0 [95% CI 1.2–3.3] p < 0.01) and ECMO following HT (sHR = 1.7 [95% CI 1.0–2.8] p = 0.04) were significantly associated with non-viral infection within 30 days after HT, as well as within 180 days after HT. Conclusion This study confirmed the high rate of infections following HT. Recipient age, prior cardiac surgery and ECMO following HT were independent risk factors for early and late bacterial and fungal infections. Electronic supplementary material The online version of this article (10.1186/s13613-019-0490-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stéphanie Pons
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Romain Sonneville
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France. .,UMR 1148, LVTS, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France.
| | - Lila Bouadma
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases Prevention, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France
| | | | | | - Mathilde Neuville
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Aguila Radjou
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Jordane Lebut
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Marie-Pierre Dilly
- Department of Anesthesiology, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France
| | - Bruno Mourvillier
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases Prevention, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France
| | - Richard Dorent
- Department of Cardiac Surgery, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France
| | - Patrick Nataf
- Department of Cardiac Surgery, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France
| | - Michel Wolff
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75877, Paris Cedex, France.,UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases Prevention, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France
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8
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Monitoring of Cytomegalovirus (CMV)-Specific Cell-Mediated Immunity in Heart Transplant Recipients: Clinical Utility of the QuantiFERON-CMV Assay for Management of Posttransplant CMV Infection. J Clin Microbiol 2018; 56:JCM.01040-17. [PMID: 29305542 DOI: 10.1128/jcm.01040-17] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/18/2017] [Indexed: 11/20/2022] Open
Abstract
The clinical utility of the QuantiFERON-CMV (QFN-CMV) assay in heart transplant recipients was assessed. Forty-four cytomegalovirus (CMV)-seropositive patients were enrolled: 17 received antiviral prophylaxis, and 27 were managed preemptively. CMV-DNAemia monitoring was performed by the use of a quantitative real-time PCR assay. The QFN-CMV assay was retrospectively performed on blood samples collected at five posttransplant time points. A higher proportion of patients with an indeterminate QFN-CMV result after the suspension of prophylaxis than of patients who showed a global T-cell responsiveness developed CMV infection (P = 0.036). Patients who reconstituted a CMV-specific response following the first CMV-DNAemia-positive result (42.9%) showed a median CMV-DNAemia peak 1 log of magnitude lower than that seen with patients with indeterminate results, and all controlled viral replication spontaneously. The 25% of patients with an indeterminate result developed CMV disease. In the preemptive strategy group, no differences in the development of subsequent infection, magnitude of viral load, and viral control were observed on the basis of QFN-CMV measurements performed before and after the first CMV-DNAemia-positive result. Considering both CMV prevention strategies, viral relapse was associated with the failure to reconstitute CMV-specific cell-mediated immunity (CMI) after the resolution of the first episode of CMV infection (P = 0.032). QFN-CMV measurements can be a useful tool for identifying patients (i) at higher risk of developing infection after discontinuing antiviral prophylaxis, (ii) with late CMV infection who would benefit from appropriate antiviral interventions, and (iii) at higher risk of viral relapses. QFN-CMV measurements taken within 1 month posttransplantation (early period) are not revealing.
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9
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Recent Advances in Mammalian Target of Rapamycin Inhibitor Use in Heart and Lung Transplantation. Transplantation 2016; 100:2558-2568. [DOI: 10.1097/tp.0000000000001432] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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10
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Pascual J, Royuela A, Fernández AM, Herrero I, Delgado JF, Solé A, Guirado L, Serrano T, de la Torre-Cisneros J, Moreno A, Cordero E, Gallego R, Lumbreras C, Aguado JM. Role of mTOR inhibitors for the control of viral infection in solid organ transplant recipients. Transpl Infect Dis 2016; 18:819-831. [PMID: 27600985 DOI: 10.1111/tid.12601] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/25/2016] [Accepted: 06/24/2016] [Indexed: 12/11/2022]
Abstract
Appropriate post-transplant immunosuppressive regimens that avoid acute rejection, while reducing risk of viral reactivation, have been sought, but remain a chimera. Recent evidence suggesting potential regulatory and antiviral effects of mammalian target of rapamycin inhibitors (mTORi) is of great interest. Although the concept of an immunosuppressive drug with antiviral properties is not new, little effort has been made to put the evidence together to assess the management of immunosuppressive therapy in the presence of a viral infection. This review was developed to gather the evidence on antiviral activity of the mTORi against the viruses that most commonly reactivate in adult solid organ recipients: cytomegalovirus (CMV), polyomavirus, Epstein-Barr virus (EBV), human herpesvirus 8 (HHV8), and hepatitis C virus (HCV). A rapid review methodology and evaluation of quality and consistency of evidence based on the GRADE system was used. The existing literature was variable in nature, although indicating a potential advantage of mTORi in CMV, polyomavirus, and HHV8 infection, and a most doubtful relation with EBV and HCV infection. Several recommendations about the management of these infections are presented that can change certain current patterns of immunosuppression and help to improve the prognosis of the direct and indirect effects of viral infection in solid organ recipients.
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Affiliation(s)
- Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.,Institut Mar for Medical Research, Barcelona, Spain.,REDINREN Spanish Network for Renal Research RD12/0021, Barcelona, Spain
| | - Ana Royuela
- Clinical Biostatistics Unit, Puerta de Hierro University Hospital, Instituto de Investigacion Puerta de Hierro (IDIPHIM), Madrid, Spain
| | - Ana M Fernández
- REDINREN Spanish Network for Renal Research RD12/0021, Barcelona, Spain.,Department of Nephrology, Hospital Ramón y Cajal, IRICYS, Madrid, Spain
| | - Ignacio Herrero
- Liver Unit, Clínica Universidad de Navarra, CIBERehd, IdiSNA, Pamplona, Spain
| | - Juan F Delgado
- Department of Cardiology, Institute of Investigation 1+12, Universidad Complutense de Madrid, University Hospital 12 de Octubre, Madrid, Spain
| | - Amparo Solé
- Lung Transplant Unit, Hospital Universitario y Politecnico la FE, Universidad de Valencia, Valencia, Spain
| | - Lluis Guirado
- REDINREN Spanish Network for Renal Research RD12/0021, Barcelona, Spain.,Department of Nephrology, Fundació Puigvert, Barcelona, Spain
| | - Trinidad Serrano
- Liver Unit, University Hospital Lozano Blesa, Zaragoza, IIS Aragon, Spain
| | | | - Asunción Moreno
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Elisa Cordero
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBiS), Hospital Universitario Virgen del Rocío, CSIC, University of Seville, Seville, Spain
| | - Roberto Gallego
- Department of Nephrology, Hospital Universitario de Gran Canaria Dr Negrin, Gran Canaria, Spain
| | - Carlos Lumbreras
- Unit of Infectious Diseases, Institute of Investigation 1+12, Universidad Complutense de Madrid, University Hospital 12 de Octubre, Madrid, Spain
| | - José M Aguado
- Unit of Infectious Diseases, Institute of Investigation 1+12, Universidad Complutense de Madrid, University Hospital 12 de Octubre, Madrid, Spain
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11
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Thomas MN, Kalnins A, Andrassy M, Wagner A, Klussmann S, Rentsch M, Habicht A, Pratschke S, Stangl M, Bazhin AV, Meiser B, Fischereder M, Werner J, Guba M, Andrassy J. SDF-1/CXCR4/CXCR7 is pivotal for vascular smooth muscle cell proliferation and chronic allograft vasculopathy. Transpl Int 2015; 28:1426-35. [PMID: 26265085 DOI: 10.1111/tri.12651] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 02/09/2015] [Accepted: 07/20/2015] [Indexed: 01/29/2023]
Abstract
Chronic rejection remains a major obstacle in transplant medicine. Recent studies suggest a crucial role of the chemokine SDF-1 on neointima formation after injury. Here, we investigate the potential therapeutic effect of inhibiting the SDF-1/CXCR4/CXCR7 axis with an anti-SDF-1 Spiegelmer (NOX-A12) on the development of chronic allograft vasculopathy. Heterotopic heart transplants from H-2bm12 to B6 mice and aortic transplants from Balb/c to B6 were performed. Mice were treated with NOX-A12. Control animals received a nonfunctional Spiegelmer (revNOX-A12). Samples were retrieved at different time points and analysed by histology, RT-PCR and proliferation assay. Blockade of SDF-1 caused a significant decrease in neointima formation as measured by intima/media ratio (1.0 ± 0.1 vs. 1.8 ± 0.1, P < 0.001 AoTx; 0.35 ± 0.05 vs. 1.13 ± 0.27, P < 0.05 HTx). In vitro treatment of primary vascular smooth muscle cells with NOX-A12 showed a significant reduction in proliferation (0.42 ± 0.04 vs. 0.24 ± 0.03, P < 0.05). TGF-β, TNF-α and IL-6 levels were significantly reduced under SDF-1 inhibition (3.42 ± 0.37 vs. 1.67 ± 0.33, P < 0.05; 2.18 ± 0.37 vs. 1.0 ± 0.39, P < 0.05; 2.18 ± 0.26 vs. 1.6 ± 0.1, P < 0.05). SDF-1/CXCR4/CXCR7 plays a critical role in the development of chronic allograft vasculopathy (CAV). Therefore, pharmacological inhibition of SDF-1 with NOX-A12 may represent a therapeutic option to ameliorate chronic rejection changes.
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Affiliation(s)
- Michael N Thomas
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Aivars Kalnins
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Martin Andrassy
- Innere Medizin III: Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Rupprecht-Karls Universität, Heidelberg, Germany
| | - Anne Wagner
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | | | - Markus Rentsch
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Antje Habicht
- Transplantationszentrum, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Sebastian Pratschke
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Manfred Stangl
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Alexandr V Bazhin
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Bruno Meiser
- Transplantationszentrum, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Michael Fischereder
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Jens Werner
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Markus Guba
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
| | - Joachim Andrassy
- Klinik für Allgemeine-,Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Klinikum der Universität München, Ludwig-Maximilians Universität, München, Germany
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12
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Fernández-Ruiz M, Arias M, Campistol JM, Navarro D, Gómez-Huertas E, Gómez-Márquez G, Díaz JM, Hernández D, Bernal-Blanco G, Cofan F, Jimeno L, Franco-Esteve A, González E, Moreso FJ, Gómez-Alamillo C, Mendiluce A, Luna-Huerta E, Aguado JM. Cytomegalovirus prevention strategies in seropositive kidney transplant recipients: an insight into current clinical practice. Transpl Int 2015; 28:1042-54. [DOI: 10.1111/tri.12586] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 12/17/2014] [Accepted: 04/07/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases; Hospital Universitario “12 de Octubre”; Instituto de Investigación Hospital “12 de Octubre” (i+12); Madrid Spain
| | - Manuel Arias
- Department of Nephrology; Hospital Universitario “Marqués de Valdecilla”; Instituto de Formación e Investigación “Marqués de Valdecilla” (IFIMAV); Santander Spain
| | - Josep M. Campistol
- Department of Nephrology; Hospital Clinic; Institut d'Investigacions Biomèdiques “August Pi i Sunyer” (IDIBAPS); Barcelona Spain
| | - David Navarro
- Department of Microbiology; Hospital Clínico Universitario; Instituto de Investigación Sanitaria INCLIVA; University of Valencia; Valencia Spain
| | | | - Gonzalo Gómez-Márquez
- Department of Nephrology; Hospital Universitario Son Espases; Palma de Mallorca Spain
| | | | - Domingo Hernández
- Department of Nephrology; Hospital Universitario “Carlos Haya”; Málaga Spain
| | - Gabriel Bernal-Blanco
- Department of Nephrology; Hospital Universitario “Virgen del Rocío”; Instituto de Biomedicina de Sevilla (IBIS); Sevilla Spain
| | - Frederic Cofan
- Department of Nephrology; Hospital Clinic; Institut d'Investigacions Biomèdiques “August Pi i Sunyer” (IDIBAPS); Barcelona Spain
| | - Luisa Jimeno
- Department of Nephrology; Hospital Universitario “Virgen de la Arrixaca”; El Palmar; Murcia Spain
| | | | - Esther González
- Department of Nephrology; Hospital Universitario “12 de Octubre”; Instituto de Investigación Hospital “12 de Octubre” (i+12); Madrid Spain
| | - Francesc J. Moreso
- Department of Nephrology; Hospital Universitari Vall d'Hebron; Barcelona Spain
| | - Carlos Gómez-Alamillo
- Department of Nephrology; Hospital Universitario “Marqués de Valdecilla”; Instituto de Formación e Investigación “Marqués de Valdecilla” (IFIMAV); Santander Spain
| | - Alicia Mendiluce
- Department of Nephrology; Hospital Clínico Universitario; Valladolid Spain
| | - Enrique Luna-Huerta
- Department of Nephrology; Hospital Universitario “Infanta Cristina”; Badajoz Spain
| | - José María Aguado
- Unit of Infectious Diseases; Hospital Universitario “12 de Octubre”; Instituto de Investigación Hospital “12 de Octubre” (i+12); Madrid Spain
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13
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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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14
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Small bowel transplantation complicated by cytomegalovirus tissue invasive disease without viremia. J Clin Virol 2014; 60:177-80. [PMID: 24703746 DOI: 10.1016/j.jcv.2014.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/02/2014] [Accepted: 03/06/2014] [Indexed: 12/23/2022]
Abstract
We report on a small bowel transplant patient, donor/recipient seropositive (D+/R+) for cytomegalovirus (CMV), with a clinical course complicated by CMV disease. Anti-CMV prophylaxis was given for 100 days. Immunosuppression consisted of alemtuzumab, tacrolimus, mycophenolate mofetil and prednisolone. Five months posttransplant, CMV tissue invasive disease of the upper gastrointestinal tract was evident without the presence of viremia, tested by quantitative polymerase chain reaction (PCR). Complete viral load suppression was achieved with intravenous ganciclovir, followed by valganciclovir for secondary prophylaxis. Mycophenolate mofetil and prednisolone were discontinued. Shortly thereafter the patient presented with recurrent CMV and candida esophagitis. While on ganciclovir and caspofungin, the patient developed CMV tissue invasive disease of the ileal graft, with persistent absence of viremia. Foscarnet and CMV immunoglobulin were added. Viral load declined to undetectable levels; however, clinical improvement did not occur due to occurrence of graft rejection. Despite infliximab and high dose prednisolone, graft rejection was progressive, requiring surgical explantation of the graft. This case highlights the importance of additional diagnostic tools such as endoscopy including PCR analysis of tissue samples. Extension of primary antiviral prophylaxis interval up to 6 months and prolonged retreatment for recurrent CMV disease may be useful to avoid severe CMV-related complications.
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15
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Rodríguez-Serrano M, Sánchez-Lázaro I, Almenar-Bonet L, Martínez-Dolz L, Portolés-Sanz M, Rivera-Otero M, Salvador-Sanz A. Does the calcineurin inhibitor have influence on cytomegalovirus infection in heart transplantation? Clin Transplant 2013; 28:88-95. [PMID: 24325305 DOI: 10.1111/ctr.12282] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 12/19/2022]
Abstract
Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality in heart transplant (HTx). Our aim was to analyze the rate of CMV infection in HTx patients receiving treatment with cyclosporine (CsA) or tacrolimus (Tac). Ninety-five patients were randomized to receive either CsA (53.7%) or Tac (46.3%). We performed prophylaxis with valganciclovir in patients with the highest risk of CMV infection. We considered CMV infection as an increased viral load or the presence of CMV in histological samples. We analyzed baseline characteristics, CMV infection, and other complications. Event-free rates were calculated using the Kaplan-Meier method. There were no significant differences in baseline characteristics between both groups. CMV infection was detected in 31.6% of patients (in 66.7% due to asymptomatic replication). The group treated with Tac had a lower rate of CMV infection (15.9% vs. 45.1%, p = 0.002) and longer CMV infection-free survival time (1440 vs. 899 d, p = 0.001). No differences were observed in the complications analyzed in both groups. The independent risk factors for infection identified in the multivariate analysis were treatment with CsA and bacterial infections. This was the first study to demonstrate a lower rate of CMV infection in patients treated with Tac vs. those treated with CsA after HTx.
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Affiliation(s)
- María Rodríguez-Serrano
- Heart Failure and Transplantation Unit, Department of Cardiology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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16
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de Pablo A, Santos F, Solé A, Borro JM, Cifrian JM, Laporta R, Monforte V, Román A, de la Torre M, Ussetti P, Zurbano F. Recommendations on the use of everolimus in lung transplantation. Transplant Rev (Orlando) 2012; 27:9-16. [PMID: 23276646 DOI: 10.1016/j.trre.2012.11.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/09/2012] [Indexed: 01/05/2023]
Abstract
The antiproliferative effect of everolimus provides a therapeutic option in the immunosuppression therapy of lung transplantation, by reducing both the risk of acute rejection and the process of progressive fibrosis that determines chronic graft rejection. However, few data on the use of everolimus in lung transplantation have been published to date, and the specific indications of the drug, along with the most adequate time for its introduction or dosing, have not been defined yet. The aim of this article is to propose recommendations for the use of everolimus in lung transplant recipients, including indications, dosing schedules and the use of concomitant immunosuppression. This consensus document has been developed by experts of all the Spanish lung transplant groups from the review of the existing literature and the clinical experience.
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Affiliation(s)
- A de Pablo
- University Hospital, Doce de Octubre, Madrid, Spain.
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17
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Mendez-Eirin E, Paniagua-Martín M, Marzoa-Rivas R, Barge-Caballero E, Grille-Cancela Z, Cañizares A, Naya-Leira C, Gargallo-Fernández P, Castro-Beiras A, Crespo-Leiro M. Cumulative Incidence of Cytomegalovirus Infection and Disease After Heart Transplantation in the Last Decade: Effect of Preemptive Therapy. Transplant Proc 2012; 44:2660-2. [DOI: 10.1016/j.transproceed.2012.09.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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18
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Doesch AO, Repp J, Hofmann N, Erbel C, Frankenstein L, Gleissner CA, Schmidt C, Ruhparwar A, Zugck C, Schnitzler P, Ehlermann P, Dengler TJ, Katus HA. Effects of oral valganciclovir prophylaxis for cytomegalovirus infection in heart transplant patients. DRUG DESIGN DEVELOPMENT AND THERAPY 2012; 6:289-95. [PMID: 23091373 PMCID: PMC3472651 DOI: 10.2147/dddt.s36578] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is a serious complication following heart transplantation. This study (June 2003-January 2010) retrospectively assessed the effects of oral valganciclovir prophylaxis in adult heart transplant recipients during the first year after transplantation. METHODS In patients with normal renal function, 900 mg of oral valganciclovir was administered twice daily for 14 days after heart transplant followed by 900 mg per day for following 6 months. In the event of renal insufficiency, valganciclovir was adjusted according to the manufacturer's recommendations. Antigenemia testing for pp65 antigen and simultaneous polymerase chain reaction (PCR) were used to document exposure to CMV. From 2003 to 2010, 146 patients (74.0% men) of mean age 50.7 ± 10.3 years at the time of heart transplant were included. RESULTS A total of 16 patients (11.0% of total, 75.0% male) had a positive pp65 and PCR result (ie, CMV infection) during the year following heart transplant; three of these patients had discontinued valganciclovir prophylaxis within the first 6 months following transplant because of leukopenia, including one patient developed CMV colitis. Two further patients developed CMV pneumonia during prophylactic valganciclovir therapy. Eight patients had positive pp65 and PCR tests in the 6-12 months after heart transplant following cessation of routine prophylaxis. One of these patients developed CMV pneumonia and another developed CMV colitis and CMV pneumonia. Thirty-seven of the 146 (25.3%) patients were CMV donor-seropositive/recipient-seronegative, and seven (18.9% of this subgroup) had a positive CMV test. In patients who were CMV donor-seropositive/recipient-seronegative, the risk of a positive CMV test (ie, CMV infection) was significantly elevated (P = 0.023). CONCLUSION CMV prophylaxis with oral valganciclovir for 6 months following heart transplant is clinically feasible. In line with previous studies, CMV donor-seropositive/recipient-seronegative patients have a significantly elevated risk of CMV infection. In patients who prematurely discontinue valganciclovir, close monitoring of CMV antigenemia appears warranted. No significantly elevated rate of CMV infection was observed after 6 months of valganciclovir prophylaxis.
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19
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Kobashigawa J, Ross H, Bara C, Delgado JF, Dengler T, Lehmkuhl HB, Wang SS, Dong G, Witte S, Junge G, Potena L. Everolimus is associated with a reduced incidence of cytomegalovirus infection following de novo cardiac transplantation. Transpl Infect Dis 2012; 15:150-62. [PMID: 23013440 DOI: 10.1111/tid.12007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 04/05/2012] [Accepted: 05/27/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) causes several complications following cardiac transplantation including cardiac allograft vasculopathy. Previous studies suggested that immunosuppressive treatment based on everolimus might reduce CMV infection. Aiming to better characterize the action of everolimus on CMV and its interplay with patient/recipient serology and anti-CMV prophylaxis, we analyzed data from 3 large randomized studies comparing various everolimus regimens with azathioprine (AZA)- and mycophenolate mofetil (MMF)-based regimens. METHODS CMV data were analyzed from 1009 patients in 3 trials of de novo cardiac transplant recipients who were randomized to everolimus 1.5 mg/day, everolimus 3 mg/day, or AZA 1-3 mg/kg/day, plus standard-dose (SD) cyclosporine (CsA; study B253, n = 634); everolimus 1.5 mg/day plus SD- or reduced-dose (RD)-CsA (study A2403, n = 199); and everolimus 1.5 mg/day plus RD-CsA or MMF plus SD-CsA (study A2411, n = 176). RESULTS In study B253, patients allocated to everolimus experienced almost a 70% reduction in odds of experiencing CMV infection compared with AZA (P < 0.001). In study A2403, CMV infection was low in both everolimus arms, irrespective of CsA dosing, and in study A2411, patients allocated to everolimus experienced an 80% reduction in odds of experiencing CMV infection, compared with MMF (P < 0.001). CMV syndrome/disease was rare and less frequent in everolimus-treated patients. Subgroup analyses showed that the benefit everolimus provides, in terms of CMV events, is retained in CMV-naïve recipients and is independent of anti-CMV prophylaxis or preemptive approaches. CONCLUSIONS Everolimus is associated with a lower incidence of CMV infection compared with AZA and MMF, which combined with its immunosuppressive efficacy and antiproliferative effects may positively impact long-term outcomes.
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Affiliation(s)
- J Kobashigawa
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
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20
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Ensor CR, Doligalski CT. Proliferation signal inhibitor toxicities after thoracic transplantation. Expert Opin Drug Metab Toxicol 2012; 9:63-77. [DOI: 10.1517/17425255.2012.726219] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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21
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Muñoz P, Crespo Leiro MG. [Prophylaxis of cytomegalovirus infection in heart transplantation]. Enferm Infecc Microbiol Clin 2012; 29 Suppl 6:52-5. [PMID: 22541924 DOI: 10.1016/s0213-005x(11)70059-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cytomegalovirus (CMV) is a common complication after heart transplantation, affecting almost half of all recipients. The clinical spectrum of this infection includes, in order of greater to lesser severity, latent infection, asymptomatic viremia, CMV syndrome and CMV disease. CMV is associated with rejection and vascular graft disease and is a major cause of morbidity and mortality. The factors most frequently involved in susceptibility to this infection and its severity are donor and recipient CMV serological status, the intensity of immunosuppression and the type of immunosuppressive agents used. The management strategies of this infection include universal or targeted prophylaxis, preemptive therapy and treatment of established disease. The use of preventive measures significantly reduces the incidence of symtomatic infection or CMV disease, which has been reported to be less than 3% in some recent series.
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Affiliation(s)
- Patricia Muñoz
- Servicio de Microbiología-Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, CIBERES, GESITRA, REIPI, España.
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22
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Czer LSC, Ruzza A, Vespignani R, Rafiei M, Pixton JR, Awad M, De Robertis M, Wong AV, Trento A. Prophylaxis of cytomegalovirus disease in mismatched patients after heart transplantation using combined antiviral and immunoglobulin therapy. Transplant Proc 2011; 43:1887-92. [PMID: 21693295 DOI: 10.1016/j.transproceed.2011.01.189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Accepted: 01/18/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a common cause of infection and morbidity after heart transplantation. Seronegative recipients (R-) of seropositive donor hearts (D+) are at high risk for CMV disease. We compared three different CMV prophylaxis regimens using combined antiviral and immunoglobulin therapy. METHODS In 99 patients who survived more than 30 days after heart transplant, all received induction with antilymphocytic therapy and triple-drug therapy. In group A, D+R- patients received one dose of intravenous immunoglobulin (IVIG) followed by one dose of CMV-specific immunoglobulin (CMV-IVIG), and intravenous ganciclovir (GCV) for 4 weeks followed by 11 months of oral acyclovir (ACV). In group B, D+R- patients received one dose IVIG followed by five doses of CMV-IVIG and intravenous GCV for 14 weeks followed by 9 months of oral ACV. In group C, D+R- patients were treated with the same regimen as for group B, except oral ACV was replaced with oral GCV. RESULTS The actuarial freedom from CMV disease for D+R- patients at 1 month, 1 year, and 2 years after transplantation in group A was 100%, 25% ± 15%, and 25% ± 15%, respectively; group B was 100%, 67% ± 27%, and 67% ± 27%; group C was 100%, 83% ± 15%, and 83% ± 15% (P < .01, groups B and C vs group A). By comparison, the actuarial freedom from CMV disease for seropositive recipients (D-R+ or D+R+) at 1 month, 1 year, and 2 years in group A was 100%, 87% ± 7%, and 82% ± 8%, respectively; group B was 100%, 88% ± 8%, and 75% ± 11%; group C was 100%, 72% ± 9%, and 72% ± 9% (P = NS among groups). Rejection rates did not differ among the three groups. CONCLUSIONS A longer course of intravenous GCV with multiple doses of CMV-IVIG was a more effective prophylaxis regimen against CMV disease for the high-risk group of seronegative recipients of seropositive donor hearts.
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Affiliation(s)
- L S C Czer
- Division of Cardiothoracic Surgery and Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California 90048, USA
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