1
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Hardinger KL, Brennan DC. Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches. Ann Pharmacother 2024:10600280241237534. [PMID: 38501850 DOI: 10.1177/10600280241237534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
OBJECTIVE The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation. DATA SOURCES A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation. STUDY SELECTION AND DATA EXTRACTION Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded. DATA SYNTHESIS After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV. CONCLUSIONS Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.
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Affiliation(s)
- Karen L Hardinger
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel C Brennan
- Johns Hopkins Comprehensive Transplant Center, Baltimore, MD, USA
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2
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Yong MK, Shigle TL, Kim YJ, Carpenter PA, Chemaly RF, Papanicolaou GA. American Society for Transplantation and Cellular Therapy Series: #4 - Cytomegalovirus treatment and management of resistant or refractory infections after hematopoietic cell transplantation. Transplant Cell Ther 2021; 27:957-967. [PMID: 34560310 DOI: 10.1016/j.jtct.2021.09.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 11/29/2022]
Abstract
The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy (ASTCT) partnered with its Transpl. Infect. Dis. Special Interest Group (TID-SIG) to update its 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A new approach was employed with the goal of better serving clinical providers by publishing each standalone topic in the infectious diseases series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious diseases and HCT content experts developed and answered FAQs. Topics were finalized with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. The fourth topic in the series focuses on the management and treatment of cytomegalovirus (CMV) resistant and refractory infections. The diagnosis, definitions of resistant and refractory CMV, risk factors, virological genotypes and treatment algorithms are reviewed.
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Affiliation(s)
- Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, 3000, Australia; Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne Victoria, 3050, Australia.
| | - Terri Lynn Shigle
- Division of Pharmacy, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Centre, Seattle, WA, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, & Employee Health, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Genovefa A Papanicolaou
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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3
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Wiening V, Schmidt T, Dahmen M, Siam S, Reuter S, Pavenstädt HJ, Sester M, Suwelack B. Case Report: Management of a Multidrug-Resistant CMV-Strain in a Renal Transplant Recipient by High-Dose CMV-Specific Immunoglobulins, Modulation in Immunosuppression, and Induction of CMV-Specific Cellular Immunity. Front Immunol 2021; 11:623178. [PMID: 33569064 PMCID: PMC7868410 DOI: 10.3389/fimmu.2020.623178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/07/2020] [Indexed: 11/13/2022] Open
Abstract
The management of multidrug-resistant strains of cytomegalovirus after solid organ transplantation is challenging. This case report demonstrates the successful treatment of a multidrug-resistant strain of cytomegalovirus that may represent a valuable option for problematic cases. This report illustrates the emergence of a multidrug-resistant cytomegalovirus (CMV) UL54 mutant strain in a renal transplant recipient with severe lymphopenia and thrombocytopenia. We show that the combined treatment with high-dose intravenous cytomegalovirus-specific immunoglobulins (CMV-IVIG) after the switch to a mammalian target of rapamycin (mTOR)-inhibitor and cyclosporine A was a successful treatment alternative to direct antiviral treatment with high-dose ganciclovir and foscarnet. This treatment was associated with a quantitative induction of CMV-specific CD4 and CD8 T cells that showed maturation in phenotype and functionality with decreasing viral load. Our case report illustrates that high-dose CMV-IVIG and conversion of immunosuppressive drugs to mTOR inhibitors and cyclosporine A can be a successful treatment in a situation where the use of direct antiviral drugs was considered insufficient.
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Affiliation(s)
- Vanessa Wiening
- Transplant Nephrology/Department of Internal Medicine D, University Hospital Münster, Westphalian Wilhelm's University Münster, Münster, Germany
| | - Tina Schmidt
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Maximilian Dahmen
- Transplant Nephrology/Department of Internal Medicine D, University Hospital Münster, Westphalian Wilhelm's University Münster, Münster, Germany
| | - Sami Siam
- Transplant Nephrology/Department of Internal Medicine D, University Hospital Münster, Westphalian Wilhelm's University Münster, Münster, Germany
| | - Stefan Reuter
- Transplant Nephrology/Department of Internal Medicine D, University Hospital Münster, Westphalian Wilhelm's University Münster, Münster, Germany
| | - Hermann-Joseph Pavenstädt
- Transplant Nephrology/Department of Internal Medicine D, University Hospital Münster, Westphalian Wilhelm's University Münster, Münster, Germany
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Barbara Suwelack
- Transplant Nephrology/Department of Internal Medicine D, University Hospital Münster, Westphalian Wilhelm's University Münster, Münster, Germany
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4
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Kaminski H, Belanger J, Mary J, Garrigue I, Acquier M, Déchanet-Merville J, Merville P, Couzi L. Effect of mTOR inhibitors during CMV disease in kidney transplant recipients: Results of a pilot retrospective study. Microbiol Immunol 2020; 64:520-531. [PMID: 32249964 DOI: 10.1111/1348-0421.12794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/28/2020] [Accepted: 03/31/2020] [Indexed: 12/12/2022]
Abstract
mTOR inhibitors exert a preventive effect on cytomegalovirus (CMV) disease in CMV seropositive (R+) kidney transplant recipients, but their impact during the curative treatment of CMV disease in high-risk kidney transplant recipients has not been investigated. We aimed to evaluate the efficacy and tolerance of mTOR inhibitors compared with mycophenolic acid in 63 consecutive kidney transplant recipients (80% of D+R-) suffering from CMV disease with a persistent or a recurrent CMV DNAemia. In this monocentric retrospective study, 16 had their treatment converted to mTOR inhibitors and 47 did not. The Kaplan-Meier curves did not show any significant differences in CMV DNAemia eradication (77% vs. 88% respectively; hazard ratio (HR), 1.648 [95% confidence interval (CI), 0.913-2.973]; log-rank test, P = .132), DNAemia recurrence (36% vs. 47%; HR, 1.517 [95% CI, 0.574-4.007]; log-rank test, P = .448) and CMV clinical recurrence (17% vs. 27%; HR, 1.375 [95% CI, 0.340-5.552]; log-rank test, P = .677) between patients who received mTOR inhibitors and those who did not. These results were confirmed in uni- and multivariate time-dependent Cox regressions. In summary, conversion from mycophenolic acid to mTOR inhibitors seems inadequate for improving CMV clearance or in better preventing CMV recurrences during severe or persistent CMV disease.
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Affiliation(s)
- Hannah Kaminski
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France.,CNRS-UMR 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Juliette Belanger
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | - Julien Mary
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | - Isabelle Garrigue
- Laboratory of Virology, Pellegrin University Hospital, Bordeaux, France
| | - Mathieu Acquier
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France
| | | | - Pierre Merville
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France.,CNRS-UMR 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Pellegrin University Hospital, Bordeaux, France.,CNRS-UMR 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
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5
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The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. Transplantation 2019; 102:900-931. [PMID: 29596116 DOI: 10.1097/tp.0000000000002191] [Citation(s) in RCA: 691] [Impact Index Per Article: 138.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite recent advances, cytomegalovirus (CMV) infections remain one of the most common complications affecting solid organ transplant recipients, conveying higher risks of complications, graft loss, morbidity, and mortality. Research in the field and development of prior consensus guidelines supported by The Transplantation Society has allowed a more standardized approach to CMV management. An international multidisciplinary panel of experts was convened to expand and revise evidence and expert opinion-based consensus guidelines on CMV management including prevention, treatment, diagnostics, immunology, drug resistance, and pediatric issues. Highlights include advances in molecular and immunologic diagnostics, improved understanding of diagnostic thresholds, optimized methods of prevention, advances in the use of novel antiviral therapies and certain immunosuppressive agents, and more savvy approaches to treatment resistant/refractory disease. The following report summarizes the updated recommendations.
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6
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The Role of mTOR Inhibitors in the Management of Viral Infections: A Review of Current Literature. Transplantation 2018; 102:S50-S59. [PMID: 29369973 DOI: 10.1097/tp.0000000000001777] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Viruses are the leading cause of infections after solid organ transplant. The antiviral properties of mammalian target of rapamycin inhibitors (mTORis) have been ascribed to a variety of mechanisms and historical data have supported their use over other immunosuppressants for a myriad of viruses. Herein, we summarize the most current data to highlight the role of mTORis in the management of viral infections after solid organ transplant. The mTORis play a clear role in the management of cytomegalovirus, and have data supporting their potential use for BK virus and human herpesvirus 8-related Kaposi sarcoma. No data definitively supports mTORis for use in Epstein-Barr virus-mediated posttransplant lymphoproliferative disorder or hepatitis C virus viral replication. Although theoretically an advantageous therapy for hepatitis C virus-related liver allograft fibrosis and human immunodeficiency virus, mTORi use specifically for these indications is less attractive with modern treatments currently available. Data surrounding mTORi efficacy in preventing rejection, and their toxicity profile must be balanced with their potential antiviral effects in combination with patient-specific factors.
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7
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Uchida J, Iwai T, Nakatani T. Introduction of everolimus in kidney transplant recipients at a late posttransplant stage. World J Transplant 2018; 8:150-155. [PMID: 30211023 PMCID: PMC6134274 DOI: 10.5500/wjt.v8.i5.150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/23/2018] [Accepted: 06/28/2018] [Indexed: 02/05/2023] Open
Abstract
This minireview focuses on the current knowledge about the introduction of everolimus (EVL), a mammalian target of rapamycin inhibitor, with calcineurin inhibitor (CNI) elimination or minimization in kidney transplant recipients at a late posttransplant stage. Within, we have summarized two major clinical trials, ASCERTAIN and APOLLO, and seven other retrospective or nonrandomized studies. In the open-label multicenter ASCERTAIN study, the estimated glomerular filtration rate (eGFR) at 24 mo after conversion was not significantly different between three groups-EVL with CNI elimination, CNI minimization and continued CNI unchanged-at a mean of 5.4 years after transplantation. However, recipients with baseline creatinine clearance higher than 50 mL/min had a greater increase in measured GFR after CNI elimination. In the open-label multicenter APOLLO study, adjusted eGFR within the on-treatment population was significantly higher in the EVL continuation group than in the CNI continuation group at 12 mo after conversion at a mean of 7 years posttransplantation. Other studies on recipients without adverse events and already having satisfactory renal function showed favorable graft function by EVL late-induction with CNI elimination or reduction. These studies showed that chronic allograft nephropathy, CNI nephrotoxicity, CNI arteriolopathy, cancer and viral infection (especially cytomegalovirus infection) may be good indications for late conversion to EVL.
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Affiliation(s)
- Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tomoaki Iwai
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
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8
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Czarnecka P, Czarnecka K, Tronina O, Durlik M. Cytomegalovirus Disease After Liver Transplant-A Description of a Treatment-Resistant Case: A Case Report and Literature Review. Transplant Proc 2018; 50:4015-4022. [PMID: 30577306 DOI: 10.1016/j.transproceed.2018.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/23/2018] [Indexed: 12/18/2022]
Abstract
Cytomegalovirus (CMV) infection is a common complication in solid organ transplant recipients. In patients receiving immunosuppressive treatment, CMV may lead to life-threatening organ complications or graft loss. We describe a case of 31-year-old CMV-seronegative patient who underwent liver transplant from a CMV-seropositive donor with an early acute resistant rejection of the transplanted organ followed by primary CMV infection, despite prophylaxis, and its severe organ complications. Routine treatment of acute allograft rejection through increasing the base immunosuppression and then administering methylprednisolone infusions did not yield significant therapeutic effect. This resulted in anti-thymocyte globulin and ultimately proteasome inhibitor introduction. The cholestasis remitted and liver parameters improved. But 4 weeks later the patient was admitted again due to incorrect liver function tests. Blood tests revealed high CMV viral load, and primary CMV infection was diagnosed. On diagnosis the patient was treated with ganciclovir (GCV) intravenously. As GCV resistance was suspected based on clinical premises, foscarnet (FOS) and leflunomide (LFM) were implemented with concomitant cautious immunosuppression reduction due to the history of recent graft rejection. Despite aggressive treatment introduction, viral clearance was not obtained. Ultimately the patient died due to respiratory distress resulting from lung fibrosis, most probably owing to CMV diseases with Pneumocystis jiroveci coinfection. The presented case proves the importance of strictly following the rules of prophylaxis, especially in patients with a high risk factor of CMV infection development. A quick diagnosis, implementation of appropriate treatment, and fast reaction to the lack of satisfying therapeutic effect can be the key to a successful treatment.
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Affiliation(s)
- P Czarnecka
- Department of Transplantation Medicine, Nephrology, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - K Czarnecka
- Department of Transplantation Medicine, Nephrology, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - O Tronina
- Department of Transplantation Medicine, Nephrology, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - M Durlik
- Department of Transplantation Medicine, Nephrology, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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9
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Rolling KE, Jorgenson MR, Descourouez JL, Mandelbrot DA, Redfield RR, Smith JA. Ganciclovir-Resistant Cytomegalovirus Infection in Abdominal Solid Organ Transplant Recipients: Case Series and Review of the Literature. Pharmacotherapy 2017; 37:1258-1271. [PMID: 28699311 DOI: 10.1002/phar.1987] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Ganciclovir-resistant cytomegalovirus (GR-CMV) is emerging as a significant infection in the abdominal transplant population. GR-CMV is difficult to manage, and treatment options are limited. We report a descriptive case series of 15 patients who had documented GR-CMV at our center and review the literature on treatment of GR-CMV. The first case in this series was detected in 2012; the majority of cases occurred after January 1, 2014, with approximately 50% occurring in 2015. UL97 and UL54 viral genome mutations were present in 100% and 40% of CMV-infected patients, respectively. GR-CMV infection occurred ≤ 1 year posttransplantation in 11 patients (73%). All patients experienced dose reduction of valganciclovir (the oral prodrug of ganciclovir) before the development of GR-CMV. Initial treatment for GR-CMV included a variety of regimens, all including reduction in maintenance immunosuppression. Of the 6 patients with detectable GR-CMV by polymerase chain reaction (PCR) who were discharged without GR-CMV treatment and had a length of stay (LOS) less than 14 days, 83% were subsequently readmitted for treatment of GR-CMV within 2 months (60% in < 20 days); none received leflunomide. Of six patients with a LOS ≥ 14 days, 80% had CMV PCR below quantification on hospital discharge, and only one patient was readmitted in less than 20 days; 83% received leflunomide. Following GR-CMV, there was a 50% rejection incidence, 27% graft loss, and 20% mortality. For patients with more than three admissions for GR-CMV treatment, 100% had a major complication: 60% rejection, 20% graft loss, and 40% mortality. Common clinical characteristics of patients with GR-CMV included high-risk serostatus, lymphocyte depletion, and history of valganciclovir dose reduction. Overall, outcomes were poor. It appears that hospital readmission rate was reduced when CMV was treated to negativity with an initial treatment regimen of reduced immunosuppression, foscarnet, intravenous immunoglobulins, and leflunomide.
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Affiliation(s)
| | - Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Didier A Mandelbrot
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Robert R Redfield
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Jeannina A Smith
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
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López-Aladid R, Guiu A, Sanclemente G, López-Medrano F, Cofán F, Mosquera MM, Torre-Cisneros J, Vidal E, Moreno A, Aguado JM, Cordero E, Martin-Gandul C, Pérez-Romero P, Carratalá J, Sabé N, Niubó J, Cervera C, Cervilla A, Bodro M, Muñoz P, Fariñas C, Codina MG, Aranzamendi M, Montejo M, Len O, Marcos MA. Detection of cytomegalovirus drug resistance mutations in solid organ transplant recipients with suspected resistance. J Clin Virol 2017; 90:57-63. [PMID: 28359845 DOI: 10.1016/j.jcv.2017.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/02/2017] [Accepted: 03/16/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Current guidelines recommend that treatment of resistant cytomegalovirus (CMV) in solid organ transplant (SOT) recipients must be based on genotypic analysis. However, this recommendation is not systematically followed. OBJECTIVES To assess the presence of mutations associated with CMV resistance in SOT recipients with suspected resistance, their associated risk factors and the clinical impact of resistance. STUDY DESIGN Using Sanger sequencing we prospectively assessed the presence of resistance mutations in a nation-wide prospective study between September 2013-August 2015. RESULTS Of 39 patients studied, 9 (23%) showed resistance mutations. All had one mutation in the UL 97 gene and two also had one mutation in the UL54 gene. Resistance mutations were more frequent in lung transplant recipients (44% p=0.0068) and in patients receiving prophylaxis ≥6 months (57% vs. 17%, p=0.0180). The mean time between transplantation and suspicion of resistance was longer in patients with mutations (239 vs. 100days, respectively, p=0.0046) as was the median treatment duration before suspicion (45 vs. 16days, p=0.0081). There were no significant differences according to the treatment strategies or the mean CMV load at the time of suspicion. Of note, resistance-associated mutations appeared in one patient during CMV prophylaxis and also in a seropositive organ recipient. Incomplete suppression of CMV was more frequent in patients with confirmed resistance. CONCLUSIONS Our study confirms the need to assess CMV resistance mutations in any patient with criteria of suspected clinical resistance. Early confirmation of the presence of resistance mutations is essential to optimize the management of these patients.
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Affiliation(s)
- Rubén López-Aladid
- Department of Clinical Microbiology, Hospital Clinic, Universidad de Barcelona, Barcelona Institute for Global Health, Barcelona, (ISGlobal), Spain
| | - Alba Guiu
- Department of Clinical Microbiology, Hospital Clinic, Universidad de Barcelona, Barcelona Institute for Global Health, Barcelona, (ISGlobal), Spain
| | - Gemma Sanclemente
- Department of Infectious Diseases, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Instituto de Investigación Hospital 12 Octubre (i + 12) University Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - Frederic Cofán
- Nephrology and Renal Transplant Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - M Mar Mosquera
- Department of Clinical Microbiology, Hospital Clinic, Universidad de Barcelona, Barcelona Institute for Global Health, Barcelona, (ISGlobal), Spain
| | - Julián Torre-Cisneros
- Clinical Unit of Infectious Diseases, Hospital Universitario Reina Sofia-IMIBIC-UCO, Córdoba, Spain
| | - Elisa Vidal
- Clinical Unit of Infectious Diseases, Hospital Universitario Reina Sofia-IMIBIC-UCO, Córdoba, Spain
| | - Asunción Moreno
- Department of Infectious Diseases, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Jose Maria Aguado
- Unit of Infectious Diseases, Instituto de Investigación Hospital 12 Octubre (i + 12) University Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - Elisa Cordero
- Infectious Diseases Department, Hospital Universitario Virgen del Rocío, Sevilla, Instituto de Biomedicina de Sevilla (IBIS), Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Spain
| | - Cecilia Martin-Gandul
- Infectious Diseases Department, Hospital Universitario Virgen del Rocío, Sevilla, Instituto de Biomedicina de Sevilla (IBIS), Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Spain
| | - Pilar Pérez-Romero
- Infectious Diseases Department, Hospital Universitario Virgen del Rocío, Sevilla, Instituto de Biomedicina de Sevilla (IBIS), Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Spain
| | - Jordi Carratalá
- Department of Infectious Diseases, Bellvitge University Hospital, IDIBELL, Barcelona, Spain
| | - Nuria Sabé
- Department of Infectious Diseases, Bellvitge University Hospital, IDIBELL, Barcelona, Spain
| | - Jordi Niubó
- Department of Clinical Microbiology, Bellvitge University Hospital, IDIBELL, Barcelona, Spain
| | - Carlos Cervera
- Department of Medicine, Division of Infectious Diseases, University of Alberto, Edmonton, Canada
| | - Anna Cervilla
- Department of Clinical Microbiology, Hospital Clinic, Universidad de Barcelona, Barcelona Institute for Global Health, Barcelona, (ISGlobal), Spain
| | - Marta Bodro
- Department of Infectious Diseases, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitario Gregorio Marañón, Madrid, Spain
| | - Carmen Fariñas
- Unidad de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
| | - M Gemma Codina
- Microbiology Service, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Miguel Montejo
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Cruces, Bilbao, Spain
| | - Oscar Len
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebrón, Uniiversitat Autónoma de Barcelona, Barcelona, Spain
| | - M Angeles Marcos
- Department of Clinical Microbiology, Hospital Clinic, Universidad de Barcelona, Barcelona Institute for Global Health, Barcelona, (ISGlobal), Spain.
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11
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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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12
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Cervera C, Cofan F, Hernandez C, Soy D, Marcos MA, Sanclemente G, Bodro M, Moreno A, Diekmann F, Campistol JM, Oppenheimer F. Effect of mammalian target of rapamycin inhibitors on cytomegalovirus infection in kidney transplant recipients receiving polyclonal antilymphocyte globulins: a propensity score-matching analysis. Transpl Int 2016; 29:1216-1225. [DOI: 10.1111/tri.12848] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 05/13/2016] [Accepted: 08/17/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Carlos Cervera
- Division of Infectious Diseases; Department of Medicine; University of Alberta; Edmonton AB Canada
- Division of Infectious Diseases; IDIBAPS; Hospital Clinic of Barcelona; University of Barcelona; Barcelona Spain
| | - Frederic Cofan
- Renal Transplantation Unit; Division of Nephrology; IDIBAPS; Hospital Clinic of Barcelona; University of Barcelona; Barcelona Spain
| | - Cristina Hernandez
- Division of Infectious Diseases; Department of Medicine; University of Alberta; Edmonton AB Canada
| | - Dolors Soy
- Division of Pharmacy; IDIBAPS; Hospital Clinic of Barcelona; University of Barcelona; Barcelona Spain
| | - Maria Angeles Marcos
- Division of Microbiology; Centre Diagnòstic Biomèdic (CDB); Centre for International Health Research (CRESIB); IDIBAPS; Hospital Clinic of Barcelona; University of Barcelona; Barcelona Spain
| | - Gemma Sanclemente
- Division of Infectious Diseases; Department of Medicine; University of Alberta; Edmonton AB Canada
| | - Marta Bodro
- Division of Infectious Diseases; Department of Medicine; University of Alberta; Edmonton AB Canada
| | - Asunción Moreno
- Division of Infectious Diseases; Department of Medicine; University of Alberta; Edmonton AB Canada
| | - Fritz Diekmann
- Renal Transplantation Unit; Division of Nephrology; IDIBAPS; Hospital Clinic of Barcelona; University of Barcelona; Barcelona Spain
| | - Josep Maria Campistol
- Renal Transplantation Unit; Division of Nephrology; IDIBAPS; Hospital Clinic of Barcelona; University of Barcelona; Barcelona Spain
| | - Frederic Oppenheimer
- Renal Transplantation Unit; Division of Nephrology; IDIBAPS; Hospital Clinic of Barcelona; University of Barcelona; Barcelona Spain
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13
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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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14
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Campos AB, Ribeiro J, Boutolleau D, Sousa H. Human cytomegalovirus antiviral drug resistance in hematopoietic stem cell transplantation: current state of the art. Rev Med Virol 2016; 26:161-82. [DOI: 10.1002/rmv.1873] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/09/2016] [Accepted: 02/01/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Ana Bela Campos
- Molecular Oncology and Viral Pathology Group (CI-IPOP); Porto Portugal
- Faculty of Medicine; University of Porto; Porto Portugal
| | - Joana Ribeiro
- Molecular Oncology and Viral Pathology Group (CI-IPOP); Porto Portugal
- Virology Service; Portuguese Oncology Institute of Porto; Porto Portugal
- Faculty of Medicine; University of Porto; Porto Portugal
| | - David Boutolleau
- Sorbonne Universités; UPMC Université Paris 06, CR7, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris); Paris France
- INSERM, U1135, CIMI-Paris; Paris France
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix; Service de Virologie; Paris France
| | - Hugo Sousa
- Molecular Oncology and Viral Pathology Group (CI-IPOP); Porto Portugal
- Virology Service; Portuguese Oncology Institute of Porto; Porto Portugal
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15
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Ganciclovir-Resistant Cytomegalovirus Infection in a Kidney Transplant Recipient Successfully Treated with Foscarnet and Everolimus. Case Rep Nephrol 2016; 2016:2736805. [PMID: 26942027 PMCID: PMC4752979 DOI: 10.1155/2016/2736805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 01/17/2016] [Indexed: 11/18/2022] Open
Abstract
Cytomegalovirus (CMV) infection remains a major cause of morbidity, graft failure, and death in kidney transplant recipients. We describe a case of a 53-year-old CMV-seronegative man who underwent renal transplant from a CMV-positive donor and who developed ganciclovir- (GCV-) resistant CMV infection. Foscarnet was started while immunosuppressive therapy was modified with the introduction of everolimus minimizing tacrolimus dosage. Only two weeks after the start of this treatment regimen was the patient's viral load negative. At two-year follow-up the patient has no clinical or laboratory signs of CMV infection and a good and stable renal function or graft survival. In our case, administration of an mTOR inhibitor combined with foscarnet led to rapid and persistent viral clearance without compromising short- and medium-term graft function. This combination therapy supports the need for the kidney transplant community to individualize a target therapy for each type of GCV-resistant CMV infection.
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16
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Cherng BPZ, Tan TT, Tan BH. Resistant cytomegalovirus infection in renal transplant recipients. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815611811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Resistant cytomegalovirus infection is a significant problem in the transplant population including renal transplant recipients. A combination of factors including receipt of potent immunosuppression, high viral loads and suboptimal levels of anti-cytomegalovirus antivirals leads to emergence of resistant strains. Reports of associated poor graft survival and mortality demonstrate the potential pathogenic nature of such strains. Genotypic and phenotypic resistance testing are available for laboratory diagnosis of resistant cytomegalovirus infection and may help guide therapy. Various agents, including novel and newly minted antivirals and treatment approaches have been employed, with variable success. Thus, in spite of major advances in both diagnostics and therapeutics, management of resistant cytomegalovirus infection in renal transplant recipients remains a challenging prospect.
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Affiliation(s)
| | - Thuan Tong Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Singapore
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17
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Rauwel B, Jang SM, Cassano M, Kapopoulou A, Barde I, Trono D. Release of human cytomegalovirus from latency by a KAP1/TRIM28 phosphorylation switch. eLife 2015; 4. [PMID: 25846574 PMCID: PMC4384640 DOI: 10.7554/elife.06068] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 03/16/2015] [Indexed: 12/19/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a highly prevalent pathogen that induces life-long infections notably through the establishment of latency in hematopoietic stem cells (HSC). Bouts of reactivation are normally controlled by the immune system, but can be fatal in immuno-compromised individuals such as organ transplant recipients. Here, we reveal that HCMV latency in human CD34+ HSC reflects the recruitment on the viral genome of KAP1, a master co-repressor, together with HP1 and the SETDB1 histone methyltransferase, which results in transcriptional silencing. During lytic infection, KAP1 is still associated with the viral genome, but its heterochromatin-inducing activity is suppressed by mTOR-mediated phosphorylation. Correspondingly, HCMV can be forced out of latency by KAP1 knockdown or pharmacological induction of KAP1 phosphorylation, and this process can be potentiated by activating NFkB with TNF-α. These results suggest new approaches both to curtail CMV infection and to purge the virus from organ transplants. DOI:http://dx.doi.org/10.7554/eLife.06068.001 Human cytomegalovirus (HCMV) is an extremely common virus that causes life-long infections in humans. Most individuals are exposed to HCMV during childhood, and the infection rarely causes any symptoms of disease in healthy individuals. However, in people with weaker immune systems—for example, newborn babies, people with AIDS, or individuals who have received an organ transplant—HCMV can cause life-threatening illnesses. It is difficult for the immune system to fight the infection because HCMV is able to hide in cells within the bone marrow called hematopoietic stem cells. Inside these cells, the virus can survive in a ‘dormant’ state for many years, before being reactivated and starting to multiply again. In most people, the immune system manages to control this new outbreak of HCMV, and the virus becomes dormant again, but reactivation of the virus in individuals with weakened immune systems is much more likely to cause serious illness. The results of previous studies suggest that when HCMV infects the hematopoietic stem cells, human proteins switch off the expression of many virus genes, which makes the virus inactive. The virus can be reactivated when infected stem cells change into a type of immune cell called dendritic cells, but it is not clear how this is controlled. Here, Rauwel et al. reveal that a human protein called KAP1 is responsible for switching off the virus genes in the stem cells. It does so by interacting with two other proteins to alter the structure of the DNA in these genes. However, if the stem cells are stimulated to change into dendritic cells, KAP1 becomes inactive, which allows the virus genes to be switched on. Rauwel et al. also show that it is possible to force HCMV out of its dormant state by using drugs to block the activity of KAP1. This may aid the development of treatments that prevent the virus from causing serious illness in patients with weakened immune systems. For example, it could be used to remove dormant HCMV infections from bone marrow before it is transplanted into a new individual. DOI:http://dx.doi.org/10.7554/eLife.06068.002
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Affiliation(s)
- Benjamin Rauwel
- School of Life Sciences, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Suk Min Jang
- School of Life Sciences, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Marco Cassano
- School of Life Sciences, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Adamandia Kapopoulou
- School of Life Sciences, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Isabelle Barde
- School of Life Sciences, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Didier Trono
- School of Life Sciences, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
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18
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Chon WJ, Kadambi PV, Xu C, Becker YT, Witkowski P, Pursell K, Kane B, Josephson MA. Use of leflunomide in renal transplant recipients with ganciclovir-resistant/refractory cytomegalovirus infection: a case series from the University of Chicago. Case Rep Nephrol Dial 2015; 5:96-105. [PMID: 26000278 PMCID: PMC4427155 DOI: 10.1159/000381470] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Introduction Although antiviral prophylaxis for cytomegalovirus (CMV) is widely used, CMV infection remains common in renal transplant recipients with adverse consequences. Methods We report 5 cases of renal transplant recipients with resistant CMV infection who were successfully managed with leflunomide at the University of Chicago Medical Center. Results Five renal transplant recipients (2 simultaneous pancreas/kidney transplants, 3 deceased donor kidney transplants) were diagnosed with GCV-resistant CMV infection from 2003 to 2011. Of the 4 patients who had resistance genotype testing, 3 showed a UL97 mutation and 1 patient had a clinically resistant CMV infection. All patients received CMV prophylaxis with valganciclovir for 3 months. The number of days from the date of transplant to viremia ranged from 38 to 458 days (median 219). All 5 patients received other antiviral agents (e.g. ganciclovir, foscarnet), and in 4 patients, viremia was cleared before leflunomide was initiated as consolidation (or maintenance) therapy. Conclusion Leflunomide was well tolerated and successful in preventing recurrence of viremia in renal transplant recipients with resistant CMV infection. The beneficial effect of leflunomide in this setting warrants further investigation.
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Affiliation(s)
- W James Chon
- Section of Nephrology, University of Chicago, Chicago, Ill., USA
| | - Pradeep V Kadambi
- Division of Nephrology and Transplant Medicine, University of Arizona, Tucson, Ariz., USA
| | - Chang Xu
- Section of Nephrology, University of Chicago, Chicago, Ill., USA
| | - Yolanda T Becker
- Section of Transplant Surgery, University of Chicago, Chicago, Ill., USA
| | - Piotr Witkowski
- Section of Transplant Surgery, University of Chicago, Chicago, Ill., USA
| | - Kenneth Pursell
- Section of Infectious Disease, University of Chicago, Chicago, Ill., USA
| | - Brenna Kane
- Department of Pharmacy Services, University of Chicago, Chicago, Ill., USA
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19
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Vaz R, Barros F, Tavares I, Bustorff M, Ferreira I, Pestana M. Ganciclovir-resistant cytomegalovirus infection in renal transplantation. Clin Kidney J 2014; 7:210-3. [PMID: 25852874 PMCID: PMC4377781 DOI: 10.1093/ckj/sfu005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/16/2014] [Indexed: 12/13/2022] Open
Affiliation(s)
- Raquel Vaz
- Nephrology and Infectious Diseases Research and Development Group , INEB, University of Porto , Porto , Portugal ; Department of Nephrology , São João Hospital Center , Porto , Portugal
| | - Francisca Barros
- Nephrology and Infectious Diseases Research and Development Group , INEB, University of Porto , Porto , Portugal ; Department of Nephrology , São João Hospital Center , Porto , Portugal
| | - Isabel Tavares
- Nephrology and Infectious Diseases Research and Development Group , INEB, University of Porto , Porto , Portugal ; Department of Nephrology , São João Hospital Center , Porto , Portugal
| | - Manuela Bustorff
- Department of Nephrology , São João Hospital Center , Porto , Portugal
| | - Inês Ferreira
- Nephrology and Infectious Diseases Research and Development Group , INEB, University of Porto , Porto , Portugal ; Department of Nephrology , São João Hospital Center , Porto , Portugal
| | - Manuel Pestana
- Nephrology and Infectious Diseases Research and Development Group , INEB, University of Porto , Porto , Portugal ; Department of Nephrology , São João Hospital Center , Porto , Portugal ; Department of Renal, Urologic and Infectious Diseases, Faculty of Medicine , University of Porto , Porto , Portugal
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20
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Deback C, Burrel S, Varnous S, Carcelain G, Conan F, Aït-Arkoub Z, Autran B, Gandjbakhch I, Agut H, Boutolleau D. Management of multidrug-resistant cytomegalovirus infection in immunocompromised patients: case report of a heart-transplant recipient and review of the literature. Antivir Ther 2014; 20:249-54. [DOI: 10.3851/imp2818] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2014] [Indexed: 10/25/2022]
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21
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Ramanan P, Razonable RR. Cytomegalovirus infections in solid organ transplantation: a review. Infect Chemother 2013; 45:260-71. [PMID: 24396627 PMCID: PMC3848521 DOI: 10.3947/ic.2013.45.3.260] [Citation(s) in RCA: 212] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Indexed: 12/12/2022] Open
Abstract
Cytomegalovirus (CMV) continues to have a tremendous impact in solid organ transplantation despite remarkable advances in its diagnosis, prevention and treatment. It can affect allograft function and increase patient morbidity and mortality through a number of direct and indirect effects. Patients may develop asymptomatic viremia, CMV syndrome or tissue-invasive disease. Late-onset CMV disease continues to be a major problem in high-risk patients after completion of antiviral prophylaxis. Emerging data suggests that immunologic monitoring may be useful in predicting the risk of late onset CMV disease. There is now increasing interest in the development of an effective vaccine for prevention. Novel antiviral drugs with unique mechanisms of action and lesser toxicity are being developed. Viral load quantification is now undergoing standardization, and this will permit the generation of clinically relevant viral thresholds for the management of patients. This article provides a brief overview of the contemporary epidemiology, clinical presentation, diagnosis, prevention and treatment of CMV infection in solid organ transplant recipients.
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Affiliation(s)
- Poornima Ramanan
- Division of Infectious Diseases, Department of Medicine and the William J von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine and the William J von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota 55905, USA
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22
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Holdaas H, Midtvedt K, Åsberg A. A drug safety evaluation of everolimus in kidney transplantation. Expert Opin Drug Saf 2012; 11:1013-22. [PMID: 22954349 DOI: 10.1517/14740338.2012.722993] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Calcineurin inhibitors (CNI) have greatly reduced the rate of acute rejection and improved short-term graft survival after organ transplantation, however, long-term survival has hardly changed since their introduction. CNIs are believed to contribute to graft fibrosis, have side effects that adversely affect cardiovascular risk, and are associated with an increased rate of post-transplant malignancies. Everolimus, a mammalian target of rapamycin (mTOR) inhibitor, is not associated with graft fibrosis, has a superior cardiovascular risk profile to CNI therapy and has shown potential for the prevention and treatment of diverse forms of cancer. AREAS COVERED This review summarizes key aspects of everolimus, including its mechanism of action, pharmacokinetics, pharmacodynamics, drug-drug interactions and pivotal clinical studies with a focus on safety and efficacy. EXPERT OPINION Everolimus is effective in improving graft function in selected kidney transplant patients. Most adverse events are present for a short time after the introduction of everolimus, and are manageable. Everolimus has the potential to become an important agent in de novo and maintenance immunotherapy in kidney transplant recipients.
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Affiliation(s)
- Hallvard Holdaas
- Oslo University Hospital, Department of Transplant Medicine, Section of Nephrology, Rikshospitalet, Postbox 4950 Nydalen, N-0424 Oslo, Norway.
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