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Toyoda T, Kurihara C, Kaiho T, Arunachalam A, Lysne J, Thomae BL, Kandula V, Manerikar AJ, Cerier EJ, Tomic R, Budinger GRS, Bharat A. Predictors of Cytomegalovirus Recurrence Following Cessation of Posttransplant Prophylaxis. J Surg Res 2024; 299:129-136. [PMID: 38754251 DOI: 10.1016/j.jss.2024.04.012] [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: 06/09/2023] [Revised: 03/20/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection is associated with a poor prognosis after lung transplantation, and donor and recipient CMV serostatus is a risk factor for reactivation. CMV prophylaxis is commonly administered in the first year following transplantation to reduce CMV infection; however, the risk factors for long-term reactivation remain unclear. We investigated the timing and risk factors of CMV infection after prophylactic administration. METHODS This study was a retrospective review of the institutional lung transplantation database from June 2014 to June 2022. Data on patient characteristics, pretransplantation laboratory values, postoperative outcomes, and CMV infection were collected. Donor CMV-IgG-positive and recipient CMV-IgG-negative groups were defined as the CMV mismatch group. RESULTS During the study period, 257 patients underwent lung transplantation and received a prophylactic dose of valganciclovir hydrochloride for up to 1 y. CMV infection was detected in 69 patients (26.8%): 40 of 203 (19.7%) in the non-CMV mismatch group and 29 of 54 (53.7%) in the CMV mismatch group (P < 0.001). CMV infection after prophylaxis occurred at a median of 425 and 455 d in the CMV mismatch and non-CMV mismatch groups, respectively (P = 0.07). Multivariate logistic regression analysis revealed that preoperative albumin level (odds ratio [OR] = 0.39, P = 0.04), CMV mismatch (OR = 15.7, P < 0.001), and donor age (OR = 1.05, P = 0.009) were significantly associated with CMV infection. CONCLUSIONS CMV mismatch may have increased the risk of CMV infection after lung transplantation, which decreased after prophylaxis. In addition to CMV mismatch, low preoperative albumin level and donor age were independent predictors of CMV infection.
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Affiliation(s)
- Takahide Toyoda
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Chitaru Kurihara
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Taisuke Kaiho
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ambalavanan Arunachalam
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey Lysne
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Benjamin L Thomae
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Viswajit Kandula
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adwaiy J Manerikar
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Emily J Cerier
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rade Tomic
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - G R Scott Budinger
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ankit Bharat
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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2
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Moro A, Janjua HM, Rogers MP, Kundu MG, Pietrobon R, Read MD, Kendall MA, Zander T, Kuo PC, Grimsley EA. Survival Tree Provides Individualized Estimates of Survival After Lung Transplant. J Surg Res 2024; 299:195-204. [PMID: 38761678 PMCID: PMC11189733 DOI: 10.1016/j.jss.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 03/22/2024] [Accepted: 04/18/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Identifying contributors to lung transplant survival is vital in mitigating mortality. To enhance individualized mortality estimation and determine variable interaction, we employed a survival tree algorithm utilizing recipient and donor data. METHODS United Network Organ Sharing data (2000-2021) were queried for single and double lung transplants in adult patients. Graft survival time <7 d was excluded. Sixty preoperative and immediate postoperative factors were evaluated with stepwise logistic regression on mortality; final model variables were included in survival tree modeling. Data were split into training and testing sets and additionally validated with 10-fold cross validation. Survival tree pruning and model selection was based on Akaike information criteria and log-likelihood values. Estimated survival probabilities and log-rank pairwise comparisons between subgroups were calculated. RESULTS A total of 27,296 lung transplant patients (8175 single; 19,121 double lung) were included. Stepwise logistic regression yielded 47 significant variables associated with mortality. Survival tree modeling returned six significant factors: recipient age, length of stay from transplant to discharge, recipient ventilator duration post-transplant, double lung transplant, recipient reintubation post-transplant, and donor cytomegalovirus status. Eight subgroups consisting of combinations of these factors were identified with distinct Kaplan-Meier survival curves. CONCLUSIONS Survival trees provide the ability to understand the effects and interactions of covariates on survival after lung transplantation. Individualized survival probability with this technique found that preoperative and postoperative factors influence survival after lung transplantation. Thus, preoperative patient counseling should acknowledge a degree of uncertainty given the influence of postoperative factors.
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Affiliation(s)
- Amika Moro
- Department of Surgery, OnetoMap Analytics, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Haroon M Janjua
- Department of Surgery, OnetoMap Analytics, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Michael P Rogers
- Department of Surgery, OnetoMap Analytics, University of South Florida Morsani College of Medicine, Tampa, Florida
| | | | - Ricardo Pietrobon
- Department of Surgery, OnetoMap Analytics, University of South Florida Morsani College of Medicine, Tampa, Florida; SporeData, Inc., Durham, North Carolina
| | - Meagan D Read
- Department of Surgery, OnetoMap Analytics, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Melissa A Kendall
- Department of Surgery, OnetoMap Analytics, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Tyler Zander
- Department of Surgery, OnetoMap Analytics, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Paul C Kuo
- Department of Surgery, OnetoMap Analytics, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Emily A Grimsley
- Department of Surgery, OnetoMap Analytics, University of South Florida Morsani College of Medicine, Tampa, Florida.
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Huh K, Lee SO, Kim J, Lee SJ, Choe PG, Kang JM, Yang J, Sung H, Kim SH, Moon C, Seok H, Shi HJ, Wi YM, Jeong SJ, Park WB, Kim YJ, Kim J, Ahn HJ, Kim NJ, Peck KR, Kim MS, Kim SI. Prevention of Cytomegalovirus Infection in Solid Organ Transplant Recipients: Guidelines by the Korean Society of Infectious Diseases and the Korean Society for Transplantation. Infect Chemother 2024; 56:101-121. [PMID: 38527780 PMCID: PMC10990892 DOI: 10.3947/ic.2024.0016] [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: 01/26/2024] [Accepted: 03/04/2024] [Indexed: 03/27/2024] Open
Abstract
Cytomegalovirus (CMV) is the most important opportunistic viral pathogen in solid organ transplant (SOT) recipients. The Korean guideline for the prevention of CMV infection in SOT recipients was developed jointly by the Korean Society for Infectious Diseases and the Korean Society of Transplantation. CMV serostatus of both donors and recipients should be screened before transplantation to best assess the risk of CMV infection after SOT. Seronegative recipients receiving organs from seropositive donors face the highest risk, followed by seropositive recipients. Either antiviral prophylaxis or preemptive therapy can be used to prevent CMV infection. While both strategies have been demonstrated to prevent CMV infection post-transplant, each has its own advantages and disadvantages. CMV serostatus, transplant organ, other risk factors, and practical issues should be considered for the selection of preventive measures. There is no universal viral load threshold to guide treatment in preemptive therapy. Each institution should define and validate its own threshold. Valganciclovir is the favored agent for both prophylaxis and preemptive therapy. The evaluation of CMV-specific cell-mediated immunity and the monitoring of viral load kinetics are gaining interest, but there was insufficient evidence to issue recommendations. Specific considerations on pediatric transplant recipients are included.
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Affiliation(s)
- Kyungmin Huh
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Jungok Kim
- Division of Infectious Diseases, Department of Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Su Jin Lee
- Division of Infectious Diseases, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Man Kang
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeseok Yang
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Si-Ho Kim
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Busan Paik Hospital, College of Medicine, Busan, Korea
| | - Hyeri Seok
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Korea University Medicine, Ansan, Korea
| | - Hye Jin Shi
- Division of Infectious Diseases, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Yu Mi Wi
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Youn Jeong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Joon Ahn
- Department of Surgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myoung Soo Kim
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Il Kim
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Patrucco F, Curtoni A, Sidoti F, Zanotto E, Bondi A, Albera C, Boffini M, Cavallo R, Costa C, Solidoro P. Herpes Virus Infection in Lung Transplantation: Diagnosis, Treatment and Prevention Strategies. Viruses 2023; 15:2326. [PMID: 38140567 PMCID: PMC10747259 DOI: 10.3390/v15122326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/12/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023] Open
Abstract
Lung transplantation is an ultimate treatment option for some end-stage lung diseases; due to the intense immunosuppression needed to reduce the risk of developing acute and chronic allograft failure, infectious complications are highly incident. Viral infections represent nearly 30% of all infectious complications, with herpes viruses playing an important role in the development of acute and chronic diseases. Among them, cytomegalovirus (CMV) is a major cause of morbidity and mortality, being associated with an increased risk of chronic lung allograft failure. Epstein-Barr virus (EBV) is associated with transformation of infected B cells with the development of post-transplantation lymphoproliferative disorders (PTLDs). Similarly, herpes simplex virus (HSV), varicella zoster virus and human herpesviruses 6 and 7 can also be responsible for acute manifestations in lung transplant patients. During these last years, new, highly sensitive and specific diagnostic tests have been developed, and preventive and prophylactic strategies have been studied aiming to reduce and prevent the incidence of these viral infections. In this narrative review, we explore epidemiology, diagnosis and treatment options for more frequent herpes virus infections in lung transplant patients.
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Affiliation(s)
- Filippo Patrucco
- Respiratory Diseases Unit, Medical Department, AOU Maggiore della Carità di Novara, Corso Mazzini 18, 28100 Novara, Italy
| | - Antonio Curtoni
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Francesca Sidoti
- Division of Virology, Department of Public Health and Pediatrics, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Elisa Zanotto
- Division of Virology, Department of Public Health and Pediatrics, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Alessandro Bondi
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Carlo Albera
- Division of Respiratory Medicine, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- Medical Sciences Department, University of Turin, 10126 Turin, Italy
| | - Massimo Boffini
- Cardiac Surgery Division, Surgical Sciences Department, AOU Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy
| | - Rossana Cavallo
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Cristina Costa
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Paolo Solidoro
- Division of Respiratory Medicine, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- Medical Sciences Department, University of Turin, 10126 Turin, Italy
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5
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Mora VM, Ussetti P, de Pablo A, Iturbe D, Laporta R, Alonso R, Aguilar M, Quezada CA, Cifrián JM. Evaluation of Two Different CMV-Immunoglobulin Regimens for Combined CMV Prophylaxis in High-Risk Patients following Lung Transplant. Microorganisms 2022; 11:microorganisms11010032. [PMID: 36677327 PMCID: PMC9864217 DOI: 10.3390/microorganisms11010032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/09/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The clinical benefits of the common off-label use of cytomegalovirus (CMV)-specific immunoglobulin (CMV-Ig) combined with antivirals in organ transplantation have not been previously assessed. The objective was to compare the risk of CMV infection and other post-transplantation outcomes between two CMV-Ig prophylaxis regimens in lung transplant recipients; Methods: Retrospective study of 124 donor CMV positive/recipient negative (D+/R-) patients receiving preventive ganciclovir/valganciclovir for 12 months, of whom 62 received adjunctive CMV-Ig as per label indication (short regimen [SR-Ig]; i.e., 7 doses over 2.5 months) and were compared to 62 who received an extended off-label regimen (ER-Ig) consisting of 17 doses over one year after transplantation. RESULTS The incidence of CMV infection or disease, acute rejection, chronic lung allograft dysfunction, and survival did not differ between the two CMV-Ig schedules. Although the time to the first CMV infection after transplantation was shorter in the ER-Ig than in the SR-Ig adjunctive group (log-rank: p = 0.002), the risk was independently predicted by antiviral cessation (odds ratio = 3.74; 95% confidence interval = 1.04-13.51; p = 0.030), whereas the CMV-Ig schedule had no effect. CONCLUSIONS Extending the adjunctive CMV-Ig prophylaxis beyond the manufacturer's recommendations up to one year does not confer additional clinical benefits regarding lung post-transplantation outcomes.
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Affiliation(s)
- Víctor M. Mora
- Service of Respiratory Medicine, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
- Genetic Epidemiology and Atherosclerosis in Systemic Inflammatory Diseases Group, IDIVAL, 39008 Santander, Spain
- Correspondence: ; Tel.: +34-942-20-25-20 (ext. 75915)
| | - Piedad Ussetti
- Department of Neumology, Hospital Puerta de Hierro, Majadahonda, 28222 Madrid, Spain
| | - Alicia de Pablo
- Department of Neumology, Hospital Universitario 12 de octubre, 28041 Madrid, Spain
| | - David Iturbe
- Service of Respiratory Medicine, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
- Genetic Epidemiology and Atherosclerosis in Systemic Inflammatory Diseases Group, IDIVAL, 39008 Santander, Spain
| | - Rosalía Laporta
- Department of Neumology, Hospital Puerta de Hierro, Majadahonda, 28222 Madrid, Spain
| | - Rodrigo Alonso
- Department of Neumology, Hospital Universitario 12 de octubre, 28041 Madrid, Spain
| | - Myriam Aguilar
- Department of Neumology, Hospital Puerta de Hierro, Majadahonda, 28222 Madrid, Spain
| | - Carlos A. Quezada
- Department of Neumology, Hospital Universitario 12 de octubre, 28041 Madrid, Spain
| | - José M. Cifrián
- Service of Respiratory Medicine, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
- Genetic Epidemiology and Atherosclerosis in Systemic Inflammatory Diseases Group, IDIVAL, 39008 Santander, Spain
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6
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Charlotte R, François P, Jonathan M, Véronique B, Olivier B, Tristan D, Séverine F, Jérôme L, Adrien T, Claire D, Espérie B, Eve C, Antoine R. Use of anti-CMV immunoglobulins in lung transplant recipients: The French experience. Transpl Infect Dis 2021; 23:e13754. [PMID: 34723405 DOI: 10.1111/tid.13754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 09/28/2021] [Accepted: 10/11/2021] [Indexed: 02/05/2023]
Abstract
RATIONAL Pending the authorization of new anti-CMV drugs with fewer adverse effects, exploring the possibilities offered by CMV immunoglobulins (CMVIG) seems necessary. In France, access to CMVIG requires official authorization by the national Health authority and is restricted to second line rescue therapy for CMV infection/disease. The aim of this multicenter retrospective study is to describe the indications and clinical situations that justified its use in France. METHODS A multicenter retrospective study included 22 lung transplant patients over a 3-year period. Data on clinical indication, tolerance and efficacy were collected. RESULTS The main indication for CMVIG initiation, which was documented in 17 of them (82%) was complex clinical situations resulting from side effects to antiviral drug. CMVIG indication was documented as treatment for 15 patients (68%) and as a secondary prophylaxis for 7 patients (32%). Only one side effect (pruritus during infusion with no anaphylactic symptoms) attributable to CMVIG was reported. After CMVIG initiation, no recurrence of infection or disease was observed during a median follow-up of 174 (12-682) days after treatment initiation for respectively 68% and 66% of the patients. CONCLUSION This study describes an unusual indication of CMVIG use as a last resort treatment in complex situations, based on clinical needs. CMVIG could be useful to change the course of CMV infection with minimal adverse effects or comorbidity.
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Affiliation(s)
- Roy Charlotte
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | | | - Messika Jonathan
- Pulmonology Department and Lung Transplant Centre, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Boussaud Véronique
- Pulmonology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Brugière Olivier
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Degot Tristan
- Department of Respiratory Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Feuillet Séverine
- Department of Cardio-Thoracic Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Lepavec Jérôme
- Department of Cardio-Thoracic Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Tissot Adrien
- Pulmonology Department, Institut du Thorax, Nantes University Hospital, Nantes, France
| | - Dromer Claire
- Pulmonology Department, Bordeaux University Hospital, Bordeaux, France
| | - Burnet Espérie
- Pulmonology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Camps Eve
- Pharmacy Department, Foch Hospital, Suresnes, France
| | - Roux Antoine
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, Suresnes, France.,Versailles-Saint-Quentin-en-Yvelines University, Versailles, France
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7
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Jaksic Jurinjak S, Hulak V, Udovicic M. Late-onset cytomegalovirus pneumonitis successfully treated by cytomegalovirus immunoglobulin in heart transplant patient with renal failure. SAGE Open Med Case Rep 2021; 9:2050313X21989496. [PMID: 33796306 PMCID: PMC7970677 DOI: 10.1177/2050313x21989496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/04/2021] [Indexed: 11/16/2022] Open
Abstract
Cytomegalovirus infection is one of the most serious pathogens affecting solid organ transplant recipients. Cytomegalovirus has been identified as a risk factor for graft rejection, cardiac allograft vasculopathy and is associated with increased morbidity and mortality. Viral clearance is not achieved in all patients despite standard antiviral therapy; therefore, there is great interest in prevention and treatment strategies, as use of specific cytomegalovirus immunoglobulin, to avoid progression to organ involvement. Dose regimen of specific cytomegalovirus immunoglobulin is not well studied, especially in cytomegalovirus disease. We present the case of late onset of tissue invasive disease, pneumonitis, in young female patient after heart transplantation with acute renal failure, successfully treated with frequent intermittent cytomegalovirus immunoglobulin followed by renal dosed ganciclovir.
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Affiliation(s)
- Sandra Jaksic Jurinjak
- Institute for Cardiovascular Diseases, Clinical Hospital Dubrava, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Vanja Hulak
- Institute for Cardiovascular Diseases, Clinical Hospital Dubrava, Zagreb, Croatia
| | - Mario Udovicic
- Institute for Cardiovascular Diseases, Clinical Hospital Dubrava, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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8
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Veit T, Pan M, Munker D, Arnold P, Dick A, Kunze S, Meiser B, Schneider C, Michel S, Zoller M, Böhm S, Walter J, Behr J, Kneidinger N, Kauke T. Association of CMV-specific T-cell immunity and risk of CMV infection in lung transplant recipients. Clin Transplant 2021; 35:e14294. [PMID: 33749938 DOI: 10.1111/ctr.14294] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Protecting against CMV infection and maintaining CMV in latent state are largely provided by CMV-specific T-cells in lung transplant recipients. The aim of the study was to assess whether a specific T-cell response is associated with the risk for CMV infection in seronegative patients who are at high risk for delayed CMV infection. METHODS All CMV-seronegative recipients (R-) from CMV-seropositive donors (D+) between January 2018 and April 2019 were included and retrospectively screened for CMV infection before and after assessment of CMV-specific cell-mediated immunity. RESULTS Thirty-one of the 50 patients (62%) developed early-onset CMV infection. Lower absolute neutrophil counts were significantly associated with early-onset CMV infection. Antiviral prophylaxis was ceased after 137.2 ± 42.8 days. CMV-CMI were measured at a median of 5.5 months after LTx. 19 patients experienced early and late-onset CMV infection after prophylaxis withdrawal within 15 months post transplantation. Positive CMV-CMI was significantly associated with lower risk of late-onset CMV infection after transplantation in logistic and cox-regression analysis (OR=0.05, p = .01; OR=2,369, p = .026). CONCLUSION D+/R- lung transplant recipients are at high risk of developing early and late-onset CMV infection. Measurement of CMV-CMI soon after transplantation might further define the CMV infection prediction risk in LTx recipients being at high risk for CMV viremia.
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Affiliation(s)
- Tobias Veit
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Ming Pan
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Laboratory for Immunogenetics, University of Munich, LMU, Munich, Germany
| | - Dieter Munker
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Paola Arnold
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Andrea Dick
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Laboratory for Immunogenetics, University of Munich, LMU, Munich, Germany
| | - Susanne Kunze
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Laboratory for Immunogenetics, University of Munich, LMU, Munich, Germany
| | - Bruno Meiser
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Transplant Center, University of Munich, LMU, Munich, Germany
| | - Christian Schneider
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Department of Thoracic Surgery, University of Munich, LMU, Munich, Germany
| | - Sebastian Michel
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Clinic of Cardiac Surgery, University of Munich, LMU, Munich, Germany
| | - Michael Zoller
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Department of Anaesthesiology, University of Munich, LMU, Munich, Germany
| | - Stephan Böhm
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Faculty of Medicine, Virology, Max von Pettenkofer Institute, University of Munich, LMU, Munich, Germany
| | - Julia Walter
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Department of Thoracic Surgery, University of Munich, LMU, Munich, Germany
| | - Jürgen Behr
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Nikolaus Kneidinger
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany
| | - Teresa Kauke
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), University Hospital, LMU Munich, Munich, Germany.,Laboratory for Immunogenetics, University of Munich, LMU, Munich, Germany.,Department of Thoracic Surgery, University of Munich, LMU, Munich, Germany
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9
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Hunt J, Chapple KM, Nasar A, Cherrier L, Walia R. Efficacy of low-dose valganciclovir in CMV R+ lung transplant recipients: a retrospective comparative analysis. Multidiscip Respir Med 2021; 16:706. [PMID: 33569173 PMCID: PMC7868948 DOI: 10.4081/mrm.2021.706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/21/2020] [Indexed: 01/06/2023] Open
Abstract
Background Cytomegalovirus (CMV) infection is extremely common after lung transplant and can be associated with significant morbidity and mortality. Current practice suggests the use of 900 mg daily of valganciclovir for CMV prophylaxis, but there is no literature assessing whether 450 mg daily of valganciclovir is sufficient in intermediate CMV risk lung transplant recipients. Therefore, we sought to assess the role of low-dose valganciclovir (LDV) versus high-dose valganciclovir (HDV) prophylaxis in intermediate-risk (R+) recipients. Methods We conducted a retrospective analysis on lung transplant recipients at the Norton Thoracic Institute in Phoenix, Arizona looking at intermediate-risk patients that received either valganciclovir 450 mg per day (LDV) or 900 mg/day (HDV). All patients were followed for 1 year post-transplant for incidence of CMV viremia. The primary outcome was the rate of CMV viremia as determined by a positive CMV polymerase chain reaction ([PCR] >2.7 log copies/mL). Secondary outcomes included rate of adverse events, acute cellular rejection, and mortality. Results The primary analysis included 103 patients (55 in the LDV group, 48 in the HDV group). In the LDV group, 9 patients (16.4%) developed CMV viremia compared to 4 (8.3%) in the HDV group (p=0.221) with no difference observed in adverse event rates between groups. Conclusion There was no statistical difference between groups for the primary outcome. However, the effect size demonstrated in this analysis may be of clinical relevance and valganciclovir 450 mg daily would not be recommended in intermediate risk lung transplant recipients at this time. To confirm our results, further prospective studies enrolling larger patient populations are necessary.
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Affiliation(s)
| | | | | | | | - Rajat Walia
- Department of Pulmonology, St. Joseph's Hospital and Medical Center, Phoenix AZ, USA
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10
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Liu G, Zhang X, Wang H, Cong H, Zhang X, Dong XQ. Synthesis of chiral α-substituted α-amino acid and amine derivatives through Ni-catalyzed asymmetric hydrogenation. Chem Commun (Camb) 2020; 56:4934-4937. [PMID: 32239044 DOI: 10.1039/d0cc01220c] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Highly efficient Ni-catalyzed asymmetric hydrogenation of cyclic N-sulfonyl ketimino esters was, for the first time, successfully developed, providing various chiral α-monosubstituted α-amino acid derivatives with excellent results (97-99% yields, 90 to >99% ee). Cyclic N-sulfonyl ketimines were also hydrogenated well to afford chiral amine derivatives with 98-99% yields and 97 to >99% ee. The gram-scale asymmetric hydrogenation was performed well with 85% yield and 99% ee using only 0.2 mol% catalyst.
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Affiliation(s)
- Gongyi Liu
- Key Laboratory of Biomedical Polymers, Engineering Research Center of Organosilicon Compounds & Materials, Ministry of Education, College of Chemistry and Molecular Sciences, Suzhou Institute of Wuhan University, Wuhan University, Wuhan, Hubei 430072, P. R. China.
| | - Xianghe Zhang
- Key Laboratory of Biomedical Polymers, Engineering Research Center of Organosilicon Compounds & Materials, Ministry of Education, College of Chemistry and Molecular Sciences, Suzhou Institute of Wuhan University, Wuhan University, Wuhan, Hubei 430072, P. R. China.
| | - Heng Wang
- Shenzhen Grubbs Institute, Department of Chemistry, Southern University of Science and Technology, Shenzhen, Guangdong 518055, P. R. China.
| | - Hengjiang Cong
- Key Laboratory of Biomedical Polymers, Engineering Research Center of Organosilicon Compounds & Materials, Ministry of Education, College of Chemistry and Molecular Sciences, Suzhou Institute of Wuhan University, Wuhan University, Wuhan, Hubei 430072, P. R. China.
| | - Xumu Zhang
- Key Laboratory of Biomedical Polymers, Engineering Research Center of Organosilicon Compounds & Materials, Ministry of Education, College of Chemistry and Molecular Sciences, Suzhou Institute of Wuhan University, Wuhan University, Wuhan, Hubei 430072, P. R. China. and Shenzhen Grubbs Institute, Department of Chemistry, Southern University of Science and Technology, Shenzhen, Guangdong 518055, P. R. China.
| | - Xiu-Qin Dong
- Key Laboratory of Biomedical Polymers, Engineering Research Center of Organosilicon Compounds & Materials, Ministry of Education, College of Chemistry and Molecular Sciences, Suzhou Institute of Wuhan University, Wuhan University, Wuhan, Hubei 430072, P. R. China.
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11
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Herrera S, Khan B, Singer LG, Binnie M, Chaparro C, Chow CW, Martinu T, Tomlinson G, Keshavjee S, Husain S, Tikkanen JM. Extending cytomegalovirus prophylaxis in high-risk (D+/R-) lung transplant recipients from 6 to 9 months reduces cytomegalovirus disease: A retrospective study. Transpl Infect Dis 2020; 22:e13277. [PMID: 32170813 DOI: 10.1111/tid.13277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 02/25/2020] [Accepted: 03/08/2020] [Indexed: 12/31/2022]
Abstract
RATIONALE Cytomegalovirus (CMV)-seronegative recipients receiving a seropositive allograft (D+/R-) are at a high risk of developing CMV disease. Our program increased the duration of CMV prophylaxis from 6 to 9 months in May 2013. Here, we present the impact on the incidence of CMV infection, disease, side effects, rejection, and other factors. METHODS Retrospective cohort of 241 CMV (D+/R-) patients transplanted between January 1, 2008, and December 31, 2017. Blood CMV testing was done according to protocol. All patients received ganciclovir/valganciclovir as prophylaxis. We compared the incidence and timing of CMV infection and disease up to 6 months after cessation of prophylaxis between patients who received 9 months (May 2013 onwards) and a historical control group who received 6 months of prophylaxis (prior to May 2013). CMV infection was defined as detectable CMV viremia in the absence of symptoms. CMV disease was defined as CMV syndrome or tissue-invasive disease. Side effects of prophylaxis and CMV resistance were recorded. RESULTS A total of 116 patients were included in the 6-month group and 125 in the 9-month group. The extended 9-month CMV prophylaxis delayed the onset of CMV infection (median time to CMV infection after lung transplantation 295 vs 353 days, P < .01) but did not significantly reduce the incidence of CMV infection (65% vs 64%, P = .06, log-rank). The 9-month prophylaxis delayed the onset and decreased the incidence of CMV disease from 50% in the 6-month group to 42% (P = .02 log-rank). There was no difference in the rate of adverse effects (leukopenia in 32% in both groups, P = .53) or development of CMV resistance between the two groups (4 cases in both groups, P = .92). There were no significant differences in overall survival or the rate of chronic lung allograft dysfunction between the groups. CONCLUSIONS Extending duration of CMV prophylaxis from 6 to 9 months resulted in a delayed and decreased incidence of CMV disease in our lung transplant population. The absolute risk reduction achieved by extended CMV prophylaxis was 8%. The incidence of CMV infection, and ganciclovir resistance and side effects were similar between the two groups. Our results suggest that extending CMV prophylaxis in the highest risk CMV D+/R- group is effective in reducing CMV disease.
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Affiliation(s)
- Sabina Herrera
- Transplant Infectious Diseases, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Basha Khan
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Matthew Binnie
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Cecilia Chaparro
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Chung-Wai Chow
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network / University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Shahid Husain
- Transplant Infectious Diseases, University Health Network/University of Toronto, Toronto, ON, Canada
| | - Jussi M Tikkanen
- Toronto Lung Transplant Program, University Health Network/University of Toronto, Toronto, ON, Canada
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12
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Clausen ES, Zaffiri L. Infection prophylaxis and management of viral infection. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:415. [PMID: 32355859 PMCID: PMC7186616 DOI: 10.21037/atm.2019.11.85] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Viral infections are associated with significant morbidity and mortality in lung transplant recipients. Importantly, several viral infections have been associated with the development of chronic lung allograft dysfunction (CLAD). Community-acquired respiratory viruses (CARV) such as influenza and respiratory syncytial virus (RSV), are frequently associated with acute and chronic rejection. Cytomegalovirus (CMV) remains a significant burden in regards to morbidity and mortality in lung transplant recipients. Epstein-Barr virus (EBV) is mostly involved with the development of post-transplant lymphoproliferative disorder (PTLD), a lymphoid proliferation that occurs in the setting of immunosuppression. On the other hand, the development of direct acting antivirals for hepatitis C virus (HCV) is changing the use of HCV-positive organs in transplantation. In this article we will focus on reviewing common viral infections that have a significant impact on lung transplant recipients looking at epidemiology, prevention and potential treatment.
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Affiliation(s)
- Emily S Clausen
- Department of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Lorenzo Zaffiri
- Department of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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13
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Mullane KM. Human Cytomegalovirus Prophylaxis and Treatment in Lung Transplantation in the Current Era. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00246-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Imlay H, Dumitriu Carcoana AO, Fisher CE, Wong B, Rakita RM, Fishbein DP, Limaye AP. Impact of valganciclovir prophylaxis duration on cytomegalovirus disease in high-risk donor seropositive/recipient seronegative heart transplant recipients. Transpl Infect Dis 2020; 22:e13255. [PMID: 32020736 DOI: 10.1111/tid.13255] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/11/2020] [Accepted: 02/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Few data support use of 6 over 3 months of antiviral prophylaxis for cytomegalovirus (CMV) disease prevention in donor seropositive/recipient seronegative (D+R-) heart transplant recipients (HTR). METHODS We retrospectively assessed CMV disease and outcomes in 310 adult HTR between July 5, 2005, and December 30, 2016, at our center. Valganciclovir (VGCV) prophylaxis was given for 3-6 months in the D+R- group. Multivariable models evaluated risk factors for CMV disease in patients who received 3 vs 6 months (±1 month) of prophylaxis, with investigation of inverse probability weighting to correct for confounding variables. RESULTS The incidence of CMV disease among all patients and the D+R- group was 8.7% (27/310) and 26.5% (22/83), respectively, and included syndrome in 22.2% (6/27) and end-organ involvement in 77.8% (21/27). In a multivariable model, 6 vs 3 months of antiviral prophylaxis was not associated with reduced risk for CMV disease (OR 2.28 [95% CI 0.66, 7.91], P = .19). CMV disease in D+R- HTR was associated with higher rates of hospitalization (87.5% [14/16] vs 6.3% [1/16], P < .001) and for a longer duration than in matched D+R- controls without disease. CONCLUSIONS Cytomegalovirus disease remains a major cause of morbidity in D+R- HTR. In contrast to documented benefit in D+R- lung and kidney recipients, VGCV duration of 6 months was not associated with a lower incidence of CMV disease in D+R- HTR compared to 3-month duration and should be reconsidered in this patient population.
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Affiliation(s)
- Hannah Imlay
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington.,Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | | | - Cynthia E Fisher
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Beatrice Wong
- Department of Pharmacology, University of Washington, Seattle, Washington
| | - Robert M Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Daniel P Fishbein
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
| | - Ajit P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
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15
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Global estimate of phenotypic and genotypic ganciclovir resistance in cytomegalovirus infections among HIV and organ transplant patients; A systematic review and meta-analysis. Microb Pathog 2020; 141:104012. [PMID: 32004622 DOI: 10.1016/j.micpath.2020.104012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/21/2022]
Abstract
Human cytomegalovirus (CMV), an opportunistic pathogen belonging to Herpesviridae family, is considered as one of the major causes of morbidity and mortality among wide variety of patients, particularly in transplant recipients and HIV positive patients. As this virus can be resistant to treatment, frequency of CMV in patients who receive organ transplantation and people suffering from AIDS was studied between 1980 and 2019. Medline (via PubMed), Embase, Web of Science, and the Iranian Database were reviewed, and Comprehensive Meta-Analysis (V2.0, Biostat) software analyzed all data. Finally, we used Cochran's Q-statistic to encounter heterogeneity between different studies. Meta-analyses indicated, GCV resistance was 14.1% (95% CI 11.2-17.7); however, in patients suffering from AIDS and organ transplantation were 19.5% (95% CI 14.7-25.4) and 11.4% (95% CI 8.1-15.8), respectively. There were increasing rates in the prevalence of GCV resistance in CMV among transplant recipients, and HIV positive patients. Therefore, evaluation of these refractory infections is beneficial.
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16
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Jeong SJ. Persistent Effort to Control Infection after Lung Transplantation in Korea. Infect Chemother 2020; 52:644-646. [PMID: 33377324 PMCID: PMC7779979 DOI: 10.3947/ic.2020.52.4.644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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17
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Van Raemdonck D, Nevens F, Van Cleemput J, Vos R, Neyrinck A, Verleden GM. Fishing in the thoracic organ donor pool: What next if the catch of the day got infected with hepatitis C virus? J Thorac Cardiovasc Surg 2019; 159:2121-2125. [PMID: 31837768 DOI: 10.1016/j.jtcvs.2019.08.140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/09/2019] [Accepted: 08/14/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Chronic Diseases, Metabolism, and Ageing, Catholic University Leuven, Leuven, Belgium.
| | - Frederik Nevens
- Department of Chronic Diseases, Metabolism, and Ageing, Catholic University Leuven, Leuven, Belgium; Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Van Cleemput
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Chronic Diseases, Metabolism, and Ageing, Catholic University Leuven, Leuven, Belgium; Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium; Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Chronic Diseases, Metabolism, and Ageing, Catholic University Leuven, Leuven, Belgium; Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
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18
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A Randomized Study of Quantiferon CMV-directed Versus Fixed-duration Valganciclovir Prophylaxis to Reduce Late CMV After Lung Transplantation. Transplantation 2019; 103:1005-1013. [PMID: 30247316 DOI: 10.1097/tp.0000000000002454] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We provide the results of the first interventional study of cytomegalovirus (CMV)-specific immune monitoring to direct the length of antiviral prophylaxis in lung transplantation (LTx). METHODS Patients (n = 118) at risk of CMV infection were randomized 1:2 to either 5 months or variable length valganciclovir prophylaxis (5-11 mo post-LTx), as determined by the QuantiFERON (QFN)-CMV assay. Patients with a negative QFN-CMV assay (< 0.2 IU/mL) received prolonged valganciclovir prophylaxis. RESULTS The primary endpoint that was the incidence of CMV infection in the lung allograft within 18 months of LTx was significantly reduced in the QFN-CMV directed arm (37% versus 58%, P = 0.03). Secondary endpoints that included blood viremia, acute rejection, and chronic lung allograft dysfunction did not differ between the 2 arms. Of the 80/118 patients who ceased antiviral prophylaxis at 5 months, the incidence of viremia (> 600 copies/mL) within the blood was significantly reduced in patients with a positive QFN-CMV assay compared with those without protective immunity (13% versus 67%, P = 0.0003), as was the incidence of severe viremia (> 10 000 copies/mL) (3% versus 50%, P < 0.001). Ceasing antiviral prophylaxis at 11 months in patients with a negative assay was associated with a 25% incidence of late CMV viremia. CONCLUSIONS Cytomegalovirus immune monitoring allows an individualized approach to CMV prophylaxis and reduces late CMV infection within the lung allograft.
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19
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Heliövaara E, Husain S, Martinu T, Singer LG, Cypel M, Humar A, Keshavjee S, Tikkanen J. Drug-resistant cytomegalovirus infection after lung transplantation: Incidence, characteristics, and clinical outcomes. J Heart Lung Transplant 2019; 38:1268-1274. [PMID: 31570289 DOI: 10.1016/j.healun.2019.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/28/2019] [Accepted: 09/03/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection and development of CMV drug resistance can cause significant morbidity and mortality in patients with lung transplantation (LTX). We investigated the incidence of CMV drug resistance in adult patients with LTX and characterized this patient group and its outcomes. METHODS We analyzed a single-center retrospective cohort of 735 patients who received LTX between January 2012 and October 2017. We assessed the incidences of CMV UL97 and UL54 genotyping for clinically suspected drug resistance and confirmed drug resistance. Case-matched controls (3 control patients for each resistant patient) were identified by matching for CMV serological status, development of CMV disease or significant viremia (≥3,000 IU/ml), and transplantation date. RESULTS The incidence of drug-resistant CMV was 1.98% (11/556) in donor and/or recipient CMV-positive patients and 4.7% (7/150) in donor-positive/recipient-negative patients. Altogether, 27 patients were tested for drug resistance, and 11 strains were resistant, 8 sensitive, and 8 inconclusive. No differences in immunosuppression, acute rejection, or pre-transplant sensitization were seen between case-matched groups. The peak CMV viral load and mean duration of viremia were significantly higher in the resistant group (324,000 vs. 117,000 mean IU/ml, p = 0.048 and 140 vs. 55 days, p < 0.001, respectively). The resistant group had increased overall mortality after onset of viremia compared with controls (3-year mortality 70% vs. 30%; p = 0.01). CONCLUSIONS Drug-resistant CMV infection is rare, but patients who develop it have decreased overall survival. Peak CMV viral load and duration of CMV viremia were associated with development of resistant CMV infection.
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Affiliation(s)
- Elina Heliövaara
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shahid Husain
- Division of Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Atul Humar
- Division of Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Jussi Tikkanen
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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Abstract
Despite advances in surgical technique, lung transplantation is associated with worse survival when compared with other solid organ transplantations. Graft dysfunction and infection are the leading causes of mortality in the first 30 days following transplantation. Primary graft dysfunction (PGD) is a form of reperfusion injury that occurs early after transplantation. Management of PGD is mainly supportive with use of lung protective ventilation. Inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation may be used in severe cases. Bacterial pneumonias are the most common infectious complication in the immediate post transplant period, but invasive fungal infections may also occur. Other potential complications in the postoperative period include atrial arrhythmias and neurologic complications such as stroke. There is a lack of multicenter, randomized trials to guide ventilation strategies, infection prophylaxis, and treatment of atrial arrhythmias, therefore prevention and management of post-transplant complications vary by transplant center.
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Affiliation(s)
- Christina C Kao
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Amit D Parulekar
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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21
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Hecker M, Hecker A, Askevold I, Kuhnert S, Reichert M, Guth S, Mayer E, Slanina H, Schüttler CG, Seeger W, Padberg W, Mayer K. Indefinite cytomegalovirus prophylaxis with valganciclovir after lung transplantation. Transpl Infect Dis 2019; 21:e13138. [PMID: 31278878 DOI: 10.1111/tid.13138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/14/2019] [Accepted: 06/22/2019] [Indexed: 12/15/2022]
Abstract
Human cytomegalovirus (HCMV) infections and reactivations are common after lung transplantation and are associated with the development of bronchiolitis obliterans syndrome. Against this background, temporary HCMV prophylaxis is an established standard regimen after lung transplantation in most centers. However, the optimal duration of prophylaxis is unclear. We conducted a retrospective two-center study to determine the efficacy of indefinite lifelong HCMV prophylaxis with oral valganciclovir in a cohort of 133 lung transplant recipients with a mean follow-up time of approximately 5 years. During the follow-up period, HCMV DNA was detected in 22 recipients (16.5%). In one case, HCMV pneumonitis developed after prophylaxis had been terminated. We observed a beneficial safety profile and tolerability in our cohort, as the majority of patients still received valganciclovir after a 1- and 3-year observation period, respectively. Compared to the literature, these data indicate a beneficial effect of extended valganciclovir prophylaxis with an acceptable safety profile.
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Affiliation(s)
- Matthias Hecker
- University of Giessen and Marburg Lung Center (UGMLC), University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Ingolf Askevold
- Department of General and Thoracic Surgery, University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Stefan Kuhnert
- University of Giessen and Marburg Lung Center (UGMLC), University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Martin Reichert
- Department of General and Thoracic Surgery, University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Heiko Slanina
- Institute of Medical Virology, Justus Liebig University of Giessen, Giessen, Germany
| | - Christian G Schüttler
- Institute of Medical Virology, Justus Liebig University of Giessen, Giessen, Germany
| | - Werner Seeger
- University of Giessen and Marburg Lung Center (UGMLC), University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Winfried Padberg
- Department of General and Thoracic Surgery, University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
| | - Konstantin Mayer
- University of Giessen and Marburg Lung Center (UGMLC), University Hospital Giessen, Justus Liebig University of Giessen, Giessen, Germany
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22
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Meesing A, Razonable RR. New Developments in the Management of Cytomegalovirus Infection After Transplantation. Drugs 2019; 78:1085-1103. [PMID: 29961185 DOI: 10.1007/s40265-018-0943-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) continues to be one of the most important pathogens that universally affect solid organ and allogeneic hematopoietic stem cell transplant recipients. Lack of effective CMV-specific immunity is the common factor that predisposes to the risk of CMV reactivation and clinical disease after transplantation. Antiviral drugs are the cornerstone for prevention and treatment of CMV infection and disease. Over the years, the CMV DNA polymerase inhibitor, ganciclovir (and valganciclovir), have served as the backbone for management, while foscarnet and cidofovir are reserved for the management of CMV infection that is refractory or resistant to ganciclovir treatment. In this review, we highlight the role of the newly approved drug, letermovir, a viral terminase inhibitor, for CMV prevention after allogeneic hematopoietic stem cell transplantation. Advances in immunologic monitoring may allow for an individualized approach to management of CMV after transplantation. Specifically, the potential role of CMV-specific T-cell measurements in guiding the need for the treatment of asymptomatic CMV infection and the duration of treatment of CMV disease is discussed. The role of adoptive immunotherapy, using ex vivo-generated CMV-specific T cells, is highlighted. This article provides a review of novel drugs, tests, and strategies in optimizing our current approaches to prevention and treatment of CMV in transplant recipients.
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Affiliation(s)
- Atibordee Meesing
- Division of Infectious Diseases, Mayo Clinic, Mayo Clinic College of Medicine and Science, Marian Hall 5, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Raymund R Razonable
- Division of Infectious Diseases, Mayo Clinic, Mayo Clinic College of Medicine and Science, Marian Hall 5, 200 First Street SW, Rochester, MN, 55905, USA.
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
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Khurana MP, Lodding IP, Mocroft A, Sørensen SS, Perch M, Rasmussen A, Gustafsson F, Lundgren JD. Risk Factors for Failure of Primary (Val)ganciclovir Prophylaxis Against Cytomegalovirus Infection and Disease in Solid Organ Transplant Recipients. Open Forum Infect Dis 2019; 6:ofz215. [PMID: 31211159 PMCID: PMC6559280 DOI: 10.1093/ofid/ofz215] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/07/2019] [Indexed: 12/21/2022] Open
Abstract
Background Rates and risk factors for cytomegalovirus (CMV) prophylaxis breakthrough and discontinuation were investigated, given uncertainty regarding optimal dosing for CMV primary (val)ganciclovir prophylaxis after solid organ transplantation (SOT). Methods Recipients transplanted from 2012 to 2016 and initiated on primary prophylaxis were followed until 90 days post-transplantation. A (val)ganciclovir prophylaxis score for each patient per day was calculated during the follow-up time (FUT; score of 100 corresponding to manufacturers’ recommended dose for a given estimated glomerular filtration rate [eGFR]). Cox models were used to estimate hazard ratios (HRs), adjusted for relevant risk factors. Results Of 585 SOTs (311 kidney, 117 liver, 106 lung, 51 heart) included, 38/585 (6.5%) experienced prophylaxis breakthrough and 35/585 (6.0%) discontinued prophylaxis for other reasons. CMV IgG donor+/receipient- mismatch (adjusted HR [aHR], 5.37; 95% confidence interval [CI], 2.63 to 10.98; P < 0.001) and increasing % FUT with a prophylaxis score <90 (aHR, 1.16; 95% CI, 1.04 to 1.29; P = .01 per 10% longer FUT w/ score <90) were associated with an increased risk of breakthrough. Lung recipients were at a significantly increased risk of premature prophylaxis discontinuation (aHR, 20.2 vs kidney; 95% CI, 3.34 to 121.9; P = .001), mainly due to liver or myelotoxicity. Conclusions Recipients of eGFR-adjusted prophylaxis doses below those recommended by manufacturers were at an increased risk of prophylaxis breakthrough, emphasizing the importance of accurate dose adjustment according to the latest eGFR and the need for novel, less toxic agents.
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Affiliation(s)
- Mark P Khurana
- Centre for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Correspondence: M. P. Khurana, BSc, Department of Infectious Diseases, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark ()
| | - Isabelle P Lodding
- Centre for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Amanda Mocroft
- Institute for Global Health, Infection and Population Health, University College of London (UCL), London, United Kingdom
| | - Søren S Sørensen
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Michael Perch
- Section for Lung Transplantation, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Allan Rasmussen
- Department of Abdominal Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens D Lundgren
- Centre for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Razonable RR, Humar A. Cytomegalovirus in solid organ transplant recipients-Guidelines of the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13512. [PMID: 30817026 DOI: 10.1111/ctr.13512] [Citation(s) in RCA: 397] [Impact Index Per Article: 79.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 02/11/2019] [Indexed: 12/11/2022]
Abstract
Cytomegalovirus (CMV) is one of the most common opportunistic infections that affect the outcome of solid organ transplantation. This updated guideline from the American Society of Transplantation Infectious Diseases Community of Practice provides evidence-based and expert recommendations for screening, diagnosis, prevention, and treatment of CMV in solid organ transplant recipients. CMV serology to detect immunoglobulin G remains as the standard method for pretransplant screening of donors and transplant candidates. Antiviral prophylaxis and preemptive therapy are the mainstays of CMV prevention. The lack of a widely applicable viral load threshold for diagnosis and preemptive therapy is highlighted, as a result of variability of CMV nucleic acid testing, even in the contemporary era when calibrators are standardized. Valganciclovir and intravenous ganciclovir remain as drugs of choice for CMV management. Strategies for managing drug-resistant CMV infection are presented. There is an increasing use of CMV-specific cell-mediated immune assays to stratify the risk of CMV infection after solid organ transplantation, but their role in optimizing CMV prevention and treatment efforts has yet to be demonstrated. Specific issues related to pediatric transplant recipients are discussed.
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Affiliation(s)
| | - Atul Humar
- University Health Network, Toronto, Ontario, Canada.,Transplant Institute, University of Toronto, Toronto, Ontario, Canada
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25
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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: 727] [Impact Index Per Article: 145.4] [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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Long-Term Impact of Cytomegalovirus Serologic Status on Lung Transplantation in the United States. Ann Thorac Surg 2018; 107:1046-1052. [PMID: 30476471 DOI: 10.1016/j.athoracsur.2018.10.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/26/2018] [Accepted: 10/10/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection has been associated with poor outcomes after solid organ transplantation. The long-term impact of donor and recipient CMV serological status on lung transplant outcomes remains unclear. Accordingly, we evaluated the impact of donor and recipient CMV status on long-term patients as well as allograft survival after single (SLT) and double lung transplantation (BLT). METHODS The Scientific Registry of Transplant Recipients was used to track all adult lung transplants in United States from May 2005 to June 2016. Patient mortality and bronchiolitis obliterans syndrome were determined up to 5 years using Cox proportional hazards modeling. Additionally, landmark analysis was performed conditional on survival at 1 year. RESULTS Compared with donor negative-recipient CMV-IgG negative (D-R-), donor positive-recipient negative (D+R-) and donor positive-recipient positive (D+R+) groups had increased mortality at 1 and 5 years after BLT, with the former demonstrating highest risk. Although mortality was not increased with CMV seropositive donors after SLT at 1 year, both D+R- and D+R+ groups demonstrated greater mortality at 5 years. Risk of bronchiolitis obliterans syndrome was not affected by CMV serological status. Conditional landmark analysis confirmed that lungs from CMV seropositive donors conferred highest risk for long-term mortality. CONCLUSIONS CMV seronegative recipients undergoing either BLT or SLT from CMV seropositive donors have the highest risk of long-term mortality that extends beyond the first year. Further studies are needed to determine the causes of higher mortality observed in the CMV seronegative recipients and risks and benefits of extension of CMV prophylaxis, particularly in the high-risk group.
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27
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Meesing A, Razonable RR. Pharmacologic and immunologic management of cytomegalovirus infection after solid organ and hematopoietic stem cell transplantation. Expert Rev Clin Pharmacol 2018; 11:773-788. [DOI: 10.1080/17512433.2018.1501557] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Atibordee Meesing
- Division of Infectious Diseases and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science, Rochester, MI, USA
| | - Raymund R. Razonable
- Division of Infectious Diseases and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science, Rochester, MI, USA
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28
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Deziel PJ, Razonable R. Anti-infective chemoprophylaxis after solid-organ transplantation. Expert Rev Clin Immunol 2018; 14:469-479. [PMID: 29764228 DOI: 10.1080/1744666x.2018.1476852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Solid organ transplant (SOT) recipients are at high risk of opportunistic infections due to bacterial, viral, fungal, and parasitic pathogens. Anti-infective prophylaxis is a time-tested proven strategy for the prevention of these infections after SOT. Areas covered: The current recommendations for the prevention of surgical site infections, herpes simplex, cytomegalovirus, invasive fungal infections, and selected parasitic diseases are highlighted. Recent peer-reviewed publications on the prevention of infection after SOT were reviewed and their significance was discussed in the context of the current recommendations for preventing infectious complications. Expert commentary: The authors comment on the current approaches to infection prevention in transplant recipients, and discuss how these recommendations are implemented in their clinical practice. Notable findings published during the past year were highlighted, and their clinical significance was interpreted in the context of current recommendations. The evolution of diagnostic and immunologic assays was emphasized, with focus on their potential role in optimizing the current antimicrobial approaches to infection prevention after SOT.
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Affiliation(s)
- Paul J Deziel
- a Division of Infectious Diseases, The William J von Liebig Center for Transplantation and Clinical Regeneration , Mayo Clinic College of Medicine and Science, Mayo Clinic , Rochester , MN , USA
| | - Raymund Razonable
- a Division of Infectious Diseases, The William J von Liebig Center for Transplantation and Clinical Regeneration , Mayo Clinic College of Medicine and Science, Mayo Clinic , Rochester , MN , USA
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29
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Avery RK, Silveira FP, Benedict K, Cleveland AA, Kauffman CA, Schuster MG, Dubberke ER, Husain S, Paterson DL, Chiller T, Pappas P. Cytomegalovirus infections in lung and hematopoietic cell transplant recipients in the Organ Transplant Infection Prevention and Detection Study: A multi-year, multicenter prospective cohort study. Transpl Infect Dis 2018. [PMID: 29512935 DOI: 10.1111/tid.12877] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Most studies of post-transplant CMV infection have focused on either solid organ or hematopoietic cell transplant (HCT) recipients. A large prospective cohort study involving both lung and HCT recipients provided an opportunity to compare the epidemiology and outcomes of CMV infections in these 2 groups. METHODS Patients were followed up for 30 months in a 6-center prospective cohort study. Data on demographics, CMV infections, tissue-invasive disease, recurrences, rejection, and immunosuppression were recorded. RESULTS The overall incidence of CMV infection was 83/293 (28.3%) in the lung transplant group and 154/444 (34.7%) in the HCT group (P = .0706). Tissue-invasive CMV disease occurred in 8/83 (9.6%) of lung and 6/154 (3.9%) of HCT recipients with CMV infection, respectively (P = .087). Median time to CMV infection was longer in the lung transplant group (236 vs 40 days, P < .0001), likely reflecting the effects of prophylaxis vs preemptive therapy. Total IgG levels of < 350 mg/dL in lung recipients and graft vs host disease (GvHD) in HCT recipients were associated with increased CMV risk. HCT recipients had a higher mean number of CMV episodes (P = .008), although duration of viremia was not significantly different between the 2 groups. CMV infection was not associated with reduced overall survival in either group. CONCLUSIONS Current CMV prevention strategies have resulted in a low incidence of tissue-invasive disease in both lung transplant and HCT, although CMV viremia is still relatively common. Differences between the lung and HCT groups in terms of time to CMV and recurrences of CMV viremia likely reflect differences in underlying host immunobiology and in CMV prevention strategies in the modern era.
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Affiliation(s)
- Robin K Avery
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Carol A Kauffman
- University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - Erik R Dubberke
- Washington University School of Medicine, St. Louis, MO, USA
| | - Shahid Husain
- University of Toronto Medical Center, Toronto, ON, Canada
| | | | - Tom Chiller
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Peter Pappas
- University of Alabama at Birmingham, Birmingham, AL, USA
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30
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Dunn SP, Horslen S. Posttransplant Complications and Comorbidities. SOLID ORGAN TRANSPLANTATION IN INFANTS AND CHILDREN 2018. [PMCID: PMC7123596 DOI: 10.1007/978-3-319-07284-5_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Stephen P. Dunn
- Department of Surgery, Jefferson Medical College, Wilmington, Delaware USA
| | - Simon Horslen
- Division of Gastroenterology, Seattle Children’s Hospital, Seattle, Washington USA
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31
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Van Herck A, Verleden SE, Vanaudenaerde BM, Verleden GM, Vos R. Prevention of chronic rejection after lung transplantation. J Thorac Dis 2017; 9:5472-5488. [PMID: 29312757 DOI: 10.21037/jtd.2017.11.85] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Long-term survival after lung transplantation (LTx) is limited by chronic rejection (CR). Therapeutic strategies for CR have been largely unsuccessful, making prevention of CR an important and challenging therapeutic approach. In the current review, we will discuss current clinical evidence regarding prevention of CR after LTx.
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Affiliation(s)
- Anke Van Herck
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
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32
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Acute postoperative management after lung transplantation. Best Pract Res Clin Anaesthesiol 2017; 31:273-284. [DOI: 10.1016/j.bpa.2017.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/03/2017] [Accepted: 07/12/2017] [Indexed: 01/02/2023]
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33
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Monforte V, Sintes H, López-Gallo C, Delgado M, Santos F, Zurbano F, Solé A, Gavaldá J, Borro JM, Redel-Montero J, Cifrian JM, Pastor A, Román A, Ussetti P. Risk factors, survival, and impact of prophylaxis length in cytomegalovirus-seropositive lung transplant recipients: A prospective, observational, multicenter study. Transpl Infect Dis 2017; 19. [PMID: 28294487 DOI: 10.1111/tid.12694] [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: 03/09/2016] [Revised: 07/15/2016] [Accepted: 12/24/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal length of cytomegalovirus (CMV) prophylaxis in lung transplantation according to CMV serostatus is not well established. METHODS We have performed a prospective, observational, multicenter study to determine the incidence of CMV infection and disease in 92 CMV-seropositive lung transplant recipients (LTR), their related outcomes and risk factors, and the impact of prophylaxis length. RESULTS At 18 months post transplantation, 37 patients (40%) developed CMV infection (23 [25%]) or disease (14 [15.2%]). Overall mortality was higher in patients with CMV disease (64.3% vs 10.2%; P<.001), but only one patient died from CMV disease. In the multivariate analysis, CMV disease was an independent death risk factor (odds ratio [OR] 18.214, 95% confidence interval [CI] 4.120-80.527; P<.001). CMV disease incidence was higher in patients with 90-day prophylaxis than in those with 180-day prophylaxis (31.3% vs 11.8%; P=.049). Prophylaxis length was an independent risk factor for CMV disease (OR 4.974, 95% CI 1.231-20.094; P=.024). Sixteen patients withdrew from prophylaxis because of adverse events. CONCLUSION CMV infection and disease in CMV-seropositive LTR remain frequent despite current prophylaxis. CMV disease increases mortality, whereas 180-day prophylaxis reduces the incidence of CMV disease.
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Affiliation(s)
- Victor Monforte
- Respiratory Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Helena Sintes
- Respiratory Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Maria Delgado
- Thoracic Surgery Department, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | - Felipe Zurbano
- Respiratory Department, Hospital Marqués de Valdecilla, Santander, Spain
| | - Amparo Solé
- Respiratory Department, Hospital La Fe, Valencia, Spain
| | - Joan Gavaldá
- Infectious Disease Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Jose Maria Borro
- Thoracic Surgery Department, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | | | - Amparo Pastor
- Respiratory Department, Hospital La Fe, Valencia, Spain
| | - Antonio Román
- Respiratory Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Piedad Ussetti
- Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Respiratory Department, Hospital Puerta de Hierro, Madrid, Spain
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Almaghrabi RS, Omrani AS, Memish ZA. Cytomegalovirus infection in lung transplant recipients. Expert Rev Respir Med 2017; 11:377-383. [PMID: 28388307 DOI: 10.1080/17476348.2017.1317596] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality in solid organ transplant (SOT) patients. Lung transplant recipients are particularly at risk given the intense immunosuppression required. Areas covered: The Detailed review of the literature related to CMV infection, its direct and indirect effect on lung allograft function, as well as diagnosis, immune monitoring, treatment options and prevention strategies. Expert commentary: In lung transplant recipients, CMV infection is associated with pro-inflammatory and immune inhibitory effects that increase the risk of graft dysfunction and loss. Diagnosis of CMV infection remains challenging. Treatment options remain relatively limited.
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Affiliation(s)
- Reem S Almaghrabi
- a Section of Infectious Diseases, Department of Medicine , King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia
| | - Ali S Omrani
- a Section of Infectious Diseases, Department of Medicine , King Faisal Specialist Hospital and Research Centre , Riyadh , Saudi Arabia
| | - Ziad A Memish
- b Director Research Department , Prince Mohammed Bin Abdulaziz Hospital, Ministry of Health , Riyadh , Saudi Arabia.,c College of Medicine, Alfaisal University , Riyadh , Saudi Arabia.,d Hubert Department of Global Health, Rollins School of Public Health , Emory University , Atlanta , USA
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35
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Fishman JA. Infection in Organ Transplantation. Am J Transplant 2017; 17:856-879. [PMID: 28117944 DOI: 10.1111/ajt.14208] [Citation(s) in RCA: 454] [Impact Index Per Article: 64.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/09/2017] [Indexed: 01/25/2023]
Abstract
The prevention, diagnosis, and management of infectious disease in transplantation are major contributors to improved outcomes in organ transplantation. The risk of serious infections in organ recipients is determined by interactions between the patient's epidemiological exposures and net state of immune suppression. In organ recipients, there is a significant incidence of drug toxicity and a propensity for drug interactions with immunosuppressive agents used to maintain graft function. Thus, every effort must be made to establish specific microbiologic diagnoses to optimize therapy. A timeline can be created to develop a differential diagnosis of infection in transplantation based on common patterns of infectious exposures, immunosuppressive management, and antimicrobial prophylaxis. Application of quantitative molecular microbial assays and advanced antimicrobial therapies have advanced care. Pathogen-specific immunity, genetic polymorphisms in immune responses, and dynamic interactions between the microbiome and the risk of infection are beginning to be explored. The role of infection in the stimulation of alloimmune responses awaits further definition. Major hurdles include the shifting worldwide epidemiology of infections, increasing antimicrobial resistance, suboptimal assays for the microbiologic screening of organ donors, and virus-associated malignancies. Transplant infectious disease remains a key to the clinical and scientific investigation of organ transplantation.
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Affiliation(s)
- J A Fishman
- Transplant Infectious Disease and Immunocompromised Host Program and MGH Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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36
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Abstract
Cytomegalovirus (CMV) is a highly complex pathogen which, despite modern prophylactic regimens, continues to affect a high proportion of thoracic organ transplant recipients. The symptomatic manifestations of CMV infection are compounded by adverse indirect effects induced by the multiple immunomodulatory actions of CMV. These include a higher risk of acute rejection, cardiac allograft vasculopathy after heart transplantation, and potentially bronchiolitis obliterans syndrome in lung transplant recipients, with a greater propensity for opportunistic secondary infections. Prophylaxis for CMV using antiviral agents (typically oral valganciclovir or intravenous ganciclovir) is now almost universal, at least in high-risk transplants (D+/R-). Even with extended prophylactic regimens, however, challenges remain. The CMV events can still occur despite antiviral prophylaxis, including late-onset infection or recurrent disease, and patients with ganciclovir-resistant CMV infection or who are intolerant to antiviral therapy require alternative strategies. The CMV immunoglobulin (CMVIG) and antiviral agents have complementary modes of action. High-titer CMVIG preparations provide passive CMV-specific immunity but also exert complex immunomodulatory properties which augment the antiviral effect of antiviral agents and offer the potential to suppress the indirect effects of CMV infection. This supplement discusses the available data concerning the immunological and clinical effects of CMVIG after heart or lung transplantation.
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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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38
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Beam E, Lesnick T, Kremers W, Kennedy CC, Razonable RR. Cytomegalovirus disease is associated with higher all-cause mortality after lung transplantation despite extended antiviral prophylaxis. Clin Transplant 2016; 30:270-8. [PMID: 26701733 DOI: 10.1111/ctr.12686] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND The duration of anticytomegalovirus (CMV) prophylaxis after lung transplantation (LT) varies among transplant centers. METHODS A retrospective review of CMV donor-seropositive/recipient-seronegative (D+/R-) and CMV recipient-seropositive (R+) LT patients between January 2005 and September 2012 was performed. Starting January 2007, valganciclovir prophylaxis was given for at least 12 months (often lifelong) for CMV D+/R- and extended from three to six months for R+ LT patients. Risks of CMV infection and CMV disease, and mortality after LT, were assessed. RESULTS A total of 88 LT patients were studied, including 32 CMV D+/R-, and 56 R+ patients. During the follow-up period, 11 (12.5%) patients had asymptomatic CMV infection, and nine (10.3%) developed CMV disease. CMV disease (HR, 4.189; 95% CI: 1.672-10.495; p = 0.002) and CMV infection and disease (HR, 3.775; 95% CI: 1.729-8.240; p = 0.001) were significant risk factors for mortality. Overall, no significant difference was observed in rates of CMV infection or disease among LT recipients who received shorter vs. extended CMV prophylaxis. CONCLUSIONS Despite extended prophylaxis, LT patients remain at risk of CMV infection and disease. CMV remains associated with increased mortality after transplantation.
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Affiliation(s)
- E Beam
- Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - T Lesnick
- Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - W Kremers
- Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA.,The William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - C C Kennedy
- The William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine, Rochester, MN, USA.,Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - R R Razonable
- Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA.,Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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Resolution of Mild Ganciclovir-Resistant Cytomegalovirus Disease with Reduced-Dose Cidofovir and CMV-Hyperimmune Globulin. J Transplant 2014; 2014:342319. [PMID: 24991428 PMCID: PMC4058803 DOI: 10.1155/2014/342319] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 05/19/2014] [Indexed: 01/23/2023] Open
Abstract
Ganciclovir-resistant cytomegalovirus (CMV) is associated with significant morbidity in solid organ transplant recipients. Management of ganciclovir-resistant CMV may be complicated by nephrotoxicity which is commonly observed with recommended therapies and/or rejection induced by “indirect” viral effects or reduction of immunosuppression. Herein, we report a series of four high serologic risk (donor CMV positive/recipient CMV negative) kidney transplant patients diagnosed with ganciclovir-resistant CMV disease. All patients initially developed “breakthrough” viremia while still receiving valganciclovir prophylaxis after transplant and were later confirmed to exhibit UL97 mutations after failing to eradicate virus on adequate dosages of valganciclovir. The patients were subsequently and successfully treated with reduced-dose (1-2 mg/kg) cidofovir and CMV-hyperimmune globulin, given in 2-week intervals. In addition, all patients exhibited stable renal function after completion of therapy, and none experienced acute rejection. The combination of reduced-dose cidofovir and CMV-hyperimmune globulin appeared to be a safe and effective regimen in patients with mild disease due to ganciclovir-resistant CMV.
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Hanson K, Alexander B. Strategies for the prevention of infection after solid organ transplantation. Expert Rev Anti Infect Ther 2014; 4:837-52. [PMID: 17140359 DOI: 10.1586/14787210.4.5.837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Infection is a frequent complication of organ transplantation and is associated with significant morbidity and mortality. Preventative antimicrobial strategies are a key component of the care received by transplant patients. This review summarizes the evidence supporting anti-infective prophylaxis in this setting. Specific recommendations for the prevention of bacterial, fungal, viral and parasitic infection after transplant are made, with a focus on recent developments in the field of transplant infectious diseases.
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Affiliation(s)
- Kimberly Hanson
- Duke University Medical Center, Division of Infectious Diseases and International Health, Duke Clinical Microbiology Laboratory, NC 27710, USA.
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Abstract
Organ transplantation is one of the medical miracles or the 20th century. It has the capacity to substantially improve exercise performance and quality of life in patients who are severely limited with chronic organ failure. We focus on the most commonly performed solid-organ transplants and describe peak exercise performance following recovery from transplantation. Across all of the common transplants, evaluated significant reduction in VO2peak is seen (typically renal and liver 65%-80% with heart and/or lung 50%-60% of predicted). Those with the lowest VO2peak pretransplant have the lowest VO2peak posttransplant. Overall very few patients have a VO2peak in the normal range. Investigation of the cause of the reduction of VO2peak has identified many factors pre- and posttransplant that may contribute. These include organ-specific factors in the otherwise well-functioning allograft (e.g., chronotropic incompetence in heart transplantation) as well as allograft dysfunction itself (e.g., chronic lung allograft dysfunction). However, looking across all transplants, a pattern emerges. A low muscle mass with qualitative change in large exercising skeletal muscle groups is seen pretransplant. Many factor posttransplant aggravate these changes or prevent them recovering, especially calcineurin antagonist drugs which are key immunosuppressing agents. This results in the reduction of VO2peak despite restoration of near normal function of the initially failing organ system. As such organ transplantation has provided an experiment of nature that has focused our attention on an important confounder of chronic organ failure-skeletal muscle dysfunction.
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Affiliation(s)
- Trevor J Williams
- Department of Allergy, Immunology, and Respiratory Medicine Alfred Hospital and Monash University, Melbourne, Australia.
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Johansson I, Mårtensson G, Nyström U, Nasic S, Andersson R. Lower incidence of CMV infection and acute rejections with valganciclovir prophylaxis in lung transplant recipients. BMC Infect Dis 2013; 13:582. [PMID: 24325216 PMCID: PMC3878887 DOI: 10.1186/1471-2334-13-582] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 12/02/2013] [Indexed: 03/15/2023] Open
Abstract
Background Cytomegalovirus (CMV) is the most common opportunistic infection following lung transplantation. CMV replication in the lung allograft is described as accelerating the development of bronchiolitis obliterans syndrome (BOS). Finding a strategy to prevent CMV infection is an important issue. Methods We performed a retrospective, single-centre study of 114 lung transplant recipients (LTRs) who underwent lung transplantation from January 2001 to December 2006. In a smaller cohort of 88 CMV seropositive (R+) LTRs, three months of valganciclovir prophylaxis (2004-2006) was compared to three months of oral ganciclovir (2001-2003) with respect to the incidence of CMV infection/disease, the severity of CMV disease, acute rejection, BOS-free 4 year survival and 4 year survival. In the whole group of 114 LTRs the impact of CMV infection on long-term survival (BOS free 4 year survival and 6 year survival) was assessed. Results For the cohort of 88 CMV seropositive LTRs, the incidence of CMV infection/disease at one year was lower in the valganciclovir group compared to the ganciclovir group (24% vs. 54%, p = 0.003). There was a tendency towards reduced CMV disease, from 33% to 20% and a significant lower incidence of asymptomatic CMV infection (22% vs. 4%, p = 0.005). A lower incidence of acute rejection was observed in the valganciclovir group. However, there was no significant difference between the two groups in BOS free 4 year survival and 4 year survival. For the entire group of 114 LTRs, BOS-free 4 year survival for recipients with CMV disease was (32%, p = 0.005) and among those with asymptomatic CMV infection (36%, p = 0.061) as compared with patients without CMV infection (69%). Six year survival was lower among patients with CMV disease, (64%, p = 0.042) and asymptomatic CMV infection (55%, p = 0.018) than patients without CMV infection (84%). Conclusions A lower incidence of CMV infection/disease and acute rejections was observed with valganciclovir (3 months) when compared to oral ganciclovir (3 months). The long-term impact of CMV infection/disease was significant for BOS-free survival and survival.
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Affiliation(s)
- Inger Johansson
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Ganciclovir-resistant cytomegalovirus infections among lung transplant recipients are associated with poor outcomes despite treatment with foscarnet-containing regimens. Antimicrob Agents Chemother 2013; 58:128-35. [PMID: 24145525 DOI: 10.1128/aac.00561-13] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Ganciclovir-resistant cytomegalovirus (CMV) infections are reported infrequently among lung transplant recipients receiving extended valganciclovir prophylaxis. We performed a single-center, retrospective review of ganciclovir-resistant CMV infections in a program that employed valganciclovir prophylaxis for ≥6 months after lung transplant. CMV infections were diagnosed in 28% (170/607) of patients. UL97 mutations were detected in 9.4% (16/170) of CMV-infected patients at a median of 8.5 months posttransplant (range, 5 to 21) and despite prophylaxis for a median of 7 months (range, 4 to 21). UL97 mutations were canonical; 25% (4/16) of strains carried concurrent UL54 mutations. Ganciclovir-resistant CMV was more likely with breakthrough infections (75% [12/16] versus 19% [30/154]; P = 0.00001) and donor positive/recipient negative (D+/R-) serostatus (75% versus 45% [69/154]; P = 0.03). The median whole-blood CMV load was 4.13 log10 copies/cm(3) (range, 2.54 to 5.53), and 93% (14/15) of patients had low-moderate immune responses (Cylex Immunoknow). Antiviral therapy was successful, failed, or eradicated viremia followed by relapse in 12% (2/16), 31% (5/16), and 56% (9/16) of patients, respectively. Eighty-seven percent (14/16) of patients were treated with foscarnet-containing regimens; toxicity developed in 78% (11/14) of these. Median viral load half-life and time to viremia eradication among foscarnet-treated patients were 2.6 and 23 days, respectively, and did not correlate with protection from relapse. Sixty-nine percent (11/16) of patients developed CMV pneumonitis, and 25% (4/16) died of it. Serum viral load was independently associated with death among foscarnet-treated patients (P = 0.04). In conclusion, ganciclovir-resistant CMV infections remained a major cause of morbidity and mortality following lung transplantation. Foscarnet-based regimens often eradicated viremia rapidly but were ineffective in the long term and limited by toxicity.
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Kotton CN, Kumar D, Caliendo AM, Asberg A, Chou S, Danziger-Isakov L, Humar A. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2013; 96:333-60. [PMID: 23896556 DOI: 10.1097/tp.0b013e31829df29d] [Citation(s) in RCA: 558] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cytomegalovirus (CMV) continues to be one of the most common infections after solid-organ transplantation, resulting in significant morbidity, graft loss, and adverse outcomes. Management of CMV varies considerably among transplant centers but has been become more standardized by publication of consensus guidelines by the Infectious Diseases Section of The Transplantation Society. An international panel of experts was reconvened in October 2012 to revise and expand evidence and expert opinion-based consensus guidelines on CMV management, including diagnostics, immunology, prevention, treatment, drug resistance, and pediatric issues. The following report summarizes the recommendations.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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Lobo LJ, Noone PG. Respiratory infections in patients with cystic fibrosis undergoing lung transplantation. THE LANCET RESPIRATORY MEDICINE 2013; 2:73-82. [PMID: 24461904 DOI: 10.1016/s2213-2600(13)70162-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cystic fibrosis is an inherited disease characterised by chronic respiratory infections associated with bronchiectasis. Lung transplantation has helped to extend the lives of patients with cystic fibrosis who have advanced lung disease. However, persistent, recurrent, and newly acquired infections can be problematic. Classic cystic fibrosis-associated organisms, such as Staphylococcus aureus and Pseudomonas aeruginosa, are generally manageable post-transplantation, and are associated with favourable outcomes. Burkholderia cenocepacia poses particular challenges, although other Burkholderia species are less problematic. Despite concerns about non-tuberculous mycobacteria, especially Mycobacterium abscessus, post-transplantation survival has not been definitively shown to be less than average in patients with these infections. Fungal species can be prevalent before and after transplantation and are associated with high morbidity, so should be treated aggressively. Appropriate viral screening and antiviral prophylaxis are necessary to prevent infection with and reactivation of Epstein-Barr virus and cytomegalovirus and their associated complications. Awareness of drug pharmacokinetics and interactions in cystic fibrosis is crucial to prevent toxic effects and subtherapeutic or supratherapeutic drug dosing. With the large range of potential infectious organisms in patients with cystic fibrosis, infection control in hospital and outpatient settings is important. Despite its complexity, lung transplantation in the cystic fibrosis population is safe, with good outcomes if the clinician is aware of all the potential pathogens and remains vigilant by means of surveillance and proactive treatment.
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Affiliation(s)
- Leonard J Lobo
- Division of Pulmonary and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Peadar G Noone
- Pulmonary Division, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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Management strategies for cytomegalovirus infection and disease in solid organ transplant recipients. Infect Dis Clin North Am 2013; 27:317-42. [PMID: 23714343 DOI: 10.1016/j.idc.2013.02.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cytomegalovirus is the most common viral pathogen that affects solid organ transplant recipients. It directly causes fever, myelosuppression, and tissue-invasive disease, and indirectly, it negatively impacts allograft and patient survival. Nucleic acid amplification testing is the preferred method to confirm the diagnosis of CMV infection. Prevention of CMV disease using antiviral prophylaxis or preemptive therapy is critical in the management of transplant patients. Intravenous ganciclovir and oral valganciclovir are the first line drugs for antiviral treatment. This article provides a comprehensive review of the current epidemiology, diagnosis, prevention and treatment of CMV infection in solid organ transplant recipients.
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Razonable RR, Humar A. Cytomegalovirus in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:93-106. [PMID: 23465003 DOI: 10.1111/ajt.12103] [Citation(s) in RCA: 365] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Kim SY, Shin JA, Cho EN, Byun MK, Kim HJ, Ahn CM, Haam SJ, Lee DY, Paik HC, Chang YS. Late respiratory infection after lung transplantation. Tuberc Respir Dis (Seoul) 2013; 74:63-9. [PMID: 23483760 PMCID: PMC3591540 DOI: 10.4046/trd.2013.74.2.63] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 01/03/2013] [Accepted: 01/17/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Aiming to improve outcome of lung transplantation (LTx) patients, we reviewed risk factors and treatment practices for the LTx recipients who experienced respiratory infection in the late post-LTx period (>1 month after LTx). METHODS We analyzed the clinical data of 48 recipients and donors from 61 LTx, who experienced late respiratory infections. Late respiratory infections were classified according to the etiology, time of occurrence, and frequency of donor-to-host transmission or colonization of the recipient prior to transplantation. RESULTS During the period of observation, 42 episodes of respiratory infections occurred. The organisms most frequently involved were gram (-) bacteria: Acinetobacter baumannii (n=13, 31.0%), Pseudomonas aeruginosa (n=7, 16.7%), and Klebsiella pneumoniae (n=4, 10.0%). Among the 42 episodes recorded, 14 occurred in the late post-LTx period. These were bacterial (n=6, 42.9%), fungal (n=2, 14.3%), viral (n=4, 28.5%), and mycobacterial (n=2, 14.3%) infections. Of 6 bacterial infections, 2 were from multidrug-resistant (MDR) A. baumannii and one from each of MDR P. aeruginosa, extended spectrum β-lactamase (+) K. pneumoniae, methicillin-resistant Staphylococcus aureus and Streptococcus pneumoniae. Infection-related death occurred in 6 of the 14 episodes (43%). CONCLUSION Although the frequency of respiratory infection decreased sharply in the late post-LTx period, respiratory infection was still a major cause of mortality. Gram (-) MDR bacteria were the agents most commonly identified in these infections.
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Affiliation(s)
- Sang Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Schoeppler KE, Lyu DM, Grazia TJ, Crossno JT, Vandervest KM, Zamora MR. Late-onset cytomegalovirus (CMV) in lung transplant recipients: can CMV serostatus guide the duration of prophylaxis? Am J Transplant 2013; 13:376-82. [PMID: 23205887 DOI: 10.1111/j.1600-6143.2012.04339.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 09/28/2012] [Accepted: 10/14/2012] [Indexed: 01/25/2023]
Abstract
Evidence supports the use of 12 months of cytomegalovirus prophylaxis in all at-risk lung transplants; whether cytomegalovirus serostatus can be used to further optimize this duration remains to be determined. The purpose of this retrospective study was to determine if cytomegalovirus serostatus of both donor and recipient were associated with late-onset cytomegalovirus. The primary outcome was the proportion of lung transplants that developed cytomegalovirus infection or disease during the 180-day period following 6 months of prophylaxis in each at-risk serotype. Two hundred forty-four consecutive lung transplants were evaluated, 131 were included. The proportion of recipients with cytomegalovirus differed significantly between serotypes (20 of 41 [48.8%] D+/R- vs. 19 of 56 [33.9%] D+/R+ vs. 2 of 34 [5.9%] D-/R+; p < 0.001). In a multivariate model, older age (odds ratio [OR], 1.05, 95% confidence interval [CI] 1.004-1.099; p = 0.03) and D+/R- serostatus (OR, 3.83; 95% CI 1.674-8.770; p = 0.002) were associated with cytomegalovirus. Among R+ lung transplants, D- serostatus was associated with the absence of cytomegalovirus (OR, 0.12; 95% CI 0.0263-0.563; p = 0.007). These findings suggest that in the valganciclovir era, cytomegalovirus serostatus of both donor and recipient may identify lung transplants at heightened risk for late-onset cytomegalovirus.
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Affiliation(s)
- K E Schoeppler
- Pharmacy, University of Colorado Hospital, University of Colorado Health Sciences Center, Aurora, CO, USA.
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Meyer KC, Glanville AR. Bronchiolitis Obliterans Syndrome and Chronic Lung Allograft Dysfunction: Evolving Concepts and Nomenclature. BRONCHIOLITIS OBLITERANS SYNDROME IN LUNG TRANSPLANTATION 2013. [PMCID: PMC7122385 DOI: 10.1007/978-1-4614-7636-8_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bronchiolitis obliterans syndrome (BOS) eventually occurs in the majority of lung transplant recipients who survive beyond 1 year, can greatly impair quality of life, and is, directly or indirectly, the major cause of delayed allograft dysfunction and recipient death. A number of associated events or conditions are strongly associated with the risk for developing BOS; these include acute rejection, gastroesophageal reflux, infections, and autoimmune reactions that can occur in the setting of alloimmune responses to the lung allograft as recipients are given intense immunosuppression to prevent allograft rejection. The term chronic lung allograft dysfunction (CLAD) is being increasingly used to refer to recipients with late allograft dysfunction that meets the spirometric criteria for the diagnosis of BOS, but clinicians should recognize that such dysfunction can occur for a variety of reasons other than BOS. The recently identified entity of restrictive allograft syndrome, which is now recognized as a relatively distinct phenotype of CLAD, has features that differentiate it from classic obstructive BOS. A number of other entities that can also significantly affect allograft function must also be considered when significant allograft dysfunction is encountered following lung transplantation.
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