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Luo S, Yan P, Wang X, Ren X, Sun K, Guo L, Lv J, Su X, Zhao K, Chen J, Wang R. Talaromyces marneffei: A challenging diagnosis in a kidney transplant patient. Clin Case Rep 2024; 12:e9028. [PMID: 38911919 PMCID: PMC11192592 DOI: 10.1002/ccr3.9028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 06/25/2024] Open
Abstract
Key Clinical Message In addition to post-transplant lymphoproliferative disorders, it is necessary to be alert to the drug-resistant bacteria or fungal infection, especially Talaromyces marneffei, in kidney transplant patients who have failed antibiotic treatment and whose PET-CT indicates high metabolic mass in the transplanted kidney with a large number of other organs and lymph nodes. Abstract Talaromyces marneffei (TM) is a rare pathogenic fungus that primarily affects individuals with compromised immune systems. Post-transplant lymphoproliferative disorders (PTLD) are serious complications that can occur after solid organ and cell transplantation. Both TM infection and PTLD can invade the monocyte-macrophage system and often manifest as extranodal masses. This case report describes a kidney transplant patient who presented with symptoms of frequent, urgent, and painful urination over 6 months. Pulmonary CT scans revealed multiple nodules, and PET-CT demonstrated enlarged lymph nodes in the lungs and the transplanted kidney. The clinical manifestations closely mimicked those of PTLD. The confirmation of TM was achieved through pathogen metagenomic next-generation sequencing and renal biopsy. Unfortunately, despite receiving treatment with antifungal agents, anti-infective therapy, the patient's condition did not respond favorably, ultimately resulting in their unfortunate demise due to COVID-19.
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Affiliation(s)
- Sulin Luo
- Kidney Disease Center, The First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Kidney Disease Prevention and Control TechnologyHangzhouZhejiangChina
- National Key Clinical Department of Kidney DiseasesChina
- Institute of NephrologyZhejiang UniversityHangzhouChina
- Zhejiang Clinical Research Center of Kidney and Urinary System DiseaseHangzhouChina
| | - Pengpeng Yan
- Kidney Disease Center, The First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Kidney Disease Prevention and Control TechnologyHangzhouZhejiangChina
- National Key Clinical Department of Kidney DiseasesChina
- Institute of NephrologyZhejiang UniversityHangzhouChina
- Zhejiang Clinical Research Center of Kidney and Urinary System DiseaseHangzhouChina
| | - Xingxia Wang
- Kidney Disease Center, The First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
- Department of Nephrology903rd Hospital of PLAHangzhouChina
| | - Xue Ren
- Kidney Disease Center, The First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
- Department of Nephrology, Huzhou Central HospitalZhejiang ProvinceHuzhouChina
| | - Ke Sun
- Department of Pathology, First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
| | - Luying Guo
- Kidney Disease Center, The First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Kidney Disease Prevention and Control TechnologyHangzhouZhejiangChina
- National Key Clinical Department of Kidney DiseasesChina
- Institute of NephrologyZhejiang UniversityHangzhouChina
- Zhejiang Clinical Research Center of Kidney and Urinary System DiseaseHangzhouChina
| | - Junhao Lv
- Kidney Disease Center, The First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Kidney Disease Prevention and Control TechnologyHangzhouZhejiangChina
- National Key Clinical Department of Kidney DiseasesChina
- Institute of NephrologyZhejiang UniversityHangzhouChina
- Zhejiang Clinical Research Center of Kidney and Urinary System DiseaseHangzhouChina
| | - Xinhui Su
- Department of Nuclear Medicine, PET Centre, First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
| | - Kui Zhao
- Department of Nuclear Medicine, PET Centre, First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Kidney Disease Prevention and Control TechnologyHangzhouZhejiangChina
- National Key Clinical Department of Kidney DiseasesChina
- Institute of NephrologyZhejiang UniversityHangzhouChina
- Zhejiang Clinical Research Center of Kidney and Urinary System DiseaseHangzhouChina
| | - Rending Wang
- Kidney Disease Center, The First Affiliated Hospital, School of MedicineZhejiang UniversityHangzhouChina
- Key Laboratory of Kidney Disease Prevention and Control TechnologyHangzhouZhejiangChina
- National Key Clinical Department of Kidney DiseasesChina
- Institute of NephrologyZhejiang UniversityHangzhouChina
- Zhejiang Clinical Research Center of Kidney and Urinary System DiseaseHangzhouChina
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2
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Dogan B, Sema YA, Bora K, Veysel U, Benan D, Ezgi KT, Gozde AK, Demir D, Ozsan N, Hekimgil M, Zumrut SB, Miray K, Funda C, Sema A. Post-transplant lymphoproliferative disorder associated Epstein-Barr virus DNAemia after liver transplantation in children: Experience from single center. J Med Virol 2024; 96:e29767. [PMID: 38932460 DOI: 10.1002/jmv.29767] [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: 03/09/2024] [Revised: 06/04/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
The most prevalent malignancy that complicates both adult and pediatric solid organ transplantation is post-transplant lymphoproliferative disorder (PTLD). This study aimed to analyze the clinical and pathological characteristics, treatments, and outcomes of Epstein-Barr virus (EBV) DNAemia and PTLD in pediatric liver transplant recipients. A retrospective chart review was performed on 112 patients less than 18 years of age who underwent isolated orthotopic liver transplantation (OLT) between 2010 and 2022 at Ege University Children's Hospital. Data gathered for 1-year post-OLT included age at OLT, EBV, immunoglobulin (Ig)M/IgG status of the donor and recipient, indication for OLT, induction regimen, all immunosuppression levels, date and result of EBV polymerase chain reaction testing, rejection episodes documented by liver biopsy, and the development of PTLD. Forty-nine patients (43.75%) developed EBV DNAemia (median interval from surgery: 2 months, min-max: 2-36), of which 43 (87.8%) grafts came from living donors, and 6 (12.2%) came from deceased donors. Nine (18.4%) patients died during follow-up, and eight (16.3%) developed PTLD. Of these 8 patients; five patients developed EBV-related disease, one child developed hemophagocytic lymphohistiocytosis, one developed aplastic anemia, and one child developed B cell lymphoma. When PTLD patients and without-PTLD patients were compared, pediatric intensive care unit hospitalization, abnormal bone marrow biopsy findings, lymphadenopathy, age at diagnosis of EBV DNAemia, EBV viral load, tacrolimus (FK 506) pre-infection, were higher and tacrolimus 1-month levels were lower in patients with PTLD (p < 0.05). In logistic regression analysis, we showed that the age at diagnosis of EBV DNAemia was significantly higher in children with PTLD (p = 0.045; OR: 1.389; 95% CI: 1.007-1.914). PTLD is a rare but severe complication associated with EBV after OLT. This study demonstrated that PTLD is associated with older age, higher tacrolimus blood levels before EBV DNAemia, and higher peak EBV viral load at 1 month of EBV DNAemia.
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Affiliation(s)
- Barut Dogan
- Division of Gastroenterology, Hepatology, and Nutrition Disease, Department of Pediatrics, Medical School of Ege University, İzmir, Türkiye
| | - Yildirim Arslan Sema
- Division of Infectious Disease, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Kunay Bora
- Division of Gastroenterology, Hepatology, and Nutrition Disease, Department of Pediatrics, Medical School of Ege University, İzmir, Türkiye
| | - Umman Veysel
- Department of General Surgery, Medical School of Ege University, İzmir, Turkey
| | - Dernek Benan
- Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Kıran Taşçı Ezgi
- Department of Pediatrics, Sivas Numune Hospital, Gastroenterology, Hepatology, and Nutrition Disease, Sivas, Turkey
| | - Akkus Kayali Gozde
- Department of Microbiology, Medical School of Ege University, Izmir, Turkey
| | - Derya Demir
- Department of Pathology, Medical School of Ege University, İzmir, Turkey
| | - Nazan Ozsan
- Department of Pathology, Medical School of Ege University, İzmir, Turkey
| | - Mine Hekimgil
- Department of Pathology, Medical School of Ege University, İzmir, Turkey
| | - Sahbudak Bal Zumrut
- Division of Infectious Disease, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Karakoyun Miray
- Division of Gastroenterology, Hepatology, and Nutrition Disease, Department of Pediatrics, Medical School of Ege University, İzmir, Türkiye
| | - Cetin Funda
- Division of Gastroenterology, Hepatology, and Nutrition Disease, Department of Pediatrics, Medical School of Ege University, İzmir, Türkiye
| | - Aydogdu Sema
- Division of Gastroenterology, Hepatology, and Nutrition Disease, Department of Pediatrics, Medical School of Ege University, İzmir, Türkiye
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3
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Zhang TT, Cheng RYH, Ott AR, Dahl NP, Suchland ER, Stoffers CM, Asher GD, Hou D, Thouvenel CD, Hill TF, Rawlings DJ, James RG. BCR signaling is required for posttransplant lymphoproliferative disease in immunodeficient mice receiving human B cells. Sci Transl Med 2024; 16:eadh8846. [PMID: 38598616 DOI: 10.1126/scitranslmed.adh8846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/14/2024] [Indexed: 04/12/2024]
Abstract
Posttransplant lymphoproliferative disease (PTLD) is a major therapeutic challenge that has been difficult to study using human cells because of a lack of suitable models for mechanistic characterization. Here, we show that ex vivo-differentiated B cells isolated from a subset of healthy donors can elicit pathologies similar to PTLD when transferred into immunodeficient mice. The primary driver of PTLD-like pathologies were IgM-producing plasmablasts with Epstein-Barr virus (EBV) genomes that expressed genes commonly associated with EBV latency. We show that a small subset of EBV+ peripheral blood-derived B cells expressing self-reactive, nonmutated B cell receptors (BCRs) expand rapidly in culture in the absence of BCR stimulation. Furthermore, we found that in vitro and in vivo expansion of EBV+ plasmablasts required BCR signaling. Last, treatment of immunodeficient mice with the BCR pathway inhibitor, ibrutinib, delays onset of PTLD-like pathologies in vivo. These data have implications for the diagnosis and care of transplant recipients who are at risk of developing PTLD.
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Affiliation(s)
- Ting-Ting Zhang
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Rene Yu-Hong Cheng
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Andee R Ott
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Noelle P Dahl
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Emmaline R Suchland
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Claire M Stoffers
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Gregory D Asher
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Deyin Hou
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Christopher D Thouvenel
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Tyler F Hill
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
- MSTP and MCB Graduate Program, University of Washington, Seattle, WA 98195, USA
| | - David J Rawlings
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
- Department of Immunology, University of Washington, Seattle, WA 98195, USA
| | - Richard G James
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA 98101, USA
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
- Department of Pharmacology, University of Washington, Seattle, WA 98195, USA
- Brotman-Baty Institute for Precision Medicine, Seattle, WA 98195, USA
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4
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Yamada M, L'Huillier AG, Green M. A Focused Review of Epstein-Barr Virus Infections and PTLD in Pediatric Transplant Recipients: Guidance From the IPTA and ECIL Guidelines. J Pediatric Infect Dis Soc 2024; 13:S31-S38. [PMID: 38417085 DOI: 10.1093/jpids/piad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/08/2023] [Indexed: 03/01/2024]
Abstract
Epstein-Barr Virus (EBV) diseases, including EBV-associated post-transplant lymphoproliferative disorder (PTLD) remain important causes of morbidity and mortality in children undergoing solid organ transplantation (SOT) and hematopoietic cell transplantation (HCT). Despite progress in the prevention of EBV disease including PTLD (EBV/PTLD) in HCT, key questions in the prevention, and management of these infectious complications remain unanswered. The goal of this manuscript is to highlight key points and recommendations derived from the consensus guidelines published by the International Pediatric Transplant Association and the European Conference on Infections in Leukemia for children undergoing SOT and HCT, respectively. Additionally, we provide background and guidance on the use of EBV viral load measurement in the prevention and management of these children.
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Affiliation(s)
- Masaki Yamada
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Arnaud G L'Huillier
- Pediatric Infectious Diseases Unit, Department of Woman, Child and Adolescent Health, Geneva University Hospitals, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics Gynecology and Obstetrics, Faculty of Medicine, Geneva, Switzerland
| | - Michael Green
- Departments of Pediatrics and Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA and
- Departments of Pediatrics and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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5
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Green M, Squires JE, Chinnock RE, Comoli P, Danziger-Isakov L, Dulek DE, Esquivel CO, Höcker B, L'Huillier AG, Mazariegos GV, Visner GA, Bollard CM, Dipchand AI, Ferry JA, Gross TG, Hayashi R, Maecker-Kolhoff B, Marks S, Martinez OM, Metes DM, Michaels MG, Preiksaitis J, Smets F, Swerdlow SH, Trappe RU, Wilkinson JD, Allen U, Webber SA, Dharnidharka VR. The IPTA Nashville consensus conference on Post-Transplant lymphoproliferative disorders after solid organ transplantation in children: II-consensus guidelines for prevention. Pediatr Transplant 2024; 28:e14350. [PMID: 36369745 DOI: 10.1111/petr.14350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022]
Abstract
The International Pediatric Transplant Association (IPTA) convened an expert consensus conference to assess current evidence and develop recommendations for various aspects of care relating to post-transplant lymphoproliferative disorder after solid organ transplantation in children. In this report from the Prevention Working Group, we reviewed the existing literature regarding immunoprophylaxis and chemoprophylaxis, and pre-emptive strategies. While the group made a strong recommendation for pre-emptive reduction of immunosuppression at the time of EBV DNAemia (low to moderate evidence), no recommendations for use could be made for any prophylactic strategy or alternate pre-emptive strategy, largely due to insufficient or conflicting evidence. Current gaps and future research priorities are highlighted.
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Affiliation(s)
- Michael Green
- Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Patrizia Comoli
- Cell Factory & Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico, San Matteo, Pavia, Italy
| | - Lara Danziger-Isakov
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel E Dulek
- Division of Pediatric Infectious Diseases, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Britta Höcker
- Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Arnaud G L'Huillier
- Pediatric Infectious Diseases Unit and Laboratory of Virology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - George Vincent Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Gary A Visner
- Division of Pulmonary Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine M Bollard
- Center for Cancer and Immunology Research, Children's National Hospital, The George Washington University, Washington, District of Columbia, USA
| | - Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Judith A Ferry
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas G Gross
- Center for Cancer and Blood Diseases, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Robert Hayashi
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | | | - Stephen Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Olivia M Martinez
- Department of Surgery and Program in Immunology, Stanford University School of Medicine, Stanford, California, USA
| | - Diana M Metes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marian G Michaels
- Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jutta Preiksaitis
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Françoise Smets
- Pediatric Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Stephen H Swerdlow
- Division of Hematopathology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ralf U Trappe
- Department of Hematology and Oncology, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Germany and Department of Internal Medicine II: Hematology and Oncology, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - James D Wilkinson
- Department of Pediatrics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Upton Allen
- Division of Infectious Diseases and the Transplant and Regenerative Medicine Center, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Vikas R Dharnidharka
- Department of Pediatrics, Division of Pediatric Nephrology, Hypertension & Pheresis, Washington University School of Medicine & St. Louis Children's Hospital, St. Louis, Missouri, USA
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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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7
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Atamna A, Yahav D, Hirzel C. Prevention of Oncogenic Gammaherpesvirinae (EBV and HHV8) Associated Disease in Solid Organ Transplant Recipients. Transpl Int 2023; 36:11856. [PMID: 38046068 PMCID: PMC10689273 DOI: 10.3389/ti.2023.11856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023]
Abstract
Long-term risk for malignancy is higher among solid organ transplant (SOT) recipients compared to the general population. Four non-hepatitis viruses have been recognized as oncogenic in SOT recipients-EBV, cause of EBV-associated lymphoproliferative diseases; human herpes virus 8 (HHV8), cause of Kaposi sarcoma, primary effusion lymphoma and multicentric Castleman disease; human papilloma virus, cause of squamous cell skin cancers, and Merkel cell polyomavirus, cause of Merkel cell carcinoma. Two of these viruses (EBV and HHV8) belong to the human herpes virus family. In this review, we will discuss key aspects regarding the clinical presentation, diagnosis, treatment, and prevention of diseases in SOT recipients associated with the two herpesviruses.
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Affiliation(s)
- Alaa Atamna
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dafna Yahav
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Cédric Hirzel
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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8
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Zaffiri L, Chambers ET. Screening and Management of PTLD. Transplantation 2023; 107:2316-2328. [PMID: 36949032 DOI: 10.1097/tp.0000000000004577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) represents a heterogeneous group of lymphoproliferative diseases occurring in the setting of immunosuppression following hematopoietic stem cells transplant and solid organ transplantation. Despite its overall low incidence, PTLD is a serious complication following transplantation, with a mortality rate as high as 50% in transplant recipients. Therefore, it is important to establish for each transplant recipient a personalized risk evaluation for the development of PTLD based on the determination of Epstein-Barr virus serostatus and viral load following the initiation of immunosuppression. Due to the dynamic progression of PTLD, reflected in the diverse pathological features, different therapeutic approaches have been used to treat this disorder. Moreover, new therapeutic strategies based on the administration of virus-specific cytotoxic T cells have been developed. In this review, we summarize the available data on screening and treatment to suggest a strategy to identify transplant recipients at a higher risk for PTLD development and to review the current therapeutic options for PTLD.
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Affiliation(s)
- Lorenzo Zaffiri
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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9
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Yamada M, Fukuda A, Ogura M, Shimizu S, Uchida H, Yanagi Y, Ishikawa Y, Sakamoto S, Kasahara M, Imadome KI. Early Detection of Epstein-Barr Virus as a Risk Factor for Chronic High Epstein-Barr Viral Load Carriage at a Living-donor-dominant Pediatric Liver Transplantation Center. Transplantation 2023; 107:1322-1329. [PMID: 36476718 DOI: 10.1097/tp.0000000000004429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Epstein-Barr virus (EBV) infection and posttransplant lymphoproliferative disorders (PTLDs) after pediatric liver transplantation (LT) account for significant morbidity and mortality. Knowledge of EBV kinetics, epidemiology, and outcomes among pediatric living-donor LT cases is largely lacking. This study aims to provide clinical information related to EBV infection, chronic high EBV load (CHL) carriage, and PTLD at a living-donor-dominant pediatric LT center. METHODS A total of 5827 EBV load measurements from 394 LT recipients fulfilling inclusion criteria and their clinical data were analyzed. EBV loads >1000 copies/μg DNA (742 IU/μg DNA) were considered "high," and CHL was defined by persistence >6 mo. RESULTS The highlighted results were as follows: (1) 94% of recipients underwent living-donor LT; (2) 80% of EBV seronegative recipients developed first EBV infection <2 y post-LT, and their EBV loads were consistently higher than those of seropositive recipients within <3 y post-LT but did not differ thereafter; (3) 61 (15%) recipients met CHL criteria, but none developed PTLD; (4) age <5 y, cytomegalovirus seronegative donors, and early development of EBV DNAemia <6 mo post-LT were independent risk factors for CHL; (5) the incidence of rejections after 1-y post-LT was comparably low among CHL carriers whose immunosuppression was minimized. CONCLUSIONS Early detection of EBV following LT and CMV seronegative donors would facilitate risk stratification to prevent PTLD while titrating immunosuppression among pediatric LT recipients.
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Affiliation(s)
- Masaki Yamada
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
- Department of Medical Subspecialties, Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
- Department of Pediatrics, University of Pittsburgh, School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Miyuki Ogura
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yusuke Yanagi
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yuriko Ishikawa
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Ken-Ichi Imadome
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
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10
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Gross TG, Rubinstein JD. Post-transplant lymphoproliferative disease in children, adolescents, and young adults. Hematol Oncol 2023; 41 Suppl 1:48-56. [PMID: 37294957 DOI: 10.1002/hon.3139] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Abstract
Post-transplant lymphoproliferative disease (PTLD) remains a major complication of transplantation. PTLD is a rare entity and very heterogenous making consensus on diagnosis and treatment very challenging. The majority are Epstein-Barr virus (EBV) driven, CD20+ B-cell proliferations. PTLD does occur following hematopoietic stem cell transplant (HSCT), but due to the relative short risk period and efficacy of pre-emptive therapy, PTLD following HSCT will not be discussed in this review. This review will focus on the epidemiology, role of EBV, clinical presentation, diagnosis and evaluation and the current and emerging treatment strategies for pediatric PTLD following solid organ transplantation.
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Affiliation(s)
- Thomas G Gross
- Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado, USA
| | - Jeremy D Rubinstein
- Department of Pediatric, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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11
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Rubinstein J, Toner K, Gross T, Wistinghausen B. Diagnosis and management of post-transplant lymphoproliferative disease following solid organ transplantation in children, adolescents, and young adults. Best Pract Res Clin Haematol 2023; 36:101446. [PMID: 36907642 DOI: 10.1016/j.beha.2023.101446] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023]
Abstract
Post-transplant Lymphoproliferative Disease (PTLD) remains a major complication of solid organ transplantation (SOT) in pediatric patients. The majority are Epstein-Barr Virus (EBV) driven CD20+ B-cell proliferations responsive to reduction to immunosuppression and anti-CD20 directed immunotherapy. This review focusses on the epidemiology, role of EBV, clinical presentation, current treatment strategies, adoptive immunotherapy and future research in EBV + PTLD in pediatric patients.
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Affiliation(s)
- Jeremy Rubinstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 7018, Cincinnati, OH, 45229, USA.
| | - Keri Toner
- Center for Cancer and Blood Disorder, Children's National Hospital, Washington, DC, USA; Center for Cancer and Immunology Research, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Thomas Gross
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Box 115/AP Rm C3404, Aurora, CO, 80045, USA
| | - Birte Wistinghausen
- Center for Cancer and Blood Disorder, Children's National Hospital, Washington, DC, USA; Center for Cancer and Immunology Research, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.
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12
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Ruijter BN, Wolterbeek R, Hew M, van Reeven M, van der Helm D, Dubbeld J, Tushuizen ME, Metselaar H, Vossen ACTM, van Hoek B. Epstein-Barr Viral Load Monitoring Strategy and the Risk for Posttransplant Lymphoproliferative Disease in Adult Liver Transplantation : A Cohort Study. Ann Intern Med 2023; 176:174-181. [PMID: 36645888 DOI: 10.7326/m22-0364] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Primary infection with or reactivation of Epstein-Barr virus (EBV) can occur after liver transplant (LT) and can lead to posttransplant lymphoproliferative disease (PTLD). In pediatric LT, an EBV-DNA viral load (EBV VL) monitoring strategy, including the reduction of immunosuppression, has led to a lower incidence of PTLD. For adult LT recipients with less primary infection and more EBV reactivation, it is unknown whether this strategy is effective. OBJECTIVE To examine the effect of an EBV VL monitoring strategy on the incidence of PTLD after LT in adults. DESIGN Cohort study. SETTING Two university medical centers in the Netherlands. PATIENTS Adult recipients of first LT in Leiden between September 2003 and January 2017 with an EBV VL monitoring strategy formed the monitoring group (M1), recipients of first LT in Rotterdam between January 2003 and January 2017 without such a strategy formed the contemporary control group (C1), and those who had transplants in Leiden between September 1992 and September 2003 or Rotterdam between 1986 and January 2003 formed the historical control groups (M0 and C0, respectively). MEASUREMENTS Influence of EBV VL monitoring on incidence of PTLD. RESULTS After inverse probability of treatment weighting of the 4 groups to achieve a balance among the groups for important patient characteristics, differences within hospitals between the historical and recent era in cumulative incidences-expressed as the number of events per 1000 patients measured at 5-, 10-, and 15-year follow-up-showed fewer events in the contemporary era in both centers. This difference was considerably larger in the monitoring center, whereas the 95% CI included the null value of 0 for point estimates. LIMITATION Retrospective, low statistical power, and incompletely balanced groups, and non-EBV PTLD cannot be prevented. CONCLUSION Monitoring EBV VL may reduce PTLD incidence after LT in adults; larger studies are warranted. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Bastian N Ruijter
- Department of Gastroenterology and Hepatology, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (B.N.R., M.H., M.E.T., B.v.H.)
| | - Ron Wolterbeek
- Department of Biomedical Data Sciences, Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands (R.W.)
| | - Mitchell Hew
- Department of Gastroenterology and Hepatology, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (B.N.R., M.H., M.E.T., B.v.H.)
| | - Marjolein van Reeven
- Department of Surgery, Erasmus MC Transplant Institute, Erasmus Medical Center, Rotterdam, the Netherlands (M.v.R.)
| | - Danny van der Helm
- Department of Gastroenterology and Hepatology and Department of Surgery, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (D.v.d.H.)
| | - Jeroen Dubbeld
- Department of Surgery, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (J.D.)
| | - Maarten E Tushuizen
- Department of Gastroenterology and Hepatology, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (B.N.R., M.H., M.E.T., B.v.H.)
| | - Herold Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus Medical Center, Rotterdam, the Netherlands (H.M.)
| | - Ann C T M Vossen
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands (A.C.T.M.V.)
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (B.N.R., M.H., M.E.T., B.v.H.)
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13
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Quintero Bernabeu J, Juamperez J, Mercadal-Hally M, Larrarte King M, Gallego Melcon S, Gros Subias L, Sábado Álvarez C, Soler-Palacin P, Melendo Pérez S, Esperalba J, Navarro Jiménez A, Garrido Pontnou M, Camacho Soriano J, Hidalgo Llompart E, Bilbao Aguirre I, Charco Torra R. Epstein-Barr virus-associated risk factors for post-transplant lymphoproliferative disease in pediatric liver transplant recipients. Pediatr Transplant 2022; 26:e14292. [PMID: 35466492 DOI: 10.1111/petr.14292] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/11/2022] [Accepted: 03/23/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) are the most common de novo malignancies after liver transplantation (LT) in children. The aim of our study was to assess the role of pre-LT EBV status and post-LT EBV viral load as risk factors for developing PTLD in a cohort of pediatric LT recipients. METHODS Data of all children who underwent LT between January 2002 and December 2019 were collected. Two cohorts were built EBV pre-LT primary infected cohort and EBV post-LT primary infected cohort. Moreover, using the maximal EBV viral load, a ROC curve was constructed to find a cutoff point for the diagnosis of PTLD. RESULTS Among the 251 patients included in the study, fifteen PTLD episodes in 14 LT recipients were detected (2 plasmacytic hyperplasia, 10 polymorphic PTLD, 2 monomorphic PTLD, and 1 Classical-Hodgkin's lymphoma). Patients of the EBV post-LT primary infected cohort were 17.1 times more likely to develop a PTLD than patients of the EBV pre-LT primary infected cohort (2.2-133.5). The EBV viral load value to predict PTLD was set at 211 000 UI/mL (93.3% sensitivity and 77.1% specificity; AUC 93.8%; IC 0.89-0.98). In EBV post-LT primary infected cohort, patients with a viral load above 211 000 were 30 times more likely to develop PTLD than patients with a viral load below this value (OR 29.8; 3.7-241.1; p < 0.001). CONCLUSIONS The combination of pretransplant EBV serological status with EBV post-transplant viral load could be a powerful tool to stratify the risk of PTLD in pediatric LT patients.
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Affiliation(s)
- Jesus Quintero Bernabeu
- Pediatric Hepatology and Liver Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Javier Juamperez
- Pediatric Hepatology and Liver Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maria Mercadal-Hally
- Pediatric Hepatology and Liver Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mauricio Larrarte King
- Pediatric Hepatology and Liver Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Soledad Gallego Melcon
- Pediatric Oncology and Hematology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Luis Gros Subias
- Pediatric Oncology and Hematology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Susana Melendo Pérez
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Juliana Esperalba
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | | | - Ernest Hidalgo Llompart
- HPB Surgery and Transplantation Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Itxarone Bilbao Aguirre
- HPB Surgery and Transplantation Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ramón Charco Torra
- HPB Surgery and Transplantation Department, Vall d'Hebron University Hospital, Barcelona, Spain
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Asleh R, Alnsasra H, Habermann TM, Briasoulis A, Kushwaha SS. Post-transplant Lymphoproliferative Disorder Following Cardiac Transplantation. Front Cardiovasc Med 2022; 9:787975. [PMID: 35282339 PMCID: PMC8904724 DOI: 10.3389/fcvm.2022.787975] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/01/2022] [Indexed: 11/24/2022] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a spectrum of lymphoid conditions frequently associated with the Epstein Barr Virus (EBV) and the use of potent immunosuppressive drugs after solid organ transplantation. PTLD remains a major cause of long-term morbidity and mortality following heart transplantation (HT). Epstein-Barr virus (EBV) is a key pathogenic driver in many PTLD cases. In the majority of PTLD cases, the proliferating immune cell is the B-cell, and the impaired T-cell immune surveillance against infected B cells in immunosuppressed transplant patients plays a key role in the pathogenesis of EBV-positive PTLD. Preventive screening strategies have been attempted for PTLD including limiting patient exposure to aggressive immunosuppressive regimens by tailoring or minimizing immunosuppression while preserving graft function, anti-viral prophylaxis, routine EBV monitoring, and avoidance of EBV seromismatch. Our group has also demonstrated that conversion from calcineurin inhibitor to the mammalian target of rapamycin (mTOR) inhibitor, sirolimus, as a primary immunosuppression was associated with a decreased risk of PTLD following HT. The main therapeutic measures consist of immunosuppression reduction, treatment with rituximab and use of immunochemotherapy regimens. The purpose of this article is to review the potential mechanisms underlying PTLD pathogenesis, discuss recent advances, and review potential therapeutic targets to decrease the burden of PTLD after HT.
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Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hilmi Alnsasra
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
- Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Thomas M. Habermann
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Alexandros Briasoulis
- Division of Cardiovascular Disease, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Sudhir S. Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Sudhir S. Kushwaha
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15
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Epstein-Barr virus posttransplant lymphoproliferative disorder: update on management and outcomes. Curr Opin Infect Dis 2021; 34:635-645. [PMID: 34751183 PMCID: PMC8589110 DOI: 10.1097/qco.0000000000000787] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Management of Epstein-Barr virus posttransplant lymphoproliferative disorder (EBV PTLD) is complex, involving risk stratification, prevention and/or preemptive measures involving monitoring EBV DNAemia and balancing treatment options, using a combination of reduction of immune suppression, anti-B cell therapy, and cytotoxic T lymphocytes (CTLs). RECENT FINDINGS The highest risk factor for the development of EBV PTLD in hematopoietic cell transplant (HCT) remains T cell depletion, with increasing use of antithymocyte globulin (ATG) or alemtuzumab in conditioning. In solid organ transplantation (SOT), the incidence of PTLD is highest among EBV seronegative recipients who are at risk for primary EBV infection following transplant in the first 12 months. Prevention is a critical component of the management of EBV PTLD. Although preemptive therapy remains standard of care, there continues to be heterogenicity and debate over the optimal choice of EBV DNA quantification and the threshold to use. Novel therapies such as donor-derived multipathogen and EBV specific CTLs for the prevention and third party CTLs for the treatment of EBV PTLD are promising, with rapidly expanding evidence, including large scale Phase III trials currently underway. SUMMARY With an increasing number of risk groups for developing EBV PTLD in HCT and SOT, management strategies using prophylaxis or preemptive therapy remain standard of care, however the use of prophylactic or preemptive EBV specific or multipathogen CTLs show promising results and safety profiles.
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16
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EBV Predicts Post-Pediatric Heart Transplant Malignancy; Induction Therapy and Tacrolimus Don't. Ann Thorac Surg 2021; 114:1794-1802. [PMID: 34563503 DOI: 10.1016/j.athoracsur.2021.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/26/2021] [Accepted: 08/16/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients after heart transplantation are at increased risk for malignancy secondary to immunosuppression and oncogenic viral infections. Most common amongst children is post-transplant lymphoproliferative disorder (PTLD), occurring in 5-10% of patients. We utilized a national database to examine incidence and risk factors for post-transplant malignancy. METHODS The United Network for Organ Sharing (UNOS) database was queried for pediatric (<18 years) heart transplant recipients from 10/1987-10/2019. Kaplan-Meier analysis was performed to assess freedom from malignancy post-transplant. Cox regression was performed to generate hazard ratios (HR [95% CI]) for risk of malignancy development. RESULTS Of 8,581 pediatric heart transplant recipients, 8.1% developed malignancy over median follow-up time of 6.3 years, with PTLD compromising the majority (86.4%) of diagnosed cancers. The incidence of PTLD development was 1.3% and 4.5% at one and five years. Older age at the time of transplant was protective against the development of malignancy (HR 0.98 [0.96-0.99], p<0.001), whereas a history of previous malignancy (HR 1.9 [1.2-3.0], p=0.007) and Ebstein-Barr virus (EBV) recipient-donor mismatch (HR 1.7 [1.3-2.2], p<0.001) increased the risk. Use of induction therapy (utilized in 78.9% of the cohort) did not increase malignancy risk (p=0.355); nor did use of maintenance tacrolimus (p=0.912). CONCLUSIONS PTLD occurred after 7% of pediatric heart transplants, with risk increased by younger age and EBV mismatch, highlighting the importance of PTLD monitoring in EBV seronegative recipients. Induction therapy, utilized in the majority of pediatric heart transplants, does not seem to increase post-transplant malignancy, nor does the most commonly used calcineurin inhibitor tacrolimus.
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17
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Baker A, Frauca Remacha E, Torres Canizales J, Bravo-Gallego LY, Fitzpatrick E, Alonso Melgar A, Muñoz Bartolo G, Garcia Guereta L, Ramos Boluda E, Mozo Y, Broniszczak D, Jarmużek W, Kalicinski P, Maecker-Kolhoff B, Carlens J, Baumann U, Roy C, Chardot C, Benetti E, Cananzi M, Calore E, Dello Strologo L, Candusso M, Lopes MF, Brito MJ, Gonçalves C, Do Carmo C, Stephenne X, Wennberg L, Stone R, Rascon J, Lindemans C, Turkiewicz D, Giraldi E, Nicastro E, D’Antiga L, Ackermann O, Jara Vega P. Current Practices on Diagnosis, Prevention and Treatment of Post-Transplant Lymphoproliferative Disorder in Pediatric Patients after Solid Organ Transplantation: Results of ERN TransplantChild Healthcare Working Group Survey. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8080661. [PMID: 34438552 PMCID: PMC8394841 DOI: 10.3390/children8080661] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/25/2022]
Abstract
(1) Background: Post-transplant lymphoproliferative disease (PTLD) is a significant complication of solid organ transplantation (SOT). However, there is lack of consensus in PTLD management. Our aim was to establish a present benchmark for comparison between international centers and between various organ transplant systems and modalities; (2) Methods: A cross-sectional questionnaire of relevant PTLD practices in pediatric transplantation was sent to multidisciplinary teams from 17 European center members of ERN TransplantChild to evaluate the centers’ approach strategies for diagnosis and treatment and how current practices impact a cross-sectional series of PTLD cases; (3) Results: A total of 34 SOT programs from 13 European centers participated. The decision to start preemptive treatment and its guidance was based on both EBV viremia monitoring plus additional laboratory methods and clinical assessment (61%). Among treatment modalities the most common initial practice at diagnosis was to reduce the immunosuppression (61%). A total of 126 PTLD cases were reported during the period 2012–2016. According to their histopathological classification, monomorphic lesions were the most frequent (46%). Graft rejection after PTLD remission was 33%. Of the total cases diagnosed with PTLD, 88% survived; (4) Conclusions: There is still no consensus on prevention and treatment of PTLD, which implies the need to generate evidence. This might successively allow the development of clinical guidelines.
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Affiliation(s)
- Alastair Baker
- Paediatric Liver, Gastrointestinal and Nutrition Centre, School of Medicine, King’s College Hospital, King’s College London, Denmark Hill, London SE5 9RS, UK; (A.B.); (E.F.)
| | - Esteban Frauca Remacha
- Servicio de Hepatología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain; (E.F.R.); (G.M.B.); (P.J.V.)
| | - Juan Torres Canizales
- Lymphocyte Pathophysiology in Immunodeficiencies Group, La Paz Institute of Biomedical Research (IdiPAZ), Hospital Universitario La Paz and Center for Biomedical Network Research on Rare Diseases (CIBERER U767), 28046 Madrid, Spain;
| | - Luz Yadira Bravo-Gallego
- Lymphocyte Pathophysiology in Immunodeficiencies Group, La Paz Institute of Biomedical Research (IdiPAZ), Hospital Universitario La Paz and Center for Biomedical Network Research on Rare Diseases (CIBERER U767), 28046 Madrid, Spain;
- Correspondence: ; Tel.: +34-917277576
| | - Emer Fitzpatrick
- Paediatric Liver, Gastrointestinal and Nutrition Centre, School of Medicine, King’s College Hospital, King’s College London, Denmark Hill, London SE5 9RS, UK; (A.B.); (E.F.)
| | - Angel Alonso Melgar
- Servicio de Nefrología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Gema Muñoz Bartolo
- Servicio de Hepatología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain; (E.F.R.); (G.M.B.); (P.J.V.)
| | - Luis Garcia Guereta
- Servicio de Cardiología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Esther Ramos Boluda
- Pediatric Gastroenterology Intestinal Rehabilitation Unit, University Hospital La Paz, 28046 Madrid, Spain;
| | - Yasmina Mozo
- Pediatric Hemato-Oncology Department, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Dorota Broniszczak
- Department of Pediatric Surgery and Organ Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (D.B.); (P.K.)
| | - Wioletta Jarmużek
- Department of Nephrology and Kidney Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Piotr Kalicinski
- Department of Pediatric Surgery and Organ Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (D.B.); (P.K.)
| | - Britta Maecker-Kolhoff
- Department of Pediatric Hematology and Oncology, Hannover Medical School, 30625 Hannover, Germany;
| | - Julia Carlens
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, 30625 Hannover, Germany;
| | - Ulrich Baumann
- Division of Paediatric Gastroenterology and Hepatology, Children’s Hospital, Hannover Medical School, 30625 Hannover, Germany;
| | - Charlotte Roy
- Service de Pneumologie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Université Paris, 75015 Paris, France;
| | - Christophe Chardot
- Service de Chirurgie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Université Paris Descartes, 75015 Paris, France;
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women’s and Children’s Health, Azienda Ospedaliera di Padova, 35128 Padova, Italy;
| | - Mara Cananzi
- Unit of Paediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women’s and Children’s Health, Azienda Ospedaliera di Padova, 35128 Padova, Italy;
| | - Elisabetta Calore
- Unit of Paediatric Onco-Haematology, Department of Women’s and Children’s Health, Azienda Ospedaliera di Padova, 35128 Padova, Italy;
| | - Luca Dello Strologo
- Nephrology Unit, Bambino Gesù Children’s Research Hospital, IRCCS, 00165 Rome, Italy;
| | - Manila Candusso
- Department of Hepatology and Gastroenterology, Bambino Gesù Children Hospital, 00165 Rome, Italy;
| | - Maria Francelina Lopes
- Department of Paediatric Surgery, Centro Hospitalar e Universitário de Coimbra, and Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal;
| | - Manuel João Brito
- Department of Paediatric Oncology and Centro de Investigação e Formação Clínica, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Cristina Gonçalves
- Paediatric Liver Transplant Unit, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Carmen Do Carmo
- Paediatric Nephrology Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Xavier Stephenne
- Laboratoire d’Hépatologie Pédiatrique et Thérapie Cellulaire, Unité PEDI, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium;
| | - Lars Wennberg
- Department of Transplantation Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden;
| | - Rosário Stone
- Unidade de Nefrologia e Transplantação Renal, Serviço de Pediatria Médica, Departamento de Pediatria, Hospital de Santa Maria, Centro Académico de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal;
| | - Jelena Rascon
- Centre for Paediatric Oncology and Haematology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania;
| | - Caroline Lindemans
- Princess Maxima Center for Pediatric Oncology, Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht University, 3584 CS Utrecht, The Netherlands;
| | - Dominik Turkiewicz
- Department of Pediatrics, Skåne University Hospital, 222 42 Lund, Sweden;
| | - Eugenia Giraldi
- Pediatric Oncology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Emanuele Nicastro
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
| | - Lorenzo D’Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
| | - Oanez Ackermann
- Pediatric Hepatology, National Centre for Biliary Atresia, Université París-Saclay, APHP, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France;
| | - Paloma Jara Vega
- Servicio de Hepatología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain; (E.F.R.); (G.M.B.); (P.J.V.)
- La Paz Institute of Biomedical Research, IdiPAZ, Hospital Universitario La Paz, 28046 Madrid, Spain
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18
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Jurado LF, Gómez-Aldana A, Tapias M, Cáceres D, Vera A, López-Panqueva RDP, Andrade RE. Post-transplant lymphoproliferative disorders in a cohort of adult patients with a liver transplant from a reference hospital in Bogotá, Colombia. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2020; 40:498-506. [PMID: 33030828 PMCID: PMC7666854 DOI: 10.7705/biomedica.4861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 04/15/2020] [Indexed: 11/29/2022]
Abstract
Introduction: The post-transplant lymphoproliferative disorders (PTLD) are characterized by an uncontrolled pathological lymphoid proliferation as a consequence of transplant immunosuppression therapy. Objective: To characterize the clinical and pathological characteristics of PTLD in a cohort of adult patients with liver transplant during a 15 year period at the Hospital Universitario Fundación Santa Fe de Bogota. Materials and methods: We conducted an observational retrospective study by searching for the PTLD cases diagnosed during the study period in the databases of the Liver Transplantation Unit and the Pathology Department. We collected the epidemiological, clinical, and pathological information and performed the corresponding statistics analyses. Results: During the research period, 572 patients were transplanted; the incidence of PTDL was 2.44%; 79% of them were man and the average age at the time of diagnosis was 62.5 years; 71% of the cases were diagnosed during the first year after the transplant and the same percentage EBV-seropositive patients. The most frequent pathological phenotype was monomorphic and the majority of tumors was detected in the hepatic hilum. The one-year survival was 50%. Conclusion: The high proportion of early cases and the high frequency of Epstein-Barr virus seropositivity both in donors and receptors drewour attention. More studies are necessary to have a better understanding of this condition in Colombia. This is the first PTLD clinical and pathological analysis in liver-transplant patients from Colombia to date.
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Affiliation(s)
- Leonardo F Jurado
- Departamento de Patología y Laboratorios, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia; Departamento de Patología, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia; Pathology Department, McGill University, Montreal, Quebec, Canada.
| | - Andrés Gómez-Aldana
- Servicio de Trasplante Hepático, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia.
| | - Mónica Tapias
- Servicio de Trasplante Hepático, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia.
| | - Daniela Cáceres
- Servicio de Trasplante Hepático, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia.
| | - Alonso Vera
- Servicio de Trasplante Hepático, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia.
| | - Rocío Del Pilar López-Panqueva
- Departamento de Patología y Laboratorios, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia; Facultad de Medicina, Universidad de los Andes, Bogotá, D. C., Colombia.
| | - Rafael E Andrade
- Departamento de Patología y Laboratorios, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia; Departamento de Patología, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, D.C., Colombia; Facultad de Medicina, Universidad de los Andes, Bogotá, D. C., Colombia.
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19
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Roberts MB, Fishman JA. Immunosuppressive Agents and Infectious Risk in Transplantation: Managing the "Net State of Immunosuppression". Clin Infect Dis 2020; 73:e1302-e1317. [PMID: 32803228 DOI: 10.1093/cid/ciaa1189] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Indexed: 12/14/2022] Open
Abstract
Successful solid organ transplantation reflects meticulous attention to the details of immunosuppression, balancing risks for graft rejection against risks for infection. The 'net state of immune suppression' is a conceptual framework of all factors contributing to infectious risk. Assays which measure immune function in the immunosuppressed transplant recipient relative to infectious risk and allograft function are lacking. The best measures of integrated immune function may be quantitative viral loads to assess the individual's ability to control latent viral infections. Few studies address adjustment of immunosuppression during active infections. Thus, confronted with infection in solid organ recipients, the management of immunosuppression is based largely on clinical experience. This review examines known measures of immune function and the immunologic effects of common immunosuppressive drugs and available studies reporting modification of drug regimens for specific infections. These data provide a conceptual framework for the management of immunosuppression during infection in organ recipients.
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Affiliation(s)
- Matthew B Roberts
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA
| | - Jay A Fishman
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA.,Harvard Medical School, Boston, MA
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20
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Lam JKP, Azzi T, Hui KF, Wong AMG, McHugh D, Caduff N, Chan KH, Münz C, Chiang AKS. Co-infection of Cytomegalovirus and Epstein-Barr Virus Diminishes the Frequency of CD56 dimNKG2A +KIR - NK Cells and Contributes to Suboptimal Control of EBV in Immunosuppressed Children With Post-transplant Lymphoproliferative Disorder. Front Immunol 2020; 11:1231. [PMID: 32625211 PMCID: PMC7311655 DOI: 10.3389/fimmu.2020.01231] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/15/2020] [Indexed: 01/19/2023] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a rare but potentially life-threatening complication, frequently associated with Epstein-Barr virus (EBV), which develops after solid organ or stem cell transplantation. Immunosuppression received by transplant recipients has a significant impact on the development of PTLD by suppressing the function of T cells. The preferential proliferation of NKG2A-positive natural killer (NK) cells during primary symptomatic EBV infection known as infectious mononucleosis (IM) and their reactivity toward EBV-infected B cells point to a role of NK cell in the immune control of EBV. However, NK cell-mediated immune response to EBV in immunosuppressed transplant recipients who develop PTLD remains unclear. In this study, we longitudinally analyzed the phenotype and function of different NK cell subsets in a cohort of pediatric liver transplant patients who develop PTLD and compared them to those of children with IM. We found persistently elevated plasma EBV DNA levels in the PTLD patients indicating suboptimal anti-viral immune control. PTLD patients had markedly decreased frequency of CD56dimNKG2A+Killer Immunoglobulin-like receptor (KIR)− NK cells from the time of diagnosis through remission compared to those of IM patients. Whilst the proliferation of CD56dimNKG2A+KIR− NK cells was diminished in PTLD patients, this NK cell subset maintained its ability to potently degranulate against EBV-infected B cells. Compared to cytomegalovirus (CMV)-seropositive and -negative IM patients, PTLD patients co-infected with CMV and EBV had significantly higher levels of a CMV-associated CD56dimNKG2ChiCD57+NKG2A−KIR+ NK cell subset accumulating at the expense of NKG2A+KIR− NK cells. Taken together, our data indicate that co-infection of CMV and EBV diminishes the frequency of CD56dimNKG2A+KIR− NK cells and contributes to suboptimal control of EBV in immunosuppressed children with PTLD.
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Affiliation(s)
- Janice K P Lam
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tarik Azzi
- Experimental Infectious Diseases and Cancer Research, University Children's Hospital of Zurich, Zurich, Switzerland
| | - K F Hui
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Aikha M G Wong
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Donal McHugh
- Department of Viral Immunobiology, Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Nicole Caduff
- Department of Viral Immunobiology, Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - K H Chan
- Department of Microbiology, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Christian Münz
- Department of Viral Immunobiology, Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Alan K S Chiang
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
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21
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Seo E, Kim J, Oh SH, Kim KM, Kim DY, Lee J. Epstein-Barr viral load monitoring for diagnosing post-transplant lymphoproliferative disorder in pediatric liver transplant recipients. Pediatr Transplant 2020; 24:e13666. [PMID: 32067332 DOI: 10.1111/petr.13666] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/26/2019] [Accepted: 12/30/2019] [Indexed: 11/28/2022]
Abstract
This study aimed to investigate the incidence of PTLD in pediatric liver transplant recipients and the risk factors for the development of PTLD. We also determined clinically useful quantitative EBV PCR parameters for aiding in the diagnosis of EBV-associated PTLD in the pediatric liver transplant recipients at our institute. We reviewed children < 18 years old who had undergone liver transplantations and quantitative analysis of whole blood EBV load at our institute from January 2006 to March 2015. A total of 142 liver transplant recipients were included, and their median age was 1.5 years. Clinically significant high-level EBV DNAemia ≥ 10 000 copies/mL at least twice was observed in 53.5% and PTLD occurred in 9.9%. Among PTLD group, graft failure and mortality rate were as high as 21.4% and 14.3%, respectively. Deceased donor, presence of high-level EBV DNAemia, and primary CMV infection following transplant were associated with an increased risk for PTLD in the multivariate analysis. The peak titer at 10 875 copies/mL could be used as a cutoff value with a sensitivity of 92.9% and a specificity of 37.9%; the rate of increase in EBV load suggested a sensitivity of 64.3% and a specificity of 70.9% at the cutoff value of 44 000 copies/mL/week. In conclusion, the incidence of PTLD following liver transplant in children was as high as 10%. PTLD is associated with significant morbidity and mortality. Close monitoring of EBV DNAemia is crucial for the early diagnosis and proper treatment of PTLD in pediatric liver transplant recipients.
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Affiliation(s)
- Euri Seo
- Department of Pediatrics, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, South Korea.,Department of Pediatric, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Joonil Kim
- Department of Pediatric, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Seak Hee Oh
- Department of Pediatric, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Kyung Mo Kim
- Department of Pediatric, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
| | - Dae Yeon Kim
- Department of Pediatric Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jina Lee
- Department of Pediatric, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, South Korea
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22
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Abstract
Lung transplantation is an established therapeutic option for selected patients with advanced lung diseases. As early outcomes after lung transplantation have improved, chronic medical illnesses have emerged as significant obstacles to long-term survival. Among them is post-transplant malignancy, currently representing the 2nd most common cause of death 5–10 years after transplantation. Chronic immunosuppressive therapy and resulting impairment of anti-tumor immune surveillance is thought to have a central role in cancer development after solid organ transplantation (SOT). Lung transplant recipients receive more immunosuppression than other SOT populations, likely contributing to even higher risk of cancer among this group. The most common cancers in lung transplant recipients are non-melanoma skin cancers, followed by lung cancer and post-transplant lymphoproliferative disorder (PTLD). The purpose of this review is to outline the common malignancies following lung transplant, their risk factors, prognosis and current means for both prevention and treatment.
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Affiliation(s)
- Osnat Shtraichman
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Pulmonary Institute, Rabin Medical Center, Affiliated with Sackler School of Medicine Tel Aviv University, Petach Tikva, Israel
| | - Vivek N Ahya
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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23
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Fernández-Ruiz M, López-Medrano F, Aguado JM. Predictive tools to determine risk of infection in kidney transplant recipients. Expert Rev Anti Infect Ther 2020; 18:423-441. [PMID: 32084326 DOI: 10.1080/14787210.2020.1733976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Infection represents a major complication after kidney transplantation (KT). Therapeutic drug monitoring is essentially the only approach for the adjustment of immunosuppression in current practice, with suboptimal results. The implementation of immune monitoring strategies may contribute to minimizing the risk of adverse events attributable to over-immunosuppression without compromising graft outcomes.Areas covered: The present review (based on PubMed/MEDLINE searches from database inception to November 2019) is focused on immune biomarkers with no antigen specificity (non-pathogen-specific), including serum levels of immunoglobulins and complement factors, peripheral blood lymphocyte subpopulations, soluble CD30, intracellular ATP production by stimulated CD4+ T-cells, and other cell-based immune assays. We also summarized recent advances in the use of replication kinetics of latent viruses to assess the functionality of T-cell immunity, with focus on the nonpathogenic anelloviruses. Finally, the composite risk scores reported in the literature are critically discussed.Expert opinion: Notable efforts have been made to develop an enlarging repertoire of immune biomarkers and prediction models, although most of them still lack technical standardization and external validation. Preventive interventions based on these tools (prolongation of prophylaxis, tapering of immunosuppression, or immunoglobulin replacement therapy in hypogammaglobulinemic patients) remain to be defined, ideally in the context of controlled trials.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (Imas12), Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002), Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (Imas12), Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002), Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (Imas12), Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002), Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
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24
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Abbas F, El Kossi M, Shaheen IS, Sharma A, Halawa A. Post-transplantation lymphoproliferative disorders: Current concepts and future therapeutic approaches. World J Transplant 2020; 10:29-46. [PMID: 32226769 PMCID: PMC7093305 DOI: 10.5500/wjt.v10.i2.29] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/21/2019] [Accepted: 12/14/2019] [Indexed: 02/05/2023] Open
Abstract
Transplant recipients are vulnerable to a higher risk of malignancy after solid organ transplantation and allogeneic hematopoietic stem-cell transplant. Post-transplant lymphoproliferative disorders (PTLD) include a wide spectrum of diseases ranging from benign proliferation of lymphoid tissues to frank malignancy with aggressive behavior. Two main risk factors of PTLD are: Firstly, the cumulative immunosuppressive burden, and secondly, the oncogenic impact of the Epstein-Barr virus. The latter is a key pathognomonic driver of PTLD evolution. Over the last two decades, a considerable progress has been made in diagnosis and therapy of PTLD. The treatment of PTLD includes reduction of immunosuppression, rituximab therapy, either isolated or in combination with other chemotherapeutic agents, adoptive therapy, surgical intervention, antiviral therapy and radiotherapy. In this review we shall discuss the prevalence, clinical clues, prophylactic measures as well as the current and future therapeutic strategies of this devastating disorder.
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Affiliation(s)
- Fedaey Abbas
- Nephrology Department, Jaber El Ahmed Military Hospital, Safat 13005, Kuwait
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
| | - Mohsen El Kossi
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Doncaster Royal Infirmary, Doncaster DN2 5LT, United Kingdom
| | - Ihab Sakr Shaheen
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Paediatric Nephrology, Royal Hospital for Children, Glasgow G51 4TF, United Kingdom
| | - Ajay Sharma
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplant Surgery, Royal Liverpool University Hospitals, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool L69 3GB, United Kingdom
- Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S57AU, United Kingdom
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25
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Qin T, Gu XQ, Jeong SS, Song YY, Liu JC, Zheng JX, Xue F, Xia Q. Impact of EBV infection and immune function assay for lymphoproliferative disorder in pediatric patients after liver transplantation: A single-center experience. Hepatobiliary Pancreat Dis Int 2020; 19:3-11. [PMID: 31932195 DOI: 10.1016/j.hbpd.2019.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/20/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) is a lethal complication after pediatric liver transplantation, but information regarding risk factors for the development of PTLD remains unclear. This study was to identify characteristics and risk factors of PTLD. METHODS A total of 705 pediatric patients who underwent liver transplantation between January 2017 and October 2018 were studied. Impact of clinical characteristics and Epstein-Barr virus (EBV) infection on the development of PTLD was evaluated. In addition, ImmuKnow assay was adopted in partial patients to analyze the immune status. RESULTS Twenty-five (3.5%) patients suffered from PLTD with a median time of 6 months (3-14 months) after transplantation. Extremely high tacrolimus (TAC) level was found in 2 fatal cases at PTLD onset. EBV infection was found in 468 (66.4%) patients. A higher peak EBV DNA loads (>9590 copies/mL) within 3 months was a significant indicator for the onset of PTLD. In addition, the ImmuKnow assay demonstrated that overall immune response was significantly lower in patients with EBV infection and PTLD (P<0.0001). The cumulative incidence of PTLD was also higher in patients with lower ATP value (≤187 ng/mL, P<0.05). CONCLUSIONS A careful monitoring of EBV DNA loads and tacrolimus concentration might be supportive in prevention of PTLD in pediatric patients after liver transplantation. In addition, application of the ImmuKnow assay may provide guidance in reducing immunosuppressive agents in treatment of PTLD.
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Affiliation(s)
- Tian Qin
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Xiang-Qian Gu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Seog-Song Jeong
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Yan-Yan Song
- Department of Biostatistics, Institute of Medical Sciences, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Jin-Chuan Liu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Jian-Xin Zheng
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
| | - Feng Xue
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China.
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China
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26
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Malignancy After Lung Transplantation: How to Manage Immunosuppression? Transplant Proc 2020; 52:315-320. [DOI: 10.1016/j.transproceed.2019.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/29/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023]
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27
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Park B, Yoon J, Choi D, Kim HJ, Jung YK, Kwon OJ, Lee KG. De novo cancer incidence after kidney and liver transplantation: Results from a nationwide population based data. Sci Rep 2019; 9:17202. [PMID: 31748582 PMCID: PMC6868238 DOI: 10.1038/s41598-019-53163-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 10/16/2019] [Indexed: 12/20/2022] Open
Abstract
The cancer risk among solid organ transplantation recipients in East-Asia has been insufficiently studied. This study estimated de novo cancer incidence in kidney and liver recipients 2008-2015, compared with the general population in Korea using nationwide data. This is a retrospective cohort study using nationwide health insurance claims data. The study population was comprised of cancer-free 10,085 kidney recipients and 3,822 liver recipients. Standardized incidence ratio (SIR) of cancer using indirect standardization was calculated. Compared with the general population, the cancer risk increased by 3.19-fold in male and 2.56-fold in female kidney recipients. By cancer type, a notably increased SIR was observed for Kaposi sarcoma, renal cancer, skin cancer, and non-Hodgkin's lymphoma in male and for bladder cancer, renal cancer, and non-Hodgkin's lymphoma in female kidney recipients. In liver recipients, the SIR of all cancers was 3.43 in males and 2.30 in females. In male liver recipients, the SIRs for Kaposi sarcoma, non-Hodgkin's lymphoma, myeloid leukemia, and skin cancer and in female recipients those for non-Hodgkin's lymphoma and liver cancer were prominent. A greatly higher SIRs for overall cancer and non-Hodgkin's lymphoma in kidney and liver recipients aged 0-19 were observed, compared with recipients in other age group. The incidence of de novo cancer in kidney and liver recipients was higher than the general population and common types were different. Strategies of cancer prevention and screening after kidney and liver transplantation should be developed in response to the incidence of common types of de novo cancers.
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Affiliation(s)
- Boyoung Park
- Department of Medicine, College of Medicine, Hanyang University, Seoul, South Korea
| | - Junghyun Yoon
- Graduate School of Public Health, Hanyang University, Seoul, South Korea
| | - Dongho Choi
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea. .,Hanyang ICT fusion medical research center, Seoul, South Korea.
| | - Han Joon Kim
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| | - Yun Kyung Jung
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea.,Hanyang ICT fusion medical research center, Seoul, South Korea
| | - Oh Jung Kwon
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea
| | - Kyeong Geun Lee
- Department of Surgery, College of Medicine, Hanyang University, Seoul, South Korea
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28
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Chen HS, Ho MC, Hu RH, Wu JF, Chen HL, Ni YH, Hsu HY, Jeng YM, Chang MH. Roles of Epstein–Barr virus viral load monitoring in the prediction of posttransplant lymphoproliferative disorder in pediatric liver transplantation. J Formos Med Assoc 2019; 118:1362-1368. [DOI: 10.1016/j.jfma.2018.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/26/2018] [Accepted: 12/12/2018] [Indexed: 11/26/2022] Open
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29
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Allen UD, Preiksaitis JK. Post-transplant lymphoproliferative disorders, Epstein-Barr virus infection, and disease in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13652. [PMID: 31230381 DOI: 10.1111/ctr.13652] [Citation(s) in RCA: 165] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/19/2019] [Indexed: 02/06/2023]
Abstract
PTLD with the response-dependent sequential use of RIS, rituximab, and cytotoxic chemotherapy is recommended. Evidence gaps requiring future research and alternate treatment strategies including immunotherapy are highlighted.
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Affiliation(s)
- Upton D Allen
- Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jutta K Preiksaitis
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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30
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Wang H, Zhang TT, Qi JQ, Chu TT, Miao M, Qiu HY, Fu CC, Tang XW, Ruan CG, Wu DP, Han Y. Incidence, risk factors, and clinical significance of Epstein-Barr virus reactivation in myelodysplastic syndrome after allogeneic haematopoietic stem cell transplantation. Ann Hematol 2019; 98:987-996. [PMID: 30715567 DOI: 10.1007/s00277-019-03603-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 01/04/2019] [Indexed: 11/30/2022]
Abstract
Epstein-Barr virus (EBV) reactivation is a life-threatening complication after allogeneic haematopoietic stem cell transplantation (allo-HSCT). In this study, we investigated the characteristics of EBV reactivation in 186 consecutive myelodysplastic (MDS) patients who underwent allo-HSCT in our centre. In 35 patients (18.8%) who experienced EBV reactivation after allo-HSCT, the median onset was 53 days (range 4-381 days). The cumulative incidence of EBV reactivation at the first, sixth, and twelfth month after allo-HSCT was 10.7%, 15.1%, and 17.9%, respectively. Twenty-five patients (71.4%) received pre-emptive rituximab therapy, and no patients developed post-transplant lymphoproliferative disorders. Stem cell source was proven to be a risk factor correlated with EBV reactivation. The cumulative incidence of relapse in the EBV-positive group was 11.4%, 25.2%, and 31.0% at the first, second, and third year after transplantation, respectively, being significantly higher than the corresponding 6.8%, 10.2%, and 10.2%, in the EBV-negative group (P = 0.014). Prognostic analysis showed that EBV reactivation was an independent risk factor for relapse-free survival (RFS). Patients in the EBV-positive group showed obviously shorter RFS than those in the EBV-negative group, with 3-year RFS of 62% and 85%, respectively (P = 0.017).
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Affiliation(s)
- Hong Wang
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Tong-Tong Zhang
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Jia-Qian Qi
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Tian-Tian Chu
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Miao Miao
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - Hui-Ying Qiu
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - Cheng-Cheng Fu
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - Xiao-Wen Tang
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - Chang-Geng Ruan
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - De-Pei Wu
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China. .,Institute of Blood and Marrow Transplantation, Suzhou, China. .,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China. .,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China.
| | - Yue Han
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China. .,Institute of Blood and Marrow Transplantation, Suzhou, China. .,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China. .,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China.
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Hsu CT, Chang MH, Ho MC, Chang HH, Lu MY, Jou ST, Ni YH, Chen HL, Hsu HY, Wu JF. Post-transplantation lymphoproliferative disease in pediatric liver recipients in Taiwan. J Formos Med Assoc 2019; 118:1537-1545. [PMID: 30630698 DOI: 10.1016/j.jfma.2018.12.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 09/15/2018] [Accepted: 12/24/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Post-transplantation lymphoproliferative disorder (PTLD) is a heterogeneous, potentially life-threatening complication after liver transplantation in children. In this study, the disease characteristics, outcomes, and prognostic factors of PTLD were investigated. METHODS A retrospective, observational study was conducted on 16 pediatric liver transplant (LT) recipients who developed PTLD between February 2001 and December 2013 at a tertiary referral center in Taiwan. The disease characteristics and treatment outcomes of the patients were analyzed. RESULTS The median time from liver transplantation to the development of PTLD was 8 months. Early onset (<1 year post-transplantation) PTLD constituted 62.5% of the cases. PTLD location was frequently extranodal (81.3%) and mostly involved the gastrointestinal tract (68.8%). Histopathologic findings showed polymorphic PTLD in six cases (37.5%), diffuse large B-cell lymphoma in five cases (31.3%), and Burkitt's PTLD in two cases (12.5%). Early lesions in PTLD, T-cell lymphoma, and Hodgkin's lymphoma were observed in one case each (6.3%). Overall survival at 1- and 5-years post-PTLD diagnosis was 87.5% and 79.5%, respectively. St Jude's classification stage IV disease was associated with poor survival (hazard ratio [HR] = 13.37, P = 0.037). Two patients (12.5%) had chronic rejection after the treatment for PTLD and one patient (6.3%) developed graft failure. CONCLUSION PTLD is a major complication in pediatric LT recipients, but long-term survival is possible in most cases with an adequate treatment strategy. Stage IV disease is a major risk factor for poor survival in pediatric PTLD patients. During the management of PTLD, the possibility of chronic rejection and even graft failure should be considered.
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Affiliation(s)
- Chien-Ting Hsu
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Mei-Hwei Chang
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Ming-Chih Ho
- Department of Surgery, National Taiwan University Hospital, No. 7, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Hong-Yuan Hsu
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, No. 8, Chung-Shan S. Rd., Taipei, Taiwan.
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Viral infections in solid organ transplant recipients: novel updates and a review of the classics. Curr Opin Infect Dis 2018; 30:579-588. [PMID: 28984642 DOI: 10.1097/qco.0000000000000409] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW To summarize new discoveries in viral pathogenesis and novel therapeutic and prophylactic strategies in organ transplant recipients. RECENT FINDINGS For decades, prophylaxis of cytomegalovirus (CMV) has been the standard preventive strategy, but new clinical trials are expected to determine the advantages of preemptive therapy over prophylaxis. Novel anti-CMV agents, such as maribavir and letermovir, are being studied for the treatment of resistant/refractory CMV as alternatives to foscarnet and cidofovir. CMV immune monitoring may offer individualized management plans. Epstein-Barr virus infections in transplant recipients are difficult to prevent and treat, though recent data suggest possible merit to pretransplant rituximab among high-risk transplant recipients. We review the groundbreaking HIV-to-HIV organ transplant trials, which are expected to revolutionize the care of HIV-infected individuals. Finally, we review topical developments in human herpesvirus 8, Zika virus, RNA respiratory viruses, adenovirus, norovirus, and polyoma viruses in organ transplantation. SUMMARY Ongoing trials to optimize CMV prophylaxis and treatment, and outcomes of HIV-to-HIV organ transplantation in the United States, have significant implications to optimize management of these viruses in transplant recipients. Assessment of new antivirals and antiviral strategies, such as adoptive immunotherapy, is warranted for refractory viral infections.
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33
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Evidence-based consensus on opportunistic infections in inflammatory bowel disease (republication). Intest Res 2018; 16:178-193. [PMID: 29743831 PMCID: PMC5934591 DOI: 10.5217/ir.2018.16.2.178] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/08/2018] [Accepted: 04/16/2018] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) patients are a high-risk population for opportunistic infections. The IBD group of the Chinese Society of Gastroenterology of the Chinese Medical Association organized an expert group to discuss and develop this consensus opinion. This consensus opinion referenced clinical study results from China and other countries to provide guidance for clinical practices. Eight major topics, including cytomegalovirus infection, Epstein-Barr virus infection, viral hepatitis, bacterial infection, Mycobacterium tuberculosis infection, fungal infection, parasitic infection, and vaccines were introduced in this article.
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34
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Kamei H, Ito Y, Kawada J, Ogiso S, Onishi Y, Komagome M, Kurata N, Ogura Y. Risk factors and long-term outcomes of pediatric liver transplant recipients with chronic high Epstein-Barr virus loads. Transpl Infect Dis 2018; 20:e12911. [PMID: 29677384 DOI: 10.1111/tid.12911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 02/26/2018] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Serial monitoring of Epstein-Barr virus (EBV) reveals that certain pediatric liver transplant (LT) recipients exhibit high EBV loads for long periods. We investigated the incidence and risk factors of chronic high EBV (CHEBV) loads (continuous EBV DNA >10 000 IU/mL of whole blood for ≥6 months) and long-term outcomes. METHODS This single center, retrospective observational study investigated pediatric LT recipients who survived ≥6 months. We quantitated EBV DNA weekly during hospitalization and subsequently every 4 or 6 weeks at the outpatient clinic. Tacrolimus was maintained at a low trough level (<3 ng/mL, EBV DNA load >5000 IU/mL). RESULTS Thirty-one of 77 LT recipients developed CHEBV. Univariate analysis revealed that age <2 years and body weight <10 kg upon LT, operation time <700 minutes, warm ischemia time (WIT) >35 minutes, graft-to-recipient weight ratio (GRWR) >2.7%, and preoperative EBV seronegativity were significantly associated with the development of CHEBV loads. Multivariate analysis identified significant associations of CHEBV with WIT >35 minutes, GRWR >2.7%, and preoperative seronegative. None of the recipients developed post-transplantation lymphoproliferative disorder. Survival rates of patients with and without CHEBV loads were not significantly different. CONCLUSIONS A significant number of pediatric LT recipients developed CHEBV loads. Long WIT, high GRWR, and preoperative EBV seronegativity were significantly associated with the development of CHEBV loads. Although the long-term outcomes of patients with or without CHEBV loads were not significantly different, further studies of more subjects are warranted.
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Affiliation(s)
- Hideya Kamei
- Departments of Transplantation Surgery, Nagoya University Hospital, Showa, Nagoya, Japan
| | - Yoshinori Ito
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Showa, Nagoya, Japan
| | - Junichi Kawada
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Showa, Nagoya, Japan
| | - Satoshi Ogiso
- Departments of Transplantation Surgery, Nagoya University Hospital, Showa, Nagoya, Japan
| | - Yasuharu Onishi
- Departments of Transplantation Surgery, Nagoya University Hospital, Showa, Nagoya, Japan
| | - Masahiko Komagome
- Departments of Transplantation Surgery, Nagoya University Hospital, Showa, Nagoya, Japan
| | - Nobuhiko Kurata
- Departments of Transplantation Surgery, Nagoya University Hospital, Showa, Nagoya, Japan
| | - Yasuhiro Ogura
- Departments of Transplantation Surgery, Nagoya University Hospital, Showa, Nagoya, Japan
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Koff JL, Li JX, Zhang X, Switchenko JM, Flowers CR, Waller EK. Impact of the posttransplant lymphoproliferative disorder subtype on survival. Cancer 2018; 124:2327-2336. [PMID: 29579330 DOI: 10.1002/cncr.31339] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/25/2018] [Accepted: 02/12/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Posttransplant lymphoproliferative disorder (PTLD) is a life-threatening complication of solid organ transplantation. Histologic heterogeneity and a lack of treatment standards have made evaluating clinical outcomes in specific patient populations difficult. This systematic literature review investigated the impact of the PTLD histologic subtype on survival in a large data set. METHODS Case series were identified on PubMed with the search terms post-transplant lymphoproliferative disorder/disease, PTLD, and solid organ transplantation, with additional publications identified through reference lists. The patient characteristics, immunosuppressive regimen, treatment, survival, and follow-up time for 306 cases were extracted from 94 articles, and these cases were combined with 11 cases from Emory University Hospital. Patients with a recorded subtype were included in a Kaplan-Meier survival analysis (n = 234). Cox proportional hazards regression analyses identified predictors of overall survival (OS) for each subtype and B-cell subgroup. RESULTS OS differed significantly between monomorphic T-cell neoplasms (median, 9 months) and polymorphic, monomorphic B-cell, and Hodgkin-type neoplasms, for which the median OS was not reached (P = .0001). Significant differences in OS among B subgroups were not detected, but there was a trend toward decreased survival for patients with Burkitt-type PTLD. Kidney transplantation and a reduction of immunosuppression were associated with increased OS for patients with B-cell neoplasms in a multivariate analysis. Immunosuppression with azathioprine was associated with decreased OS for patients with T-cell neoplasms, whereas radiotherapy was associated with improved OS for patients with that subtype. CONCLUSIONS The histologic subtype represents an important prognostic factor in PTLD, with patients with T-cell neoplasms exhibiting very poor OS. Possibly lower survival for certain subsets of patients with B-cell PTLD should be explored further and suggests the need for subtype-specific therapies to improve outcomes. Cancer 2018;124:2327-36. © 2018 American Cancer Society.
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Affiliation(s)
- Jean L Koff
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jing-Xia Li
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
- Hematology, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xinyan Zhang
- Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Christopher R Flowers
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Edmund K Waller
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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36
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Affiliation(s)
- Daan Dierickx
- From the Department of Hematology, University Hospitals Leuven, and the Laboratory for Experimental Hematology, Department of Oncology, University of Leuven, Leuven, Belgium (D.D.); and the Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN (T.M.H.)
| | - Thomas M Habermann
- From the Department of Hematology, University Hospitals Leuven, and the Laboratory for Experimental Hematology, Department of Oncology, University of Leuven, Leuven, Belgium (D.D.); and the Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN (T.M.H.)
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37
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Evidence-based consensus on opportunistic infections in inflammatory bowel disease. J Dig Dis 2018; 19:54-65. [PMID: 29330905 DOI: 10.1111/1751-2980.12578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2018] [Indexed: 01/30/2023]
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38
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A rare cause of gastrointestinal bleeding in the post-transplant setting. Clin Exp Hepatol 2017; 3:215-217. [PMID: 29255810 PMCID: PMC5731430 DOI: 10.5114/ceh.2017.71447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 06/07/2017] [Indexed: 12/03/2022] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a life-threatening complication noted after solid organ transplantation and is frequently related to Epstein-Barr virus infection. The present case highlights an unusual presentation of PTLD – gastrointestinal bleeding – in the absence of systemic symptoms.
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39
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Nagle SJ, Reshef R, Tsai DE. Posttransplant Lymphoproliferative Disorder in Solid Organ and Hematopoietic Stem Cell Transplantation. Clin Chest Med 2017; 38:771-783. [DOI: 10.1016/j.ccm.2017.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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40
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Huang JG, Tan MYQ, Quak SH, Aw MM. Risk factors and clinical outcomes of pediatric liver transplant recipients with post-transplant lymphoproliferative disease in a multi-ethnic Asian cohort. Transpl Infect Dis 2017; 20. [PMID: 29071779 DOI: 10.1111/tid.12798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 06/20/2017] [Accepted: 07/09/2017] [Indexed: 11/30/2022]
Affiliation(s)
- James Guoxian Huang
- Khoo Teck Puat - National University Children's Medical Institute; National University Health System; Singapore
- Department of Paediatrics; Yong Loo Lin School of Medicine; National University of Singapore; Singapore
| | - Mervin Ye Qing Tan
- Yong Loo Lin School of Medicine; National University of Singapore; Singapore
| | - Seng-Hock Quak
- Khoo Teck Puat - National University Children's Medical Institute; National University Health System; Singapore
- Department of Paediatrics; Yong Loo Lin School of Medicine; National University of Singapore; Singapore
| | - Marion Margaret Aw
- Khoo Teck Puat - National University Children's Medical Institute; National University Health System; Singapore
- Department of Paediatrics; Yong Loo Lin School of Medicine; National University of Singapore; Singapore
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41
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Posttransplant Lymphoproliferative Disease Presenting as an Extracranial Mass. Case Rep Transplant 2017; 2017:6401086. [PMID: 29158940 PMCID: PMC5660822 DOI: 10.1155/2017/6401086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/07/2017] [Accepted: 08/30/2017] [Indexed: 11/30/2022] Open
Abstract
Posttransplant lymphoproliferative disease is a serious complication following stem cell and solid organ transplantation. Early recognition of the disease is important in facilitating timely therapy and improving long-term outcomes. We report a renal transplant recipient presenting with an extracranial frontoparietal soft tissue mass that was subsequently diagnosed as a B-cell lymphoma. The patient was treated successfully with immunosuppression reduction, anti-CD20 monoclonal antibody therapy, and cytotoxic chemotherapy. Our case highlights the importance of recognizing soft tissue masses in the head and neck as a potential clinical manifestation of PTLD in solid organ transplant recipients.
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42
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Østensen AB, Sanengen T, Holter E, Line PD, Almaas R. No effect of treatment with intravenous ganciclovir on Epstein-Barr virus viremia demonstrated after pediatric liver transplantation. Pediatr Transplant 2017; 21. [PMID: 28653462 DOI: 10.1111/petr.13010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2017] [Indexed: 11/26/2022]
Abstract
EBV after pediatric LT is a risk factor for PTLD. We wanted to evaluate the effect of intravenous ganciclovir on EBV viremia and to identify risk factors for chronic EBV viremia. All pediatric patients who underwent LT in Norway from 2002 until 2015 were reviewed. Twenty-two of 38 patients with viremia were treated with intravenous ganciclovir for a median of 22 (21-38) days. Treated and untreated patients were not different with respect to EBV seroconversion prior to transplantation or age at transplantation, but treated patients had significantly earlier viremia after transplantation (P=.005). There was no difference in the proportion of patients with reduction in virus load in patients treated with ganciclovir compared to untreated patients at 8 weeks. After 1 year, five of 19 patients treated with ganciclovir and six of 14 untreated patients had reduced virus load compared to start of viremia (P=.27). In conclusion, treatment with intravenous ganciclovir did not change the proportion of patients with reduction in EBV load at 8 weeks and 1 year after viremia. Younger age at transplantation, short time from transplantation to viremia, and lack of EBV seroconversion prior to transplantation were significant predictors of chronic EBV viremia.
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Affiliation(s)
- Anniken B Østensen
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Truls Sanengen
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Ellen Holter
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
| | - Pål-Dag Line
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Runar Almaas
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Department of Pediatric Research, Rikshospitalet, Oslo University Hospital, Oslo, Norway
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Riva N, Schaiquevich P, Cáceres Guido P, Halac E, Dip M, Imventarza O. Pharmacoepidemiology of tacrolimus in pediatric liver transplantation. Pediatr Transplant 2017; 21. [PMID: 28574195 DOI: 10.1111/petr.12982] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 11/28/2022]
Abstract
AEs during immunosuppressive treatment with tacrolimus are very common. We retrospectively evaluated FK safety and efficacy in a large pediatric liver transplant cohort in Latin America. During 2-year follow-up, we analyzed data from patients who underwent liver transplantation over the period 2010-2012 and recorded FK exposure, AEs, and AR episodes. AEs were classified according causality and severity. Tacrolimus exposure before and during AE was compared using Wilcoxon matched-pairs test. Kaplan-Meier curves were used for survival analysis. In total, 46 patients (out of 72 patients) experienced 69 AEs, such as hypomagnesemia (49%), PTLD (6%), hypertension (6%), and/or nephrotoxicity (22%). 43% of AEs were classified as moderate or serious, and 89% were assigned as probable or definitive. Patients who had one or more AR episodes accounted for 65%. The 12-month acute rejection-free survival was 41% (95% CI, 30.1%-53.1%). A significant difference was observed in FK trough concentrations before and during hypomagnesemia and nephrotoxicity (P<.05). This study is the first report of FK safety in a large group of pediatric liver transplant patients in Latin America. Children experience AEs, even in protocols with low FK doses. Therapeutic monitoring is an important tool to manage immunosuppressive schemes containing tacrolimus in vulnerable populations.
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Affiliation(s)
- Natalia Riva
- Clinical Pharmacokinetics Unit, Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina
| | - Paula Schaiquevich
- Clinical Pharmacokinetics Unit, Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina.,National Council of Scientific and Technical Research (CONICET), Buenos Aires, Argentina
| | - Paulo Cáceres Guido
- Clinical Pharmacokinetics Unit, Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina
| | - Esteban Halac
- Liver Transplantation, Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina
| | - Marcelo Dip
- Liver Transplantation, Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina
| | - Oscar Imventarza
- Liver Transplantation, Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina
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44
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Absalon MJ, Khoury RA, Phillips CL. Post-transplant lymphoproliferative disorder after solid-organ transplant in children. Semin Pediatr Surg 2017; 26:257-266. [PMID: 28964482 DOI: 10.1053/j.sempedsurg.2017.07.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The post-transplant lymphoproliferative disorders (PTLD) are a diverse group of potentially life-threatening conditions affecting organ transplant recipients. PTLD arises in the setting of an attenuated host immunologic system that is manipulated to allow a foreign graft but then fails to provide adequate immune surveillance of transformed malignant or premalignant lymphocytes. The diversity of biological behavior and clinical presentation makes for a challenging clinical situation for those involved in the care of children with PTLD occurring after solid-organ transplantation. This review details a large transplant center's multidisciplinary approach to monitoring for PTLD and systematic approach to intervention, which has been essential for early recognition and successful treatment.
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Affiliation(s)
- Michael J Absalon
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7018, Cincinnati, Ohio 45229.
| | - Ruby A Khoury
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7018, Cincinnati, Ohio 45229
| | - Christine L Phillips
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7018, Cincinnati, Ohio 45229
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45
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Jeong HJ, Ahn YH, Park E, Choi Y, Yi NJ, Ko JS, Min SI, Ha JW, Ha IS, Cheong HI, Kang HG. Posttransplantation lymphoproliferative disorder after pediatric solid organ transplantation: experiences of 20 years in a single center. KOREAN JOURNAL OF PEDIATRICS 2017; 60:86-93. [PMID: 28392824 PMCID: PMC5383637 DOI: 10.3345/kjp.2017.60.3.86] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/21/2016] [Accepted: 10/25/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE To evaluate the clinical spectrum of posttransplantation lymphoproliferative disorder (PTLD) after solid organ transplantation (SOT) in children. METHODS We retrospectively reviewed the medical records of 18 patients with PTLD who underwent liver (LT) or kidney transplantation (KT) between January 1995 and December 2014 in Seoul National University Children's Hospital. RESULTS Eighteen patients (3.9% of pediatric SOTs; LT:KT, 11:7; male to female, 9:9) were diagnosed as having PTLD over the last 2 decades (4.8% for LT and 2.9% for KT). PTLD usually presented with fever or gastrointestinal symptoms in a median period of 7 months after SOT. Eight cases had malignant lesions, and all the patients except one had evidence of Epstein-Barr virus (EBV) involvement, assessed by using in situ hybridization of tumor tissue or EBV viral load quantitation of blood. Remission was achieved in all patients with reduction of immunosuppression and/or rituximab therapy or chemotherapy, although 1 patient had allograft kidney loss and another died from complications of chemotherapy. The first case of PTLD was encountered after the introduction of tacrolimus for pediatric SOT in 2003. The recent increase in PTLD incidence in KT coincided with modification of clinical practice since 2012 to increase the tacrolimus trough level. CONCLUSION While the outcome was favorable in that all patients achieved complete remission, some patients still had allograft loss or mortality. To prevent PTLD and improve its outcome, monitoring for EBV infection is essential, which would lead to appropriate modification of immunosuppression and enhanced surveillance for PTLD.
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Affiliation(s)
- Hyung Joo Jeong
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yo Han Ahn
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Eujin Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Youngrok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Il Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Won Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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AlDabbagh MA, Gitman MR, Kumar D, Humar A, Rotstein C, Husain S. The Role of Antiviral Prophylaxis for the Prevention of Epstein-Barr Virus-Associated Posttransplant Lymphoproliferative Disease in Solid Organ Transplant Recipients: A Systematic Review. Am J Transplant 2017; 17:770-781. [PMID: 27545492 DOI: 10.1111/ajt.14020] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 08/12/2016] [Accepted: 08/15/2016] [Indexed: 01/25/2023]
Abstract
The role of antiviral prophylaxis for the prevention of posttransplant lymphoproliferative disease (PTLD) remains controversial for solid organ transplantation (SOT) recipients who are seronegative for Epstein-Barr virus (EBV) but who received organs from seropositive donors. We performed a systematic review and meta-analysis to address this issue. Two independent assessors extracted data from studies after determining patient eligibility and completing quality assessments. Overall, 31 studies were identified and included in the quantitative synthesis. Nine studies were included in the direct comparisons (total 2366 participants), and 22 were included in the indirect analysis. There was no significant difference in the rate of EBV-associated PTLD in SOT recipients among those who received prophylaxis (acyclovir, valacyclovir, ganciclovir, valganciclovir) compared with those who did not receive prophylaxis (nine studies; risk ratio 0.95, 95% confidence interval 0.58-1.54). No significant differences were noted across all types of organ transplants, age groups, or antiviral use as prophylaxis or preemptive therapy. There was no significant heterogeneity in the effect of antiviral prophylaxis on the incidence of PTLD. In conclusion, the use of antiviral prophylaxis in high-risk EBV-naive patients has no effect on the incidence of PTLD in SOT recipients.
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Affiliation(s)
- M A AlDabbagh
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Pediatrics, Division of Infectious Diseases, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Saudi Arabia
| | - M R Gitman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - D Kumar
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Medicine, Division of Infectious Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
| | - A Humar
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Medicine, Division of Infectious Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
| | - C Rotstein
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Medicine, Division of Infectious Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
| | - S Husain
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Department of Medicine, Division of Infectious Diseases, University Health Network, University of Toronto, Toronto, ON, Canada
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Rahbar M, Poormand G, Mahmoodi MK, Jazayeri A, Jazayeri SM. Asymptomatic Epstein-Barr Virus Shedding in the Urine of Kidney Transplant Recipients: Case Reports and Review of the Literature. Infect Dis Rep 2016; 8:6817. [PMID: 28191298 PMCID: PMC5226041 DOI: 10.4081/idr.2016.6817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 08/30/2016] [Accepted: 10/10/2016] [Indexed: 12/13/2022] Open
Abstract
Epstein-Barr virus (EBV) is associated with a wide range of malignancies and complications like post-transplant lymphoproliferative disorder (PTLD). To suppress active EBV infection in transplant recipients, who are at a heightened risk of developing PTLD, EBV DNAemia monitoring has been recommended. Quantitative multiplex real time polymerase chain reaction (QMRTPCR) offered the advantage of detection of more than one target in the same sample. We present four cases of kidney transplant recipient who were admitted for rising serum creatinine between 9 and 20 months post-transplant with a suspicion of BKV-associated nephropathy. All but one patient had unusual sonography findings in their genitourinary tracts and were positive for urinary culture for bacteria. Using a commercial QMRTPCR that could detect and quantitate BKV, EBV and cytomegalovirus simultaneously, all patients were positive for EBV in their urine for the levels between 2500 and 8×108 U/mL. None of the patients had any symptoms regarding this finding. On following up survey 3 month post discharge from hospital, all patients were negative for plasma and urine EBV. Absent of EBV DNAemia together with alternating phases of detectable EBV in urine might reflect the presence of functionally efficient central/effector memory T cells against EBV. The significance of this finding in immunocompromized patients necessitates prospective longitudinal studies.
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Affiliation(s)
| | | | - Masoud Karkhaneh Mahmoodi
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences , Tehran, Iran
| | | | - Seyed Mohammad Jazayeri
- Hepatitis B Molecular Laboratory, Department of Virology, School of Public Health, Tehran University of Medical Sciences , Tehran, Iran
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Schachtner T, Reinke P. Pretransplant prophylactic rituximab to prevent Epstein-Barr virus (EBV) viremia in EBV-seronegative kidney transplant recipients from EBV-seropositive donors: results of a pilot study. Transpl Infect Dis 2016; 18:881-888. [DOI: 10.1111/tid.12605] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 06/17/2016] [Accepted: 06/29/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Thomas Schachtner
- Department of Nephrology and Internal Intensive Care; Charité University Medicine Berlin; Campus Virchow Clinic; Berlin Germany
- Berlin-Brandenburg Center of Regenerative Therapies (BCRT); Berlin Germany
| | - Petra Reinke
- Department of Nephrology and Internal Intensive Care; Charité University Medicine Berlin; Campus Virchow Clinic; Berlin Germany
- Berlin-Brandenburg Center of Regenerative Therapies (BCRT); Berlin Germany
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Post-transplant lymphoproliferative disorder of the pediatric airway: Presentation and management. Int J Pediatr Otorhinolaryngol 2016; 86:218-23. [PMID: 27260610 DOI: 10.1016/j.ijporl.2016.04.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Post-transplant lymphoproliferative disorder (PTLD) is a rare complication of immunosuppression with little consensus on its evaluation and management. The purpose of this contemporary review is to describe a pediatric patient with PTLD of the airway and review the literature to provide multidisciplinary recommendations regarding management. DATA SOURCES Retrospective chart and literature review. REVIEW METHODS A pediatric patient with PTLD of the airway is described. An extensive literature search to review the existing data on pediatric PTLD of the upper airway was also performed. RESULTS A pediatric patient with mixed fetal/embryonal hepatoblastoma developed laryngo-tracheal PTLD following liver transplantation. Diagnostic positron emission tomography (PET) scan demonstrated multiple sites of abnormal fluorodeoxyglucose (FDG) uptake within the larynx, distal esophagus, cervical lymph nodes, and abdomen concerning for PTLD. Laryngeal biopsy demonstrated Epstein-Barr virus (EBV) positive cells confirming the diagnosis. Rituximab therapy and reduction of immunosuppression resulted in resolution of his laryngeal disease in 3 months. An extensive literature search to review the existing data on pediatric PTLD of the larynx and trachea revealed 14 reported cases. CONCLUSIONS PTLD of the pediatric airway is an EBV-associated disease that requires a high index of suspicion as patients can often present with non-specific signs and symptoms but progress to have significant airway compromise. Evaluation consists of peripheral blood polymerase chain reaction (PCR) assays, biopsy, and PET/CT imaging. Management options include reduction of immunosuppression and/or systemic therapies.
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Doycheva I, Amer S, Watt KD. De Novo Malignancies After Transplantation: Risk and Surveillance Strategies. Med Clin North Am 2016; 100:551-67. [PMID: 27095645 DOI: 10.1016/j.mcna.2016.01.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
De novo malignancies are one of the leading causes of late mortality after liver and kidney transplantation. Nonmelanoma skin cancer is the most common malignancy, followed by posttransplant lymphoproliferative disorder and solid organ tumors. Immunosuppression is a key factor for cancer development, although many other transplant-related and traditional risk factors also play a role. In this review, the authors summarize risk factors and outcomes of frequently encountered de novo malignancies after liver and kidney transplantation to stratify recipients at highest risk. Future efforts in prospectively validated, cost-effective surveillance strategies that improve survival of these complex patients are greatly needed.
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Affiliation(s)
- Iliana Doycheva
- Division of Gastroenterology and Hepatology, Medical University-Sofia, 1 G. Sofiisky Boulevard, Sofia 1431, Bulgaria
| | - Syed Amer
- Division of Internal Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, CH-10, 200 First Street Southwest, Rochester, MN 55905, USA.
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