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Silva Junior HT, Tokat Y, Cai J, Singh I, Sandhu A, Demuth D, Kim J. Epidemiology, management, and burden of cytomegalovirus in solid organ transplant recipients in selected countries outside of Europe and North America: A systematic review. Transpl Infect Dis 2023; 25:e14070. [PMID: 37254966 DOI: 10.1111/tid.14070] [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: 02/21/2023] [Revised: 04/17/2023] [Accepted: 05/06/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a frequent infectious complication following solid organ transplantation (SOT). Considering significant differences in healthcare systems, a systematic review was conducted to describe the epidemiology, management, and burden of CMV post-SOT in selected countries outside of Europe and North America. METHODS MEDLINE, Embase, and Cochrane databases were searched for observational studies in SOT recipients across 15 countries in the regions of Asia, Pacific, and Latin America (search period: January 1, 2011 to September 17, 2021). Outcomes included incidence of CMV infection/disease, recurrence, risk factors, CMV-related mortality, treatment patterns and guidelines, refractory and/or resistant CMV, patient-reported outcomes, and economic burden. RESULTS Of 2708 studies identified, 49 were eligible (n = 43/49; 87.8% in adults; n = 34/49, 69.4% in kidney recipients). Across studies, selection of CMV preventive strategy was based on CMV serostatus. Overall, rates of CMV infection (within 1 year) and CMV disease post-SOT were respectively, 10.3%-63.2% (9 studies) and 0%-19.0% (17 studies). Recurrence occurred in 35.4%-41.0% cases (3 studies) and up to 5.3% recipients died of CMV-associated causes (11 studies). Conventional treatments for CMV infection/disease included ganciclovir (GCV) or valganciclovir. Up to 4.4% patients were resistant to treatment (3 studies); no studies reported on refractory CMV. Treatment-related adverse events with GCV included neutropenia (2%-29%), anemia (13%-48%), leukopenia (11%-37%), and thrombocytopenia (13%-24%). Data on economic burden were scarce. CONCLUSION Outside of North America and Europe, rates of CMV infection/disease post-SOT are highly variable and CMV recurrence is frequent. CMV resistance and treatment-associated adverse events, including myelosuppression, highlight unmet needs with conventional therapy.
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Affiliation(s)
| | - Yaman Tokat
- International Liver Center & Acibadem Healthcare Hospitals, Istanbul, Turkey
| | - Jinzhen Cai
- Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | - Anudeep Sandhu
- Takeda Pharmaceuticals International AG-Singapore Branch, Singapore, Singapore
| | - Dirk Demuth
- Takeda Pharmaceuticals International AG-Singapore Branch, Singapore, Singapore
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Dulek DE, Ardura MI. "Weight-ing" for an answer on optimal valganciclovir prophylaxis dosing in pediatric solid organ transplantation recipients. Pediatr Transplant 2023; 27:e14494. [PMID: 36945839 DOI: 10.1111/petr.14494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/17/2023] [Indexed: 03/23/2023]
Affiliation(s)
- D E Dulek
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Tennessee, Nashville, USA
| | - M I Ardura
- Department of Pediatrics, Division of Infectious Diseases & Host Defense, Nationwide Children's Hospital & The Ohio State University College of Medicine, Ohio, Columbus, USA
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Liverman R, Serluco A, Nance G, George R, Rodriguez DS, Deshpande S, Mao C, Garro R, Yildirim I. Incidence of cytomegalovirus DNAemia in pediatric kidney, liver, and heart transplant recipients: Efficacy and risk factors associated with failure of weight-based dosed valganciclovir prophylaxis. Pediatr Transplant 2023; 27:e14493. [PMID: 36945819 DOI: 10.1111/petr.14493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 01/03/2023] [Accepted: 01/17/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) is associated with morbidity and mortality in solid organ transplant recipients (SOTR). Valganciclovir (VGC) is extensively used for prophylaxis. Optimal dosing in children, risk factors for failure, and the impact of dose adjustments on CMV DNAemia is not well established. METHODS This retrospective cohort study of pediatric SOTR transplanted between 2010-2018 evaluated the epidemiology of CMV DNAemia and used Cox-regression to assess the risk factors for CMV DNAemia within one-year following SOTR. RESULTS In 393 pediatric SOTR (heart [96, 24.4%], kidney [180, 45.6%], liver [117, 29.8%]; median age 9.5 ± 0.3 years), overall CMV DNAemia incidence was 6.6/10 000 days (95%CI 5.1/10 000-7.9/10 000) and varied by organ groups: heart 8.2/10 000 days (95%CI 4.9/10 000-11.4/10 000), kidney 5.8/10 000 days (95%CI 3.9/10 000-7.8/10 000), liver 6.2/10 000 days (95%CI 3.7/10 000-8.7/10 000). CMV DNAemia was detected in 75 of 275 (27.2%) patients who received prophylaxis (40 cases occurred during prophylaxis and 35 occurred after completion of prophylaxis). The median VGC dose given according to institutional weight-based algorithm was approximately 1.5-fold lower than the manufacturer-recommended dose. This discordance was more prominent at younger age groups (3.2-fold lower in <2-year-old [100 mg versus 325 mg], 2.5-fold lower in <6-year-old [200 mg versus 447 mg]). Dose reduction due to adverse events was an independent risk factor for breakthrough CMV DNAemia (hazard ratio 2.2, 95%CI 1.2-3.8) among patients with similar age, CMV risk stratification, starting VGC dose, immunosuppressive therapy, and organ group. CONCLUSION CMV events occurred while on VGC prophylaxis. Weight-based VGC may prevent supratherapeutic VGC exposure especially in younger children. Dose reduction of VGC prophylaxis for adverse event management places patients at an increased risk for CMV DNAemia suggesting other agents with fewer adverse effects should be considered and need to be studied in children.
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Affiliation(s)
| | | | - Gwen Nance
- Joe DiMaggio Children's Hospital, Florida, Hollywood, USA
| | - Roshan George
- Children's Healthcare of Atlanta, Georgia, Atlanta, USA
- Division of Pediatric Nephrology, Emory University School of Medicine, Georgia, Atlanta, USA
| | - Dellys Soler Rodriguez
- Children's Healthcare of Atlanta, Georgia, Atlanta, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Georgia, Atlanta, USA
| | - Shriprasad Deshpande
- Division of Pediatric Cardiology, Children's National Hospital, DC, Washington, USA
| | - Chad Mao
- Division of Pediatric Cardiology, Emory University School of Medicine, Georgia, Atlanta, USA
- Sibley Heart Center Cardiology, Georgia, Atlanta, USA
| | - Rouba Garro
- Children's Healthcare of Atlanta, Georgia, Atlanta, USA
- Division of Pediatric Nephrology, Emory University School of Medicine, Georgia, Atlanta, USA
| | - Inci Yildirim
- Department of Pediatrics, Section of Infectious Diseases, Yale University, School of Medicine, Connecticut, New Haven, USA
- Department of Epidemiology of Microbial Diseases, Yale University, School of Public Health, Connecticut, New Haven, USA
- Yale Institute of Global Health, Connecticut, New Haven, USA
- Yale Center for Infection and Immunity, Connecticut, New Haven, USA
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4
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Downes KJ, Sharova A, Boge CLK, Vader D, Mitrou M, Hayes M, Galetaki DM, Gianchetti L, Vella LA, Li Y. CMV infection and management among pediatric solid organ transplant recipients. Pediatr Transplant 2022; 26:e14220. [PMID: 34994041 DOI: 10.1111/petr.14220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/29/2021] [Accepted: 12/26/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is an important cause of morbidity and mortality in pediatric solid organ transplant (SOT) recipients. However, the impact of asymptomatic CMV infections (ie, DNAemia) on clinical outcomes is not well established. METHODS We performed a retrospective cohort study of children undergoing first SOT at our institution from January 2012 to June 2018. We evaluated the epidemiology of CMV infections and performed multivariable Cox regression to assess the association between CMV DNAemia without disease or CMV disease (syndrome or end-organ disease) on negative outcomes (death, re-transplantation, or moderate/severe rejection) within the first year after SOT. RESULTS Among 271 individuals, 43 (15.9%) developed ≥1 CMV infection during the first year after SOT. There were 56 unique CMV infections including 14 episodes of CMV disease. In 167 patients offered CMV prophylaxis, only 8 (4.8%) developed their first CMV DNAemia episode while on prophylaxis 32 developed CMV DNAemia after prophylaxis completion; only 1 episode of CMV disease occurred while on antiviral prophylaxis. When accounting for receipt of ATG, oral steroids, and number of immunosuppressives on a given day, CMV disease was more strongly associated with negative outcomes (Hazard Ratio (HR): 3.28, 95% CI: 0.73-14.64; p = .12) than CMV DNAemia without disease (HR 1.42, 95% CI: 0.19- 10.79; p = .74), although not to a statistically significant degree. CONCLUSIONS Most CMV infections occurred after completion of antiviral prophylaxis. CMV disease was more strongly associated with negative outcomes than asymptomatic CMV DNAemia and should be the focus of CMV prevention practices.
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Affiliation(s)
- Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna Sharova
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Craig L K Boge
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniel Vader
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marina Mitrou
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Molly Hayes
- Antimicrobial Stewardship Program, Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Despoina M Galetaki
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lauren Gianchetti
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Laura A Vella
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yun Li
- Pediatric IDEAS Research Group of the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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5
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Cheyssac E, Savadogo H, Lagoutte N, Baudouin V, Charbit M, Novo R, Sellier-Leclerc AL, Fila M, Decramer S, Merieau E, Zaloszyc A, Harambat J, Roussey G. Valganciclovir is not associated with decreased EBV infection rate in pediatric kidney transplantation. Front Pediatr 2022; 10:1085101. [PMID: 36704127 PMCID: PMC9871758 DOI: 10.3389/fped.2022.1085101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Primary infection or reactivation of Epstein-Barr Virus (EBV) is a significant cause of morbidity and mortality in pediatric kidney transplantation. Valganciclovir (VGC) treatment is recommended for prophylaxis of cytomegalovirus infection, but its role for the prevention of EBV infection remains controversial. PATIENTS AND METHODS All pediatric kidney transplant recipients aged <18 years old were considered for inclusion in this retrospective study. EBV negative recipients with an EBV positive donor (a group at risk of primary infection) or EBV positive recipients (a group at risk of reactivation) were included. Severe infection was defined by post-transplant lymphoproliferative disorder (PTLD), symptomatic EBV infection or by asymptomatic EBV infection with a viral load >4.5 log/ml. Outcomes were compared between patients receiving VGC prophylaxis (group P+) and those not receiving VGC prophylaxis (group P-). RESULTS A total of 79 patients were included, 57 (72%) in the P+ group and 22 (28%) in the P- group; 25 (31%) were at risk of primary infection and 54 (69%) at risk of reactivation. During the first year post-transplant, the occurrence of severe EBV infection was not different between the P+ group (n = 13, 22.8%) and the P- group (n = 5, 22.7%) (p = 0.99). Among patients at risk of primary infection, the rate of severe EBV infection was not different between the two groups (42.1% in P+ vs. 33.3% in P-). A higher frequency of neutropenia was found in the P+ group (66.6%) than in the P- group (33.4%) (p < 0.01). CONCLUSION Our observational study suggests no effect of VGC for the prevention of EBV infection in pediatric kidney transplant recipients, irrespective of their EBV status. Adverse effects revealed an increased risk of neutropenia.
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Affiliation(s)
- Elodie Cheyssac
- Department of Pediatric Nephrology, Robert Debré University Hospital, APHP, Paris, France
| | - Hamidou Savadogo
- Department of Pediatrics, Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
| | - Nathan Lagoutte
- Department of Pediatrics, Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
| | - Véronique Baudouin
- Department of Pediatric Nephrology, Robert Debré University Hospital, APHP, Paris, France
| | - Marina Charbit
- Department of Pediatric Nephrology, Necker Enfants Malades University Hospital, APHP, Paris, France
| | - Robert Novo
- Pediatric Nephrology Unit, Lille University Hospital, Lille, France
| | | | - Marc Fila
- Pediatric Nephrology Unit, Montpellier University Hospital, Montpellier, France
| | - Stéphane Decramer
- Pediatric Nephrology Unit, Toulouse University Hospital, Toulouse, France
| | - Elodie Merieau
- Department of Pediatrics, Tours University Hospital, Tours, France
| | - Ariane Zaloszyc
- Department of Pediatrics, Strasbourg University Hospital, France, Strasbourg, France
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | - Gwenaelle Roussey
- Department of Pediatrics, Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
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Valencia Deray KG, Hosek KE, Chilukuri D, Dunson JR, Spielberg DR, Swartz SJ, Spinner JA, Leung DH, Moulton EA, Munoz FM, Demmler-Harrison GJ, Bocchini CE. Epidemiology and long-term outcomes of cytomegalovirus DNAemia and disease in pediatric solid organ transplant recipients. Am J Transplant 2022; 22:187-198. [PMID: 34467658 DOI: 10.1111/ajt.16822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/08/2021] [Accepted: 08/28/2021] [Indexed: 01/25/2023]
Abstract
Despite prevention strategies, cytomegalovirus (CMV) remains a common infection in pediatric solid organ transplant recipients (SOTR). We sought to determine the frequency, associations with, and long-term outcomes of CMV DNAemia in pediatric SOTR. We performed a single-center retrospective cohort study, including 687 first time SOTR ≤21 years receiving universal prophylaxis from 2011 to 2018. Overall, 159 (23%) developed CMV DNAemia, the majority occurring after completing primary prophylaxis. CMV disease occurred in 33 (5%) SOTR, 25 (4%) with CMV syndrome and 10 (1%) with proven/probable tissue-invasive disease. CMV contributed to the death of three (0.4%) patients (all lung). High-risk (OR 6.86 [95% CI, 3.6-12.9]) and intermediate-risk (4.36 [2.3-8.2]) CMV status and lung transplantation (4.63 [2.33-9.2]) were associated with DNAemia on multivariable analysis. DNAemia was associated with rejection in liver transplant recipients (p < .01). DNAemia was not associated with an increase in graft failure, all-cause mortality, or other organ-specific poor outcomes. We report one of the lowest rates of CMV disease after SOTR, showing that universal prophylaxis is effective and should be continued. However, we observed CMV morbidity and mortality in a subset of patients, highlighting the need for research on optimal prevention strategies. This study was IRB approved.
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Affiliation(s)
- Kristen G Valencia Deray
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Kathleen E Hosek
- Department of Pediatrics, Section of Quality, Texas Children's Hospital, Houston, Texas, USA
| | - Divya Chilukuri
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jordan R Dunson
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - David R Spielberg
- Department of Pediatrics, Section of Pulmonology, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph A Spinner
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel H Leung
- Department of Pediatrics, Section of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Elizabeth A Moulton
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Flor M Munoz
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Gail J Demmler-Harrison
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Claire E Bocchini
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
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7
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Dzhumabaeva BT, Tikhomirov DS, Biryukova LS, Tupoleva TA, Nesterenko IV, Purlo NV, Chebоtarev DI. Herpesviruses in patients after renal transplantation. TERAPEVT ARKH 2021; 93:1264-1270. [DOI: 10.26442/00403660.2021.11.201164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 11/22/2022]
Abstract
Aim. To estimate graft function after kidney transplantation during active herpesviruses or superinfection
Materials and methods. The study included 32 patients (men 21, women 11) with end-stage chronic kidney disease. The median age was 43 years. Cytomegalovirus (CMV), EpsteinBarr virus (EBV) and human herpes virus 6 (HHV-6) DNAs were screened by RT-PCR in the donor's transplant biopsy, and recipients peripheral blood and urine after kidney transplantation (KT) on 0, 1, 2, 4, 6, 12 months. Antiviral antibodies (IgM and IgG) were also screened by Enzyme-linked immunoassay analysis (ELISA) along with PCR. The 500 or less copies of viral DNA per 105 nuclear cells or 1 ml of urine was considered as low, more than 1000 copies high.
Results. On the first month after KT CMV DNA was detected in 50% of pts., EBV DNA in 40% and HHV-6 DNA in 33%. During first year after KT two or three viruses simultaneously were found in 12 recipients: CMV, EBV, and HHV-6 were detected in 5 recipients; CMV and EBV in 4 patients; CMV and HHV-6 in 2 pts; EBV and HHV-6 in 1 pt. Graft dysfunction was observed in 9 patients with a high concentration of viral DNA of one, two or three viruses simultaneously. An upraise of the concentration of virus DNA (CMV, EBV and HHV 6) was detected primarily in the urine, while in the blood its concentration was less than 500 cop or undetectable. Renal dysfunction was not observed on the background of low concentrations of viral DNA in urine and blood. However, with an increase of DNA concentration, an impaired graft function in 8 of 12 patients appeared. Low viral DNA level proved to be a background for another virus activation or bacterial/fungal superinfection.
Conclusion. Graft dysfunction occurs at high viral DNA levels detection during mono-or superinfection. Low viral load can serve as a background for another virus activation and/or bacterial/fungal superinfection.
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8
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CMV, EBV, JCV and BKV infection and outcome following kidney transplantation in children initiated on a corticosteroid-minimisation immunosuppressive regimen. Pediatr Nephrol 2021; 36:3229-3240. [PMID: 33825043 DOI: 10.1007/s00467-021-05047-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Modern immunosuppressive regimens in paediatric kidney transplant recipients have contributed to improved long-term allograft survival, but at the expense of an increased incidence of viral infections. Here, we describe, for the first time, the incidence, risk factors and clinical outcome of CMV, EBV, BKV and JCV viraemia in a cohort of paediatric allograft recipients treated with a corticosteroid-minimisation immunosuppressive regimen (CMR). METHODS We retrospectively analysed 98 children treated with a CMR (basiliximab induction, corticosteroids until day 4, long-term tacrolimus and mycophenolate mofetil), who received a kidney transplant in our centre between 2009 and 2019. RESULTS Over the first 4 years post-transplant, the incidences of viraemia were as follows: CMV, 25.5%; EBV, 52.0%; JCV, 16.3%; BKV, 26.5%. Younger children at time of transplant were more likely to develop EBV and BKV viraemia. EBV viraemia was also associated with a regimen involving corticosteroids, but lacking MMF. Recipient CMV serology predicted the development of EBV, BKV and CMV viraemia. Fifty-six percent of CMV viraemia episodes in high-risk patients occurred whilst the graft recipients were still receiving anti-viral prophylaxis or within 3 months of cessation. There was no difference in graft function at latest follow-up between those with and without viraemia. CONCLUSIONS Judicious monitoring of viraemia, coupled with timely clinical intervention, can result in similar long-term outcomes for graft recipients compared to controls. The high incidence of CMV viraemia observed within a short period of cessation of anti-viral prophylaxis supports an extension of the length of prophylactic treatment in high-risk allograft recipients.
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9
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Oomen L, de Wall LL, Cornelissen EAM, Feitz WFJ, Bootsma-Robroeks CMHHT. Prognostic Factors on Graft Function in Pediatric Kidney Recipients. Transplant Proc 2020; 53:889-896. [PMID: 33257001 DOI: 10.1016/j.transproceed.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/26/2020] [Accepted: 10/20/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Graft survival in pediatric kidney transplant recipients has increased in the last decades. Determining prognostic factors for graft function over time allows the identification of patients at risk for graft loss and could lead to improvement of current guidelines. METHODS Data were collected among pediatric kidney transplant recipients in a single center during the first 5 years after transplantation. Mixed model analysis was used to indicate possible prognostic factors for the loss of graft function. RESULTS A total of 100 pediatric kidney transplant recipients were analyzed. Negative prognostics of graft function are higher donor age and higher recipient age, presence of obstructive uropathology, re-transplant, and occurrence of BK viremia. The negative influence on graft function of both donor age and presence of obstructive uropathology increased over time. In this study, the factors that did not influence graft function over time were the number of HLA mismatches, pre-transplant dialysis, intra-abdominal graft placement, ischemia time, occurrence of acute rejection, presence of lower urinary tract dysfunction, occurrence of urinary tract infections, and infections with cytomegalovirus and Epstein-Barr virus. CONCLUSIONS This study showed that a higher donor age and higher recipient age, presence of obstructive uropathology, a re-transplant, and the occurrence of BK viremia were negative prognostic factors of graft function over time, in the first 5 years after transplant. Graft function was comparable between steroid-sparing regimens (preferable in low-risk patients) and regimens including steroids (for special reasons).
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Affiliation(s)
- Loes Oomen
- Radboudumc Amalia Children's Hospital, Pediatric Urology, Nijmegen, the Netherlands
| | - Liesbeth L de Wall
- Radboudumc Amalia Children's Hospital, Pediatric Urology, Nijmegen, the Netherlands
| | | | - Wout F J Feitz
- Radboudumc Amalia Children's Hospital, Pediatric Urology, Nijmegen, the Netherlands
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10
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Zar HJ, Moore DP, Andronikou S, Argent AC, Avenant T, Cohen C, Green RJ, Itzikowitz G, Jeena P, Masekela R, Nicol MP, Pillay A, Reubenson G, Madhi SA. Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines. Afr J Thorac Crit Care Med 2020; 26:10.7196/AJTCCM.2020.v26i3.104. [PMID: 34471872 PMCID: PMC7433705 DOI: 10.7196/ajtccm.2020.v26i3.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis. OBJECTIVES To produce revised guidelines for pneumonia in South African children under 5 years of age. METHODS The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision. RECOMMENDATIONS Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided. VALIDATION The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.
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Affiliation(s)
- H J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
- South African Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - D P Moore
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S Andronikou
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
- Department of Pediatric Radiology, Perelman School of Medicine, University of Philadephia, USA
| | - A C Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - T Avenant
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, South Africa
| | - C Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - R J Green
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, South Africa
| | - G Itzikowitz
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - P Jeena
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - R Masekela
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - M P Nicol
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, South Africa; and Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - A Pillay
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - G Reubenson
- Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - S A Madhi
- South African Medical Research Council Vaccine and Infectious Diseases Analytics Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: South African Research Chair in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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11
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Albatati S, Sharma A, Haubrich K, Wright A, Gantt S, Blydt-Hansen TD. Valganciclovir prophylaxis delays onset of EBV viremia in high-risk pediatric solid organ transplant recipients. Pediatr Res 2020; 87:892-896. [PMID: 31377753 DOI: 10.1038/s41390-019-0523-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/15/2019] [Accepted: 07/16/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND The role of antiviral prophylaxis to prevent Epstein-Barr virus (EBV) viremia or posttransplant lymphoproliferative disorder in pediatric solid organ transplant recipients is controversial. We examined whether valganciclovir (VAL) prophylaxis for cytomegalovirus infection was associated with EBV viremia following transplantation in EBV-naive children. METHODS A single-center, retrospective study was conducted of EBV-naive pediatric heart and renal transplant recipients with an EBV-positive donor from January 1996 to April 2017. VAL was tested for association with EBV viremia-free survival in the first 6 months posttransplantation when immunosuppressant exposure is the highest. Survival models evaluated VAL duration, with adjustment for other baseline confounders. RESULTS Among the cohort (n = 44), 3 (6.8%) were heart transplants, 25 (56.8%) received VAL, and 22 (50%) developed EBV viremia in the first-year posttransplantation. Mean time-to-viremia was 143 vs. 90 days for the VAL and no-VAL groups, respectively (p = 0.008), in the first 6 months. Only two patients developed viremia while on VAL. Each additional day of VAL was associated with 1.4% increase in viremia-free survival (p < 0.001). Multivariable modeling of VAL with other baseline risk factors did not identify other independent risk factors. CONCLUSION VAL is independently associated with delayed onset of EBV viremia, with prolongation of delay with each additional day of antiviral prophylaxis.
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Affiliation(s)
- Sawsan Albatati
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Atul Sharma
- Department of Pediatrics and Child Health, University of Manitoba, Children's Hospital at Health Sciences Center, Winnipeg, MB, Canada
| | - Kathryn Haubrich
- Department of Pharmacy, Vancouver General Hospital, Vancouver, BC, Canada
| | - Alissa Wright
- Department of Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - Soren Gantt
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada.
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12
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Pangonis S, Paulsen G, Andersen H, Flores F, Miethke A, Peters A, Kocoshis S, Lazear D, Garr B, Schecter M, Chin C, Hemmelgarn T, Danziger-Isakov L. Evaluation of a change in cytomegalovirus prevention strategy following pediatric solid organ transplantation. Transpl Infect Dis 2019; 22:e13232. [PMID: 31840369 DOI: 10.1111/tid.13232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/09/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND An optimal cytomegalovirus (CMV) prevention strategy following solid organ transplantation (SOT) remains uncertain. This study reports on the rates of CMV events following a change in a local prevention guideline involving increased surveillance, earlier transition to oral valganciclovir, and decreased CMV-immunoglobulin use. METHODS A retrospective cohort study utilizing historical controls evaluated the rates of CMV invasive disease pre- and post-intervention among pediatric heart, liver, and kidney recipients. Outcomes were recorded for the 4 years pre- and post-intervention, 9/2009-10/2017. Logistic regression was used to estimate the risk of a CMV event. RESULTS There was no difference in the rates of CMV invasive disease between the two study groups (P = 1). An increase in the detection of CMV events occurred (P = .04), predominantly asymptomatic CMV infection. This increase was independently associated with increased surveillance testing among high-risk heart and liver recipients, aOR 1.08 (1.06-1.12). Surprisingly, 28.9% of CMV events occurred during antiviral prophylaxis. CONCLUSIONS Modification of the local CMV prevention guideline did not result in an increase in CMV invasive disease. CMV events occurred while on prophylaxis, highlighting a potential difference from adult solid organ transplant (SOT) and emphasizing the potential need for monitoring on prophylaxis in the pediatric population.
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Affiliation(s)
- Scott Pangonis
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Grant Paulsen
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Heidi Andersen
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Francisco Flores
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Alexander Miethke
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Anna Peters
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Samuel Kocoshis
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Danielle Lazear
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - BreAnn Garr
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Marc Schecter
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Clifford Chin
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Trina Hemmelgarn
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Medical Center, Cincinnati, Ohio
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13
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Savassi-Ribas F, Gomes Dos Santos de Almeida S, Baez CF, Magalhães de Souza L, Wagner TCS, Matuck TA, Monteiro de Carvalho DDB, Marandino Guimarães MAA, Varella RB. Impact assessment and investigation of factors associated with herpesviruses viremia in the first year of renal transplantation. J Med Virol 2019; 92:107-112. [PMID: 31463932 DOI: 10.1002/jmv.25580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 08/26/2019] [Indexed: 12/16/2022]
Abstract
The increased risk for opportunistic infections after a renal transplant requires monitoring of viral infections to avoid future complications. Our goal was to investigate the impact and factors associated with Epstein-Barr virus (EBV), human cytomegalovirus (HCMV) and human herpesvirus type 6 (HHV-6) viremia in renal transplant recipients. Whole blood samples were collected monthly from 82 patients during the first semester and then quarterly up to 1 year after transplantation. EBV, HCMV, and HHV-6 were detected and quantified by TaqMan real-time polymerase chain reaction. The results showed that EBV and HCMV viremia were detected in 32 patients (39% each), while HHV-6 viremia in only 3 patients (3.7%). EBV was significantly associated with age (P = .050), thymoglobuline induction (P = .019), mTOR inhibitor-based therapy (P = .003), and female gender (P = .044). HCMV was significantly associated with basiliximab induction (P = .015), mycophenolate mofetil (MMF)-based therapy (P = .003) and allograft acute rejection (P = .033). Moreover, HCMV-disease was correlated with MMF-based therapy (P = .021) and female gender (P = .003). In conclusion, EBV and HCMV viremia were associated with different immunosuppressive induction and maintenance strategies. Additionally, higher HCMV viremia (> 10 4 copies/mL) was related to acute allograft rejection.
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Affiliation(s)
- Flavia Savassi-Ribas
- Department of Microbiology and Parasitology, Biomedical Institute, Fluminense Federal University, Niteroi, Brazil
| | | | - Camila Freze Baez
- Department of Preventive Medicine, University Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leandro Magalhães de Souza
- Department of Preventive Medicine, University Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tereza Cristina Simão Wagner
- Service of Renal Transplantation, Rio de Janeiro State Center of transplantation, São Francisco na Providência de Deus Hospital, Rio de Janeiro, Brazil
| | - Tereza Azevedo Matuck
- Service of Renal Transplantation, Rio de Janeiro State Center of transplantation, São Francisco na Providência de Deus Hospital, Rio de Janeiro, Brazil
| | - Deise De Boni Monteiro de Carvalho
- Service of Renal Transplantation, Rio de Janeiro State Center of transplantation, São Francisco na Providência de Deus Hospital, Rio de Janeiro, Brazil
| | | | - Rafael Brandão Varella
- Department of Microbiology and Parasitology, Biomedical Institute, Fluminense Federal University, Niteroi, Brazil
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