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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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Zorzetti N, Marino IR, Sorrenti S, Navarra GG, D'Andrea V, Lauro A. Small bowel transplant - novel indications and recent progress. Expert Rev Gastroenterol Hepatol 2023; 17:677-690. [PMID: 37264646 DOI: 10.1080/17474124.2023.2221433] [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: 12/12/2022] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Advances in the management of intestinal failure have led to a reduction in the number of intestinal transplants. The number of bowel transplants has been mainly stable even though a slight increase has been observed in the last 5 years. AREAS COVERED Standard indication includes patients with a reasonable life expectancy. Recent progress can be deduced by the increased number of intestine transplants in adults: this is due to the continuous improvement of 1-year graft survival worldwide (without differences in 3- and 5-year) associated with better abdominal wall closure techniques. This review aims to provide an update on new indications and changes in trends of pediatric and adult intestine transplantation. This analysis, which stretches through the past 5 years, is based on a collection of related manuscripts from PubMed. EXPERT COMMENTARY Intestinal transplants should be solely intended for a group of individuals for whom indications for transplantation are clear and both medical and surgical rehabilitations have failed. Nevertheless, many protocols developed over the years have not yet solved the key question represented by the over-immunosuppression. Novel indications and recent progress in the bowel transplant field, minimal yet consistent, represent a pathway to be followed.
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Affiliation(s)
- Noemi Zorzetti
- General Surgery, Ospedale Civile "A. Costa", Alto Reno Terme, Bologna, Italy
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Salvatore Sorrenti
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Augusto Lauro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
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Wood P, Huang YS, Sanchez L, Kitt E, Abt PL, Bittermann T. The effectiveness and safety of antibody induction immunosuppression in a large cohort of United States pediatric liver transplant recipients. Am J Transplant 2023; 23:794-804. [PMID: 36933831 PMCID: PMC10247522 DOI: 10.1016/j.ajt.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 01/31/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
Data on the potential benefits and risks of induction therapy in pediatric liver transplantation (LT) are limited. This was a retrospective cohort study of 2748 pediatric LT recipients at 26 children's hospitals between January 1, 2006 to May 31, 2017 using data from the pediatric health information system linked to the United Network for Organ Sharing database. The induction regimen was obtained from the pediatric health information system day-by-day pharmacy resource utilization. Cox proportional hazards evaluated the association of induction regimen (none/corticosteroid-only, nondepleting, and depleting) on patient and graft survival. Additional outcomes, including opportunistic infections and posttransplant lymphoproliferative disorder, were studied using multivariable logistic regression. Overall, 64.9% received none/corticosteroid-only induction, whereas 28.1% received nondepleting, 8.3% received depleting, and 2.5% other antibody regimens. Differences in patient characteristics were small, but center practices were heterogeneous. Compared with none/corticosteroid-only induction, nondepleting induction was associated with reduced acute rejection (odd ratio [OR], 0.53; P <.001) but with the increased posttransplant lymphoproliferative disorder (OR, 1.75; P =.021). Depleting induction was associated with improved graft survival (hazard ratio [HR], 0.64; P =.028) but with increased noncytomegalovirus opportunistic infections (OR, 1.46; P =.046). Depleting induction is underused yet may offer long-term benefits in this large multicenter cohort. Greater consensus guidance in this aspect of pediatric LT care is warranted.
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Affiliation(s)
- Phoebe Wood
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yuan-Shung Huang
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lucia Sanchez
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eimear Kitt
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Raghu VK, Vetterly CG, Horslen SP. Immunosuppression Regimens for Intestinal Transplantation in Children. Paediatr Drugs 2022; 24:365-376. [PMID: 35604536 DOI: 10.1007/s40272-022-00512-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
Pediatric intestinal transplant serves as the only definitive treatment for children with irreversible intestinal failure. Successful intestinal transplant hinges upon appropriate management of immunosuppression. The indications for intestinal transplant have changed over time. Immunosuppression regimens can be divided into induction and maintenance phases along with treatment of acute rejection. Intestinal transplant induction now often includes antithymocyte globulin or basiliximab in addition to corticosteroids. Maintenance regimens continue to be dominated by tacrolimus, with additional agents used to either decrease goal tacrolimus levels to limit toxicity or as an adjunct in sensitized patients. Careful monitoring can help to limit serious complications, such as rejection, infection, and malignancy. Future work will aim to decrease variation in practice and identify methods to determine optimal immunosuppression for a particular patient. Furthermore, there is a need for non-invasive monitoring of the intestinal graft and functional assessments of immunosuppression.
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Affiliation(s)
- Vikram Kalathur Raghu
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh, School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Carol G Vetterly
- Department of Pharmacy, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Simon Peter Horslen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh, School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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Dogra H, Hind J. Innovations in Immunosuppression for Intestinal Transplantation. Front Nutr 2022; 9:869399. [PMID: 35782951 PMCID: PMC9241336 DOI: 10.3389/fnut.2022.869399] [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: 02/04/2022] [Accepted: 05/03/2022] [Indexed: 11/13/2022] Open
Abstract
It has been 57 years since the first intestinal transplant. An increased incidence of graft rejection has been described compared to other solid organ transplants due to high immunogenicity of the bowel, which in health allows the balance between of dietary antigen with defense against pathogens. Expanding clinical experience, knowledge of gastrointestinal physiology and immunology have progress post-transplant immunosuppressive drug regimens. Current regimes aim to find the window between prevention of rejection and the risk of infection (the leading cause of death) and malignancy. The ultimate aim is to achieve graft tolerance. In this review we discuss advances in mucosal immunology and technologies informing the development of new anti-rejection strategies with the hope of improved survival in the next generation of transplant recipients.
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Pediatric intestinal transplantation. Semin Pediatr Surg 2022; 31:151181. [PMID: 35725057 DOI: 10.1016/j.sempedsurg.2022.151181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Advancements in donor management, organ preservation and operative techniques, as well as immunosuppressive therapies, have provided children with intestinal failure and its complications a chance not only for enteral autonomy but also long-term survival through intestinal transplantation (ITx). First described in the 1960's, experience has grown in managing these complex patients both pre- and post-transplant. The goals of this review are to provide a brief history of intestinal transplantation and intestinal rehabilitation in pediatric patients, followed by focused discussions of the indications for ITx, induction and maintenance immunosuppression therapies, common post-operative complications, and outcomes/quality of life post-transplant.
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Merola J, Shamim A, Weiner J. Update on immunosuppressive strategies in intestinal transplantation. Curr Opin Organ Transplant 2022; 27:119-125. [PMID: 35232925 PMCID: PMC8915446 DOI: 10.1097/mot.0000000000000958] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The intestine is the most immunologically complex solid organ allograft with the greatest risk of both rejection and graft-versus-host disease (GVHD). High levels of immunosuppression are required, further increasing morbidity. Due to low volume of transplants and few centers with experience, there is paucity of evidence-based, standardized, and effective therapeutic regimens. We herein review the most recent data about immunosuppression, focusing on novel and emerging therapies. RECENT FINDINGS Recent data are moving the field toward increasing use of basilixumab and consideration of alemtuzumab for induction and inclusion of mammalian target of rapamycin inhibitors and antimetabolites for maintenance. For rejection, we highlight novel roles for tumor necrosis factor-α inhibition, α4β7 integrin inhibition, microbiome modulation, desensitization protocols, and tolerance induction strategies. We also highlight emerging novel therapies for GVHD, especially the promising role of Janus kinase inhibition. SUMMARY New insights into immune pathways associated with rejection and GVHD in intestinal allografts have led to an evolution of therapies from broad-based immunosuppression to more targeted strategies that hold promise for reducing morbidity from infection, rejection, and GVHD. These should be the focus of further study to facilitate their widespread use.
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Affiliation(s)
- Jonathan Merola
- Department of Surgery, Columbia University Irving Medical Center, New York, NY 10032
| | - Abrar Shamim
- Columbia University College of Dental Medicine, New York, NY 10032
- Columbia Center for Translational Immunology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032
| | - Joshua Weiner
- Department of Surgery, Columbia University Irving Medical Center, New York, NY 10032
- Columbia Center for Translational Immunology, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032
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