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Siripoon T, Apiwattanakul N, Mongkolrattanakul P, Tongsook C, Unwanatham N, Hongeng S, Kantachuvesiri S, Bruminhent J. Clinical and immunological characteristics for BK polyomavirus-associated nephropathy after kidney transplantation. Immun Inflamm Dis 2023; 11:e956. [PMID: 37647426 PMCID: PMC10461421 DOI: 10.1002/iid3.956] [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: 01/05/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION BK polyomavirus (BKPyV)-associated nephropathy (BKPyVAN) can cause a significant risk of allograft impairment after kidney transplantation (KT). Intact BKPyV-specific immunity is associated with viral containment. This study investigated BKPyV-specific immunological factors among KT recipients. METHODS This prospective study in a single transplant center from January 2019 to August 2019 assessed associations between clinical and immunological characteristics, with a focus on BKPyV-cell-specific immunity and BKPyVAN, among KT recipients aged ≥15 years. The numbers of interferon-gamma (IFN-γ)-producing CD4+ T, CD8+ T, natural killer (NK), and natural killer T (NKT) cells were measured after stimulation with large T antigen and viral capsid protein 1 (VP1). RESULTS In total, 100 KT recipients were included (mean age ± SD, 42 ± 11 years); 35% of the recipients were female patients, and 70% had received induction immunosuppressive therapy. The 1-year cumulative incidence of high-level BKPyV DNAuria (possible BKPyVAN) and (presumptive BKPyVAN) was 18%. Among 40 patients with immunological factor data, pre-KT %NK cells (hazard ratio [HR], 1.258; 95% confidence interval [CI], 1.077-1.469; p = .004) and %VP1-specific NK cells (HR, 1.209; 95% CI, 1.055-1.386; p = .006) were factors independently associated with possible and presumptive BKPyVAN. KT recipients with possible and presumptive BKPyVAN were more likely to exhibit significant mean coefficients of %NK, %VP1-specific NK, and %NKT cells at 1 month after KT than before KT (all p < .05). CONCLUSION Individuals with nonspecific and VP1-specific NK cells before KT and increasing numbers of these cells after KT may be at risk for high-level BKPyV DNAuria and presumptive BKPyVAN. Further studies are needed to determine the utility of BKPyV-specific innate immune surveillance in predicting the occurrence of BKPyVAN.
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Affiliation(s)
- Tanaya Siripoon
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Department of Clinical Tropical Medicine, Faculty of Tropical MedicineMahidol UniversityBangkokThailand
| | - Nopporn Apiwattanakul
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Pannawat Mongkolrattanakul
- Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Chutatip Tongsook
- Division of Virology, Department of Pathology, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Nattawut Unwanatham
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Suradej Hongeng
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Surasak Kantachuvesiri
- Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Jackrapong Bruminhent
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
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BK Viremia and Changes in Estimated Glomerular Filtration Rate in Children and Young Adults after Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:187.e1-187.e8. [PMID: 36494016 DOI: 10.1016/j.jtct.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/14/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022]
Abstract
Kidney disease in allogeneic hematopoietic cell transplantation (HCT) recipients is associated with increased mortality rates. BK virus (BKV) viremia has been associated with kidney dysfunction in pediatric HCT recipients; however, few studies have investigated longer-term kidney outcomes in association with BKV in this population. Here we assessed the relationship between BK viremia and changes in estimated glomerular filtration rate (eGFR) in children in the first year post-HCT. We selected 136 patients age ≤26 years who underwent HCT in 2007 to 2018 at a single center and had plasma BK viral load data available at 2 time points, weeks 4 to 7 post-HCT and weeks 10 to 13 post-HCT from prospectively collected stored plasma samples. A total of 272 samples were analyzed for BKV using quantitative PCR. We used multivariate linear models to determine the association of BK viremia and change in eGFR by 1 year post-HCT. Forty percent of the patients (54 of 136) had BKV detection in weeks 4 to 7, 13% of whom (7 of 54) had a BK viral load of ≥10,000 copies/mL, and 46% (62 of 136) had BKV detected in weeks 10 to 13, 34% (21 of 62) of whom had a BK viral load of ≥10,000 copies/mL. The mean decline in eGFR was 25.73 mL/min/1.73 m2 by 1 year post-HCT. In multivariate models, a BK viral load of ≥10,000 copies/mL during weeks 4 to 7 was associated with a mean decline in eGFR of 30.6 mL/min/1.73 m2 (95% confidence interval, -55.94 to -5.17; P = .019) compared with a BK viral load <10,000 copies/mL. In adjusted analyses, a high BK viral load in the blood (≥10,000 copies/mL) was associated with a significant decline in eGFR by 1 year post-HCT.
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Laskin BL, Denburg MR, Furth SL, Moatz T, Altrich M, Kleiboeker S, Lutzko C, Zhu X, Blackard JT, Jodele S, Lane A, Wallace G, Dandoy CE, Lake K, Duell A, Litts B, Seif AE, Olson T, Bunin N, Davies SM. The Natural History of BK Polyomavirus and the Host Immune Response After Stem Cell Transplantation. Clin Infect Dis 2021; 71:3044-3054. [PMID: 31851312 DOI: 10.1093/cid/ciz1194] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/16/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND BK polyomavirus (BKPyV) is associated with symptomatic hemorrhagic cystitis after hematopoietic cell transplantation (HCT). Little is known about the host immune response, effectiveness of antiviral treatment, or impact of asymptomatic replication on long-term kidney function. METHODS In children and young adults undergoing allogeneic HCT, we quantified BKPyV viruria and viremia (pre-HCT and at Months 1-4, 8, 12, and 24 post-HCT) and tested associations of peak viremia ≥10 000 or viruria ≥109 copies/mL with estimated kidney function (glomerular filtration rate, eGFR) and overall survival at 2 years posttransplant. We examined the factors associated with viral clearance by Month 4, including BKPyV-specific T cells by enzyme-linked immune absorbent spot at Month 3 and cidofovir use. RESULTS We prospectively enrolled 193 participants (median age 10 years) and found that 18% had viremia ≥10 000 copies/mL and 45% had viruria ≥109 copies/mL in the first 3 months post-HCT. Among the 147 participants without cystitis (asymptomatic), 58 (40%) had any viremia. In the entire cohort and asymptomatic subset, having viremia ≥10 000 copies/mL was associated with a lower creatinine/cystatin C eGFR at 2 years post-HCT. Viremia ≥10 000 copies/mL was associated with a higher risk of death (adjusted hazard ratio, 2.2; 95% confidence interval, 1.1-4.2). Clearing viremia was associated with detectable BKPyV-specific T cells and having viremia <10 000 copies/mL, but not cidofovir exposure. CONCLUSIONS Screening for BKPyV viremia after HCT identifies asymptomatic patients at risk for kidney disease and reduced survival. These data suggest potential changes to clinical practice, including prospective monitoring for BKPyV viremia to test virus-specific T cells to prevent or treat BKPyV replication.
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Affiliation(s)
- Benjamin L Laskin
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle R Denburg
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan L Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Taylor Moatz
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Carolyn Lutzko
- Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Xiang Zhu
- Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jason T Blackard
- Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adam Lane
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Gregory Wallace
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher E Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kelly Lake
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexandra Duell
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bridget Litts
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alix E Seif
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Timothy Olson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nancy Bunin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stella M Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Assawawiroonhakarn S, Apiwattanakul N, Pakakasama S, Hongeng S, Anurathapan U, Yoksan S, Klinmalai C, Sae-Chew P, Techasaensiri C. Immunogenicity of Vero Cell Culture-derived Japanese Encephalitis Vaccine in Pediatric and Young Hematopoietic Stem Cell Transplantation Recipients. Pediatr Infect Dis J 2021; 40:264-268. [PMID: 33427799 DOI: 10.1097/inf.0000000000003007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Children and young adults undergoing hematopoietic stem cell transplantation (HSCT) typically lose their immunity to vaccine-preventable diseases, including Japanese encephalitis (JE). Revaccination against JE in this population has not been well characterized. METHODS This prospective study evaluated the immunogenicity of inactivated Vero cell culture-derived JE vaccine in children and young adults (<25 years of age) who had completed HSCT >1 year prior. Each patient received inactivated Vero cell culture-derived JE vaccine at enrollment and 1 month after enrollment, as well as a booster dose 13 months after enrollment. Serum JE plaque reduction neutralization test and JE-specific T lymphocyte count assay were performed at baseline, 1 month after the second dose, on the day of the booster dose, and 1 month after the booster dose. RESULTS Thirty-seven patients were enrolled. At baseline, 15 patients (40.5%) had plaque reduction neutralization titer >10, which is considered protective. Among 22 seronegative patients, 15 (68.2%) and 19 (86.4%) exhibited seroconversion after revaccination and booster dose, respectively. Median JE-specific T lymphocyte counts also increased. Twenty of 111 (18.0%) vaccination doses resulted in self-limiting side effects. CONCLUSIONS The inactivated Vero cell culture-derived JE vaccine may be safe and effective for immunization against JE virus in children and young adults who have undergone HSCT.
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Affiliation(s)
- Surapat Assawawiroonhakarn
- From the Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Samart Pakakasama
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suradej Hongeng
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Usanarat Anurathapan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sutee Yoksan
- Center for Vaccine Development, Mahidol University, Nakhon Pathom, Thailand
| | - Chompunuch Klinmalai
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pattarana Sae-Chew
- Research Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonnamet Techasaensiri
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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CMV-Reactive NK Cells in Pediatric Post-Hematopoietic Stem Cell Transplant. Transplant Proc 2020; 52:353-359. [DOI: 10.1016/j.transproceed.2019.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/21/2019] [Accepted: 11/10/2019] [Indexed: 12/19/2022]
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Bruminhent J, Srisala S, Klinmalai C, Pinsai S, Watcharananan SP, Kantachuvesiri S, Hongeng S, Apiwattanakul N. BK Polyomavirus-specific T cell immune responses in kidney transplant recipients diagnosed with BK Polyomavirus-associated nephropathy. BMC Infect Dis 2019; 19:974. [PMID: 31744480 PMCID: PMC6862809 DOI: 10.1186/s12879-019-4615-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 11/04/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Adjustment of immunosuppression is the main therapy for BK polyomavirus (BKPyV)-associated nephropathy (BKPyVAN) after kidney transplantation (KT). Studies of BKPyV-specific T cell immune response are scarce. Here, we investigated BKPyV-specific T cell immunity in KT recipients diagnosed with BKPyVAN. METHODS All adult KT recipients with BKPyVAN diagnosed at our institution from January 2017 to April 2018 were included. Laboratory-developed intracellular cytokine assays measuring the percentage of IFN-γ-producing CD4+ and CD8+ T cells, after stimulation with large-T antigen (LT) and viral capsid protein 1 (VP1), were performed both at the time of diagnosis and after adjustment of immunosuppression. RESULTS We included 12 KT recipients diagnosed with BKPyVAN (7 proven, 4 presumptive, and 1 possible). Those with presumptive BKPyVAN had a median plasma BKPyV DNA load of 5.9 log10 copies/ml (interquartile range [IQR]: 4.9-6.1). Adjusted dosing of mycophenolic acid and tacrolimus with (86%) or without (14%) adjunctive therapies were implemented after diagnosis. There was a significantly higher median percentage of IFN-γ-producing CD4+ T cells to LT at a median of 3 (IQR: 1-4) months after adjustment of immunosuppression compared with at the time of diagnosis (0.004 vs. 0.015; p = 0.047). However, the difference between the median percentage of IFN-γ-producing CD4+ T cells to VP1 and CD8+ T cells to LT and VP1 did not reach statistical significance. Four (33%) patients achieved plasma BKPyV DNA clearance, and the remaining eight (67%) patients had persistent BKPyV DNAemia. Although eight (67%) patients developed allograft dysfunction, none required hemodialysis. CONCLUSIONS We observed a marginal trend of BKPyV-specific CD4+ T cell recovery after adjustment of immunosuppression in KT recipients diagnosed with BKPyVAN. A further study would be benefited to confirm and better assess BKPyV-specific immune response after KT.
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Affiliation(s)
- Jackrapong Bruminhent
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
- Excellence Center of Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Supranart Srisala
- Research Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chompunut Klinmalai
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Subencha Pinsai
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Siriorn P Watcharananan
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Kantachuvesiri
- Excellence Center of Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suradej Hongeng
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Bruminhent J, Apiwattanakul N, Hongeng S, Kantachuvesiri S, Watcharananan SP. Absolute lymphocyte count and human adenovirus-specific T-cell immune restoration of human adenovirus infection after kidney transplantation. J Med Virol 2019; 91:1432-1439. [PMID: 30905076 DOI: 10.1002/jmv.25468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Human adenovirus (HAdV) infection can cause substantial morbidity in kidney transplant (KT) recipients. Cell-mediated immunity plays an important role in controlling HAdV infection after KT. METHODS We prospectively (January 2015 to June 2018) investigated the absolute lymphocyte count (ALC) and interferon-γ-producing CD4+ and CD8 + T cells at diagnosis and at viral clearance by an intracellular cytokine assay after stimulating with HAdV whole lysate, hexon, and penton proteins. HAdV infection was defined as the presence of HAdV DNA load in plasma or clinical specimens measured by the polymerase chain reaction assay. RESULTS Eighteen adult KT recipients were diagnosed with HAdV infection at a median of 16 months (interquartile range [IQR], 2-39) after KT. The majority (94%) had HAdV-associated hemorrhagic cystitis. The median ALC at viral clearance was significantly higher compared with diagnosis (2257 cells/mm3 [IQR, 1544-3078] vs 1001 cells/mm3 [IQR, 641-1385]; P < 0.001). Eleven patients underwent measurement of the HAdV-specific T-cell response. The median numbers of CD4+ and CD8+ T cells at viral clearance were significantly higher compared with diagnosis (448 cells/mm3 [IQR, 248-651] vs 215 cells/mm3 [IQR, 159-272], P = 0.02; and 623 cells/mm3 [IQR, 242-772] vs 235 cells/mm3 [IQR, 129-266], P < 0.01), respectively. The median percentages of penton-specific CD4+ and hexon-specific CD8+ T cells at viral clearance were significantly higher compared with diagnosis (0.012% vs 0%, P = 0.03%; and 0.136% vs 0.016%, P = 0.003, respectively). CONCLUSIONS Our findings suggest a trend of ALC and HAdV-specific T-cell immune restoration in KT recipients who achieve successful HAdV clearance.
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Affiliation(s)
- Jackrapong Bruminhent
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Excellence Center of Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suradej Hongeng
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Kantachuvesiri
- Excellence Center of Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Siriorn P Watcharananan
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Hannick JH, Koyle MA. Canadian Urological Association Best Practice Report: Pediatric hemorrhagic cystitis. Can Urol Assoc J 2019; 13:E325-E334. [PMID: 31763977 DOI: 10.5489/cuaj.5993] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Jessica H Hannick
- Division of Pediatric Urology, UH Rainbow Babies and Children's Hospital, Cleveland, OH, United States.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Martin A Koyle
- The Hospital for Sick Children, Toronto, ON, Canada.,Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
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