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Yilmaz ZB, Memisoglu F, Akbulut S. Management of cytomegalovirus infection after liver transplantation. World J Transplant 2024; 14:93209. [DOI: 10.5500/wjt.v14.i3.93209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/05/2024] [Accepted: 05/27/2024] [Indexed: 07/31/2024] Open
Abstract
Cytomegalovirus (CMV) infection is one of the primary causes of morbidity and mortality following liver transplantation (LT). Based on current worldwide guidelines, the most effective strategies for avoiding post-transplant CMV infection are antiviral prophylaxis and pre-emptive treatment. CMV- IgG serology is the established technique for pretransplant screening of both donors and recipients. The clinical presentation of CMV infection and disease exhibits variability, prompting clinicians to consistently consider this possibility, particularly within the first year post-transplantation or subsequent to heightened immunosuppression. At annual symposia to discuss CMV prevention and how treatment outcomes can be improved, evidence on the incorporation of immune functional tests into clinical practice is presented, and the results of studies with new antiviral treatments are evaluated. Although there are ongoing studies on the use of letermovir and maribavir in solid organ transplantation, a consensus reflected in the guidelines has not been formed. Determining the most appropriate strategy at the individual level appears to be the key to enhancing outcomes. Although prevention strategies reduce the risk of CMV disease, the disease can still occur in up to 50% of high-risk patients. A balance between the risk of infection and disease development and the use of immunosuppressants must be considered when talking about the proper management of CMV in solid organ transplant recipients. The objective of this study was to establish a comprehensive framework for the management of CMV in patients who have had LT.
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Affiliation(s)
- Zeynep Burcin Yilmaz
- Infectious Diseases and Clinical Microbiology, Inonu University Faculty of Medicine, Malatya 44280, Türkiye
| | - Funda Memisoglu
- Infectious Diseases and Clinical Microbiology, Inonu University Faculty of Medicine, Malatya 44280, Türkiye
| | - Sami Akbulut
- Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Türkiye
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Blom KB, Birkeland GK, Midtvedt K, Jenssen TG, Reisæter AV, Rollag H, Hartmann A, Sagedal S, Sjaastad I, Tylden G, Njølstad G, Nilsen E, Christensen A, Åsberg A, Birkeland JA. Cytomegalovirus High-risk Kidney Transplant Recipients Show No Difference in Long-term Outcomes Following Preemptive Versus Prophylactic Management. Transplantation 2023; 107:1846-1853. [PMID: 37211633 PMCID: PMC10358437 DOI: 10.1097/tp.0000000000004615] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Following kidney transplantation (KT), cytomegalovirus (CMV) infection remains an important challenge. Both prophylactic and preemptive antiviral protocols are used for CMV high-risk kidney recipients (donor seropositive/recipient seronegative; D+/R-). We performed a nationwide comparison of the 2 strategies in de novo D+/R- KT recipients accessing long-term outcomes. METHODS A nationwide retrospective study was conducted from 2007 to 2018, with follow-up until February 1, 2022. All adult D+/R- and R+ KT recipients were included. During the first 4 y, D+/R- recipients were managed preemptively, changing to 6 mo of valganciclovir prophylaxis from 2011. To adjust for the 2 time eras, de novo intermediate-risk (R+) recipients, who received preemptive CMV therapy throughout the study period, served as longitudinal controls for possible confounders. RESULTS A total of 2198 KT recipients (D+/R-, n = 428; R+, n = 1770) were included with a median follow-up of 9.4 (range, 3.1-15.1) y. As expected, a greater proportion experienced a CMV infection in the preemptive era compared with the prophylactic era and with a shorter time from KT to CMV infection ( P < 0.001). However, there were no differences in long-term outcomes such as patient death (47/146 [32%] versus 57/282 [20%]; P = 0.3), graft loss (64/146 [44%] versus 71/282 [25%]; P = 0.5), or death censored graft loss (26/146 [18%] versus 26/282 [9%]; P = 0.9) in the preemptive versus prophylactic era. Long-term outcomes in R+ recipients showed no signs of sequential era-related bias. CONCLUSIONS There were no significant differences in relevant long-term outcomes between preemptive and prophylactic CMV-preventive strategies in D+/R- kidney transplant recipients.
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Affiliation(s)
- Kjersti B. Blom
- Department of Nephrology, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute for Experimental Medical Research, KG Jebsen Center for Cardiac Research, Oslo University Hospital, Ullevål and University of Oslo, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Karsten Midtvedt
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Trond G. Jenssen
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anna V. Reisæter
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Halvor Rollag
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Solbjørg Sagedal
- Department of Nephrology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Ivar Sjaastad
- Institute for Experimental Medical Research, KG Jebsen Center for Cardiac Research, Oslo University Hospital, Ullevål and University of Oslo, Oslo, Norway
| | - Garth Tylden
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Gro Njølstad
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Einar Nilsen
- Department of Microbiology, Møre and Romsdal Hospital Trust, Molde, Norway
| | - Andreas Christensen
- Department of Medical Microbiology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- The Norwegian Renal Registry, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Jon A. Birkeland
- Department of Nephrology, Oslo University Hospital, Ullevål, Oslo, Norway
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Kumar L, Murray-Krezan C, Singh N, Brennan DC, Rakita RM, Dasgupta S, Fisher CE, Limaye AP. A Systematic Review and Meta-analysis of Optimized CMV Preemptive Therapy and Antiviral Prophylaxis for CMV Disease Prevention in CMV High-Risk (D+R-) Kidney Transplant Recipients. Transplant Direct 2023; 9:e1514. [PMID: 37456587 PMCID: PMC10348730 DOI: 10.1097/txd.0000000000001514] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023] Open
Abstract
The optimal strategy for cytomegalovirus (CMV) disease prevention in CMV donor/recipient kidney transplant recipients remains uncertain. Conclusions of prior meta-analyses that CMV disease rates with preemptive therapy (PET) and universal prophylaxis (UP) were comparable may have been affected by inclusion of studies lacking key determinants of efficacy of the respective strategies. Methods We conducted a systematic review and meta-analysis of PET with weekly CMV polymerase chain reaction monitoring for ≥3 mo and UP with 6 mo of valganciclovir. PubMed and Embase databases were reviewed from January 1, 2010, to April 1, 2022. Risk of bias was assessed with 3 instruments (Cochrane RoB, Cochrane RoBINS-I, and an instrument for assessing risk in observational studies). The primary outcome was CMV disease incidence by 1-y posttransplant. Secondary outcomes by 1-y were graft loss, acute allograft rejection, and mortality. Results were synthesized using generalized linear mixed model meta-analysis. PET studies were stratified into low-threshold (LT) and high-threshold (HT) PET based on the viral load threshold for initiation of antiviral therapy. Results Twenty-five studies met inclusion criteria (6 PET, 19 UP). CMV disease incidence was significantly higher in HT (0.30 [95% confidence interval (CI), 0.22-0.39]) versus LT PET (0.06 [95% CI, 0.03-0.12]). LT PET was associated with a significantly lower CMV disease incidence (0.06 [95% CI, 0.03-0.12]) versus UP (0.21 [95% CI, 0.17-0.27]). Incidence of graft loss, acute allograft rejection, or mortality was not significantly different between LT PET and UP (P > 0.05 for all comparisons). Receipt of lymphocyte-depleting antibodies was not associated with a significant difference in CMV disease incidence (odds ratio = 1.34 [95% CI, 0.80-2.25]). Conclusions LT PET is associated with a significantly lower incidence of CMV disease compared to UP with similar rates of other clinical outcomes. These findings provide rationale and preliminary data for a randomized superiority trial of optimized LT-PET versus UP in donor seropositive recipient seronegative kidney transplant recipients.
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Affiliation(s)
- Lakshin Kumar
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
| | - Cristina Murray-Krezan
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nina Singh
- Department of Medicine, VA Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, PA
| | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert M. Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
| | - Sayan Dasgupta
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Cynthia E. Fisher
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
| | - Ajit P. Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
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Cytomegalovirus and other herpesviruses after hematopoietic cell and solid organ transplantation: From antiviral drugs to virus-specific T cells. Transpl Immunol 2022; 71:101539. [PMID: 35051589 DOI: 10.1016/j.trim.2022.101539] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 12/13/2022]
Abstract
Herpesviruses can either cause primary infection or may get reactivated after both hematopoietic cell and solid organ transplantations. In general, viral infections increase post-transplant morbidity and mortality. Prophylactic, preemptive, or therapeutically administered antiviral drugs may be associated with serious side effects and may induce viral resistance. Virus-specific T cells represent a valuable addition to antiviral treatment, with high rates of response and minimal side effects. Even low numbers of virus-specific T cells manufactured by direct selection methods can reconstitute virus-specific immunity after transplantation and control viral replication. Virus-specific T cells belong to the advanced therapy medicinal products, and their production is regulated by appropriate legislation; also, strict safety regulations are required to minimize their side effects.
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Ruenroengbun N, Numthavaj P, Sapankaew T, Chaiyakittisopon K, Ingsathit A, Mckay GJ, Attia J, Thakkinstian A. Efficacy and safety of conventional antiviral agents in preventive strategies for cytomegalovirus infection after kidney transplantation: a systematic review and network meta-analysis. Transpl Int 2021; 34:2720-2734. [PMID: 34580930 PMCID: PMC9298054 DOI: 10.1111/tri.14122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/27/2021] [Accepted: 09/03/2021] [Indexed: 02/03/2023]
Abstract
Cytomegalovirus (CMV) infection is common in kidney transplantation (KT). Antiviral-agents are used as universal prophylaxis. Our purpose aimed to compare and rank efficacy and safety. MEDLINE, Embase, SCOPUS, and CENTRAL were used from inception to September 2020 regardless language restriction. We included randomized clinical trials (RCTs) comparing the CMV infection/disease prophylaxis among antiviral-agents in adult KT recipients. Of 24 eligible RCTs, prophylactic valganciclovir (VGC) could significantly lower the overall CMV infection and disease risks than placebo with pooled risk differences (RDs) [95% confidence interval (CI)] of -0.36 (-0.54, -0.18) and -0.28 (-0.48, -0.08), respectively. Valacyclovir (VAC) and ganciclovir (GC) significantly decreased risks with the corresponding RDs of -0.25 (-0.32, -0.19) and -0.30 (-0.37, -0.22) for CMV infection and -0.26 (-0.40, -0.12) and -0.22 (-0.31, -0.12) for CMV disease. For subgroup analysis by seropositive-donor and seronegative-recipient (D+/R-), VGC and GC significantly lowered the risk of CMV infection/disease with RDs of -0.42 (-0.84, -0.01) and -0.35 (-0.60, -0.12). For pre-emptive strategies, GC lowered the incidence of CMV disease significantly with pooled RDs of -0.33 (-0.47, -0.19). VGC may be the best in prophylaxis of CMV infection/disease follow by GC. VAC might be an alternative where VGC and GC are not available.
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Affiliation(s)
- Narisa Ruenroengbun
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Pharmaceutics, Clinical Pharmacy, Slipakorn University, Nakorn Prathom, Thailand
| | - Pawin Numthavaj
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tunlanut Sapankaew
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kamolpat Chaiyakittisopon
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Community Pharmacy and Administrations, Faculty of Pharmacy, Slipakorn University, Nakorn Prathom, Thailand
| | - Atiporn Ingsathit
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Gareth J Mckay
- School of Medicine, Dentistry and Biomedical Sciences, Center for Public Health, Queen's University Belfast, Belfast, UK
| | - John Attia
- School of Medicine and Public Health, Centre for Clinical Epidemiology and Biostatistics, Hunter Medical Research Institute, University of Newcastle, New Lambton, NSW, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Hemmersbach-Miller M, Alexander BD, Pieper CF, Schmader KE. Age matters: older age as a risk factor for CMV reactivation in the CMV serostatus-positive kidney transplant recipient. Eur J Clin Microbiol Infect Dis 2019; 39:455-463. [PMID: 31758441 DOI: 10.1007/s10096-019-03744-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/17/2019] [Indexed: 12/29/2022]
Abstract
Evaluate risk factors for cytomegalovirus (CMV) reactivation during the first year after kidney transplantation in the CMV-seropositive older recipient. Retrospective single-center study. Between 2011 and 2015, 91 patients ≥ 65 years received a kidney transplant; these were matched with 91 controls, aged 40-60. Risk of CMV reactivation in the CMV-seropositive recipients was analyzed. Sixty-three older and 54 younger recipients were included; 50% had received CMV-directed prophylaxis. CMV reactivation was significantly more frequent in the older group (71.4% vs 44.4%, p = 0.003) and occurred earlier (p = 0.003). A multivariate model showed that only age was associated with CMV reactivation (OR 2.48, p = 0.03). After excluding patients that received thymoglobulin, older age group remained the only risk factor of CMV reactivation (OR 3.81, p = 0.014). Recurrent event analysis showed that the older cohort had an HR of 1.94 (p = 0.01) of CMV viremia; there was significant episode-cohort interaction (p < 0.01). While the older group had a higher risk of infection (HR = 2.43), after the initial episode the relative hazards were approximately equal (HR = 1.08, at period 2). This suggests that it is key to specifically avoid the first episode of reactivation. Universal prophylaxis or a hybrid prophylaxis model should be considered in the CMV-seropositive kidney transplant recipient aged ≥ 65 years.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
| | - Barbara D Alexander
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Carl F Pieper
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center, Durham, NC, USA.,GRECC, Durham VA, Durham, NC, USA
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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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[Benefits and risks of early versus late ureteric stent removal after kidney transplantation]. Urologe A 2019; 58:168-171. [PMID: 30666384 DOI: 10.1007/s00120-019-0856-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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