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Belga S, Hernandez C, Kabbani D, Cervera C. Incidence of valganciclovir-related leukopenia and neutropenia in solid organ transplant recipients at high risk of cytomegalovirus disease. Transpl Infect Dis 2024; 26:e14227. [PMID: 38180285 DOI: 10.1111/tid.14227] [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: 02/11/2023] [Accepted: 02/12/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Valganciclovir (VGCV) prophylaxis is associated with an increased risk of hematologic side effects. We analyzed the impact of VGCV prophylaxis on leukopenia and neutropenia rates and explored risk factors for its occurrence. METHODS Retrospective cohort study of adult cytomegalovirus (CMV)-seronegative solid organ transplantation (SOT) recipients of either CMV-seropositive (CMV D+/R-) or CMV-seronegative (CMV D-/R-) donors between July 2005 and March 2019. CMV D+/R- SOT recipients received 3-12 months of VGCV prophylaxis whereas CMV D-/R- SOT recipients received no VGCV prophylaxis. Competing risk regression was used to calculate risk factors for significant neutropenia (neutrophil count < 1000/μL). RESULTS A total of 430 CMV-seronegative SOT recipients (median age of 52.1 years, 76.5% males) were included, of which 203 (47.2%) were CMV D+/R- and 227 (52.8%) CMV D-/R-. The unadjusted incidence rate ratio of significant neutropenia attributable to VGCV exposure in the first year post-transplant was 13.50 (95% confidence interval 7.36-27.11). Acute rejection occurred more frequently in neutropenic patients at 32.5% compared to 19.1% in those without neutropenia (p = .033). On multivariate analysis, VGCV prophylaxis for 1-90 days and 91-180 days versus no VGCV were the strongest risk factors for significant neutropenia with a sub-distribution hazard ratio of 39.6 (95% CI, 8.57-182.6) and 13.2 (95% CI, 5.46-32.0), respectively. CONCLUSIONS VGCV prophylaxis is limited by high rates of neutropenia. Future prospective studies are needed to assess alternative CMV prophylactic strategies in SOT recipients.
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Affiliation(s)
- Sara Belga
- Department of Medicine, Division of Infectious Diseases, University of British Columbia, Vancouver, Canada
- Immunity and Infection Research Centre, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | | | - Dima Kabbani
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, Canada
| | - Carlos Cervera
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, Canada
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Stewart AG, Kotton CN. What's New: Updates on Cytomegalovirus in Solid Organ Transplantation. Transplantation 2024; 108:884-897. [PMID: 37899366 DOI: 10.1097/tp.0000000000004855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Cytomegalovirus (CMV) is one of the most common infections occurring after solid organ transplantation. This high burden of disease, which incurs sizeable morbidity, may be worsening with the proportion of high-risk D+/R- solid organ transplantation recipients increasing in some regions globally. Cohort studies continue to support either universal prophylaxis or preemptive therapy as effective prevention strategies. Letermovir prophylaxis was noninferior to valganciclovir in adult high-risk D+/R- kidney transplant recipients with fewer drug-related adverse events in a recent clinical trial and has now been approved for such use in some regions. Maribavir preemptive therapy failed to demonstrate noninferiority when compared with valganciclovir in hematopoietic stem cell transplant recipients but looked promising for safety. Donor matching could be useful in prevention CMV disease with a survival advantage demonstrated in seronegative recipients waiting up to 30 mo for a seronegative kidney. Immune-guided prophylaxis resulted in fewer CMV infection episodes in lung transplant recipients when compared with fixed-duration prophylaxis in a recent clinical trial. For treatment of refractory or resistant CMV infection, maribavir was more efficacious and better tolerated when compared with investigator-initiated therapy in its registration trial for this condition. Further research regarding best treatment and prophylaxis of resistant or refractory CMV infection is needed to reflect best clinical practice choices. Optimal use of immune globulin or CMV-specific T cells for prevention or treatment of CMV disease remains undefined. Standardized definitions for the design of CMV clinical trials have been developed. In this review, we highlight recent updates in the field from data published since 2018.
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Affiliation(s)
- Adam G Stewart
- Centre for Clinical Research, Faculty of Medicine, University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, QLD, Australia
| | - Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Batra J, DeFilippis EM, Golob S, Lumish H, Clerkin K, Topkara VK, Restaino S, Lee SH, Latif F, Raikhelkar J, Fried J, Oh KT, Lin E, Colombo PC, Yuzefpolskaya M, Sayer G, Uriel N. Early post-transplant leukopenia in heart transplant recipients and its impact on outcomes. Clin Transplant 2023; 37:e14934. [PMID: 36798992 DOI: 10.1111/ctr.14934] [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: 11/10/2022] [Revised: 01/11/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Leukopenia in the early period following heart transplantation (HT) is not well-studied. The aim of this study was to evaluate risk factors for the development of post-transplant leukopenia and its consequences for HT recipients. METHODS Adult patients at a large-volume transplant center who received HT between January 1, 2010 and December 31, 2020 were included. The incidence of leukopenia (WBC ≤3 × 103 /μL) in the first 90-days following HT, individual risk factors, and its effect on 1-year outcomes were evaluated. RESULTS Of 506 HT recipients, 184 (36%) developed leukopenia within 90-days. Median duration of the first leukopenia episode was 15.5 days (IQR 8-42.5 days). Individuals who developed leukopenia had lower pre-transplant WBC counts compared to those who did not (6.1 × 103 /μL vs. 6.9 × 103 /μL, p = .02). Initial immunosuppressive and infectious chemoprophylactic regimens were not significantly different between groups. Early leukopenia was associated with a higher mortality at 1-year (6.6% vs. 2.1%, p = .008; adjusted HR 3.0) and an increased risk of recurrent episodes. Rates of infection and rejection were not significantly different between the two groups. CONCLUSIONS Leukopenia in the early period following HT is common and associated with an increased risk of mortality. Further study is needed to identify individuals at highest risk for leukopenia prior to transplant and optimize immunosuppressive and infectious chemoprophylactic regimens for this subgroup.
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Affiliation(s)
- Jaya Batra
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Stephanie Golob
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Heidi Lumish
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kevin Clerkin
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Susan Restaino
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Sun Hi Lee
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Farhana Latif
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jayant Raikhelkar
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Justin Fried
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kyung Taek Oh
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Edward Lin
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Otokubo M, Wada K, Ikura M, Hayase K, Uno T, Nakagita K, Hayakawa N, Watanabe T, Seguchi O, Fukushima N, Nakamura T. Risk Assessment of Neutropenia during Low-Dose Valganciclovir Prophylaxis for Heart Transplant Recipients. Biol Pharm Bull 2022; 45:452-459. [DOI: 10.1248/bpb.b21-00860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Mai Otokubo
- Education and Research Center for Clinical Pharmacy, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University
| | - Kyoichi Wada
- Education and Research Center for Clinical Pharmacy, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University
| | - Megumi Ikura
- Department of Pharmacy, National Cerebral and Cardiovascular Center
| | - Kotoka Hayase
- Education and Research Center for Clinical Pharmacy, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University
| | - Takaya Uno
- Department of Pharmacy, National Cerebral and Cardiovascular Center
| | - Kazuki Nakagita
- Department of Pharmacy, National Cerebral and Cardiovascular Center
| | - Naoki Hayakawa
- Department of Pharmacy, National Cerebral and Cardiovascular Center
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Osamu Seguchi
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Tsutomu Nakamura
- Education and Research Center for Clinical Pharmacy, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University
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