1
|
Schweitzer L, Muranski P. Virus-specific T cell therapy to treat refractory viral infections in solid organ transplant recipients. Am J Transplant 2024:S1600-6135(24)00347-2. [PMID: 38857784 DOI: 10.1016/j.ajt.2024.05.019] [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: 02/09/2024] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 06/12/2024]
Abstract
Solid organ transplant recipients require ongoing immunosuppression to prevent acute rejection, which puts them at risk of opportunistic infections. Viral infections are particularly challenging to prevent and treat as many establish latency and thus cannot be eliminated, whereas targets for small molecule antiviral medications are limited. Resistance to antivirals and unacceptable toxicity also complicate treatment. Virus-specific T cell therapies aim to restore host-specific immunity to opportunistic viruses that is lacking due to ongoing immunosuppressive therapy. This minireview will provide a state-of-the-art update of the current virus-specific T cell pipeline and translational research that is likely to lead to further treatment options for viral infections in solid organ transplant recipients.
Collapse
Affiliation(s)
- Lorne Schweitzer
- Department of Medicine, Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York, USA; Columbia Center for Translational Immunology, New York, New York, USA
| | - Pawel Muranski
- Department of Medicine, Division of Hematology, Columbia University Irving Medical Center, New York, New York, USA; Columbia Center for Translational Immunology, New York, New York, USA.
| |
Collapse
|
2
|
Heldman MR, Dunn B, Clemens E, Henderson M, Fisher CE, Rakita RM, Kling CE, Limaye AP. A practical guide to real-world implementation of pre-emptive therapy for Cytomegalovirus disease prevention in high-risk seronegative liver transplant recipients with seropositive donors. Transpl Infect Dis 2024; 26:e14229. [PMID: 38214192 PMCID: PMC11187685 DOI: 10.1111/tid.14229] [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: 10/07/2023] [Revised: 12/14/2023] [Accepted: 12/16/2023] [Indexed: 01/13/2024]
Abstract
The Comparison of Antiviral Preventative Strategies In Liver Transplant (CAPSIL) study showed pre-emptive therapy (PET) to be superior to antiviral prophylaxis for Cytomegalovirus (CMV) disease prevention in high-risk CMV seronegative liver transplant recipients (LTRs) with seropositive donors (D+R-). Despite the statistical superiority of PET over prophylaxis in research settings, PET is perceived as a logistically more complex strategy that requires careful coordination of weekly CMV PCR testing, prompt initiation of CMV antivirals upon viremia detection, and timely cessation of antivirals following viremia resolution. Transplant centers may be hesitant to use PET for CMV disease prevention in D+R- LTRs out of concern that PET coordination is not feasible in clinical practice. We recently described our experience using PET in CMV D+R- LTRs in a real-world setting, and found it to be as effective for CMV disease prevention as PET performed as part of a clinical trial. Here, we describe a systematic approach for PET implementation in real-world settings and provide practical tools to address anticipated challenges. This framework can support transplant programs in overcoming logistical barriers to PET and incorporating an evidence-based and cost-effective CMV prevention strategy into routine care for high-risk CMV D+R- LTRs.
Collapse
Affiliation(s)
- Madeleine R. Heldman
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, NC, USA
| | - Bailey Dunn
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - Evan Clemens
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Megan Henderson
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Cynthia E. Fisher
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Robert M. Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Catherine E. Kling
- Division of Transplant Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ajit P. Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
3
|
Chung MC, Chen CH, Chang SS, Lee CY, Tian YC, Wu MY, Wang HH, Yu CC, Chen TW, Kao CC, Hsu CY, Chiang YJ, Wu MJ, Chen YT, Wu MS. Prevention and management of cytomegalovirus infection and disease in kidney transplant: A consensus statement of the Transplantation Society of Taiwan. J Formos Med Assoc 2024:S0929-6646(24)00245-6. [PMID: 38777672 DOI: 10.1016/j.jfma.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/24/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Kidney transplant recipients have an increased risk of cytomegalovirus (CMV) infection and disease. A strategy for mitigating the risk of CMV infection in kidney transplant recipients has not yet been established in Taiwan. The Transplantation Society of Taiwan aimed to develop a consensus by expert opinion on the prevention and management of CMV infection. Based on the results of Consensus Conference, we suggested low-dose valganciclovir prophylaxis (450 mg once daily) for kidney transplant recipients. The prophylaxis duration was ≥6 months for high-risk (D+/R-) patients and 3 months for moderate-risk (R+) patients. Even for low-risk (D-/R-) patients, prophylaxis for at least 3 months is recommended because of the high seroprevalence of CMV in Taiwan. CMV prophylaxis was suggested after anti-thymocyte globulin treatment but not after methylprednisolone pulse therapy. Routine surveillance after prophylaxis, secondary prophylaxis after CMV disease treatment, and mTOR inhibitors for primary CMV prophylaxis were not recommended. Letermovir and marabavir are emerging CMV agents used for prophylaxis and refractory CMV disease. CMV immunoglobulins have been used to treat refractory CMV disease in Taiwan. We hope this consensus will help professionals manage patients with CMV in Taiwan to improve the quality of care.
Collapse
Affiliation(s)
- Mu-Chi Chung
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Ph.D. Program in Tissue Engineering and Regenerative Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; Department of Life Science, Tunghai University, Taichung, Taiwan
| | - Shen-Shin Chang
- Division of Transplantation, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Yuan Lee
- Department of Surgery, National Taiwan University Hospital, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center and Department of Nephrology Linkou Chang Aging Memorial Hospital, Taiwan
| | - Mei-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan; Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
| | - Hsu-Han Wang
- Department of Urology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Cheng Yu
- Division of Urology, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Teng-Wei Chen
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Chang Kao
- Division of Urology, Department of Surgery, Tri-service General Hospital, National Defense Medical, Taiwan
| | - Chih-Yang Hsu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Taiwan
| | - Yang-Jen Chiang
- Department of Urology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Ju Wu
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yen-Ta Chen
- Division of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan; TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
4
|
Cochran WV, Dioverti MV, Langlee J, Barker LN, Shedeck A, Toman LP, Avery RK. Approaches and Challenges in the Current Management of Cytomegalovirus in Transplant Recipients: Highlighting the Role of Advanced Practice Providers (Nurse Practitioners and Physician Assistants). Ann Transplant 2024; 29:e941185. [PMID: 38650316 PMCID: PMC11055468 DOI: 10.12659/aot.941185] [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: 05/22/2023] [Accepted: 01/22/2024] [Indexed: 04/25/2024] Open
Abstract
Cytomegalovirus (CMV) infection is associated with increased morbidity and mortality in hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients, with traditional anti-CMV therapies limited by their associated toxicities and the development of resistance. Clinical providers are often faced with challenging and complicated CMV infections that require multiple courses of antiviral therapies. Increasingly, advanced practice providers (APPs) are playing an important role in the day-to-day management of transplant recipients with CMV infection, including resistant/refractory CMV and other complex CMV syndromes. Here, we provide an overview of current preventative and treatment strategies for CMV infection in HCT and SOT recipients, highlighting the challenging aspects of current management and the potential utility of newer antiviral agents. This article also focuses on how a multidisciplinary team, orchestrated by APPs, can improve CMV-associated patient outcomes. Protocols using antiviral agents for the prevention or treatment of CMV infections require carefully designed and meticulously implemented strategies to ensure the best clinical outcomes for patients. APPs, who have increasingly become the frontline providers of outpatient care for transplant recipients, are ideally positioned to design and carry out these protocols.
Collapse
Affiliation(s)
- Willa V. Cochran
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Julie Langlee
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Audra Shedeck
- Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lindsey P. Toman
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Robin K. Avery
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| |
Collapse
|
5
|
Krueger MB, Bonifacius A, Dragon AC, Santamorena MM, Nashan B, Taubert R, Kalinke U, Maecker-Kolhoff B, Blasczyk R, Eiz-Vesper B. In Vitro Profiling of Commonly Used Post-transplant Immunosuppressants Reveals Distinct Impact on Antiviral T-cell Immunity Towards CMV. Transpl Int 2024; 37:12720. [PMID: 38655204 PMCID: PMC11035762 DOI: 10.3389/ti.2024.12720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/27/2024] [Indexed: 04/26/2024]
Abstract
Infectious complications, including widespread human cytomegalovirus (CMV) disease, frequently occur after hematopoietic stem cell and solid organ transplantation due to immunosuppressive treatment causing impairment of T-cell immunity. Therefore, in-depth analysis of the impact of immunosuppressants on antiviral T cells is needed. We analyzed the impact of mTOR inhibitors sirolimus (SIR/S) and everolimus (EVR/E), calcineurin inhibitor tacrolimus (TAC/T), purine synthesis inhibitor mycophenolic acid (MPA/M), glucocorticoid prednisolone (PRE/P) and common double (T+S/E/M/P) and triple (T+S/E/M+P) combinations on antiviral T-cell functionality. T-cell activation and effector molecule production upon antigenic stimulation was impaired in presence of T+P and triple combinations. SIR, EVR and MPA exclusively inhibited T-cell proliferation, TAC inhibited activation and cytokine production and PRE inhibited various aspects of T-cell functionality including cytotoxicity. This was reflected in an in vitro infection model, where elimination of CMV-infected human fibroblasts by CMV-specific T cells was reduced in presence of PRE and all triple combinations. CMV-specific memory T cells were inhibited by TAC and PRE, which was also reflected with double (T+P) and triple combinations. EBV- and SARS-CoV-2-specific T cells were similarly affected. These results highlight the need to optimize immune monitoring to identify patients who may benefit from individually tailored immunosuppression.
Collapse
Affiliation(s)
- Markus Benedikt Krueger
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Agnes Bonifacius
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
| | - Anna Christina Dragon
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Maria Michela Santamorena
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Björn Nashan
- Clinic for Hepatopancreaticobiliary Surgery and Transplantation, First Affiliated Hospital, University of Science and Technology of China, Hefei, China
| | - Richard Taubert
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Ulrich Kalinke
- TWINCORE, Centre for Experimental and Clinical Infection Research, A Joint Venture Between the Helmholtz Centre for Infection Research and the Hannover Medical School, Hannover, Germany
| | - Britta Maecker-Kolhoff
- German Center for Infection Research (DZIF), Braunschweig, Germany
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Britta Eiz-Vesper
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Braunschweig, Germany
| |
Collapse
|
6
|
Grossi PA, Peghin M. Recent advances in cytomegalovirus infection management in solid organ transplant recipients. Curr Opin Organ Transplant 2024; 29:131-137. [PMID: 38288947 PMCID: PMC10919264 DOI: 10.1097/mot.0000000000001139] [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] [Indexed: 03/08/2024]
Abstract
PURPOSE OF REVIEW Human cytomegalovirus (CMV) continues to be the most important infectious complication following solid organ transplantation (SOT). RECENT FINDINGS Universal prophylaxis and preemptive therapy are the most adopted strategies for prevention of CMV disease globally. Prophylaxis with valganciclovir is the most widely used approach to CMV prevention, however leukopenia and late onset CMV disease after discontinuation of prophylaxis requires new strategies to prevent this complication. The use of assays detecting CMV-specific T cell-mediated immunity may individualize the duration of antiviral prophylaxis after transplantation. Letermovir has been recently approved for prophylaxis in kidney transplant recipients. CMV-RNAemia used together with CMV-DNAemia in the viral surveillance of CMV infection provides accurate information on viral load kinetics, mostly in patients receiving letermovir prophylaxis/therapy. The development of refractory and resistant CMV infection remains a major challenge and a new treatment with maribavir is currently available. In the present paper we will review the most recent advances in prevention and treatment of CMV diseases in SOT recipients. SUMMARY Recent findings, summarized in the present paper, may be useful to optimize prevention and treatment of CMV infection in SOT.
Collapse
Affiliation(s)
- Paolo Antonio Grossi
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy
| | | |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Hardinger KL, Brennan DC. Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches. Ann Pharmacother 2024:10600280241237534. [PMID: 38501850 DOI: 10.1177/10600280241237534] [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: 03/20/2024] Open
Abstract
OBJECTIVE The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation. DATA SOURCES A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation. STUDY SELECTION AND DATA EXTRACTION Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded. DATA SYNTHESIS After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV. CONCLUSIONS Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.
Collapse
Affiliation(s)
- Karen L Hardinger
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel C Brennan
- Johns Hopkins Comprehensive Transplant Center, Baltimore, MD, USA
| |
Collapse
|
9
|
Kotton CN, Torre-Cisneros J, Yakoub-Agha I. Slaying the "Troll of Transplantation"-new frontiers in cytomegalovirus management: A report from the CMV International Symposium 2023. Transpl Infect Dis 2024; 26:e14183. [PMID: 37942955 DOI: 10.1111/tid.14183] [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: 10/05/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023]
Abstract
The 2023 International CMV Symposium took place in Barcelona in May 2023. During the 2-day meeting, delegates and faculty discussed the ongoing challenge of managing the risk of cytomegalovirus infection (the Troll of Transplantation) after solid organ or hematopoietic cell transplantation. Opportunities to improve outcomes of transplant recipients by applying advances in antiviral prophylaxis or pre-emptive therapy, immunotherapy, and monitoring of cell-mediated immunity to routine clinical practice were debated and relevant educational clinical cases presented. This review summarizes the presentations, cases, and discussions from the meeting and describes how further advances are needed before the Troll of Transplantation is slain.
Collapse
Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Torre-Cisneros
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | | |
Collapse
|
10
|
Alsanea MS, Al-Qahtani AA, Almaghrabi RS, AlAbdulkareem MA, Alahideb BM, Obeid D, Alsuwairi FA, Alhamlan FS. Diagnosis of Human Cytomegalovirus Drug Resistance Mutations in Solid Organ Transplant Recipients-A Review. Diagnostics (Basel) 2024; 14:203. [PMID: 38248079 PMCID: PMC10814084 DOI: 10.3390/diagnostics14020203] [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: 05/02/2023] [Revised: 06/11/2023] [Accepted: 06/21/2023] [Indexed: 01/23/2024] Open
Abstract
Human cytomegalovirus (HCMV) infection may be asymptomatic in healthy individuals but can cause severe complications in immunocompromised patients, including transplant recipients. Breakthrough and drug-resistant HCMV infections in such patients are major concerns. Clinicians are first challenged to accurately diagnose HCMV infection and then to identify the most effective antiviral drug and determine when to initiate therapy, alter drug dosage, or switch medication. This review critically examines HCMV diagnostics approaches, particularly for immunocompromised patients, and the development of genotypic techniques to rapidly diagnose drug resistance mutations. The current standard method to identify prevalent and well-known resistance mutations involves polymerase chain reaction amplification of UL97, UL54, and UL56 gene regions, followed by Sanger sequencing. This method can confirm clinical suspicion of drug resistance as well as determine the level of drug resistance and range of cross-resistance with other drugs. Despite the effectiveness of this approach, there remains an urgent need for more rapid and point-of-care HCMV diagnosis, allowing for timely lifesaving intervention.
Collapse
Affiliation(s)
- Madain S. Alsanea
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
| | - Ahmed A. Al-Qahtani
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Reem S. Almaghrabi
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia;
| | - Maha A. AlAbdulkareem
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
| | - Basma M. Alahideb
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
| | - Dalia Obeid
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia;
| | - Feda A. Alsuwairi
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
| | - Fatimah S. Alhamlan
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia
| |
Collapse
|
11
|
Walti CS, Khanna N, Avery RK, Helanterä I. New Treatment Options for Refractory/Resistant CMV Infection. Transpl Int 2023; 36:11785. [PMID: 37901297 PMCID: PMC10600348 DOI: 10.3389/ti.2023.11785] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023]
Abstract
Despite advances in monitoring and treatment, cytomegalovirus (CMV) infections remain one of the most common complications after solid organ transplantation (SOT). CMV infection may fail to respond to standard first- and second-line antiviral therapies with or without the presence of antiviral resistance to these therapies. This failure to respond after 14 days of appropriate treatment is referred to as "resistant/refractory CMV." Limited data on refractory CMV without antiviral resistance are available. Reported rates of resistant CMV are up to 18% in SOT recipients treated for CMV. Therapeutic options for treating these infections are limited due to the toxicity of the agent used or transplant-related complications. This is often the challenge with conventional agents such as ganciclovir, foscarnet and cidofovir. Recent introduction of new CMV agents including maribavir and letermovir as well as the use of adoptive T cell therapy may improve the outcome of these difficult-to-treat infections in SOT recipients. In this expert review, we focus on new treatment options for resistant/refractory CMV infection and disease in SOT recipients, with an emphasis on maribavir, letermovir, and adoptive T cell therapy.
Collapse
Affiliation(s)
- Carla Simone Walti
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Biomedicine and Clinical Research, University and University Hospital of Basel, Basel, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Biomedicine and Clinical Research, University and University Hospital of Basel, Basel, Switzerland
| | - Robin K. Avery
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
12
|
Malahe SRK, van Kampen JJA, Manintveld OC, Hoek RAS, den Hoed CM, Baan CC, Kho MML, Verjans GMGM. Current Perspectives on the Management of Herpesvirus Infections in Solid Organ Transplant Recipients. Viruses 2023; 15:1595. [PMID: 37515280 PMCID: PMC10383436 DOI: 10.3390/v15071595] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Solid organ transplant recipients (SOTRs) are at high risk of human herpesvirus (HHV)-related morbidity and mortality due to the use of immunosuppressive therapy. We aim to increase awareness and understanding of HHV disease burden in SOTRs by providing an overview of current prevention and management strategies as described in the literature and guidelines. We discuss challenges in both prevention and treatment as well as future perspectives.
Collapse
Affiliation(s)
- S Reshwan K Malahe
- Department of Internal Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jeroen J A van Kampen
- Department of Viroscience, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Olivier C Manintveld
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Cardiology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Rogier A S Hoek
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Pulmonary Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Caroline M den Hoed
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Carla C Baan
- Department of Internal Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Marcia M L Kho
- Department of Internal Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Georges M G M Verjans
- Department of Viroscience, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- HerpeslabNL, Department of Viroscience, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| |
Collapse
|
13
|
Kotton CN, Kamar N. New Insights on CMV Management in Solid Organ Transplant Patients: Prevention, Treatment, and Management of Resistant/Refractory Disease. Infect Dis Ther 2023; 12:333-342. [PMID: 36583845 PMCID: PMC9925645 DOI: 10.1007/s40121-022-00746-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/08/2022] [Indexed: 12/31/2022] Open
Abstract
Cytomegalovirus (CMV) infection can have both direct and indirect effects after solid-organ transplantation, with a significant impact on transplant outcomes. Prevention strategies decrease the risk of CMV disease, although CMV still occurs in up to 50% of high-risk patients. Ganciclovir (GCV) and valganciclovir (VGCV) are the main drugs currently used for preventing and treating CMV. Emerging data suggest that letermovir is as effective as VGCV with fewer hematological side effects. Refractory and resistant CMV also still occur in solid-organ-transplant patients. Maribavir has been shown to be effective and have less toxicity in the treatment of refractory and resistant CMV. In this review paper, we discuss prevention strategies, refractory and resistant CMV, and drug-related side effects and their impact, as well as optimal use of novel anti-CMV therapies.
Collapse
Affiliation(s)
- Camille Nelson Kotton
- grid.32224.350000 0004 0386 9924Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, 55 Fruit Street, Cox 5, Boston, MA 02114 USA
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Nassim Kamar
- grid.414295.f0000 0004 0638 3479Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, CHU Toulouse Rangueil, TSA 50032, 31059 Toulouse Cedex 9, France
- grid.7429.80000000121866389INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Toulouse, France
- grid.15781.3a0000 0001 0723 035XPaul Sabatier University, Toulouse, France
| |
Collapse
|
14
|
Madden I, Baudouin V, Charbit M, Ranchin B, Roussey G, Novo R, Garaix F, Decramer S, Fila M, Merieau E, Vrillon I, Zaloszyc A, Hogan J, Harambat J. National survey of prevention and management of CMV infection in pediatric kidney transplantation in comparison to clinical practice guidelines. Front Pediatr 2022; 10:1057352. [PMID: 36589153 PMCID: PMC9800817 DOI: 10.3389/fped.2022.1057352] [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: 09/29/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) is one of the most frequent opportunistic infections in kidney transplant (KT) recipients and is a risk factor for patient and graft survival after KT. Center-to-center variation, optimal prevention and treatment strategies in pediatric KT are currently unknown. This survey aimed to assess current CMV prevention and treatment strategies used among French pediatric KT centers. METHODS A web-based survey was sent to all 13 French pediatric kidney transplantation centers. RESULTS Twelve (92%) centers responded to the survey. All centers used prophylaxis for the donor-positive/recipient-negative (D+/R-) group. For R + patients, 54% used prophylaxis, 37% used a pre-emptive strategy. In the low-risk group, D-/R-, 50% used a pre-emptive approach and 50% had no specific prevention strategy. The antiviral used by all centers for prophylaxis was valganciclovir (VGCV). The duration of prophylaxis varied from 3 to 7 months and the duration of viral load monitoring varied from 6 months to indefinitely. No center used a hybrid/sequential approach. For the treatment of CMV DNAemia, VGCV or intravenous GCV were used. Therapeutic drug monitoring of VGCV was performed in 5 centers (42%). Five centers reported drug resistance. Eight centers (67%) administered VGCV during the treatment of acute graft rejection. CONCLUSIONS There is uniformity in CMV management in some areas among pediatric KT centers in France but not in others which remain diverse and are not up to date with current guidelines, suggesting unnecessary variation which could be reduced with better evidence to inform practice.
Collapse
Affiliation(s)
- Iona Madden
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | | | - Marina Charbit
- Pediatric Nephrology Unit, Hôpital Necker Enfants Malades, APHP, Paris, France
| | - Bruno Ranchin
- Pediatric Nephrology Unit, Hospices Civils de Lyon, Lyon, France
| | - Gwenaëlle Roussey
- Pediatric Nephrology Unit, Nantes University Hospital, Nantes, France
| | - Robert Novo
- Pediatric Nephrology Unit, Lille University Hospital, Lille, France
| | - Florentine Garaix
- Pediatric Nephrology Unit, AP-Hôpitaux de Marseille, Marseille, France
| | - Stéphane Decramer
- Pediatric Nephrology Unit, Toulouse University Hospital, Toulouse, France
| | - Marc Fila
- Pediatric Nephrology Unit, Montpellier University Hospital, Montpellier, France
| | - Elodie Merieau
- Pediatric Nephrology Unit, Tours University Hospital, Tours, France
| | - Isabelle Vrillon
- Pediatric Nephrology Unit, Nancy University Hospital, Nancy, France
| | - Ariane Zaloszyc
- Pediatric Nephrology Unit, Strasbourg University Hospital, Strasbourg, France
| | - Julien Hogan
- Pediatric Nephrology Unit, Robert Debré Hospital, APHP, Paris, France
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| |
Collapse
|