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Jorgenson MR, Parajuli S, Kleiboeker HL, Felix DC, Astor BC, Saddler CM, Smith JA, Mandelbrot DA. Incidence and outcomes of fever of unknown origin after kidney transplant in the modern era. Clin Transplant 2024; 38:e15217. [PMID: 38078682 DOI: 10.1111/ctr.15217] [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: 06/29/2023] [Revised: 11/08/2023] [Accepted: 11/21/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND While presumably less common with modern molecular diagnostic and imaging techniques, fever of unknown origin (FUO) remains a challenge in kidney transplant recipients (KTRs). Additionally, the impact of FUO on patient and graft survival is poorly described. METHODS A cohort of adult KTRs between January 1, 1995 and December 31, 2018 was followed at the University of Wisconsin Hospital. Patients transplanted from January 1, 1995 to December 31, 2005 were included in the "early era"; patients transplanted from January 1, 2006 to December 31, 2018 were included in the "modern era". The primary objective was to describe the epidemiology and etiology of FUO diagnoses over time. Secondary outcomes included rejection, graft and patient survival. RESULTS There were 5590 kidney transplants at our center during the study window. FUO was identified in 323 patients with an overall incidence rate of .8/100 person-years. Considering only the first 3 years after transplant, the incidence of FUO was significantly lower in the modern era than in the early era, with an Incidence Rate Ratio (IRR) per 100 person-years of .48; 95% CI: .35-.63; p < .001. A total of 102 (31.9%) of 323 patients had an etiology determined within 90 days after FUO diagnosis: 100 were infectious, and two were malignancies. In the modern era, FUO remained significantly associated with rejection (HR = 44.1; 95% CI: 16.6-102; p < .001) but not graft failure (HR = 1.21; 95% CI: .68-2.18; p = .52) total graft loss (HR = 1.17; 95% CI: .85-1.62; p = .34), or death (HR = 1.17; 95% CI: .79-1.76; p = .43. CONCLUSIONS FUO is less common in KTRs during the modern era. Our study suggests infection remains the most common etiology. FUO remains associated with significant increases in risk of rejection, warranting further inquiry into the management of immunosuppressive medications in SOT recipients in the setting of FUO.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Hanna L Kleiboeker
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Daniel C Felix
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Brad C Astor
- Department of Medicine and Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Christopher M Saddler
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Jeannina A Smith
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
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Damas J, Vida AC, Marques J, Caeiro F, Aires I, Dias JM, Vieira MB, Cotovio P, Magriço R, Ferreira A. Adenovirus Infection in a Kidney-Pancreatic Transplant Recipient: Case Report. Transplant Proc 2023; 55:1441-1443. [PMID: 37482436 DOI: 10.1016/j.transproceed.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/03/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023]
Abstract
Adenovirus infection in transplant recipients may present from asymptomatic viremia to multisystemic involvement. Most frequently, it occurs in the first year after a kidney transplant, and it is secondary to the reactivation of latent disease. However, primary infection may occur, and disseminated disease is more common when related to primary infection. Kidney involvement may be confirmed by biopsy, although diagnosis may be presumptive. Reduction of immunosuppression and supportive care are important components of therapy. CASE DESCRIPTION: A 41-year-old female renal-pancreatic recipient 12 years before with chronic renal graft dysfunction and a functional pancreatic graft had a history of cytomegalovirus and polyoma virus infection 2 years after transplantation. She was taking tacrolimus, mycophenolate mofetil, and prednisolone. The patient was admitted after persistent uncharacteristic diarrhea 3 weeks before hospitalization without any relevant epidemiologic context. She was dehydrated, and the lab results showed worsened kidney function and leucocytosis. The viral culture revealed adenovirus. Vigorous hydration was implemented, and the mycophenolate mofetil dose was reduced. The patient was discharged, and renal function returned to previous values. DISCUSSION AND CONCLUSION: Adenovirus infection has a wide clinical presentation, and multisystemic involvement may occur in transplant recipients. Supportive care is paramount. The clinical features and viral culture confirm the diagnosis, although tissue samples and quantitative polymerase chain reaction may be required in more severe cases.
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Affiliation(s)
- Juliana Damas
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal.
| | - Ana Carlota Vida
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Serviço de Nefrologia, Hospital Dr Nélio Mendonça, Funchal, Portugal
| | - Joana Marques
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Fernando Caeiro
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Inês Aires
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Joana Monteiro Dias
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Miguel Bigotte Vieira
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Patrícia Cotovio
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Rita Magriço
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - Aníbal Ferreira
- Serviço de Nefrologia, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
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Watanabe M, Kaneko S, Usui J, Takahashi K, Kawanishi K, Takahashi-Kobayashi M, Shimizu T, Ishii R, Tawara T, Tsunoda R, Nagai K, Kawamura T, Fujita A, Kai H, Morito N, Saito C, Oda T, Nagata M, Yamagata K. Literature review of allograft adenovirus nephritis and a case presenting as mass lesions in a transplanted kidney without symptoms of urinary tract infection or acute kidney injury. Transpl Infect Dis 2020; 23:e13468. [PMID: 32945064 DOI: 10.1111/tid.13468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/19/2020] [Accepted: 09/06/2020] [Indexed: 01/07/2023]
Abstract
Adenovirus (AdV) infection is a common complication in bone marrow/hematopoietic stem cell transplant and solid organ transplant recipients. AdV infection usually presents as hemorrhagic cystitis, but sometimes it can progress to acute kidney injury showing AdV nephritis (AdVN). We present the case of a 52-year-old Japanese female who had received a living kidney transplantation (KT) from her husband. At 21 months post-KT, the patient presented with a fever, but no renal dysfunction and no abnormal urine findings. A contrast-enhanced computed tomography (CT) scan revealed a few mass lesions with hypoperfusion in the transplanted kidney. An enhanced CT-guided biopsy targeting one of these lesions revealed a necrotizing tubulointerstitial nephritis suggesting AdVN. The polymerase chain reaction tests for ADV were negative in a urine sample but positive in the sera and the frozen kidney biopsy samples. AdVN can manifest as an unusual pattern of acute lobar nephritis/acute focal bacterial nephritis-like localization without symptoms of acute kidney injury or urinary tract infection. Enhanced CT can provide clues for clinical diagnosis.
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Affiliation(s)
- Megumi Watanabe
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shuzo Kaneko
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Joichi Usui
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kazuhiro Takahashi
- Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kunio Kawanishi
- Kidney and Vascular Pathology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | | | - Tatsuya Shimizu
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Ryota Ishii
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takashi Tawara
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Ryoya Tsunoda
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kei Nagai
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tetsuya Kawamura
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Akiko Fujita
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hirayasu Kai
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Naoki Morito
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Chie Saito
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tatsuya Oda
- Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Michio Nagata
- Kidney and Vascular Pathology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kunihiro Yamagata
- Nephrology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Gu J, Su QQ, Zuo TT, Chen YB. Adenovirus diseases: a systematic review and meta-analysis of 228 case reports. Infection 2020; 49:1-13. [PMID: 32720128 DOI: 10.1007/s15010-020-01484-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/19/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The clinical characteristics of various adenovirus (ADV) infection are underexplored up till now. To investigate the risk factors, manifestation, current status of ADV species, treatment and prognosis of this disease. METHODS We performed a Pubmed and Embase systematic review for case report reporting the ADV infection to analyze the clinical characteristics of disease. RESULTS Initial database searched identified articles of which 168 (228 cases) were included in the final analysis. Previous solid organ transplantation [odds ratio (OR) = 3.45, 95% CI 1.31-9.08, P = 0.01], hematopoietic stem cell transplant (OR = 4.24, 95% CI 1.33-13.51, P = 0.01) and hematological malignancy (OR = 4.78, 95% CI 1.70-13.46, P = 0.01) were associated with increased risk of disseminated ADV infection. Use of corticosteroids (OR = 3.86, 95% CI 1.21-12.24, P = 0.02) was a significant risk factor for acquiring urinary tract infections. A total of six species (21 types) of ADV infection have been identified in 100/228 (43.9%) cases. ADV B was the most common species. ADV B species (26/60, 52.0% or 5/41, 12.2% P = 0.001) were more isolated in patients with ADV pneumonia. ADV C (13/15, 86.7% versus 35/86, 40.7% P = 0.001) species were more identified in patients with disseminated disease. The species associated with keratoconjunctivitis is only ADV D in our analysis. Urinary tract ADV infections were observed in ADV A/B/D species. Cidofovir (CDV) (82/228, 36.0%) remained the most commonly antiviral therapy in our cases, followed by ribavirin (15/228, 6.6%), ganciclovir (18/228, 7.9%), and brincidofovir (12/228, 5.3%). Brincidofovir was administered as salvage therapy in 10 cases. Death was reported in 81/228 (35.5%) patients. Mortality rate was higher among patients with gastrointestinal (GI) ADV infection (5/10, 50.0%), ADV pneumonia (20/45, 44.4%) and disseminated ADV infection (53/122, 43.4%). CONCLUSION Previous solid organ transplantation, hematopoietic stem cell transplant and hematological malignancy were risk factors for disseminated ADV infection. Use of corticosteroids was significant for urinary tract ADV infection. Different species correlated with different clinical manifestations of infection. Mortality rate was higher among patients with GI disease, pneumonia and disseminated disease. Our review clarified the current treatment of ADV infections, and more treatment required further investigation.
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Affiliation(s)
- Jie Gu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, 899# Pinghai Road, Suzhou, 215000, China
| | - Qing-Qing Su
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, 899# Pinghai Road, Suzhou, 215000, China
| | - Ting-Ting Zuo
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, 899# Pinghai Road, Suzhou, 215000, China
| | - Yan-Bin Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Soochow University, 899# Pinghai Road, Suzhou, 215000, China.
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Hemmersbach-Miller M, Bailey ES, Kappus M, Prasad VK, Gray GC, Alspaugh JA. Disseminated Adenovirus Infection After Combined Liver-Kidney Transplantation. Front Cell Infect Microbiol 2018; 8:408. [PMID: 30524972 PMCID: PMC6256197 DOI: 10.3389/fcimb.2018.00408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/31/2018] [Indexed: 12/16/2022] Open
Abstract
Human adenovirus (HAdV) infections are well-described after hematopoietic stem cell transplantation but less well understood in solid organ transplantation (SOT). We describe a case of disseminated HAdV type 21 infection 5 months after combined liver-kidney transplantation, expanding the limited literature describing this infection in the SOT population.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, United States.,Duke Clinical Research Institute, Duke University, Durham, NC, United States
| | - Emily S Bailey
- Division of Infectious Diseases, School of Medicine and Global Health Institute, Duke University School of Medicine, Durham, NC, United States
| | - Matthew Kappus
- Division of Hepatology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Vinod K Prasad
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Gregory C Gray
- Division of Infectious Diseases, School of Medicine and Global Health Institute, Duke University School of Medicine, Durham, NC, United States
| | - J Andrew Alspaugh
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
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