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Wong DD, van Zuylen WJ, Novos T, Stocker S, Reuter SE, Au J, Foster CSP, Day RO, Horvath AR, Endre Z, Rawlinson WD. Detection of Ganciclovir-Resistant Cytomegalovirus in a Prospective Cohort of Kidney Transplant Recipients Receiving Subtherapeutic Valganciclovir Prophylaxis. Microbiol Spectr 2022; 10:e0268421. [PMID: 35658598 PMCID: PMC9241781 DOI: 10.1128/spectrum.02684-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/20/2022] [Indexed: 11/20/2022] Open
Abstract
Cytomegalovirus infection during antiviral prophylaxis occurs in transplant recipients despite individualized regimens based on renal function. Fifty kidney transplant recipients were assessed between 2016 and 2019 for valganciclovir dosing, ganciclovir exposure, cytomegalovirus infection, and genotypic resistance markers during the first year posttransplant. Ganciclovir plasma concentrations were measured using mass spectrometry. Population pharmacokinetics was used to determine individual ganciclovir exposure and to evaluate the ability of manufacturer dosing guidelines to meet therapeutic target daily area under the curve (AUC24) of 40 to 50 μg·h/mL. Full-length UL54 and UL97 were assessed using high-throughput sequencing in cytomegalovirus DNA-positive patient specimens. Valganciclovir doses administered to recipients with creatinine clearance of <40 mL/min were higher than specified by guidelines, and they were lower for recipients with creatinine clearance of ≥40 mL/min. The mean ganciclovir AUC24 was 33 ± 13 μg·h/mL, and 82% of subjects did not attain the therapeutic target. Pharmacokinetic simulations showed that the guidelines similarly could not attain the therapeutic target in 79% of individuals. Cytomegalovirus breakthrough occurred in 6% (3/50) of recipients, while 12% (6/50) developed late-onset infection. The mean AUC24s of recipients with (n = 3) and without (n = 47) infection were not significantly different (P = 0.528). However, one recipient with an AUC24 of 20 μg·h/mL acquired two UL97 ganciclovir resistance mutations. Current prophylaxis guidelines resulted in subtherapeutic ganciclovir exposure in several study recipients, including the emergence of resistance genotypes. IMPORTANCE This study examined the pharmacokinetics and viral genomic data from a prospective cohort of kidney transplant recipients undergoing valganciclovir prophylaxis for cytomegalovirus (CMV) prevention. We showed for the first time using high-throughput sequencing the detection of ganciclovir resistance mutations in breakthrough CMV infection during subtherapeutic plasma ganciclovir as indicated by the pharmacokinetic parameter daily area under the curve (AUC24). In addition, we found that current valganciclovir dosing guidelines for CMV prophylaxis are predicted to attain therapeutic targets in only 21% of recipients, which is consistent with previous pharmacokinetic studies. The novel findings of resistance mutations during subtherapeutic ganciclovir exposure presented here can inform future studies investigating the dynamics of drug selection pressure and the emergence of resistance mutations in vivo.
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Affiliation(s)
- Diana D. Wong
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Wendy J. van Zuylen
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Talia Novos
- Department of Chemical Pathology, New South Wales Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Sophie Stocker
- Sydney Pharmacy School, Faculty of Medicine & Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Stephanie E. Reuter
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Jane Au
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Charles S. P. Foster
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Richard O. Day
- Department of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Sydney, New South Wales, Australia
- St Vincent’s Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Andrea R. Horvath
- Department of Chemical Pathology, New South Wales Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Zoltan Endre
- Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - William D. Rawlinson
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
- School of Biotechnology and Biomolecular Sciences, University of New South Wales Sydney, Sydney, New South Wales, Australia
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2
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Global estimate of phenotypic and genotypic ganciclovir resistance in cytomegalovirus infections among HIV and organ transplant patients; A systematic review and meta-analysis. Microb Pathog 2020; 141:104012. [PMID: 32004622 DOI: 10.1016/j.micpath.2020.104012] [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: 09/10/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/21/2022]
Abstract
Human cytomegalovirus (CMV), an opportunistic pathogen belonging to Herpesviridae family, is considered as one of the major causes of morbidity and mortality among wide variety of patients, particularly in transplant recipients and HIV positive patients. As this virus can be resistant to treatment, frequency of CMV in patients who receive organ transplantation and people suffering from AIDS was studied between 1980 and 2019. Medline (via PubMed), Embase, Web of Science, and the Iranian Database were reviewed, and Comprehensive Meta-Analysis (V2.0, Biostat) software analyzed all data. Finally, we used Cochran's Q-statistic to encounter heterogeneity between different studies. Meta-analyses indicated, GCV resistance was 14.1% (95% CI 11.2-17.7); however, in patients suffering from AIDS and organ transplantation were 19.5% (95% CI 14.7-25.4) and 11.4% (95% CI 8.1-15.8), respectively. There were increasing rates in the prevalence of GCV resistance in CMV among transplant recipients, and HIV positive patients. Therefore, evaluation of these refractory infections is beneficial.
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Highlighting of a LAGLIDADG and a Zing Finger Motifs Located in the pUL56 Sequence Crucial for HCMV Replication. Viruses 2019; 11:v11121093. [PMID: 31779110 PMCID: PMC6950143 DOI: 10.3390/v11121093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 02/05/2023] Open
Abstract
The human cytomegalovirus (HCMV) terminase complex is part of DNA-packaging machinery that delivers a unit-length genome into a procapsid. Sequence comparison of herpesvirus homologs allowed us to identify a potential LATLNDIERFL and zinc finger pattern in N-terminal part of pUL56. Recombinant viruses were generated with specific serine or alanine substitutions in these putative patterns. We identified a LATLNDIERFL pattern characteristic of LAGLIDADG homing endonucleases and a metal-binding pattern involving the cysteine and histidine residues C191-X2-C194-X22-C217-X-H219 (CCCH) close to the region conferring letermovir resistance. These patterns are crucial for viral replication, suggesting that they are essential for pUL56 structure and function. Thus, these patterns represent potential targets for the development of new antivirals such as small molecules or peptides and may allow to better understand the letermovir mechanism of action.
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4
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Ligat G, Da Re S, Alain S, Hantz S. Identification of Amino Acids Essential for Viral Replication in the HCMV Helicase-Primase Complex. Front Microbiol 2018; 9:2483. [PMID: 30405556 PMCID: PMC6205958 DOI: 10.3389/fmicb.2018.02483] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 09/28/2018] [Indexed: 12/14/2022] Open
Abstract
Promising new inhibitors that target the viral helicase-primase complex have been reported to block replication of herpes simplex and varicella-zoster viruses, but they have no activity against human cytomegalovirus (HCMV), another herpesvirus. The HCMV helicase-primase complex (pUL105-pUL102-pUL70) is essential for viral DNA replication and could thus be a relevant antiviral target. The roles of the individual subunits composing this complex remain to be defined. By using sequence alignment of herpesviruses homologs, we identified conserved amino acids in the putative pUL105 ATP binding site and in the putative pUL70 zinc finger pattern. Mutational analysis of several of these amino acids both in pUL105 and pUL70, proved that they are crucial for viral replication. We also constructed, by homology modeling, a theoretical structure of the pUL105 N-terminal domain which indicates that the mutated conserved amino acids in this domain could be involved in ATP hydrolysis.
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Affiliation(s)
- Gaetan Ligat
- U1092, RESINFIT, CHU Limoges, INSERM, University of Limoges, Limoges, France.,CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses, Limoges, France
| | - Sandra Da Re
- U1092, RESINFIT, CHU Limoges, INSERM, University of Limoges, Limoges, France
| | - Sophie Alain
- U1092, RESINFIT, CHU Limoges, INSERM, University of Limoges, Limoges, France.,CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses, Limoges, France
| | - Sébastien Hantz
- U1092, RESINFIT, CHU Limoges, INSERM, University of Limoges, Limoges, France.,CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses, Limoges, France
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5
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Identification of a short sequence in the HCMV terminase pUL56 essential for interaction with pUL89 subunit. Sci Rep 2017; 7:8796. [PMID: 28821882 PMCID: PMC5562894 DOI: 10.1038/s41598-017-09469-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/26/2017] [Indexed: 12/16/2022] Open
Abstract
The human cytomegalovirus (HCMV) terminase complex consists of several components acting together to cleave viral DNA into unit length genomes and translocate them into capsids, a critical process in the production of infectious virions subsequent to DNA replication. Previous studies suggest that the carboxyl-terminal portion of the pUL56 subunit interacts with the pUL89 subunit. However, the specific interacting residues of pUL56 remain unknown. We identified a conserved sequence in the C-terminal moiety of pUL56 (671WMVVKYMGFF680). Overrepresentation of conserved aromatic amino acids through 20 herpesviruses homologues of pUL56 suggests an involvement of this short peptide into the interaction between the larger pUL56 terminase subunit and the smaller pUL89 subunit. Use of Alpha technology highlighted an interaction between pUL56 and pUL89 driven through the peptide 671WMVVKYMGFF680. A deletion of these residues blocks viral replication. We hypothesize that it is the consequence of the disruption of the pUL56-pUL89 interaction. These results show that this motif is essential for HCMV replication and could be a target for development of new small antiviral drugs or peptidomimetics.
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6
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Garrigue I, Moulinas R, Recordon-Pinson P, Delacour ML, Essig M, Kaminski H, Rerolle JP, Merville P, Fleury H, Alain S. Contribution of next generation sequencing to early detection of cytomegalovirus UL97 emerging mutants and viral subpopulations analysis in kidney transplant recipients. J Clin Virol 2016; 80:74-81. [DOI: 10.1016/j.jcv.2016.04.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/17/2016] [Accepted: 04/24/2016] [Indexed: 11/15/2022]
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7
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Andouard D, Mazeron MC, Ligat G, Couvreux A, Pouteil-Noble C, Cahen R, Yasdanpanah Y, Deering M, Viget N, Alain S, Hantz S. Contrasting effect of new HCMV pUL54 mutations on antiviral drug susceptibility: Benefits and limits of 3D analysis. Antiviral Res 2016; 129:115-119. [PMID: 26872863 DOI: 10.1016/j.antiviral.2016.02.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/29/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Abstract
Human cytomegalovirus (HCMV) resistance to antiviral drugs is a major drawback of repeated or long-duration treatment in immunocompromised patients. Resistance testing is usually performed by genotypic assays. For accurate interpretation of these assays, the role of new mutations in HCMV resistance has to be assessed. Two previously unknown UL54 single point mutations (D515Y and V787A) were characterized for phenotypic drug-resistance by marker transfer analysis using bacterial artificial chromosome (BAC) mutagenesis. Increases in 50% inhibitory concentrations of ganciclovir and foscarnet were found for both mutated recombinant strains showing that mutations D515Y and V787A induce resistance to both antivirals. Importantly, none of those impacted the viral growth kinetics. For a better understanding of their molecular resistance mechanisms, a 3D homology model was used to localize the mutated amino-acids in functional domains of UL54 and predict their impact on UL54 function and resistance. However, 3D homology model analysis has limits and phenotypic characterization using BAC-HCMV is still essential to measure the role of unknown mutations.
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Affiliation(s)
- D Andouard
- Univ. Limoges, UMR, 1092, Limoges, France; INSERM, UMR, 1092, Limoges, France; CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Cytomegaloviruses (NRC), Limoges, France
| | - M-C Mazeron
- CHU Saint Louis, Laboratoire de Bactériologie-Virologie, NRC-Associated Laboratory, Paris, France
| | - G Ligat
- Univ. Limoges, UMR, 1092, Limoges, France; INSERM, UMR, 1092, Limoges, France; CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Cytomegaloviruses (NRC), Limoges, France
| | - A Couvreux
- Univ. Limoges, UMR, 1092, Limoges, France; INSERM, UMR, 1092, Limoges, France; CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Cytomegaloviruses (NRC), Limoges, France
| | - C Pouteil-Noble
- CHU Lyon, Service de Transplantation rénale, Hôpital Edouard Herriot, Lyon, France
| | - R Cahen
- CHU Lyon, Service de Transplantation rénale, Hôpital Edouard Herriot, Lyon, France
| | - Y Yasdanpanah
- CHU Bichat, Service de Maladies infectieuses et Tropicales, Paris, France
| | - M Deering
- Univ. Limoges, UMR, 1092, Limoges, France; INSERM, UMR, 1092, Limoges, France; CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Cytomegaloviruses (NRC), Limoges, France
| | - N Viget
- Department of Infectious Diseases, Lille School of Medicine, Tourcoing Hospital, Tourcoing, France
| | - S Alain
- Univ. Limoges, UMR, 1092, Limoges, France; INSERM, UMR, 1092, Limoges, France; CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Cytomegaloviruses (NRC), Limoges, France
| | - S Hantz
- Univ. Limoges, UMR, 1092, Limoges, France; INSERM, UMR, 1092, Limoges, France; CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Cytomegaloviruses (NRC), Limoges, France.
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8
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Alain S, Revest M, Veyer D, Essig M, Rerolles JP, Rawlinson W, Mengelle C, Huynh A, Kamar N, Garrigue I, Kaminski H, Segard C, Presne C, Mazeron MC, Avettant-Fenoël V, Lecuit M, Lortholary O, Coaquette A, Hantz S, Leruez-Ville M, Ploy MC. Maribavir use in practice for cytomegalovirus infection in French transplantation centers. Transplant Proc 2013; 45:1603-7. [PMID: 23726629 DOI: 10.1016/j.transproceed.2013.01.082] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 01/24/2013] [Indexed: 01/12/2023]
Abstract
Maribavir (MBV), a UL97 inhibitor, shows good oral bioavailability, low host cell toxicity, and theoretical benefits to inhibit cross-resistant viruses. We herein examined clinical and virological outcomes of 12 patients, including 3 bone marrow recipients and 9 organ recipients infected with resistant cytomegalovirus (CMV) and treated with MBV during 2011-2012. All received at least 800-mg daily doses. They had developed clinical (12/12) and/or virological (11/12) resistance to CMV infection. Based on a decrease of viral load in blood >1.5 log copies/mL half of them responded to MBV treatment. The individual changes varied from a rapid decrease in viral load (n = 4) to no response (n = 3) with some late response slowly decreasing viremia (n = 3). In 2 cases MBV was used as secondary prophylaxis. No clear parameter emerged as a clinical surrogate for nonresponse to MBV. These results contrast with the lack of efficacy in phase III trials of MBV prophylaxis among stem cell recipients, which were possibly due to low doses or inadequate timing of drug initiation in the study. Additional clinical and surrogate laboratory markers are needed to determine antiviral responses to guide MBV use. Dosage ranging studies might benefit future MBV use.
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Affiliation(s)
- S Alain
- Virology Department, CHU Limoges, University Limoges, Inserm UMR-S1092, National Reference Center for Cytomegaloviruses, Limoges, France.
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9
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Germi R, Mariette C, Alain S, Lupo J, Thiebaut A, Brion JP, Epaulard O, Saint Raymond C, Malvezzi P, Morand P. Success and failure of artesunate treatment in five transplant recipients with disease caused by drug-resistant cytomegalovirus. Antiviral Res 2013; 101:57-61. [PMID: 24184983 DOI: 10.1016/j.antiviral.2013.10.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 10/16/2013] [Accepted: 10/24/2013] [Indexed: 11/16/2022]
Abstract
Cytomegalovirus (CMV) strains resistant to ganciclovir, cidofovir and/or foscarnet were genotypically and phenotypically characterised in two haematopoietic stem cell transplant recipients and three solid-organ transplant recipients with CMV disease. The anti-malaria drug artesunate led to a favourable virological and clinical response in three cases with mild CMV diseases (fever and neutropaenia) but was ineffective in two fatal CMV diseases with lung involvement in spite of a decrease in the CMV DNA load in blood and bronchoalveolar fluid.
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Affiliation(s)
- R Germi
- Department of Virology, University Hospital, Grenoble, France; Unit of Virus Host Cell Interactions UMI 3265 UJF-EMBL-CNRS, B.P. 181, 6, rue Jules Horowitz, 38042 Grenoble Cedex 9, France.
| | - C Mariette
- Department of Infectious diseases, University Hospital, Grenoble, France
| | - S Alain
- Department of Virology, French National Cytomegalovirus Reference Center, University Hospital, Limoges, France
| | - J Lupo
- Department of Virology, University Hospital, Grenoble, France; Unit of Virus Host Cell Interactions UMI 3265 UJF-EMBL-CNRS, B.P. 181, 6, rue Jules Horowitz, 38042 Grenoble Cedex 9, France
| | - A Thiebaut
- Department of Hematology, University Hospital, Grenoble, France
| | - J P Brion
- Department of Infectious diseases, University Hospital, Grenoble, France
| | - O Epaulard
- Department of Virology, University Hospital, Grenoble, France; Unit of Virus Host Cell Interactions UMI 3265 UJF-EMBL-CNRS, B.P. 181, 6, rue Jules Horowitz, 38042 Grenoble Cedex 9, France; Department of Infectious diseases, University Hospital, Grenoble, France
| | - C Saint Raymond
- Department of Pneumology, University Hospital, Grenoble, France
| | - P Malvezzi
- Department of Nephrology, University Hospital, Grenoble, France
| | - P Morand
- Department of Virology, University Hospital, Grenoble, France; Unit of Virus Host Cell Interactions UMI 3265 UJF-EMBL-CNRS, B.P. 181, 6, rue Jules Horowitz, 38042 Grenoble Cedex 9, France
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10
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Temporal and spatial compartmentalization of drug-resistant cytomegalovirus (CMV) in a child with CMV meningoencephalitis: implications for sampling in molecular diagnosis. J Clin Microbiol 2013; 51:4266-9. [PMID: 24108608 DOI: 10.1128/jcm.02411-13] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We describe a case of antiviral-resistant cytomegalovirus meningoencephalitis occurring after hematopoietic stem cell transplantation. Antiviral-resistant cytomegalovirus was identified in blood 16 months earlier. However, wild-type cytomegalovirus was evidenced in blood when the meningoencephalitis was diagnosed. Treatment of meningoencephalitis should be adapted to all previously identified resistance mutations in any compartment.
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Hantz S, Cotin S, Borst E, Couvreux A, Salmier A, Garrigue I, Merville P, Mengelle C, Attal M, Messerle M, Alain S. Novel DNA polymerase mutations conferring cytomegalovirus resistance: Input of BAC-recombinant phenotyping and 3D model. Antiviral Res 2013; 98:130-4. [DOI: 10.1016/j.antiviral.2013.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/30/2013] [Accepted: 02/04/2013] [Indexed: 10/27/2022]
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12
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Cunha-Bang CD, Kirkby N, Sønderholm M, Sørensen SS, Sengeløv H, Iversen M, Rasmussen A, Gustafsson F, Frederiksen CM, Kjaer J, Lepri AC, Lundgren JD. The time course of development and impact from viral resistance against ganciclovir in cytomegalovirus infection. Am J Transplant 2013; 13:458-66. [PMID: 23282281 DOI: 10.1111/ajt.12042] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 10/12/2012] [Accepted: 10/24/2012] [Indexed: 01/25/2023]
Abstract
(Val)ganciclovir is used to treat cytomegalovirus (CMV) infection following solid organ (SOT) or hematopoietic stem cell (HSCT) transplantation. Treatment failures occur, but the contribution from 39 known ganciclovir-related mutations (GRMs) in the CMV-UL97 gene remains controversial. We propose a categorization of these GRMs potentially useful when interpreting sequence analyses in clinical settings. The UL97 gene was sequenced from first/recurrent CMV infections among consecutive SOT or HSCT recipients during 2004-2009. GRMs were categorized as: Signature GRM (sGRM) if in vitro ganciclovir IC(50) ratio for mutated versus wild-type virus >2 (n = 24); polymorphic GRM (pGRM) if ratio <2 (n = 15). (Val)ganciclovir treatment failure was defined as persistent viremia for 30 days or switch to foscarnet within this period. Of 99 (49 HSCT and 50 SOT) recipients with one CMV infection episode, 15 (13 HSCT and 2 SOT) experienced a total of 19 recurrent infection episodes. The prevalence of sGRM was 0% at start of first episode, whereas at start of recurrent episodes, prevalence was 37%. Only one sGRM was present at a time in individual patients. Patients with CMV containing an sGRM (vs. wild type)-but not with a pGRM-were at excess risk of treatment failure (odds ratio = 70.6 [95% CI:8.2-609.6]; p < 0.001). sGRMs emerged only following longer termed use of antiherpetic drugs and usually in recurrent CMV infection episodes. Risk of ganciclovir treatment failure was raised if an sGRM was detected.
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Affiliation(s)
- C da Cunha-Bang
- Center for Viral Diseases, Department of Infectious Diseases, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark.
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13
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Clinical outcome with low-dose valacyclovir in high-risk renal transplant recipients: a 10-year experience. Nephrol Dial Transplant 2012; 28:758-65. [DOI: 10.1093/ndt/gfs531] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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14
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Le Page AK, Jager MM, Iwasenko JM, Scott GM, Alain S, Rawlinson WD. Clinical Aspects of Cytomegalovirus Antiviral Resistance in Solid Organ Transplant Recipients. Clin Infect Dis 2012; 56:1018-29. [DOI: 10.1093/cid/cis1035] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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15
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Boivin G, Goyette N, Farhan M, Ives J, Elston R. Incidence of cytomegalovirus UL97 and UL54 amino acid substitutions detected after 100 or 200 days of valganciclovir prophylaxis. J Clin Virol 2012; 53:208-13. [DOI: 10.1016/j.jcv.2011.12.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 11/29/2011] [Accepted: 12/15/2011] [Indexed: 10/14/2022]
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16
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Wang Y, Sun B, Volk HD, Proesch S, Kern F. Comparative Study of the Influence of Proteasome Inhibitor MG132 and Ganciclovir on the Cytomegalovirus-Specific CD8+T-Cell Immune Response. Viral Immunol 2011; 24:455-61. [DOI: 10.1089/vim.2011.0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yanjun Wang
- Institut für Medizinische Immunologie der Charité, Abteilung Klinische Immunologie, Humboldt-Universität zu Berlin (Charité), Campus Charité Mitte, Berlin, Germany
- Beijing Institute of Liver Diseases, Capital Medical University, Beijing, China
| | - Bin Sun
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Hans-Dieter Volk
- Institut für Medizinische Immunologie der Charité, Abteilung Klinische Immunologie, Humboldt-Universität zu Berlin (Charité), Campus Charité Mitte, Berlin, Germany
| | - Susanna Proesch
- Institut für Virologie der Charité, Campus Mitte, Berlin, Germany
| | - Florian Kern
- BSMS, University of Sussex, Falmer, Brighton, U.K
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Posthuma CC, van der Beek MT, van der Blij-de Brouwer CS, van der Heiden PLJ, Marijt EWA, Spaan WJM, Claas ECJ, Nederstigt C, Vossen ACTM, Snijder EJ, Kroes ACM. Mass spectrometry-based comparative sequencing to detect ganciclovir resistance in the UL97 gene of human cytomegalovirus. J Clin Virol 2011; 51:25-30. [PMID: 21388868 DOI: 10.1016/j.jcv.2011.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 01/11/2011] [Accepted: 01/20/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Persistent infections with herpesviruses such as human cytomegalovirus (HCMV) frequently occur after solid organ or stem cell transplantation, and are due to either failure of the host to immunologically control the virus or emerging resistance of the virus to the antiviral drug(s) used. Antiviral therapy can be guided by viral drug susceptibility testing based on screening for known resistance-inducing mutations in the viral genome. Mass spectrometry-based comparative sequence analysis (MSCSA) might be advantageous for this purpose because of its suitability for semi-automation. OBJECTIVES The applicability of MSCSA to detect sequence polymorphisms and drug resistance-inducing mutations in the HCMV genome was investigated. STUDY DESIGN We analyzed the 3' part of the HCMV UL97 gene, which encodes the kinase that is activated by the commonly used anti-HCMV drug ganciclovir. Sequences obtained by MSCSA of material from HCMV-infected patients (43 samples) and the HCMV type strain were compared to conventional cycle sequencing results. RESULTS In 94.1% of all samples the results obtained by MSCSA of the UL97 gene were identical to those from conventional cycle sequencing. The threshold to detect mutant sequences in a mixture with wild-type material was 20% using either technique. Furthermore, MSCSA was successfully applied to study the development of drug resistance in a patient who developed encephalitis due to ganciclovir-resistant HCMV. CONCLUSIONS MSCSA was found to be equally accurate compared to conventional cycle sequencing in the analysis of UL97 of HCMV.
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Affiliation(s)
- Clara C Posthuma
- Department of Medical Microbiology, Center of Infectious Diseases, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands.
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18
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Hantz S, Garnier-Geoffroy F, Mazeron MC, Garrigue I, Merville P, Mengelle C, Rostaing L, Saint Marcoux F, Essig M, Rerolle JP, Cotin S, Germi R, Pillet S, Lebranchu Y, Turlure P, Alain S. Drug-resistant cytomegalovirus in transplant recipients: a French cohort study. J Antimicrob Chemother 2010; 65:2628-40. [PMID: 20961907 DOI: 10.1093/jac/dkq368] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Cytomegalovirus (CMV) drug resistance is a therapeutic challenge in the transplant setting. No longitudinal cohort studies of CMV resistance in a real-life setting have been published in the valganciclovir era. We report findings for a French multicentre prospective cohort of 346 patients enrolled at initial diagnosis of CMV infection (clinical trial registered at clinicaltrials.gov: NCT01008540). PATIENTS AND METHODS Patients were monitored for detection of CMV infection for ≥2 years. Real-time detection of resistance by UL97 and UL54 gene sequencing and antiviral phenotyping was performed if viral replication persisted for >21 days of appropriate antiviral treatment. Plasma ganciclovir assays were performed when resistance was suspected. RESULTS Resistance was suspected in 37 (10.7%) patients; 18/37 (5.2% of the cohort) had virological resistance, associated with poorer outcome. Most cases involved single UL97 mutations, but four cases of multidrug resistance were due to UL54 mutations. In solid organ transplant recipients, resistance occurred mainly during primary CMV infection (odds ratio 8.78), but also in two CMV-seropositive kidney recipients. Neither CMV prophylaxis nor antilymphocyte antibody administration was associated with virological resistance. CONCLUSIONS These data show the feasibility of surveying resistance. Virological resistance was frequent in patients failing antiviral therapy. More than 1/5 resistant isolates harboured UL54 mutations alone or combined with UL97 mutations, which conferred a high level of resistance and sometimes were responsible for cross-resistance, leading to therapeutic failure.
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Affiliation(s)
- Sébastien Hantz
- CHU Limoges, Laboratoire de Bactériologie-Virologie, Centre National de Référence des Cytomégalovirus, Limoges, France
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19
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Preemptive Versus Sequential Prophylactic-Preemptive Treatment Regimens for Cytomegalovirus in Renal Transplantation: Comparison of Treatment Failure and Antiviral Resistance. Transplantation 2010; 89:320-6. [DOI: 10.1097/tp.0b013e3181bc0301] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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20
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Agut H, Boutolleau D, Deback C, Bonnafous P, Gautheret-Dejean A. Testing the susceptibility of human herpesviruses to antivirals. Future Microbiol 2010; 4:1111-23. [PMID: 19895215 DOI: 10.2217/fmb.09.83] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Herpesviruses cause chronic lifelong infections in humans and may cause life-threatening diseases in immunosuppressed patients. Antiviral drugs targeted to viral DNA polymerase, such as acyclovir, penciclovir, ganciclovir, foscarnet and cidofovir, are currently available and have been proven to be efficient against clinical symptoms of herpesvirus infections. The resistance of herpesviruses to these drugs is associated with specific mutations of viral genes encoding either DNA polymerase or enzymes phosphorylating nucleoside analogs. Resistance is detected and characterized by means of specific susceptibility assays, which can be classified as phenotypic, genetic and functional. These tests are used both to investigate novel antiviral compounds and look for the emergence of resistant viruses in treated patients in case of clinical failure. Although susceptibility assays are often time consuming and present some limitations regarding the interpretation of their results, their use in the monitoring of antiherpetic treatments should be promoted and improved, in parallel to the development of novel efficient drugs.
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Affiliation(s)
- Henri Agut
- Service de Virologie AP-HP, ER DETIV UPMC, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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21
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Schreiber A, Härter G, Schubert A, Bunjes D, Mertens T, Michel D. Antiviral treatment of cytomegalovirus infection and resistant strains. Expert Opin Pharmacother 2009; 10:191-209. [PMID: 19236193 DOI: 10.1517/14656560802678138] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This review discusses the management of resistant cytomegalovirus and prevention strategies for fatal therapy failures. Five drugs, ganciclovir/valganciclovir, cidofovir, foscarnet and fomivirsen, have been approved so far for the treatment of human cytomegalovirus (HCMV) diseases. Except for fomivirsen, all of the approved drugs share the same target molecule, the viral DNA polymerase. The emergence of drug-resistant HCMV has also been reported for all of them. For optimal care of patients, the clinical virologist has to provide the most meaningful assays for monitoring of therapy and early detection of emerging drug-resistant HCMV. Additionally, a quantitative drug monitoring would be helpful. New antiviral agents are urgently needed with less adverse effects, good oral bioavailability and possibly novel targets or mechanisms of action to avoid cross-resistance and to improve the ability to suppress the selection of resistant virus strains by combination therapy. Compounds like maribavir, leflunomide and artesunate, which exhibit anti-HCMV activity in vitro and in patients need to be evaluated in clinical studies. Besides these, new therapy approaches like immunotherapy or new diagnostic techniques like pyrosequencing have to be considered in the future.
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Affiliation(s)
- Andreas Schreiber
- Universitätsklinikum Ulm, Institut für Virologie, Albert-Einstein Allee 11, 89081 Ulm, Germany
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22
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Scalzo AA, Corbett AJ, Rawlinson WD, Scott GM, Degli-Esposti MA. The interplay between host and viral factors in shaping the outcome of cytomegalovirus infection. Immunol Cell Biol 2006; 85:46-54. [PMID: 17146464 DOI: 10.1038/sj.icb.7100013] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cytomegalovirus (CMV) remains a major human pathogen causing significant morbidity and mortality in immunosuppressed or immunoimmature individuals. Although significant advances have been made in dissecting out certain features of the host response to human CMV (HCMV) infection, the strict species specificity of CMVs means that most aspects of antiviral immunity are best assessed in animal models. The mouse model of murine CMV (MCMV) infection is an important tool for analysis of in vivo features of host-virus interactions and responses to antiviral drugs that are difficult to assess in humans. Important studies of the contribution of host resistance genes to infection outcome, interplays between innate and adaptive host immune responses, the contribution of virus immune evasion genes and genetic variation in these genes to the establishment of persistence and in vivo studies of resistance to antiviral drugs have benefited from the well-developed MCMV model. In this review, we discuss recent advances in the immunobiology of host-CMV interactions that provide intriguing insights into the complex interplay between host and virus that ultimately facilitates viral persistence. We also discuss recent studies of genetic responses to antiviral therapy, particularly changes in DNA polymerase and protein kinase genes of MCMV and HCMV.
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Affiliation(s)
- Anthony A Scalzo
- Immunology and Virology Program, Centre for Ophthalmology and Visual Science, The University of Western Australia, Nedlands, Western Australia, Australia.
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23
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Das V, Peraldi MN, Legendre C. Adverse neuropsychiatric effects of cytomegalovirus prophylaxis with valaciclovir in renal transplant recipients. Nephrol Dial Transplant 2006; 21:1395-401. [PMID: 16401626 DOI: 10.1093/ndt/gfk031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Valaciclovir (VACV) has been reported to induce adverse neuropsychiatric effects (ANE), especially in patients with renal failure, but few data are available for renal transplant recipients (RTR). METHODS We conducted a retrospective study in RTR given VACV as cytomegalovirus prophylaxis, from January 1999 to December 2000, to define the incidence rate, type and outcome of VACV-induced ANE, and to identify risk factors for ANE. The VACV-induced ANE were defined as neuropsychiatric disorders justifying VACV dose reduction or withdrawal. Patients with and without VACV-induced ANE were compared by univariate and multivariate analysis. RESULTS In all, 167 RTR were included, of whom 25 (15%) displayed VACV-induced ANE (mainly hallucinations and confusion), which occurred with a mean of 4 days after the start of VACV. ANE were reversible in all cases. Multivariate analysis showed that delayed graft function (DGF) was the main risk factor for VACV-induced ANE [Odds ratio (OR): 12.1; 95% CI = 3.4-43.4; P = 0.0001]. All VACV doses given to patients with ANE were in accordance with the current recommended adaptation to estimated glomerular filtration rate (GFR). CONCLUSION In RTR, VACV-induced ANE are significantly frequent but reversible. DGF occurrence is the main risk factor for these ANE. In RTR with DGF, the recommended doses for GFR below 10 ml/min might be too high. Several strategies, in RTR with DGF, might lower the risk of ANE, including reduction of the currently recommended VACV dosage, delayed VACV introduction until improvement of renal function, or use of another anti-cytomegalovirus drug.
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Affiliation(s)
- Vincent Das
- Service de Transplantation Rénale, Hôpital Necker-Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
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24
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Pavlopoulou ID, Syriopoulou VP, Chelioti H, Daikos GL, Stamatiades D, Kostakis A, Boletis JN. A comparative randomised study of valacyclovir vs. oral ganciclovir for cytomegalovirus prophylaxis in renal transplant recipients. Clin Microbiol Infect 2005; 11:736-43. [PMID: 16104989 DOI: 10.1111/j.1469-0691.2005.01215.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
An open, prospective, randomised study was conducted to compare the safety and efficacy of valacyclovir vs. oral ganciclovir for cytomegalovirus (CMV) prophylaxis in renal transplant recipients. Eighty-three renal transplant recipients were assigned randomly to receive valacyclovir (n=43) or oral ganciclovir (n=40) for the first 3 months after transplantation. Both groups were similar in terms of demographics, primary renal disease, graft source, HLA matching, immunosuppressive therapy and donor-recipient CMV antibody status. CMV infection was diagnosed by detection of virus DNA in plasma with the Amplicor CMV Test. CMV disease was observed in only one patient belonging to the ganciclovir group, who developed enterocolitis 6 months post-transplantation. No difference was observed between the two treatment groups with respect to detection of CMV DNA, virus infections other than CMV, acute rejection episodes, and serum creatinine levels at 3 and 6 months following transplantation. An increased number of bacterial infections was noted in the ganciclovir group (p 0.003). No adverse reactions with either treatment were reported. The estimated cost of valacyclovir treatment was 20% higher than that of ganciclovir treatment. Overall, both valacyclovir and oral ganciclovir were found to be effective and safe for CMV prophylaxis in renal transplant recipients. Decisions regarding prophylactic regimens should include additional criteria, such as cost or possible development of resistance.
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Affiliation(s)
- I D Pavlopoulou
- First Department of Paediatrics, Athens University, and Transplantation Cenre, Laiko General Hospital, First Department of Propedeutic Medicine, Athens, Greece.
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25
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Sagedal S, Hartmann A, Rollag H. The impact of early cytomegalovirus infection and disease in renal transplant recipients. Clin Microbiol Infect 2005; 11:518-30. [PMID: 15966969 DOI: 10.1111/j.1469-0691.2005.01190.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Human cytomegalovirus (HCMV) infection is the single most frequent infectious complication in the early period after kidney transplantation. The HCMV load in blood, measured by HCMV PCR or the HCMV pp65 antigen test, is a predictor of HCMV disease in seropositive recipients. However, plasma virus load measurements are of only modest value in predicting the risk of HCMV disease in seronegative recipients of kidneys from seropositive donors. HCMV infection is an independent risk-factor for acute kidney graft rejection. There is also evidence that HCMV is associated with an increased long-term mortality and post-transplant diabetes mellitus. Whether pre-emptive or prophylactic therapy should be the preferred strategy is not yet decided. Some studies indicate that HCMV prophylaxis may reduce the risk of acute rejection, and thereby increase long-term graft survival in seronegative recipients of kidneys from seropositive donors.
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Affiliation(s)
- S Sagedal
- Department of Internal Medicine, Rikshospitalet University Hospital, Oslo, Norway.
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26
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Hantz S, Michel D, Fillet AM, Guigonis V, Champier G, Mazeron MC, Bensman A, Denis F, Mertens T, Dehee A, Alain S. Early selection of a new UL97 mutant with a severe defect of ganciclovir phosphorylation after valaciclovir prophylaxis and short-term ganciclovir therapy in a renal transplant recipient. Antimicrob Agents Chemother 2005; 49:1580-3. [PMID: 15793144 PMCID: PMC1068598 DOI: 10.1128/aac.49.4.1580-1583.2005] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We describe the emergence of a new ganciclovir resistance mutation in the UL97 gene of human cytomegalovirus, deletion of codon 601, after valaciclovir and short-term ganciclovir therapy following kidney transplantation. Its role in ganciclovir resistance was supported by decreased ganciclovir phosphorylation in a recombinant vaccinia virus system.
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Affiliation(s)
- Sébastien Hantz
- Department of Bacteriology-Virology-Hygiene, EA 3175, Teaching Hospital Dupuytren, Limoges cedex, France
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