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Tang R, Wang L, Zhang J, Fei W, Zhang R, Liu J, Lv M, Wang M, Lv R, Nan H, Tao R, Chen Y, Chen Y, Jiang Y, Zhang H. Boosting the immunogenicity of the CoronaVac SARS-CoV-2 inactivated vaccine with Huoxiang Suling Shuanghua Decoction: a randomized, double-blind, placebo-controlled study. Front Immunol 2024; 15:1298471. [PMID: 38633263 PMCID: PMC11021573 DOI: 10.3389/fimmu.2024.1298471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction In light of the public health burden of the COVID-19 pandemic, boosting the safety and immunogenicity of COVID-19 vaccines is of great concern. Numerous Traditional Chinese medicine (TCM) preparations have shown to beneficially modulate immunity. Based on pilot experiments in mice that showed that supplementation with Huoxiang Suling Shuanghua Decoction (HSSD) significantly enhances serum anti-RBD IgG titers after inoculation with recombinant SARS-CoV-2 S-RBD protein, we conducted this randomized, double-blind, placebo-controlled clinical trial aimed to evaluate the potential immunogenicity boosting effect of oral HSSD after a third homologous immunization with Sinovac's CoronaVac SARS-CoV-2 (CVS) inactivated vaccine. Methods A total of 70 participants were randomly assigned (1:1 ratio) to receive a third dose of CVS vaccination and either oral placebo or oral HSSD for 7 days. Safety aspects were assessed by recording local and systemic adverse events, and by blood and urine biochemistry and liver and kidney function tests. Main outcomes evaluated included serum anti-RBD IgG titer, T lymphocyte subsets, serum IgG and IgM levels, complement components (C3 and C4), and serum cytokines (IL-6 and IFN-γ). In addition, metabolomics technology was used to analyze differential metabolite expression after supplementation with HSSD. Results Following a third CVS vaccination, significantly increased serum anti-RBD IgG titer, reduced serum IL-6 levels, increased serum IgG, IgM, and C3 and C4 levels, and improved cellular immunity, evidenced by reduce balance deviations in the distribution of lymphocyte subsets, was observed in the HSSD group compared with the placebo group. No serious adverse events were recorded in either group. Serum metabolomics results suggested that the mechanisms by which HSSD boosted the immunogenicity of the CVS vaccine are related to differential regulation of purine metabolism, vitamin B6 metabolism, folate biosynthesis, arginine and proline metabolism, and steroid hormone biosynthesis. Conclusion Oral HSSD boosts the immunogenicity of the CVS vaccine in young and adult individuals. This trial provides clinical reference for evaluation of TCM immunomodulators to improve the immune response to COVID-19 vaccines.
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Affiliation(s)
- Ruying Tang
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, China
| | - Linyuan Wang
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Jianjun Zhang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Wenting Fei
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Rui Zhang
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Jinlian Liu
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Meiyu Lv
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Mengyao Wang
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Ruilin Lv
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Haipeng Nan
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Ran Tao
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yawen Chen
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yan Chen
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yanxin Jiang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Hui Zhang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
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Yamaguchi M, Suzuki T, Kidokoro H, Iwata KI, Fukuda Y, Haruta K, Torii Y, Ito Y, Kawada JI. Proteomic Analysis Reveals Novel Plasma Biomarkers for Neurological Complications in Patients With Congenital Cytomegalovirus Infection. J Pediatric Infect Dis Soc 2023; 12:525-533. [PMID: 37738566 DOI: 10.1093/jpids/piad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/20/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Congenital cytomegalovirus (cCMV) infection is a leading cause of nonhereditary neurological complications. When considering antiviral treatment, it is important to differentiate between symptomatic and asymptomatic patients. This study aimed to identify candidate plasma biomarkers for neurological complications of cCMV infection using proteomic analysis. METHODS This study retrospectively enrolled five patients with symptomatic cCMV infection, four with asymptomatic cCMV infection with isolated sensorineural hearing loss (SNHL), and five with asymptomatic cCMV infection. The plasma samples were collected during neonatal period. The peptides were analyzed using liquid chromatography-mass spectrometry. The concentrations of differentially expressed proteins were validated using an enzyme-linked immunosorbent assay. RESULTS A total of 456 proteins were identified and quantified. The levels of 80 proteins were significantly different between patients with and without cCMV-related symptoms including isolated SNHL. The levels of 31 proteins were significantly different between patients with and without neuroimaging abnormalities. The plasma concentrations of Fms-related receptor tyrosine kinase 4 in patients with cCMV-related symptoms were significantly higher than those in patients with asymptomatic cCMV infection. Moreover, plasma peptidylprolyl isomerase A levels were significantly higher in patients with neuroimaging abnormalities than in those without. CONCLUSIONS Proteomic analysis of patients with cCMV infection showed that Fms-related receptor tyrosine kinase 4 and peptidylprolyl isomerase A could be novel diagnostic biomarkers for neurological complications of cCMV infection.
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Affiliation(s)
- Makoto Yamaguchi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takako Suzuki
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Kidokoro
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ken-Ichi Iwata
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuto Fukuda
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazunori Haruta
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuka Torii
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinori Ito
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Jun-Ichi Kawada
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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3
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Alfaro R, Rodríguez-Aguilar L, Llorente S, Jimenez-Coll V, Martínez-Banaclocha H, Galián JA, Botella C, Moya-Quiles MR, Muro-Perez M, Minguela A, Legaz I, Muro M. Early Cytomegalovirus Reactivation in Renal Recipients Is Associated with High Levels of B Cell Maturation Antigen Transcript Expression Prior to Transplantation. Int J Mol Sci 2023; 24:10491. [PMID: 37445668 DOI: 10.3390/ijms241310491] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Cytomegalovirus (CMV) infection is the most frequent infection episode in kidney transplant (KT) recipients. Reactivation usually occurs in the first three months after transplantation and is associated with higher cellular and/or antibody-mediated rejection rates and poorer graft performance. CMV induces the expression of BAFF (B-cell-activating factor, a cytokine involved in the homeostasis of B cells), which communicates signals for survival and growth to B cells and virus-specific plasma cells via the R-BAFF (BAFF receptor), TACI (the calcium modulator, the cyclophilin ligand interactor), and BCMA (B cell maturation antigen) receptors. These molecules of the BAFF system have also been suggested as biomarkers for the development of alloantibodies and graft dysfunction. This prospective study included 30 CMV-IgG seropositive KT recipients. The expression levels of the genes BAFF-R, transmembrane activator and CAML interactor (TACI), and B cell maturation antigen (BCMA) in peripheral blood leukocytes (PBL) pre-KT were determined using qPCR. qPCR was also used to monitor CMV reactivation in the first three months following KT. The remainder of the KT recipients were classified as CMV- reactivation, and those with more than 500 copies/mL in at least one sample were classified as CMV+ reactivation. There were no discernible variations in the BAFF-R and TACI transcript expression levels. In the CMV+ group, we examined the relationship between the transcript levels and peak viremia. Peak viremia levels and BCMA transcript levels showed a strong correlation. BAFF-R and TACI expressions showed no measurable differences. In patients with early CMV reactivation, high BCMA receptor expression was associated with increased plasmablast, lymphocyte B cell class-switched levels (LBCS), and viral load. Our findings demonstrate that pre-KT BCMA transcript levels increased in KT recipients with early CMV reactivation. These transcript levels positively correlate with peak viremia and weakly with plasmablast and LBCS levels in PBLs.
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Affiliation(s)
- Rafael Alfaro
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Luis Rodríguez-Aguilar
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Santiago Llorente
- Nephrology Services, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Victor Jimenez-Coll
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Helios Martínez-Banaclocha
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - José Antonio Galián
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Carmen Botella
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - María Rosa Moya-Quiles
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Manuel Muro-Perez
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Alfredo Minguela
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Isabel Legaz
- Department of Legal and Forensic Medicine, Biomedical Research Institute of Murcia (IMIB), Regional Campus of International Excellence "Campus Mare Nostrum", Faculty of Medicine, University of Murcia, 30100 Murcia, Spain
| | - Manuel Muro
- Immunology Service, Hospital Clinico Universitario Virgen de la Arrixaca (HCUVA), Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
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Perry WA, Martino AEA, Garcia MR, Chow JK, Snydman DR. Sex- and age-based comparison of serum immunoglobulins following liver transplantation. Transpl Immunol 2023; 78:101826. [PMID: 36934899 PMCID: PMC10192009 DOI: 10.1016/j.trim.2023.101826] [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: 02/06/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Over a quarter of organ transplant recipients have low immunoglobulin levels in their early post-transplant course, which is associated with increased risk of infection and mortality. Although immunoglobulin level varies by sex among healthy individuals, it is unknown how such differences are affected by transplant-related immunosuppression. This study compared post-liver transplant immunoglobulin G (IgG) between sexes at varying ages. METHODS Serum specimens from a prospective cohort of 130 liver transplant recipients were analyzed. IgG was measured at time of transplant and from one-month post-transplant samples. Post-transplant IgG was compared between sexes using multivariable linear regression. Four age and sex categories were created (women<50, women≥50, men<50, men≥50) and the model repeated with this as the explanatory variable. The relationship between sex hormone concentrations and post-transplant IgG was also explored. Infection type and incidence were examined within groups. RESULTS The cohort included 99 men, 31 women (mean age 53). In adjusted linear regression, post-transplant IgG was not significantly different by sex (p = 0.92). However, when broken into four categories by age and sex, the contrast in IgG levels between younger versus older patients was strikingly greater among women than among men. An interaction term including age and sex was statistically significant (p = 0.03). The combined age-sex categorical variable was also significantly associated with post-transplant IgG (p = 0.01). Finally, an association was identified between baseline estradiol level and post-transplant change in IgG (p = 0.04). CONCLUSIONS Sex and age have an important relationship with post-transplant IgG with older women demonstrating lowest concentrations. Immunoglobulin levels have previously demonstrated association with post-transplant outcomes.
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Affiliation(s)
- Whitney A Perry
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, USA.
| | | | | | - Jennifer K Chow
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, USA
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, USA
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5
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van den Hoogen P, Huibers MMH, van den Dolder FW, de Weger R, Siera-de Koning E, Oerlemans MIF, de Jonge N, van Laake LW, Doevendans PA, Sluijter JPG, Vink A, de Jager SCA. Elevated Plasma Immunoglobulin Levels Prior to Heart Transplantation Are Associated with Poor Post-Transplantation Survival. BIOLOGY 2022; 12:biology12010061. [PMID: 36671753 PMCID: PMC9855413 DOI: 10.3390/biology12010061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022]
Abstract
Cardiac allograft vasculopathy (CAV) and antibody-mediated rejection are immune-mediated, long-term complications that jeopardize graft survival after heart transplantation (HTx). Interestingly, increased plasma levels of immunoglobulins have been found in end-stage heart failure (HF) patients prior to HTx. In this study, we aimed to determine whether increased circulating immunoglobulin levels prior to transplantation are associated with poor post-HTx survival. Pre-and post-HTx plasma samples of 36 cardiac transplant recipient patients were used to determine circulating immunoglobulin levels. In addition, epicardial tissue was collected to determine immunoglobulin deposition in cardiac tissue and assess signs and severity of graft rejection. High levels of IgG1 and IgG2 prior to HTx were associated with a shorter survival post-HTx. Immunoglobulin deposition in cardiac tissue was significantly elevated in patients with a survival of less than 3 years. Patients with high plasma IgG levels pre-HTx also had significantly higher plasma levels after HTx. Furthermore, high pre-HTX levels of IgG1 and IgG2 levels were also significantly increased in patients with inflammatory infiltrate in CAV lesions. Altogether the results of this proof-of-concept study suggest that an activated immune response prior to transplantation negatively affects graft survival.
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Affiliation(s)
- Patricia van den Hoogen
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Circulatory Health Laboratory, Regenerative Medicine Center, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Manon M. H. Huibers
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
- Department of Genetics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Floor W. van den Dolder
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Roel de Weger
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Erica Siera-de Koning
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Marish I. F. Oerlemans
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Linda W. van Laake
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Pieter A. Doevendans
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Netherlands Heart Institute (NLHI), 3511 EP Utrecht, The Netherlands
- Centraal Militair Hospitaal (CMH), 3584 EZ Utrecht, The Netherlands
| | - Joost. P. G. Sluijter
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Circulatory Health Laboratory, Regenerative Medicine Center, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Aryan Vink
- Department of Pathology, Circulatory Health Laboratory, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands
| | - Saskia C. A. de Jager
- Laboratory for Experimental Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Circulatory Health Laboratory, Regenerative Medicine Center, Utrecht University, 3584 CX Utrecht, The Netherlands
- Laboratory of Translational Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Correspondence:
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6
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Immohr MB, Böttger C, Aubin H, Westenfeld R, Oehler D, Bruno RR, Dalyanoglu H, Tudorache I, Akhyari P, Lichtenberg A, Boeken U. IgM-enriched immunoglobulin as adjuvant therapy for heart transplant after infection of left ventricular assist devices. ESC Heart Fail 2022; 9:3630-3635. [PMID: 35854478 DOI: 10.1002/ehf2.14074] [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: 04/18/2022] [Revised: 06/07/2022] [Accepted: 06/27/2022] [Indexed: 11/07/2022] Open
Abstract
Patients undergoing heart transplantation (HTx) with active infection of left ventricular assist devices (LVAD) are at high risk for postoperative infections. Between 2021 and 2022, five (P1-P5) of a total of n = 44 patients underwent HTx in our department while suffering from LVAD infection. Postoperatively, patients received adjuvant IgM-enriched human intravenous immunoglobulin (IGM-IVIG), consisting of 76% IgG, 12% IgM, and 12% IgA as a novel approach to prevent infective complications. While in P1, P2, and P4, LVAD driveline infection was known before HTx; in P3 and P5, abscess of device pocket was found incidentally during HTx. After a single dose of IGM-IVIG, all patients showed adequate rise in serum immunoglobulins. In the postoperative course, no patient developed infective complications. All patients were successfully discharged and in good condition at the last follow-up. Therefore, IGM-IVIG seems to be an effective adjuvant treatment for patients undergoing HTx with LVAD infections.
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Affiliation(s)
- Moritz Benjamin Immohr
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Charlotte Böttger
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Oehler
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hannan Dalyanoglu
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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8
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Hoang J, Krisl J, Moaddab M, Nguyen DT, Graviss EA, Hussain I, Kassi M, Yousefzai R, Kim J, Trachtenberg B, Bhimaraj A, Guha A. Intravenous Immunoglobulin in Heart Transplant Recipients with Mild to Moderate Hypogammaglobulinemia and Infection. Clin Transplant 2021; 36:e14571. [DOI: 10.1111/ctr.14571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Johnny Hoang
- Department of Pharmacy Houston Methodist Hospital Houston Texas
| | - Jill Krisl
- Department of Pharmacy Houston Methodist Hospital Houston Texas
| | - Mozhgon Moaddab
- Department of Pharmacy Houston Methodist Hospital Houston Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Houston Texas
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Houston Texas
- Department of Surgery Houston Methodist Hospital Houston Texas
| | - Imad Hussain
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Mahwash Kassi
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Rayan Yousefzai
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Ju Kim
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Barry Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Arvind Bhimaraj
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Ashrith Guha
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
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9
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Herrera S, Colmenero J, Pascal M, Escobedo M, Castel MA, Sole-González E, Palou E, Egri N, Ruiz P, Mosquera M, Moreno A, Juan M, Vilella A, Soriano A, Farrero M, Bodro M. Cellular and humoral immune response after mRNA-1273 SARS-CoV-2 vaccine in liver and heart transplant recipients. Am J Transplant 2021; 21:3971-3979. [PMID: 34291552 PMCID: PMC9800111 DOI: 10.1111/ajt.16768] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/02/2021] [Accepted: 07/17/2021] [Indexed: 01/25/2023]
Abstract
Recently published studies have found an impaired immune response after SARS-CoV-2 vaccination in solid organ recipients. However, most of these studies have not assessed immune cellular responses in liver and heart transplant recipients. We prospectively studied heart and liver transplant recipients eligible for SARS-CoV-2 vaccination. Patients with past history of SARS-CoV-2 infection or SARS-CoV-2 detectable antibodies (IgM or IgG) were excluded. We assessed IgM/IgG antibodies and ELISpot against the S protein 4 weeks after receiving the second dose of the mRNA-1273 (Moderna) vaccine. Side effects, troponin I, liver tests and anti-HLA donor-specific antibodies (DSA) were also assessed. A total of 58 liver and 46 heart recipients received two doses of mRNA-1273 vaccine. Median time from transplantation to vaccination was 5.4 years (IQR 0.3-27). Sixty-four percent of the patients developed SARS-CoV-2 IgM/IgG antibodies and 79% S-ELISpot positivity. Ninety percent of recipients developed either humoral or cellular response (87% in heart recipients and 93% in liver recipients). Factors associated with vaccine unresponsiveness were hypogammaglobulinemia and vaccination during the first year after transplantation. Local and systemic side effects were mild or moderate, and none presented DSA or graft dysfunction after vaccination. Ninety percent of our patients did develop humoral or cellular responses to mRNA-1273 vaccine. Factors associated with vaccine unresponsiveness were hypogammaglobulinemia and vaccination during the first year after transplantation, highlighting the need to further protect these patients.
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Affiliation(s)
- Sabina Herrera
- Department of Infectious Diseases, Hospital Clínic, University of Barcelonae, Barcelona, Spain
| | - Jordi Colmenero
- Liver Transplantation, Liver Unit, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Mariona Pascal
- Department of Immunology, CDB, Hospital Clínic, Barcelona, Spain,Immunoal·lergia Clínica Respiratoria i Experimental (IRCE), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Red Nacional de Alergia, Asma, Reacciones Adversas y Alérgicas (ARADyAL), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Miguel Escobedo
- Liver Transplantation, Liver Unit, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - María A. Castel
- Unit for Heart Failure and Heart Transplantation, Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Eduard Sole-González
- Unit for Heart Failure and Heart Transplantation, Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Eduard Palou
- Department of Immunology, CDB, Hospital Clínic, Barcelona, Spain,Immunoal·lergia Clínica Respiratoria i Experimental (IRCE), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Red Nacional de Alergia, Asma, Reacciones Adversas y Alérgicas (ARADyAL), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Natalia Egri
- Department of Immunology, CDB, Hospital Clínic, Barcelona, Spain
| | - Pablo Ruiz
- Liver Transplantation, Liver Unit, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Mar Mosquera
- Department of Microbiology, Hospital Clínic, Barcelona, Spain
| | - Asunción Moreno
- Department of Infectious Diseases, Hospital Clínic, University of Barcelonae, Barcelona, Spain
| | - Manel Juan
- Department of Immunology, CDB, Hospital Clínic, Barcelona, Spain,Immunoal·lergia Clínica Respiratoria i Experimental (IRCE), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Red Nacional de Alergia, Asma, Reacciones Adversas y Alérgicas (ARADyAL), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Anna Vilella
- Department of Preventive Medicine and Epidemiology, Hospital Clinic, University of barcelonae, Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic, University of Barcelonae, Barcelona, Spain
| | - Marta Farrero
- Unit for Heart Failure and Heart Transplantation, Department of Cardiology, Hospital Clínic, Barcelona, Spain,Correspondence Marta Bodro and Marta Farrero, Department of Infectious Diseases and Unit for Heart Failure and Heart Transplantation, Hospital Clínic of Barcelona, Carrer Villarroel, Barcelona, Spain. (M. B.) and (M. F.)
| | - Marta Bodro
- Department of Infectious Diseases, Hospital Clínic, University of Barcelonae, Barcelona, Spain,Correspondence Marta Bodro and Marta Farrero, Department of Infectious Diseases and Unit for Heart Failure and Heart Transplantation, Hospital Clínic of Barcelona, Carrer Villarroel, Barcelona, Spain. (M. B.) and (M. F.)
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10
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Gallego A, Sarmiento E, Sousa I, Zatarain E, Fernández-Yáñez J, Navarro J, Gil J, Carbone J. Immunologic Abnormalities Associated With Health Status of Heart Recipients Long Term After Transplantation. Transplant Proc 2021; 53:2724-2727. [PMID: 34598808 DOI: 10.1016/j.transproceed.2021.08.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/12/2021] [Accepted: 08/25/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND With improvements in survival rates, health-related quality of life is an important outcome parameter to evaluate the effectiveness of transplantation. We aimed to identify potential immunologic abnormalities as factors associated with poorer health-related quality of life at distinct scales of the 36-Item Short Form Health Survey in heart transplant recipients long term after transplantation. METHODS One hundred heart transplant recipients were evaluated in a single center. Short-form 36 questionnaires were sent by mail to participants. All patients were clinically and immunologically evaluated after the first year of heart transplantation. RESULTS A high prevalence of several immunologic abnormalities persisted even after the first year of transplantation, including IgG hypogammaglobulinemia, low IgG-specific antipneumococcal antibodies, C4 hypocomplementemia, CD8 T-cell lymphocytopenia, and CD19 B-cell lymphocytopenia. Older recipients (>55 years), posttransplant diabetes, digestive complications, and posttransplant infections were associated with lower physical functioning scores (scale < 60). Older recipients (>55 years), pretransplant diabetes, pretransplant arterial hypertension, posttransplant digestive complications, and lower CD8 counts were associated with lower physical role scores (scale <25). CONCLUSION In a single center study, lower CD8 cell counts were found to be associated with poorer health status in heart recipients after the first year of transplantation.
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Affiliation(s)
- Antonio Gallego
- Servicio de Inmunología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Elizabeth Sarmiento
- Servicio de Inmunología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Iago Sousa
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Eduardo Zatarain
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan Fernández-Yáñez
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Joaquín Navarro
- Servicio de Inmunología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juana Gil
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Carbone
- Servicio de Inmunología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Departamento de Inmunología, Oftalmología y ORL, Universidad Complutense, Madrid, Spain.
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11
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San-Juan R, Fernández-Ruiz M, Ruiz-Ruigómez M, López-Medrano F, Ruiz-Merlo T, Andrés A, Loinaz C, Len O, Azancot MA, Montejo M, Rodriguez-Alvarez R, Fortún J, Escudero-Sánchez R, Giménez E, Lora D, Albert E, Navarro D, Aguado JM. A New Clinical and Immunovirological Score for Predicting the Risk of Late Severe Infection in Solid Organ Transplant Recipients: The CLIV Score. J Infect Dis 2021; 222:479-487. [PMID: 32112085 DOI: 10.1093/infdis/jiaa090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 02/25/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND We aimed at constructing a composite score based on Epstein-Barr virus DNAemia (EBVd) and simple clinical and immunological parameters to predict late severe infection (LI) beyond month 6 in solid organ transplantation (SOT) recipients. METHODS Kidney and liver transplant recipients between May 2014 and August 2016 at 4 participating centers were included. Serum immunoglobulins and complement factors, peripheral blood lymphocyte subpopulations, and whole blood EBVd were determined at months 1, 3, and 6. Cox regression analyses were performed to generate a weighted score for the prediction of LI. RESULTS Overall, 309 SOT recipients were followed-up for a median of 1000 days from transplant (interquartile range, 822-1124). Late severe infection occurred in 104 patients (33.6%). The CLIV Score consisted of the following variables at month 6: high-level EBVd (>1500 IU/mL) and recurrent infection during the previous months (6 points); recipient age ≥70 years and chronic graft dysfunction (5 points); cytomegalovirus mismatch (4 points); and CD8+ T-cell count <400 cells/μL (2 points). The area under receiver operating characteristics curve was 0.77 (95% confidence interval, 0.71-0.84). The risk of LI at day 1000 was as follows: score 0, 12.6%; score 2-5, 25.5%; score 6-9, 52.7%; score ≥10, 73.5%. CONCLUSIONS While waiting for further external validation, the CLIV Score based on clinical and immune-virological parameters is potentially useful to stratify the risk of LI after SOT.
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Affiliation(s)
- Rafael San-Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - María Ruiz-Ruigómez
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Carmelo Loinaz
- Department of General Surgery, Alimentary Tract and Abdominal Organ Transplantation, Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Oscar Len
- Department of Infectious Diseases, Hospital Universitari Vall d'Hebron, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, Spain
| | - María Antonieta Azancot
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Miguel Montejo
- Unit of Infectious Diseases, Hospital Universitario de Cruces, Bilbao, Spain
| | | | - Jesús Fortún
- Department of Infectious Diseases, Hospital Universitario "Ramón y Cajal," Instituto "Ramón y Cajal" de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Rosa Escudero-Sánchez
- Department of Infectious Diseases, Hospital Universitario "Ramón y Cajal," Instituto "Ramón y Cajal" de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Estela Giménez
- Department of Microbiology, Hospital Clínico Universitario, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - David Lora
- Clinical Research Unit, Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain, Facultad de Estudios Estadísticos, Universidad Complutense de Madrid, Madrid, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Eliseo Albert
- Department of Microbiology, Hospital Clínico Universitario, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - David Navarro
- Department of Microbiology, Hospital Clínico Universitario, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
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12
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Sarmiento E, Jimenez M, di Natale M, Rodriguez-Ferrero M, Anaya F, Lopez-Hoyos M, Rodrigo E, Arias M, Perello M, Seron D, Karanovic B, Ezzahouri I, Mezzano S, Jaramillo M, Calahorra L, Alarcon A, Navarro J, Muñoz P, Carbone J. Secondary antibody deficiency is associated with development of infection in kidney transplantation: Results of a multicenter study. Transpl Infect Dis 2020; 23:e13494. [PMID: 33064917 DOI: 10.1111/tid.13494] [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: 08/08/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND We performed a multicenter study to assess the association between secondary antibody deficiency (immunoglobulin G [IgG] hypogammaglobulinemia combined with low levels of specific antibodies) and development of infection in kidney transplantation. METHODS We prospectively analyzed 250 adult kidney recipients at four centers. The assessment points were before transplantation and 7 and 30 days after transplantation. The immune parameters were as follows: IgG, IgA, and IgM and complement factors C3 and C4 tested by nephelometry; specific IgG antibodies to cytomegalovirus (CMV) and IgG and IgG2 antibodies to pneumococcal polysaccharide (anti-PPS) determined using enzyme-linked immunosorbent assay. The clinical follow-up period lasted 6 months. The clinical outcomes were CMV disease and recurrent bacterial infections requiring antimicrobial therapy. STATISTICS Multivariate logistic regression. RESULTS At day 7, IgG hypogammaglobulinemia (IgG levels < 700 mg/dL) combined with low IgG anti-CMV antibody titers (defined as levels < 10 000 units) was present in 12% of kidney recipients. IgG hypogammaglobulinemia combined with low IgG anti-PPS antibody titers (defined as levels < 10 mg/dL) at 1 month after kidney transplantation were recorded in 16% of patients. At day 7 the combination of IgG hypogammaglobulinemia and low anti-CMV titers was independently associated with the development of CMV disease (odds ratio [OR], 6.95; 95% confidence interval [CI], 1.17-41.31; P = .033). At day 30 after transplantation, the combination of IgG < 700 mg/dL and IgG anti-PPS < 10 mg/dL, was independently associated with recurrent bacterial infection (OR, 5.942; 95% CI, 1.943-18.172; P = .002). CONCLUSION In a prospective multicenter study, early immunologic monitoring of secondary antibody deficiency proved useful for the identification of kidney recipients who developed severe infection.
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Affiliation(s)
- Elizabeth Sarmiento
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maricela Jimenez
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Marisa di Natale
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Fernando Anaya
- Nephrology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Marcos Lopez-Hoyos
- Immunology Department, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain.,Histocompatibility Testing Laboratory, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Emilio Rodrigo
- Nephrology Department, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Manuel Arias
- Nephrology Department, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Manel Perello
- Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniel Seron
- Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Boris Karanovic
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ikram Ezzahouri
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Sergio Mezzano
- Division of Nephrology, School of Medicine, Universidad Austral, Valdivia, Chile
| | - Maria Jaramillo
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Medicine Institute, Universidad Austral, Valdivia, Chile
| | - Leticia Calahorra
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Alba Alarcon
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Joaquin Navarro
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Patricia Muñoz
- Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Immunology Department, Universidad Complutense, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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13
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Fujino T, Kumai Y, Nitta D, Holzhauser L, Nguyen A, Lourenco L, Rodgers D, Raikhelkar J, Kim G, Sayer G, Uriel N. Hypogammaglobulinemia following heart transplantation: Prevalence, predictors, and clinical importance. Clin Transplant 2020; 34:e14087. [PMID: 32955148 DOI: 10.1111/ctr.14087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/09/2020] [Accepted: 09/08/2020] [Indexed: 01/14/2023]
Abstract
Hypogammaglobulinemia (HGG) can occur following solid organ transplantation. However, there are limited data describing the prevalence, risk factors, and clinical outcomes associated with HGG following heart transplantation. We retrospectively reviewed data of 132 patients who had undergone heart transplantation at our institution between April 2014 and December 2018. We classified patients into three groups based on the lowest serum IgG level post-transplant: normal (≥700 mg/dL), mild HGG (≥450 and <700 mg/dL), and severe HGG (<450 mg/dL). We compared clinical outcomes from the date of the lowest IgG level. Mean age was 57 (47, 64) years, and 94 (71%) patients were male. Prevalence of severe HGG was the highest (27%) at 3-6 months following heart transplantation and then decreased to 5% after 1 year. Multivariate analysis showed that older age and Caucasian race were independent risk factors for HGG. Overall survival was comparable between the groups; however, survival free of infection was 73%, 60%, and 45% at 1 year in the normal, mild HGG, and severe HGG groups, respectively (P = .013). In conclusion, there is a high prevalence of HGG in the early post-heart transplant period that decreases over time. HGG is associated with an increased incidence of infection.
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Affiliation(s)
- Takeo Fujino
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Yuto Kumai
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Daisuke Nitta
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Luise Holzhauser
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Ann Nguyen
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Laura Lourenco
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Daniel Rodgers
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Jayant Raikhelkar
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Gene Kim
- Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Gabriel Sayer
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Nir Uriel
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
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14
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Roberts MB, Fishman JA. Immunosuppressive Agents and Infectious Risk in Transplantation: Managing the "Net State of Immunosuppression". Clin Infect Dis 2020; 73:e1302-e1317. [PMID: 32803228 DOI: 10.1093/cid/ciaa1189] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Indexed: 12/14/2022] Open
Abstract
Successful solid organ transplantation reflects meticulous attention to the details of immunosuppression, balancing risks for graft rejection against risks for infection. The 'net state of immune suppression' is a conceptual framework of all factors contributing to infectious risk. Assays which measure immune function in the immunosuppressed transplant recipient relative to infectious risk and allograft function are lacking. The best measures of integrated immune function may be quantitative viral loads to assess the individual's ability to control latent viral infections. Few studies address adjustment of immunosuppression during active infections. Thus, confronted with infection in solid organ recipients, the management of immunosuppression is based largely on clinical experience. This review examines known measures of immune function and the immunologic effects of common immunosuppressive drugs and available studies reporting modification of drug regimens for specific infections. These data provide a conceptual framework for the management of immunosuppression during infection in organ recipients.
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Affiliation(s)
- Matthew B Roberts
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA
| | - Jay A Fishman
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA.,Harvard Medical School, Boston, MA
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15
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Fernández-Ruiz M, Seron D, Alonso Á, Lora D, Hernández D, González E, Pérez-Sáez MJ, Gómez G, Pallardó-Mateu LM, Jimeno-García L, Cofán F, Gutierrez-Dalmau A, Ruiz JC, Ramírez-Puga A, Santana Estupiñán R, Marcén R, Portolés JM, Muñoz-Cepeda MÁ, López-Medrano F, San Juan R, Andrés A, Aguado JM. Derivation and external validation of the SIMPLICITY score as a simple immune-based risk score to predict infection in kidney transplant recipients. Kidney Int 2020; 98:1031-1043. [PMID: 32540404 DOI: 10.1016/j.kint.2020.04.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 04/10/2020] [Accepted: 04/30/2020] [Indexed: 11/16/2022]
Abstract
Existing approaches for infection risk stratification in kidney transplant recipients are suboptimal. Here, we aimed to develop and validate a weighted score integrating non-pathogen-specific immune parameters and clinical variables to predict the occurrence of post-transplant infectious complications. To this end, we retrospectively analyzed a single-center derivation cohort of 410 patients undergoing kidney transplantation in 2008-2013 in Madrid. Peripheral blood lymphocyte subpopulations, serum immunoglobulin and complement levels were measured at one-month post-transplant. The primary and secondary outcomes were overall and bacterial infection through month six. A point score was derived from a logistic regression model and prospectively applied on a validation cohort of 522 patients undergoing kidney transplantation at 16 centers throughout Spain in 2014-2015. The SIMPLICITY score consisted of the following variables measured at month one after transplantation: C3 level, CD4+ T-cell count, CD8+ T-cell count, IgG level, glomerular filtration rate, recipient age, and infection within the first month. The discrimination capacity in the derivation and validation cohorts was good for overall (areas under the receiver operating curve of 0.774 and 0.730) and bacterial infection (0.767 and 0.734, respectively). The cumulative incidence of overall infection significantly increased across risk categories in the derivation (low-risk 13.7%; intermediate-risk, 35.9%; high-risk 77.6%) and validation datasets (10.2%, 28.9% and 50.4%, respectively). Thus, the SIMPLICITY score, based on easily available immune parameters, allows for stratification of kidney transplant recipients at month one according to their expected risk of subsequent infection.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Daniel Seron
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Vall d' Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Ángel Alonso
- Department of Nephrology, Complexo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - David Lora
- Clinical Research Unit, Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP)
| | - Domingo Hernández
- Department of Nephrology, Hospital Universitario "Carlos Haya", Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - Esther González
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - María José Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Gonzalo Gómez
- Department of Nephrology, Hospital Universitari "Son Espases", Palma de Mallorca, Spain
| | | | - Luisa Jimeno-García
- Department of Nephrology, Hospital Universitario "Virgen de la Arrixaca", Murcia, Spain
| | - Frederic Cofán
- Department of Nephrology and Kidney Transplantation, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alex Gutierrez-Dalmau
- Department of Nephrology, IIS Aragón, Hospital Universitario "Miguel Servet", Zaragoza, Spain
| | - Juan Carlos Ruiz
- Department of Nephrology, Hospital Universitario "Marqués de Valdecilla", Instituto de Investigación "Marqués de Valdecilla" (IDIVAL), Santander, Spain
| | - Ana Ramírez-Puga
- Department of Nephrology, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
| | - Raquel Santana Estupiñán
- Department of Nephrology, Hospital Universitario "Doctor Negrín", Las Palmas de Gran Canaria, Spain
| | - Roberto Marcén
- Department of Nephrology, Hospital Universitario "Ramón y Cajal", Instituto "Ramón y Cajal" de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - José María Portolés
- Department of Nephrology, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro "Segovia de Arana", Madrid, Spain
| | - Miguel Ángel Muñoz-Cepeda
- Department of Nephrology, Hospital "Virgen de la Salud", Complejo Hospitalario de Toledo, Toledo, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario "Carlos Haya", Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), Madrid, Spain.
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16
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Silva JT, Fernández-Ruiz M, Aguado JM. Prevention and therapy of viral infections in patients with solid organ transplantation. Enferm Infecc Microbiol Clin 2020; 39:87-97. [PMID: 32143894 DOI: 10.1016/j.eimc.2020.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 12/28/2022]
Abstract
Solid organ transplantation (SOT) is the best treatment option for end-stage organ disease. The number of SOT procedures has been steadily increasing worldwide during the past decades. This trend has been accompanied by the continuous incorporation of new antimicrobial drugs and by the refinement of strategies aimed at minimizing the risk of opportunistic infection. Nonetheless, viral infections, which can occur at any stage of the post-transplant period, remain a clinical challenge that negatively impacts both patient and graft outcomes. This review offers an overview of the most relevant viral infections in the SOT population, with a focus on herpesviruses (cytomegalovirus, Epstein-Barr virus, varicella-zoster virus, and herpes simplex virus 1 and 2) and polyomaviruses (human BK polyomavirus). In addition, the currently recommended prophylactic and treatment approaches are summarized, as well as the new antiviral agents in different phases of clinical development.
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Affiliation(s)
- Jose Tiago Silva
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (imas12), School of Medicine, Universidad Complutense, Madrid, Spain.
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17
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Fernández-Ruiz M, López-Medrano F, Aguado JM. Predictive tools to determine risk of infection in kidney transplant recipients. Expert Rev Anti Infect Ther 2020; 18:423-441. [PMID: 32084326 DOI: 10.1080/14787210.2020.1733976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: Infection represents a major complication after kidney transplantation (KT). Therapeutic drug monitoring is essentially the only approach for the adjustment of immunosuppression in current practice, with suboptimal results. The implementation of immune monitoring strategies may contribute to minimizing the risk of adverse events attributable to over-immunosuppression without compromising graft outcomes.Areas covered: The present review (based on PubMed/MEDLINE searches from database inception to November 2019) is focused on immune biomarkers with no antigen specificity (non-pathogen-specific), including serum levels of immunoglobulins and complement factors, peripheral blood lymphocyte subpopulations, soluble CD30, intracellular ATP production by stimulated CD4+ T-cells, and other cell-based immune assays. We also summarized recent advances in the use of replication kinetics of latent viruses to assess the functionality of T-cell immunity, with focus on the nonpathogenic anelloviruses. Finally, the composite risk scores reported in the literature are critically discussed.Expert opinion: Notable efforts have been made to develop an enlarging repertoire of immune biomarkers and prediction models, although most of them still lack technical standardization and external validation. Preventive interventions based on these tools (prolongation of prophylaxis, tapering of immunosuppression, or immunoglobulin replacement therapy in hypogammaglobulinemic patients) remain to be defined, ideally in the context of controlled trials.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (Imas12), Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002), Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (Imas12), Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002), Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (Imas12), Madrid, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0002), Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Universidad Complutense, Madrid, Spain
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18
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Rodríguez-Goncer I, Fernández-Ruiz M, Aguado JM. A critical review of the relationship between post-transplant atherosclerotic events and cytomegalovirus exposure in kidney transplant recipients. Expert Rev Anti Infect Ther 2019; 18:113-125. [PMID: 31852276 DOI: 10.1080/14787210.2020.1707079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Introduction: Cytomegalovirus (CMV) infection after kidney transplantation (KT) has been implicated in the so-called 'indirect effects' attributable to the viral ability to evade host's immunity and trigger sustained inflammation. Whether CMV exposure contributes to the development of post-transplant atherosclerotic events (AEs) remains controversial.Areas covered: This review (based on a PubMed/MEDLINE search from database inception to October 2019) summarizes the proposed mechanisms for the role of CMV in atherogenesis, including accelerated immunosenescence, endothelial injury and inflammatory milieu in the vessel wall. Sero-epidemiological evidence linking CMV exposure and cardiovascular disease in the general population is discussed. Finally, we performed a comprehensive review of observational studies investigating the impact of CMV infection on the occurrence of AE after KT, as well as the potential protective effect of antiviral prophylaxis.Expert opinion: Reviewed studies provide biological plausibility and preliminary clinical evidence pointing to the pathogenic role of CMV in post-transplant atherogenesis. However, no definitive recommendations can be made regarding the use of antiviral prophylaxis to prevent post-transplant AE, since existing evidence is mainly founded on inadequately powered post hoc analysis. Well-designed observational studies should clarify the differential impact of prophylactic or preemptive approaches on the occurrence of CMV-associated post-transplant AE among KT recipients.
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Affiliation(s)
- Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", School of Medicine, Universidad Complutense, Madrid, Spain.,Spanish Network for Research in Infectious Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", School of Medicine, Universidad Complutense, Madrid, Spain.,Spanish Network for Research in Infectious Diseases, Instituto de Salud Carlos III, Madrid, Spain
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19
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Kaplan B, Bonagura VR. Secondary Hypogammaglobulinemia: An Increasingly Recognized Complication of Treatment with Immunomodulators and After Solid Organ Transplantation. Immunol Allergy Clin North Am 2019; 39:31-47. [PMID: 30466771 DOI: 10.1016/j.iac.2018.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Secondary hypogammaglobulinemia is a common development in patients treated with immunomodulatory agents for autoimmune, connective tissue, and malignant diseases. It has been observed in the medical management of patients undergoing hematopoietic stem cell and solid organ transplantation. Some patients have preexisting immunodeficiency associated with these illnesses; immunosuppressive treatment magnifies their immune defect. This article reviews immunosuppressive medications, including biological treatments that cause secondary hypogammaglobulinemia. It summarizes risk factors for rituximab-induced hypogammaglobulinemia, such as preexisting low immunoglobulin G levels, CD19 levels, host factors, and additive effect of all immunomodulatory drugs used. The evaluation and management of secondary hypogammaglobulinemia are discussed.
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Affiliation(s)
- Blanka Kaplan
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Steven and Alexandra Cohen Medical Center of New York, 865 Northern Boulevard, Suite 101, Great Neck, NY 11021, USA.
| | - Vincent R Bonagura
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Steven and Alexandra Cohen Medical Center of New York, 865 Northern Boulevard, Suite 101, Great Neck, NY 11021, USA
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20
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Hanson KE, Limaye AP. Prediction of Infection After Solid Organ Transplantation: Is Measuring Cell-Mediated Immunity the Answer? Clin Infect Dis 2019; 66:1398-1399. [PMID: 29281087 DOI: 10.1093/cid/cix1009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/13/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kimberly E Hanson
- Division of Infectious Diseases, Department of Medicine, University of Utah, Salt Lake City
| | - Ajit P Limaye
- Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle
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21
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Patel SY, Carbone J, Jolles S. The Expanding Field of Secondary Antibody Deficiency: Causes, Diagnosis, and Management. Front Immunol 2019; 10:33. [PMID: 30800120 PMCID: PMC6376447 DOI: 10.3389/fimmu.2019.00033] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022] Open
Abstract
Antibody deficiency or hypogammaglobulinemia can have primary or secondary etiologies. Primary antibody deficiency (PAD) is the result of intrinsic genetic defects, whereas secondary antibody deficiency may arise as a consequence of underlying conditions or medication use. On a global level, malnutrition, HIV, and malaria are major causes of secondary immunodeficiency. In this review we consider secondary antibody deficiency, for which common causes include hematological malignancies, such as chronic lymphocytic leukemia or multiple myeloma, and their treatment, protein-losing states, and side effects of a number of immunosuppressive agents and procedures involved in solid organ transplantation. Secondary antibody deficiency is not only much more common than PAD, but is also being increasingly recognized with the wider and more prolonged use of a growing list of agents targeting B cells. SAD may thus present to a broad range of specialties and is associated with an increased risk of infection. Early diagnosis and intervention is key to avoiding morbidity and mortality. Optimizing treatment requires careful clinical and laboratory assessment and may involve close monitoring of risk parameters, vaccination, antibiotic strategies, and in some patients, immunoglobulin replacement therapy (IgRT). This review discusses the rapidly evolving list of underlying causes of secondary antibody deficiency, specifically focusing on therapies targeting B cells, alongside recent advances in screening, biomarkers of risk for the development of secondary antibody deficiency, diagnosis, monitoring, and management.
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Affiliation(s)
- Smita Y. Patel
- Clinical Immunology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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22
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The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. Transplantation 2019; 102:900-931. [PMID: 29596116 DOI: 10.1097/tp.0000000000002191] [Citation(s) in RCA: 688] [Impact Index Per Article: 137.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite recent advances, cytomegalovirus (CMV) infections remain one of the most common complications affecting solid organ transplant recipients, conveying higher risks of complications, graft loss, morbidity, and mortality. Research in the field and development of prior consensus guidelines supported by The Transplantation Society has allowed a more standardized approach to CMV management. An international multidisciplinary panel of experts was convened to expand and revise evidence and expert opinion-based consensus guidelines on CMV management including prevention, treatment, diagnostics, immunology, drug resistance, and pediatric issues. Highlights include advances in molecular and immunologic diagnostics, improved understanding of diagnostic thresholds, optimized methods of prevention, advances in the use of novel antiviral therapies and certain immunosuppressive agents, and more savvy approaches to treatment resistant/refractory disease. The following report summarizes the updated recommendations.
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23
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Vanichanan J, Udomkarnjananun S, Avihingsanon Y, Jutivorakool K. Common viral infections in kidney transplant recipients. Kidney Res Clin Pract 2018; 37:323-337. [PMID: 30619688 PMCID: PMC6312768 DOI: 10.23876/j.krcp.18.0063] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/22/2018] [Accepted: 10/07/2018] [Indexed: 12/15/2022] Open
Abstract
Infectious complications have been considered as a major cause of morbidity and mortality after kidney transplantation, especially in the Asian population. Therefore, prevention, early detection, and prompt treatment of such infections are crucial in kidney transplant recipients. Among all infectious complications, viruses are considered to be the most common agents because of their abundance, infectivity, and latency ability. Herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, hepatitis B virus, BK polyomavirus, and adenovirus are well-known etiologic agents of viral infections in kidney transplant patients worldwide because of their wide range of distribution. As DNA viruses, they are able to reactivate after affected patients receive immunosuppressive agents. These DNA viruses can cause systemic diseases or allograft dysfunction, especially in the first six months after transplantation. Pretransplant evaluation and immunization as well as appropriate prophylaxis and preemptive approaches after transplant have been established in the guidelines and are used effectively to reduce the incidence of these viral infections. This review will describe the etiology, diagnosis, prevention, and treatment of viral infections that commonly affect kidney transplant recipients.
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Affiliation(s)
- Jakapat Vanichanan
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Renal Immunology and Therapeutic Apheresis Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Renal Immunology and Therapeutic Apheresis Research Unit, Chulalongkorn University, Bangkok, Thailand.,Excellence Center of Immunology and Immune-mediated Diseases, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kamonwan Jutivorakool
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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24
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Los-Arcos I, Len O, Perello M, Torres IB, Codina G, Esperalba J, Sellarés J, Moreso F, Seron D, Gavaldà J. Is antibody-mediated rejection in kidney transplant recipients a risk factor for developing cytomegalovirus or BK virus infection? Results from a case-control study. J Clin Virol 2018; 110:45-50. [PMID: 30537648 DOI: 10.1016/j.jcv.2018.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/08/2018] [Accepted: 11/30/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Data are scarce on cytomegalovirus (CMV) and BK virus (BKV) infection after antibody-mediated rejection (ABMR). OBJECTIVES We hypothesized that the immunological response in patients with ABMR or the immune modulation associated with its treatment could predispose to CMV and BKV infection. Our objective was to investigate this hypothesis. STUDY DESIGN We conducted a single-center, matched case-control study (1:2 ratio) to analyze CMV and BKV replication during the first year after the ABMR diagnosis in kidney transplant recipients. Adult recipients with a histopathological diagnosis of ABMR between 2007-2015 were included as cases. Controls were kidney recipients who underwent transplantation immediately before and after the index case. RESULTS Fifty-eight patients diagnosed with ABMR (33 chronic active ABMR and 25 acute ABMR), with their matched controls (116) were included. Forty-four cases received treatment for ABMR, including plasmapheresis (41), immunoglobulins (40), and rituximab (31). Within 1 year after ABMR, cases showed CMV replication more often than controls (9/58, 15.5% vs 7/116, 6%, OR = 4.21, CI 1.10-16.16, p = 0.04). Over the study period, CMV PCR determinations were requested more frequently in cases than controls (46/58, 79.3% vs 63/116, 54.3%, OR = 4.58, CI 1.92-10.9, p = 0.001). On multivariate analysis adjusted for CMV PCR determinations, retransplantation, antithymocyte globulin treatment and methylprednisolone treatment for acute rejection, CMV replication remained more common in cases than in controls (OR = 2.41, CI 0.49-11.73, p = 0.28). There were no differences in BKV replication in either urine or blood. CONCLUSIONS ABMR may be a risk factor for CMV but not for BKV replication in kidney transplant recipients.
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Affiliation(s)
- Ibai Los-Arcos
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oscar Len
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Manel Perello
- Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Irina B Torres
- Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Gemma Codina
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Juliana Esperalba
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Joana Sellarés
- Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Francesc Moreso
- Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniel Seron
- Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Joan Gavaldà
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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25
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Navarro D, Fernández-Ruiz M, Aguado JM, Sandonís V, Pérez-Romero P. Going beyond serology for stratifying the risk of CMV infection in transplant recipients. Rev Med Virol 2018; 29:e2017. [PMID: 30358016 DOI: 10.1002/rmv.2017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 12/12/2022]
Abstract
Knowledge of donor and recipient (D/R) cytomegalovirus (CMV) serostatus is critical for risk stratification of CMV infection and disease in transplant recipients, particularly in the solid organ transplantation (SOT) setting. Despite its broad availability and the success of it use, the risk stratification based on the D/R serostatus is not free of limitations since there are a nondepreciable number of patients that are not accurately categorized by this approach. In fact, up to 20% of seropositive SOT recipients, classically considered at intermediate risk, develop episodes of CMV infection and disease after transplantation. Here, we provide an overview of additional donor and recipient factors that may have utility in identifying patients at risk for post-transplant CMV infection. Specifically, we summarize our current understanding regarding the potential use of use CMV-specific T-cell-mediated immunity, neutralizing antibodies and host genetics that may influence the risk of CMV infection and disease. We provide an overview of the benefits and limitations associated with using these immunological factors in risk stratification and propose specific variables that could be analyzed at the pretransplant evaluation to improve the identification of patients with increased individual susceptibility.
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Affiliation(s)
- David Navarro
- Microbiology Service, Hospital Clínico Universitario, Fundación INCLIVA, Valencia, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital,"12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital,"12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Virginia Sandonís
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital,"12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Pilar Pérez-Romero
- National Center of Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
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26
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Dendle C, Mulley WR, Holdsworth S. Can immune biomarkers predict infections in solid organ transplant recipients? A review of current evidence. Transplant Rev (Orlando) 2018; 33:87-98. [PMID: 30551846 DOI: 10.1016/j.trre.2018.10.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 12/12/2022]
Abstract
Despite improvements in graft survival, solid organ transplantation is still associated with considerable infection induced morbidity and mortality. If we were able to show that serious infection risk was associated with excessive suppression of immune capacity, we would be justified in "personalizing" the extent of immunosuppression by carefully monitored reduction to see if we can improve immune compromize without increasing the risk of rejection. Reliable biomarkers are needed to identify this patients at an increased risk of infection. This review focuses on the currently available evidence in solid organ transplant recipients for immune non-pathogen specific biomarkers to predict severe infections with the susceptibility to particular pathogens according to the component of the immune system that is suppressed. This review is categorized into immune biomarkers representative of the humoral, cellular, phagocytic, natural killer cell and complement system. Biomarkers humoral and cellular systems of the that have demonstrated an association with infections include immunoglobulins, lymphocyte number, lymphocyte subsets, intracellular concentrations of adenosine triphosphate in stimulated CD4+ cells and soluble CD30. Biomarkers of the innate immune system that have demonstrated an association with infections include natural killer cell numbers, complement and mannose binding lectin. Emerging evidence shows that quantification of viral nucleic acid (such as Epstein Barr Virus) can act as a biomarker to predict all-cause infections. Studies that show the most promise are those in which several immune biomarkers are assessed in combination. Ongoing research is required to validate non-pathogen specific immune biomarkers in multi-centre studies using standardized study designs.
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Affiliation(s)
- Claire Dendle
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University and Monash Infectious Diseases, Monash Health, Australia.
| | - William R Mulley
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Australia; Department of Nephrology, Monash Medical Centre, Clayton, Victoria 3168, Australia.
| | - Stephen Holdsworth
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Australia; Department of Nephrology, Monash Medical Centre, Clayton, Victoria 3168, Australia.
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27
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Sarmiento E, Cifrian J, Calahorra L, Bravo C, Lopez S, Laporta R, Ussetti P, Sole A, Morales C, de Pablos A, Jaramillo M, Ezzahouri I, García S, Navarro J, Lopez-Hoyos M, Carbone J. Monitoring of early humoral immunity to identify lung recipients at risk for development of serious infections: A multicenter prospective study. J Heart Lung Transplant 2018; 37:1001-1012. [DOI: 10.1016/j.healun.2018.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/12/2018] [Accepted: 04/03/2018] [Indexed: 12/13/2022] Open
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28
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Paul P, Picard C, Sampol E, Lyonnet L, Di Cristofaro J, Paul-Delvaux L, Lano G, Nicolino-Brunet C, Ravis E, Collart F, Dignat-George F, Dussol B, Sabatier F, Mouly-Bandini A. Genetic and Functional Profiling of CD16-Dependent Natural Killer Activation Identifies Patients at Higher Risk of Cardiac Allograft Vasculopathy. Circulation 2017; 137:1049-1059. [PMID: 29097449 DOI: 10.1161/circulationaha.117.030435] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 10/19/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cardiac transplantation is an effective therapy for end-stage heart failure. Because cardiac allograft vasculopathy (CAV) is the major cause of late mortality after heart transplant (HT), there is a need to identify markers that reflect inflammatory or cytotoxic immune mechanisms contributing to its onset. Noninvasive and early stratification of patients at risk remains a challenge for adapting individualized therapy. The CD16 (Fc-gamma receptor 3A [FCGR3A]) receptor was recently identified as a major determinant of antibody-mediated natural killer (NK) cell activation in HT biopsies; however, little is known about the role of CD16 in promoting allograft vasculopathy. This study aimed to investigate whether markers that reflect CD16-dependent circulating NK cell activation may identify patients at higher risk of developing CAV after HT. METHODS Blood samples were collected from 103 patients undergoing routine coronarography angiography for CAV diagnosis (median 5 years since HT). Genomic and phenotypic analyses of FCGR3A/CD16 Fc-receptor profiles were compared in CAV-positive (n=52) and CAV-free patients (n=51). The levels of CD16 expression and rituximab-dependent cell cytotoxic activity of peripheral NK cells in HT recipients were evaluated using a noninvasive NK-cellular humoral activation test. RESULTS Enhanced levels of CD16 expression and antibody-dependent NK cell cytotoxic function of HT recipients were associated with the FCGR3A-VV genotype. The frequency of the FCGR3A-VV genotype was significantly higher in the CAV+ group (odds ratio, 3.9; P=0.0317) than in the CAV- group. The FCGR3A-VV genotype was identified as an independent marker correlated with the presence of CAV at the time of coronary angiography by using multivariate logistic regression models. The FCGR3A-VV genotype was also identified as a baseline-independent predictor of CAV risk (odds ratio, 4.7; P=0.023). CONCLUSIONS This study unravels a prominent role for the CD16-dependent NK cell activation pathway in the complex array of factors that favor the progression of transplant arteriosclerosis. It highlights the clinical potential of a noninvasive evaluation of FCGR3A/CD16 in the early stratification of CAV risk. The recognition of CD16 as a major checkpoint that controls immune surveillance may promote the design of individualized NK cell-targeted therapies to limit vascular damage in highly responsive sensitized patients. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01569334.
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Affiliation(s)
- Pascale Paul
- Assistance Publique-Hôpitaux Marseille (AP-HM), Vascular Biology and Cell Therapy Department, France (P.P., L.L., C.N.B., F.D.G., F.S.). .,INSERM, Aix-Marseille Université (AMU), VRCM, UMR-1076, France (P.P., F.D.G., F.S.)
| | - Christophe Picard
- Immunogenetic Laboratory, Établissement Français du Sang, Marseille, France (C.P.).,Aix Marseille Université, Etablissement Français du Sang, CNRS, UMR 7268 ADÉS, France (C.P., J.D.C.)
| | - Emmanuelle Sampol
- Assistance Publique-Hôpitaux Marseille (AP-HM), Pharmacokinetics Department, France (E.S.)
| | - Luc Lyonnet
- Assistance Publique-Hôpitaux Marseille (AP-HM), Vascular Biology and Cell Therapy Department, France (P.P., L.L., C.N.B., F.D.G., F.S.)
| | - Julie Di Cristofaro
- Assistance Publique-Hôpitaux Marseille (AP-HM), Pharmacokinetics Department, France (E.S.)
| | - Louise Paul-Delvaux
- ENSAE-Paristech, Data Science & Statistics Department, Paris, France (L.P.-D.)
| | - Guillaume Lano
- Assistance Publique-Hôpitaux Marseille (AP-HM), Aix Marseille Univ, Center for Clinical Investigation, France (G.L., B.D.)
| | - Corinne Nicolino-Brunet
- Assistance Publique-Hôpitaux Marseille (AP-HM), Vascular Biology and Cell Therapy Department, France (P.P., L.L., C.N.B., F.D.G., F.S.)
| | - Eleonore Ravis
- Assistance Publique Hopitaux de Marseille (AP-HM), Adult Cardiac Surgery Department, France (E.R., F.C., A.M.B.)
| | - Frederic Collart
- Assistance Publique Hopitaux de Marseille (AP-HM), Adult Cardiac Surgery Department, France (E.R., F.C., A.M.B.)
| | - Francoise Dignat-George
- Assistance Publique-Hôpitaux Marseille (AP-HM), Vascular Biology and Cell Therapy Department, France (P.P., L.L., C.N.B., F.D.G., F.S.).,INSERM, Aix-Marseille Université (AMU), VRCM, UMR-1076, France (P.P., F.D.G., F.S.)
| | - Bertrand Dussol
- Assistance Publique-Hôpitaux Marseille (AP-HM), Aix Marseille Univ, Center for Clinical Investigation, France (G.L., B.D.)
| | - Florence Sabatier
- Assistance Publique-Hôpitaux Marseille (AP-HM), Vascular Biology and Cell Therapy Department, France (P.P., L.L., C.N.B., F.D.G., F.S.).,INSERM, Aix-Marseille Université (AMU), VRCM, UMR-1076, France (P.P., F.D.G., F.S.)
| | - Annick Mouly-Bandini
- Assistance Publique Hopitaux de Marseille (AP-HM), Adult Cardiac Surgery Department, France (E.R., F.C., A.M.B.)
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Carbone J. Complement genomics and antibody-mediated rejection in heart recipients. J Heart Lung Transplant 2017; 37:439-440. [PMID: 28864337 DOI: 10.1016/j.healun.2017.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 08/16/2017] [Indexed: 10/19/2022] Open
Abstract
In this issue of the Journal of Heart and Lung Transplantation, Marrón-Liñares et al report the results of an interesting study in which they evaluated 51 genes associated with the complement pathway in a small number of heart recipients to explore their relationship with antibody-mediated rejection (AMR). Next-generation sequencing was used in 46 heart transplant recipients (23 with AMR and 23 without AMR). The authors identified a significant association of 2 single-nucleotide polymorphisms with the absence or presence of AMR, respectively, p.Gly54Asp-MBL2 in the mannose-binding lectin (MBL) 2 gene and p.Asn428(p=)-CFP in the alternative complement factor properdin (CFP) gene. This article is a new contribution to the heart transplant literature. It suggests that complement single-nucleotide polymorphisms may influence circulating levels of selected proteins of both the lectin pathway and alternative complement pathways, thus potentially determining which patients will develop AMR.
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Affiliation(s)
- Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañón, the Immunology Unit, Complutense University, and Instituto para la Investigación Biomédica del Hospital Gregorio Marañón, Madrid, Spain.
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30
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Ye MH, Bao H, Meng Y, Guan LL, Stothard P, Plastow G. Comparative transcriptomic analysis of porcine peripheral blood reveals differentially expressed genes from the cytokine-cytokine receptor interaction pathway related to health status. Genome 2017; 60:1021-1028. [PMID: 28763624 DOI: 10.1139/gen-2017-0074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
While some research has looked into the host genetic response in pigs challenged with specific viruses or bacteria, few studies have explored the expression changes of transcripts in the peripheral blood of sick pigs that may be infected with multiple pathogens on farms. In this study, the architecture of the peripheral blood transcriptome of 64 Duroc sired commercial pigs, including 18 healthy animals at entry to a growing facility (set as a control) and 23 pairs of samples from healthy and sick pen mates, was generated using RNA-Seq technology. In total, 246 differentially expressed genes were identified to be specific to the sick animals. Functional enrichment analysis for those genes revealed that the over-represented gene ontology terms for the biological processes category were exclusively immune activity related. The cytokine-cytokine receptor interaction pathway was significantly enriched. Nine functional genes from this pathway encoding members (as well as their receptors) of the interleukins, chemokines, tumor necrosis factors, colony stimulating factors, activins, and interferons exhibited significant transcriptional alteration in sick animals. Our results suggest a subset of novel marker genes that may be useful candidate genes in the evaluation and prediction of health status in pigs under commercial production conditions.
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Affiliation(s)
- M H Ye
- a Department of Agricultural, Food and Nutritional Science, University of Alberta, 1400 College Plaza, 8215 112 Street, Edmonton, AB T6G 2C8, Canada.,b College of Bioscience and Biotechnology, Yangzhou University, Yangzhou 225009, China
| | - H Bao
- a Department of Agricultural, Food and Nutritional Science, University of Alberta, 1400 College Plaza, 8215 112 Street, Edmonton, AB T6G 2C8, Canada
| | - Y Meng
- a Department of Agricultural, Food and Nutritional Science, University of Alberta, 1400 College Plaza, 8215 112 Street, Edmonton, AB T6G 2C8, Canada
| | - L L Guan
- a Department of Agricultural, Food and Nutritional Science, University of Alberta, 1400 College Plaza, 8215 112 Street, Edmonton, AB T6G 2C8, Canada
| | - P Stothard
- a Department of Agricultural, Food and Nutritional Science, University of Alberta, 1400 College Plaza, 8215 112 Street, Edmonton, AB T6G 2C8, Canada
| | - G Plastow
- a Department of Agricultural, Food and Nutritional Science, University of Alberta, 1400 College Plaza, 8215 112 Street, Edmonton, AB T6G 2C8, Canada
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31
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Sarmiento E, Arraya M, Jaramillo M, Diez P, Fernandez-Yañez J, Palomo J, Navarro J, Carbone J. Intravenous immunoglobulin as an intervention strategy of risk factor modification for prevention of severe infection in heart transplantation. Clin Exp Immunol 2015; 178 Suppl 1:156-8. [PMID: 25546803 DOI: 10.1111/cei.12552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- E Sarmiento
- Transplant Immunology Group, Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
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