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Kwon OK, Jeong ES, Lee KW, Choi MR, Sonn CH, Cho B, Shim J, Choi K, Kim SJ, Park JB. Monitoring Porcine Cytomegalovirus in Both Donors and Recipients is Crucial for Recipient's Survival in Pig-to-Cynomolgus Xenotransplantation. Transplant Proc 2024; 56:686-691. [PMID: 38378341 DOI: 10.1016/j.transproceed.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/16/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Xenotransplantation, particularly when involving pig donors, presents challenges related to the transmission of porcine cytomegalovirus (pCMV) and its potential impact on recipient outcomes. This study aimed to investigate the relationship between pCMV positivity in both donors and recipients and the survival time of cynomolgus monkey recipients after xenogeneic kidney transplantation. METHODS We conducted 20 cynomolgus xenotransplants using 18 transgenic pigs. On the surgery day, donor pig blood was sampled, and DNA was extracted from serum and peripheral blood mononuclear cells. Recipient DNA extraction followed the same protocol from pre-transplantation to post-transplantation. Porcine cytomegalovirus detection used real-time polymerase chain reaction (real-time PCR) with the ViroReal kit, achieving a sensitivity of 50 copies/reaction. A Ct value of 37.0 was the pCMV positivity threshold. RESULTS Of 20 cynomolgus recipients, when donors tested negative for pCMV, recipients also showed negative results in 9 cases. In 4 cases where donors were negative, recipients tested positive. All 5 cases with pCMV-positive donors resulted in positive assessments for recipients. Detection of donor pCMV correlated with shorter recipient survival. Continuous recipient positivity during observation correlated with shorter survival, whereas transient detection showed no significant change in survival rates. However, donor pig phenotypes and transplantation protocols did not significantly impact survival. CONCLUSION The detection of pCMV in both donors and recipients plays a crucial role in xenotransplantation outcomes. These findings suggest the importance of monitoring and managing pCMV in xenotransplantation to enhance long-term outcomes.
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Affiliation(s)
- O Kyung Kwon
- Transplantation Research Center, Samsung Medical Center, Seoul, Republic of Korea; Department of Health Sciences & Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Eun Sung Jeong
- Department of Surgery, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Goyang, Republic of Korea
| | - Kyo Won Lee
- Transplantation Research Center, Samsung Medical Center, Seoul, Republic of Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mi Ran Choi
- Transplantation Research Center, Samsung Medical Center, Seoul, Republic of Korea; Department of Health Sciences & Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Chung Hee Sonn
- Transplantation Research Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Bumrae Cho
- GenNBio Co, Ltd, 80, Dreamsandan 2-ro, Cheongbuk-eup, Pyeongtaek-si, Gyeonggi-do, Republic of Korea
| | - Joohyun Shim
- Optipharm Inc., Cheongju-si, Chungcheongbuk-do, Republic of Korea
| | - Kimyung Choi
- Optipharm Inc., Cheongju-si, Chungcheongbuk-do, Republic of Korea
| | - Sung Joo Kim
- GenNBio Co, Ltd, 80, Dreamsandan 2-ro, Cheongbuk-eup, Pyeongtaek-si, Gyeonggi-do, Republic of Korea
| | - Jae Berm Park
- Transplantation Research Center, Samsung Medical Center, Seoul, Republic of Korea; Department of Health Sciences & Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul 06355, Republic of Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Post-transplant absolute lymphocyte count predicts early cytomegalovirus infection after heart transplantation. Sci Rep 2021; 11:1426. [PMID: 33446808 PMCID: PMC7809401 DOI: 10.1038/s41598-020-80790-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 12/07/2020] [Indexed: 12/22/2022] Open
Abstract
Immunosuppressive therapy can decrease rejection episodes and increase the risk of severe and fatal infections in heart transplantation (HT) recipients. Immunosuppressive therapy can also decrease the absolute lymphocyte count (ALC), but the relationship between early post-transplant ALC and early cytomegalovirus (CMV) infection is largely unknown, especially in HT. We retrospectively analyzed 58 HT recipients who tested positive for CMV IgG antibody and received basiliximab induction therapy. We collected preoperative and 2-month postoperative data on ALC and CMV load. The CMV load > 1200 IU/mL was used as the cutoff value to define early CMV infection. Post-transplant lymphopenia was defined as an ALC of < 500 cells/μL at postoperative day (POD) #7. On POD #7, 29 (50.0%) patients had post-transplant lymphopenia and 29 (50.0%) patients did not. The incidence of CMV infection within 1 or 2 months of HT was higher in the post-transplant lymphopenia group than in the non-lymphopenia group (82.8% vs. 48.3%, P = 0.013; 89.7% vs. 65.5%, P = 0.028, respectively). ALC < 500 cells/μL on POD #7 was an independent risk factor for early CMV infection within 1 month of HT (odds ratio, 4.14; 95% confidence interval, 1.16-14.77; P = 0.029). A low ALC after HT was associated with a high risk of early CMV infection. Post-transplant ALC monitoring is simple and inexpensive and can help identify patients at high risk of early CMV infection.
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Khurana A, Saxena S. Immunosuppressive agents for dermatological indications in the ongoing COVID-19 pandemic: Rationalizing use and clinical applicability. Dermatol Ther 2020; 33:e13639. [PMID: 32436617 PMCID: PMC7280701 DOI: 10.1111/dth.13639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
The ongoing COVID-19 epidemic has brought to the fore many concerns related to use of immunosuppressive agents (ISAs) in dermatology. While it is unclear whether the patients on ISAs for skin conditions are more prone to develop COVID-19, and what impact the ISA may have on the clinical outcome if a patient does get infected, rationalizations based on the specific immune effects of each drug, and existing literature on incidence of various infections with each, are possible. In this review, we provide the readers with practically useful insights into these aspects, related to the conventional ISAs, and briefly mention the clinical outcome data available on related scenarios from other patient groups so far. In the end, we have attempted to provide some clinically useful points regarding practical use of each dermatologically relevant conventional ISA in the current scenario.
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Affiliation(s)
- Ananta Khurana
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
| | - Snigdha Saxena
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
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Tiguman GMB, Poll LB, Alves CEDC, Pontes GS, Silva MT, Galvao TF. Seroprevalence of cytomegalovirus and its coinfection with Epstein-Barr virus in adult residents from Manaus: a population-based study. Rev Soc Bras Med Trop 2020; 53:e20190363. [PMID: 31994666 PMCID: PMC7083370 DOI: 10.1590/0037-8682-0363-2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/10/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION This study assessed the seroprevalence of cytomegalovirus, associated factors, and Epstein-Barr virus coinfection among adult residents of Manaus. METHODS Using a cross-sectional study design, we collected blood samples from 136 individuals in a household survey in 2016. Prevalence ratios were calculated using Poisson regression. RESULTS Cytomegalovirus and Epstein-Barr virus seroprevalences were 67.6% (95% CI: 9.7-75.6%) and 97.8% (95% CI: 95.3-100.0%), respectively. Coinfection was observed in 66.2% (95% CI: 58.1-74.2%) of participants. Bivariate analysis showed no statistical association. CONCLUSIONS Seroprevalences were high among participants and approximately 7 out of 10 individuals had cytomegalovirus and Epstein-Barr virus coinfection.
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Affiliation(s)
| | - Laura Beatrice Poll
- Universidade Estadual de Campinas, Faculdade de Ciências Farmacêuticas, Campinas, SP, Brasil
| | | | | | - Marcus Tolentino Silva
- Universidade de Sorocaba, Programa de Pós-Graduação em Ciências Farmacêuticas, Sorocaba, SP, Brasil
| | - Tais Freire Galvao
- Universidade Estadual de Campinas, Faculdade de Ciências Farmacêuticas, Campinas, SP, Brasil
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Ruiz P, Martínez-Picola M, Santana M, Muñoz J, Pérez-Del-Pulgar S, Koutsoudakis G, Sastre L, Colmenero J, Crespo G, Navasa M. Torque Teno Virus Is Associated With the State of Immune Suppression Early After Liver Transplantation. Liver Transpl 2019; 25:302-310. [PMID: 30375165 DOI: 10.1002/lt.25374] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 10/20/2018] [Indexed: 12/13/2022]
Abstract
The development of noninvasive biomarkers that reflect the state of immunosuppression (IS) remains an unmet need in liver transplantation (LT). Torque Teno virus (TTV) is a highly prevalent, nonpathogenic DNA virus whose plasma levels may be associated with the immune status of the host. The aim of this study was to assess the role of TTV as a biomarker of IS in LT recipients. TTV DNA in plasma was quantified by real-time polymerase chain reaction at different time points during the first year after transplant in a prospectively followed cohort of 63 de novo LT recipients, and any correlation between TTV DNA and biopsy-proven acute cellular rejection (ACR) and opportunistic infections was then evaluated. In addition, TTV DNA was studied in 10 longterm LT recipients in monotherapy with tacrolimus, 10 tolerant recipients, and 10 healthy controls. TTV was detected in the plasma of all patients. Among the 63 LT recipients, 20 episodes of ACR were diagnosed, and there were 28 opportunistic infections, 26 of them being cytomegalovirus (CMV) infections. TTV viremia was significantly lower during ACR (4.41 versus 5.95 log10 copies/mL; P = 0.002) and significantly higher during CMV infections (5.79 versus 6.59 log10 copies/mL; P = 0.009). The area under the receiver operating characteristic curve of TTV viral load for the diagnosis of moderate ACR was 0.869, with a sensitivity and negative predictive value of 100%, respectively, for a cutoff point of 4.75 log10 copies/mL. There were no statistically significant differences in TTV DNA in either longterm or tolerant patients and healthy controls. In conclusion, plasma TTV DNA levels are associated with immune-related events after LT and could constitute a potential biomarker of the state of IS during the first months after transplant.
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Affiliation(s)
- Pablo Ruiz
- Liver Transplant Unit, Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Marta Martínez-Picola
- Liver Transplant Unit, Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Miguel Santana
- Liver Transplant Unit, Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Javier Muñoz
- Liver Transplant Unit, Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Sofía Pérez-Del-Pulgar
- Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Giorgos Koutsoudakis
- Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Lydia Sastre
- Liver Transplant Unit, Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Jordi Colmenero
- Liver Transplant Unit, Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Gonzalo Crespo
- Liver Transplant Unit, Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Liver Transplant Unit, Liver Unit, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
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Alfakeekh K, Azar M, Sowailmi BA, Alsulaiman S, Makdob SA, Omair A, Albanyan E, Bawazeer MS. Immunosuppressive burden and risk factors of infection in primary childhood nephrotic syndrome. J Infect Public Health 2018; 12:90-94. [PMID: 30279098 DOI: 10.1016/j.jiph.2018.09.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 05/09/2018] [Accepted: 09/19/2018] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Patients with primary childhood nephrotic syndrome (PCNS) develop alterations in their cellular and humoral immunity that predisposes them to the development of infection, and lead them to have frequent relapses. Also, infection could be significantly enhanced by immunosuppressive agents. This study aims to estimate the immunosuppressive burden, rate of infection and identify possible risk factors in PCNS requiring hospitalization. METHODOLOGY A cross-sectional study of hospitalized children≤14years of age diagnosed with PCNS in King Abdul-Aziz Medical City, Riyadh from January 2003 to December 2013. RESULT Out of 111 patients admitted with PCNS, 84 (76%) had both minor and major types of infection. Upper respiratory tract infection (URTI) was the most predominant type (n=44, 52%). Among the major types of infection, urinary tract infection (UTI) was the most common infection (n=21, 25%) followed by pneumonia (n=17, 20%) then cellulitis (n=6, 6%). Infection in children who received a higher annual cumulative dose of steroids (CDS) strikingly had a higher rate of infection in comparison to those who received lower CDS (p<0.01). Moreover, those who received primary and secondary immunosuppressant's had 100% infection rate. CONCLUSION About half of infection encountered by PCNS patients were URTI followed by UTI and pneumonia. Higher annual CDS, combination of primary and secondary immunosuppressants were the highest independent risk factors for infection. Among the infection, URTI was considered as the predominant entity whereas among the major infection, UTI was predominant followed by pneumonia then cellulitis.
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Affiliation(s)
- Khalid Alfakeekh
- Department of Paediatrics, Division of Nephrology, Ministry of National Guard, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, King Abdullah Specialized Children Hospital, Mail Code 1940, P. O. Box 22490, Riyadh,11426, Saudi Arabia.
| | - Mohammed Azar
- Department of Paediatrics, Division of Nephrology, Ministry of National Guard, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, King Abdullah Specialized Children Hospital, Mail Code 1940, P. O. Box 22490, Riyadh,11426, Saudi Arabia.
| | - Banan Al Sowailmi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Saja Alsulaiman
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Salwa Al Makdob
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Aamir Omair
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Esam Albanyan
- Department of Paediatrics, Division of Nephrology, Ministry of National Guard, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, King Abdullah Specialized Children Hospital, Mail Code 1940, P. O. Box 22490, Riyadh,11426, Saudi Arabia.
| | - Manal Saleh Bawazeer
- Department of Paediatrics, Division of Nephrology, Ministry of National Guard, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, King Abdullah Specialized Children Hospital, Mail Code 1940, P. O. Box 22490, Riyadh,11426, Saudi Arabia.
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Bae E, Lee SW, Park S, Kim DK, Lee H, Huh H, Chin HJ, Lee S, Ryu DR, Park JI, Kim S, Park DJ, Kang SW, Kim YS, Oh YK, Kim YC, Lim CS, Park JT, Lee JP. Treatment and clinical outcomes of elderly idiopathic membranous nephropathy: A multicenter cohort study in Korea. Arch Gerontol Geriatr 2018. [DOI: 10.1016/j.archger.2018.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Meije Y, Fortún J, Len Ó, Aguado JM, Moreno A, Cisneros JM, Gurguí M, Carratalà J, Muñoz P, Montejo M, Blanes M, Bou G, Pérez JL, Torre-Cisneros J, Ramos A, Pahissa A, Gavaldà J. Prevention strategies for cytomegalovirus disease and long-term outcomes in the high-risk transplant patient (D+/R-): experience from the RESITRA-REIPI cohort. Transpl Infect Dis 2014; 16:387-96. [PMID: 24807640 DOI: 10.1111/tid.12226] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 12/27/2013] [Accepted: 01/20/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV)-negative recipients of a graft from a CMV-positive donor (D+/R-) are at high risk of CMV disease. Current preventive strategies include universal prophylaxis (UP) and preemptive therapy (PT). However, the best strategy to prevent CMV disease and achieve better long-term outcomes remains a matter of debate. METHODS We analyzed the incidence of CMV disease and long-term outcomes including graft dysfunction and patient mortality at 5 years after transplantation with both preventive strategies. High-risk (D+/R-) kidney and liver transplant recipients from the RESITRA cohort were included. RESULTS Of 2410 kidney or liver transplant patients, 195 (8.3%) were D+/R-. The final cohort included 58 liver and 102 kidney recipients. UP was given in 92 patients and 68 received PT; 10.9% and 36.8% developed CMV disease, respectively (P < 0.01). The independent risk factors for CMV disease were PT strategy (hazard ratio [HR], 3.30; 95% confidence interval [CI], 1.6-6.9), kidney transplantation (HR, 3.8; 95% CI, 1.4-9.9), and cyclosporine immunosuppression (HR, 2.4; 95% CI, 1.2-4.7). PT strategy was also a risk factor for CMV disease in both liver transplantation (HR, 11.0; 95% CI, 1.2-98.7) and kidney transplantation (HR, 2.7; 95% CI, 1.3-6.0), independently. The development of CMV replication during the first 2 years after transplantation was a risk factor for graft dysfunction at 5 years after transplantation (odds ratio, 3.4; 95% CI, 1.3-9.0). Nevertheless, no significant differences were seen in either graft dysfunction or mortality between the 2 strategies. CONCLUSIONS The study supports the benefit of the UP strategy to prevent CMV disease in D+/R- liver or kidney transplant patients. The development of CMV replication during the first 2 years after transplantation was associated with graft dysfunction at 5 years after transplantation.
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Affiliation(s)
- Y Meije
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Orlicka K, Barnes E, Culver EL. Prevention of infection caused by immunosuppressive drugs in gastroenterology. Ther Adv Chronic Dis 2013; 4:167-85. [PMID: 23819020 PMCID: PMC3697844 DOI: 10.1177/2040622313485275] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Immunosuppressive therapy is frequently used to treat gastrointestinal diseases such as inflammatory bowel disease, autoimmune hepatitis, IgG4-related disease (autoimmune pancreatitis and sclerosing cholangitis) and in the post-transplantation setting. These drugs interfere with the immune system. The main safety concern with their use is the risk of infections. Certain infections can be prevented or their impact minimized. Physicians must adopt preventative strategies and should have a high degree of suspicion to recognize infections early and treat appropriately. This article reviews the risk factors for infections, the mechanism of action of immunosuppressive therapy and proposes preventive strategies.
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Affiliation(s)
- Katarzyna Orlicka
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Eid AJ, Razonable RR. New developments in the management of cytomegalovirus infection after solid organ transplantation. Drugs 2010; 70:965-81. [PMID: 20481654 DOI: 10.2165/10898540-000000000-00000] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite remarkable advances in the diagnostic and therapeutic modalities for its management, cytomegalovirus (CMV) remains one of the most important pathogens impacting on the outcome of transplantation. Not only does CMV directly cause morbidity and occasional mortality, it also influences many short-term and long-term indirect effects that collectively contribute to reduced allograft and patient survival. Prevention of CMV infection and disease is therefore key in ensuring the successful outcome of solid organ transplantation (SOT). In this regard, antiviral prophylaxis and pre-emptive therapy are similarly effective in preventing CMV disease after transplantation. However, current guidelines prefer antiviral prophylaxis over pre-emptive therapy in preventing CMV disease in high-risk SOT recipients, such as CMV-seronegative recipients of organs from CMV-seropositive donors (CMV D+/R-), and lung, intestinal and pancreas transplant recipients. Antiviral prophylaxis has the benefits of reducing not only the incidence of CMV disease, but also the indirect effects of CMV on allograft and patient survival. The major drawback of antiviral prophylaxis is delayed-onset CMV disease, which occurs in 15-38% of CMV D+/R- SOT recipients who received 3 months of prophylaxis. Allograft rejection, over-immunosuppression and lack of CMV-specific immunity are factors that predispose patients to delayed-onset CMV disease. A recent randomized trial in CMV D+/R- kidney recipients demonstrates a significant reduction in the incidence of CMV disease when valganciclovir prophylaxis is extended to 200 days (compared with the standard 100 days) after transplantation; however, the safety and cost of this prolonged approach has yet to be assessed. In some studies, delayed-onset CMV disease has been significantly associated with allograft loss and mortality. In the vast majority of patients, CMV disease responds to treatment with intravenous ganciclovir. Recently, oral valganciclovir was demonstrated to have an efficacy that is comparable to intravenous ganciclovir in treating mild to moderate cases of CMV disease in SOT recipients. Reduction in the degree of immunosuppression should complement antiviral treatment of CMV disease. Although it remains rare, ganciclovir-resistant CMV disease is increasingly seen in clinical practice, potentially fostered by the prolonged use of antivirals in high-risk over-immunosuppressed transplant recipients. Treatment of drug-resistant CMV is currently non-standardized and may include foscarnet, cidofovir, CMV hyperimmune globulins or leflunomide. The investigational drug marivabir had the potential to treat ganciclovir-resistant CMV disease as it acts through a different mechanism. However, the recent phase III clinical trial in allogeneic bone marrow transplant recipients showed that maribavir was not significantly better than placebo for the prevention of CMV disease. Similarly, the preliminary data in a liver transplant population suggests that maribavir was inferior to oral ganciclovir for the prevention of CMV disease. This article reviews the recent data and other developments in the management of CMV infection after SOT.
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Affiliation(s)
- Albert J Eid
- Division of Infectious Diseases, University of Kansas Medical Center, Kansas City, Kansas, USA
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Asberg A, Jardine AG, Bignamini AA, Rollag H, Pescovitz MD, Gahlemann CC, Humar A, Hartmann A. Effects of the intensity of immunosuppressive therapy on outcome of treatment for CMV disease in organ transplant recipients. Am J Transplant 2010; 10:1881-8. [PMID: 20486914 DOI: 10.1111/j.1600-6143.2010.03114.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
An effective host immune response, critical for successful control of Cytomegalovirus (CMV) disease in solid organ transplant recipients, is affected by intensity and type of immunosuppressive therapy. We used information prospectively captured in the VICTOR-trial to investigate the impact of immunosuppressive therapy on short- and long-term outcomes of CMV treatment in organ transplant recipients. Dual, as compared to triple, immunosuppressive therapy ([odds ratios] OR of 2.55; 95% CI: 1.51-4.60; p = 0.002), lower blood concentrations of calcineurin inhibitors (OR of 5.53; CI: 1.04-29.35; p = 0.045), and longer time since transplantation (OR of 1.70; CI: 1.01-2.87; p = 0.047) all showed better early (Day 21) CMV DNAemia eradication. We observed no effect of the intensity of the immunosuppressive therapy on overall rates of viral eradication or recurrence. The type of calcineurin inhibitor (tacrolimus/cyclosporine) or use of mycophenolate did not affect treatment efficacy, although both tacrolimus and mycophenolate treated patients showed a lower rate of virological recurrence OR 0.51 (95% CI: 0.26-0.98; p = 0.044) and OR 0.45 (95% CI: 0.22-0.93; p = 0.031), respectively. Lower total intensity of immunosuppressive therapy was associated with more effective early, but not overall, CMV DNAemia eradication by valganciclovir/ganciclovir therapy. Both mycophenolate and tacrolimus (rather than cyclosporine) therapy seem to be associated with reduced risk of recurrence.
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Affiliation(s)
- A Asberg
- Department of Pharmaceutical Biosciences, University of Oslo, Oslo, Norway.
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Minor versus major hepatic resection for small hepatocellular carcinoma (HCC) in cirrhotic patients: a 20-year experience. Surgery 2009; 18:32-8. [PMID: 20004441 DOI: 10.1007/s00534-010-0286-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 03/23/2010] [Indexed: 01/22/2023]
Abstract
BACKGROUND The choice between minor versus major resection or anatomic versus nonantatomic resection for small (<5 cm) solitary hepatocellular carcinoma (HCC) in patients with cirrhosis is controversial. The aim of our study was to evaluate the long-term disease-free survival (DFS) and overall survival (OS) after minor or major hepatic resection for small solitary HCC in cirrhotic patients. METHODS Between January 1983 and December 2002, patients with solitary HCC of < or = 5 cm in size who had histologically proven liver cirrhosis and microscopically tumor-free margin were included. These selected patients underwent either minor (< or = 2 segments) or major (> or = 3 segments) hepatectomy. RESULTS In 373 patients, 259 underwent minor and 114 underwent major hepatectomy. Patients in the minor resection group had more severe underlying liver disease (P = .005). Therefore, only 29.3% received anatomic resection in the minor resection group in comparison with 72.8% in the major hepatectomy group (P = .0001). No difference was found in postoperative morbidity (P = .105), mortality (P =.222), intrahepatic recurrence (P = .742), and 5-year DFS and OS (31.6% vs 31.8%, P = .932 and 50.7% vs 44.0%, P = .114) in both groups. The type of operative resection was not found to be a significant factor affecting survival in univariate analysis, but the preoperative liver function (alanine aminotransferase [AST] or alanine aminotransferase [ALT], serum albumin, or Child-Pugh status), tumor characteristics (alpha-feto protein, size, and presence of daughter nodules), and blood transfusion were found to be independent factors that affect the DFS and OS in a multivariate analysis. CONCLUSION The severity of cirrhosis and tumor characteristics depicts long-term survival rather than the type of resection in HCC.
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Brady RL, Green K, Frei C, Maxwell P. Oral ganciclovir versus valganciclovir for cytomegalovirus prophylaxis in high-risk liver transplant recipients. Transpl Infect Dis 2009; 11:106-11. [PMID: 19054381 DOI: 10.1111/j.1399-3062.2008.00356.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This retrospective review compared oral valganciclovir (VGCV) 450 mg daily for 6 months versus oral ganciclovir (GCV) 1000 mg 3 times daily for 3 months in preventing cytomegalovirus (CMV) disease in high-risk liver transplant recipients.We evaluated all CMV donor positive-recipient negative liver transplant recipients managed at University Health System in San Antonio,Texas from August 1996 to September 2006. CMV disease was confirmed by polymerase chain-reaction or antigenemia assay, and CMV invasive disease by tissue biopsy. Patient demographics, laboratory results, complications, and therapies were collected via retrospective chart review. Patients < 18 years of age or those who died during transplant admission were excluded. Primary endpoints included incidence, onset, and severity of CMV disease up to 1 year post transplant. Data collection also included patient demographics, immunosuppression, CMV treatment regimens, and relevant lab results. A total of 64 patients (43 VGCV and 21 GCV) were identified. Four patients developed CMV disease:VGCV (3/43,7%) versus GCV (1/21, 5%) (P=1.0), with 1 VGCV patient experiencing tissue-invasive CMV. In all cases, onset of CMV disease occurred after prophylaxis was discontinued. Onset occurred at 24, 27, and 45 weeks post transplant in the VGCVgroup, and at 26 weeks in the 1 patient on GCV. Four patients received rabbit antithymocyte globulin (rATG) induction; 1 patient received rATG and developed CMV disease, with no statistical difference compared with the 3 remaining patients who received rATG but did not develop CMV disease (P=0.09). No difference was found in incidence of CMV disease between patients who received GCV and those who received VGCV at our institution.
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Affiliation(s)
- R L Brady
- Pharmacy Department, University Health System, San Antonio, Texas 78229, USA
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San Juan R, Aguado J, Lumbreras C, Fortun J, Muñoz P, Gavalda J, Lopez‐Medrano F, Montejo M, Bou G, Blanes M, Ramos A, Moreno A, Torre‐Cisneros J, Carratalá J. Impact of Current Transplantation Management on the Development of Cytomegalovirus Disease after Renal Transplantation. Clin Infect Dis 2008; 47:875-82. [DOI: 10.1086/591532] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Egli A, Bergamin O, Müllhaupt B, Seebach J, Mueller N, Hirsch H. Cytomegalovirus-associated chorioretinitis after liver transplantation: case report and review of the literature. Transpl Infect Dis 2008; 10:27-43. [DOI: 10.1111/j.1399-3062.2007.00285.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cytomegalovirus disease in solid organ transplant recipients: advances lead to new challenges and opportunities. Curr Opin Organ Transplant 2007. [DOI: 10.1097/mot.0b013e3282f0d386] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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