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Prakash K, Chandorkar A, Saharia KK. Utility of CMV-Specific Immune Monitoring for the Management of CMV in Solid Organ Transplant Recipients: A Clinical Update. Diagnostics (Basel) 2021; 11:875. [PMID: 34068377 PMCID: PMC8153332 DOI: 10.3390/diagnostics11050875] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023] Open
Abstract
Cytomegalovirus (CMV) is one of the most important opportunistic infections in solid organ transplant (SOT) recipients. However, current techniques used to predict risk for CMV infection fall short. CMV-specific cell mediated immunity (CMI) plays an important role in protecting against CMV infection. There is evidence that assays measuring CMV-CMI might better identify SOT recipients at risk of complications from CMV compared to anti-CMV IgG, which is our current standard of care. Here, we review recently published studies that utilize CMV-CMI, at various points before and after transplantation, to help predict risk and guide the management of CMV infection following organ transplantation. The evidence supports the use of these novel assays to help identify SOT recipients at increased risk and highlights the need for larger prospective trials evaluating these modalities in this high-risk population.
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Affiliation(s)
- Katya Prakash
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Aditya Chandorkar
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Kapil K. Saharia
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
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Camargo JF, Anderson AD, Rosa R, Kimble E, Komanduri KV, Morris MI. Use of maintenance therapy and incidence of recurrent Cytomegalovirus DNAemia among allogeneic hematopoietic cell transplant recipients. Transpl Infect Dis 2019; 21:e13054. [PMID: 30689300 DOI: 10.1111/tid.13054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/28/2018] [Accepted: 01/15/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is the most common infection following hematopoietic cell transplantation (HCT). Preemptive antiviral therapy is highly effective at halting viral replication and preventing CMV disease; however, recurrence rates after clearance of CMV DNAemia are high (50-70%). Current treatment guidelines recommend maintenance therapy after initial clearance. Yet, the effectiveness of this intervention to prevent recurrence is not well defined. OBJECTIVES We aimed to assess the impact of maintenance therapy on the probability of recurrent CMV in allogeneic HCT recipients with early CMV reactivation. STUDY DESIGN Sixty-six patients with an initial episode of early CMV reactivation who achieved viral clearance in response to preemptive therapy were included. We compared the incidence of recurrent CMV DNAemia in patients who received maintenance therapy vs those who underwent early discontinuation of antiviral therapy. RESULTS Recurrence occurred in 47/64 (73%) patients, including 11/14 (79%) patients without maintenance therapy and 36/50 (72%) of patients who received maintenance therapy (P = 0.74). The propensity score adjusted risk ratio for the effect of maintenance therapy on recurrence was 0.89 (95% CI 0.64-1.25; P = 0.41). In a time to event analysis using the unweighted cohort, the 90-day probability of CMV recurrence was similar between patient groups independent of maintenance therapy administration (54% vs 64% for maintenance vs non-maintenance groups, respectively; log-rank P = 0.37). CONCLUSION These data suggest that maintenance antiviral therapy does not reduce the incidence of CMV recurrence while off therapy and is of limited value in HCT recipients who have successfully eradicated CMV DNAemia in response to preemptive therapy. Larger studies in this area are needed.
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Affiliation(s)
- Jose F Camargo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Anthony D Anderson
- Department of Pharmacy, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Rossana Rosa
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Erik Kimble
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Krishna V Komanduri
- Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Michele I Morris
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
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Gardiner BJ, Chow JK, Price LL, Nierenberg NE, Kent DM, Snydman DR. Role of Secondary Prophylaxis With Valganciclovir in the Prevention of Recurrent Cytomegalovirus Disease in Solid Organ Transplant Recipients. Clin Infect Dis 2018; 65:2000-2007. [PMID: 29020220 DOI: 10.1093/cid/cix696] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/03/2017] [Indexed: 02/07/2023] Open
Abstract
Background Cytomegalovirus (CMV) is a major contributor to morbidity and mortality in solid organ transplant recipients (SOTRs). Ganciclovir and valganciclovir are highly effective antiviral drugs with a well-established role in primary prophylaxis and treatment of CMV disease. Our objective in this study was to examine the effect of secondary prophylaxis (SP) on the risk of relapse in SOTRs following an episode of CMV disease. Methods We performed a retrospective cohort study of SOTRs from 1995 to 2015 and used propensity score-based inverse probability of treatment weighting methodology to control for confounding by indication. A weighted Cox model was created to determine the effect of SP on time to relapse within 1 year of treatment completion. Results Fifty-two heart, 34 liver, 79 kidney, and 5 liver-kidney transplant recipients who completed treatment for an episode of CMV infection/disease were included. A total of 120 (70.6%) received SP (median duration, 61 days; range, 5-365) and 39 (23%) relapsed. SP was protective against relapse from 0 to 6 weeks following treatment completion (hazard ratio [HR], 0.19; 95% confidence interval [CI], 0.05-0.69). However, after 6 weeks, risk of relapse did not significantly differ between the 2 groups (HR, 1.18; 95% CI, 0.46-2.99). Conclusions Our findings demonstrate that use of SP following treatment of CMV disease did not confer long-term protection against relapse, although it did delay relapse while patients were receiving antivirals. This suggests that SP has limited clinical utility in the overall prevention of recurrent CMV disease.
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Affiliation(s)
- Bradley J Gardiner
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center and Tufts University School of Medicine
| | - Jennifer K Chow
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center and Tufts University School of Medicine
| | - Lori Lyn Price
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center
- Tufts Clinical and Translational Science Institute, Tufts University
| | - Natalie E Nierenberg
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center and Tufts University School of Medicine
| | - David M Kent
- Tufts Clinical and Translational Science Institute, Tufts University
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center and Tufts University School of Medicine
- Tufts Clinical and Translational Science Institute, Tufts University
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4
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Fishman JA. Infection in Organ Transplantation. Am J Transplant 2017; 17:856-879. [PMID: 28117944 DOI: 10.1111/ajt.14208] [Citation(s) in RCA: 454] [Impact Index Per Article: 64.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/09/2017] [Indexed: 01/25/2023]
Abstract
The prevention, diagnosis, and management of infectious disease in transplantation are major contributors to improved outcomes in organ transplantation. The risk of serious infections in organ recipients is determined by interactions between the patient's epidemiological exposures and net state of immune suppression. In organ recipients, there is a significant incidence of drug toxicity and a propensity for drug interactions with immunosuppressive agents used to maintain graft function. Thus, every effort must be made to establish specific microbiologic diagnoses to optimize therapy. A timeline can be created to develop a differential diagnosis of infection in transplantation based on common patterns of infectious exposures, immunosuppressive management, and antimicrobial prophylaxis. Application of quantitative molecular microbial assays and advanced antimicrobial therapies have advanced care. Pathogen-specific immunity, genetic polymorphisms in immune responses, and dynamic interactions between the microbiome and the risk of infection are beginning to be explored. The role of infection in the stimulation of alloimmune responses awaits further definition. Major hurdles include the shifting worldwide epidemiology of infections, increasing antimicrobial resistance, suboptimal assays for the microbiologic screening of organ donors, and virus-associated malignancies. Transplant infectious disease remains a key to the clinical and scientific investigation of organ transplantation.
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Affiliation(s)
- J A Fishman
- Transplant Infectious Disease and Immunocompromised Host Program and MGH Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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5
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The Role of Secondary Cytomegalovirus Prophylaxis for Kidney and Liver Transplant Recipients. Transplantation 2015; 99:855-9. [DOI: 10.1097/tp.0000000000000386] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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6
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Maatouk I, Moutran R, Josiane H. Cytomegalovirus Proctitis: A Rare Sexually Transmitted Disease. J Sex Med 2014; 11:1092. [DOI: 10.1111/jsm.12351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Florescu DF, Langnas AN, Grant W, Mercer DF, Botha J, Qiu F, Shafer L, Kalil AC. Incidence, risk factors, and outcomes associated with cytomegalovirus disease in small bowel transplant recipients. Pediatr Transplant 2012; 16:294-301. [PMID: 22212495 DOI: 10.1111/j.1399-3046.2011.01628.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite improved prophylaxis, monitoring, and more efficient immunosuppression, CMV infection remains a common opportunistic infection in transplant recipients. We assessed the incidence of CMV disease in pediatric SBT recipients, the timing of CMV disease after transplantation, and its impact on patient outcome. The medical records of 98 SBT recipients were reviewed. We performed descriptive analysis, regression analysis, and Kaplan-Meier curves to determine the time-to-event after transplantation. Fifty-three percent patients were male and 47% female, with a mean age of 38.3 months. Thirty-five percent of patients received prophylactic VGC, 55% GCV, 10% a combination of GCV/VGC, and 99% CMV immunoglobulins. A total of 24.5% recipients were CMV D+/R- (CMV serostatus donor positive/recipient negative). Seven (c. 7%) patients developed CMV disease. CMV disease was associated with 2.5 times (0.52-12.1; p = 0.25) higher rate of CMV mismatch and 11.1 times (1.3-95.9; p = 0.03) higher risk of death. CMV prophylaxis increased time-to-death (p = 0.074). Time-to-CMV disease was shorter in patients with enteritis (p < 0.0001), and CMV disease was associated with shorter time-to-death after transplantation (p = 0.001). CMV disease in SBT recipients was associated with an 11-fold mortality increase and a fourfold faster time-to-death. Time-to-death was significantly shorter with CMV enteritis.
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Affiliation(s)
- D F Florescu
- Infectious Diseases Division, Transplant Infectious Diseases Program, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198-5400, USA.
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8
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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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Shanahan A, Malani P, Kaul D. Relapsing cytomegalovirus infection in solid organ transplant recipients. Transpl Infect Dis 2009; 11:513-8. [DOI: 10.1111/j.1399-3062.2009.00443.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Asberg A, Humar A, Jardine AG, Rollag H, Pescovitz MD, Mouas H, Bignamini A, Töz H, Dittmer I, Montejo M, Hartmann A. Long-term outcomes of CMV disease treatment with valganciclovir versus IV ganciclovir in solid organ transplant recipients. Am J Transplant 2009; 9:1205-13. [PMID: 19422345 DOI: 10.1111/j.1600-6143.2009.02617.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Though an important cause of morbidity and mortality in solid organ transplantation (SOT), the long-term outcomes of cytomegalovirus (CMV) disease treatment have not been well studied. In a randomized trial, 321 SOT recipients with CMV disease were followed 1 year after treatment with either twice daily intravenous ganciclovir or oral valganciclovir (for 21 days) followed by once daily valganciclovir until day 49 in all patients. Clinical and viral eradication of CMV disease was similar between groups. Clinical recurrence beyond day 49 was found in 15.1% and virological recurrence in 30.0%, no difference between groups (p > 0.77). In a multivariable logistic regression analysis, the only independent predictor for recurrence was failure to eradicate DNAemia by day 21 (clinical: OR 3.9 [1.3-11.3], p = 0.012; virological: OR 5.6 [2.5-12.6], p < 0.0001). Eight patients developed ganciclovir resistance, with no difference between groups (p = 0.62). Twenty patients (valganciclovir: 11, ganciclovir: 9, p = 0.82) died, 12 due to infections, two involving CMV disease. There were no differences in long-term outcomes between treatment arms, further supporting the use of oral valganciclovir for treatment of CMV disease. Persistent DNAemia at day 21, CMV IgG serostatus and development of resistance may be relevant factors for further individualization of treatment.
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Affiliation(s)
- A Asberg
- Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway.
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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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12
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Prevention and Treatment of Infection in Kidney Transplant Recipients. THERAPY IN NEPHROLOGY & HYPERTENSION 2008. [PMCID: PMC7152127 DOI: 10.1016/b978-141605484-9.50092-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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13
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Kijpittayarit-Arthurs S, Eid AJ, Kremers WK, Pedersen RA, Dierkhising RA, Patel R, Razonable RR. Clinical Features and Outcomes of Delayed-onset Primary Cytomegalovirus Disease in Cardiac Transplant Recipients. J Heart Lung Transplant 2007; 26:1019-24. [DOI: 10.1016/j.healun.2007.07.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Revised: 06/23/2007] [Accepted: 07/11/2007] [Indexed: 11/26/2022] Open
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Carstens J, Andersen HK, Spencer E, Madsen M. Cytomegalovirus infection in renal transplant recipients. Transpl Infect Dis 2006; 8:203-12. [PMID: 17116133 DOI: 10.1111/j.1399-3062.2006.00169.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We have retrospectively analyzed the incidence of cytomegalovirus (CMV) infection in 250 consecutive renal allograft transplants performed in 244 recipients. The mean follow-up was 35.1+/-25.4 months. Immunosuppression was cyclosporine- or tacrolimus-based triple therapy. CMV infection prophylaxis with ganciclovir for 3 months post transplant was prescribed in CMV-seronegative recipients of allografts from seropositive donors (D+R-) and in all recipients treated with OKT3. CMV antigenemia was monitored by the pp65-antigen assay. Thirteen of 57 D+R- recipients (22.8%) developed CMV antigenemia. One recipient had a breakthrough of CMV antigenemia during ganciclovir prophylaxis; 12 D+R- recipients developed CMV antigenemia 147.5+/-173.8 days after transplantation. Four of 13 (30.7%) D+R- recipients had asymptomatic CMV infection, 8 (61.6%) had CMV infection with non-specific symptoms including fever, and 1 (7.7%) developed CMV pneumonia. Six of 13 (46.1%) D+R- patients had been treated with intensified immunosuppressive therapy before CMV infection. In the low-risk CMV groups (D+R+; D-R+; D-R-), 28 recipients (14.5%) developed CMV antigenemia 42.5+/-15.2 days post transplantation. Ten of the 28 (35.7%) recipients had asymptomatic CMV infection, 17 (60.7%) developed CMV infection with non-specific symptoms, and 1 (3.6%) developed CMV pneumonia. Twenty-one of 28 (75.0%) had intensified immunosuppressive therapy before CMV infection. In conclusion, ganciclovir prophylaxis diminished and delayed the onset of CMV infection but did not totally prevent it from occurring in D+R- renal transplant recipients. Clinicians should be vigilant to the possibility of CMV infection in both seronegative and seropositive recipients, especially after anti-rejection therapy.
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Affiliation(s)
- J Carstens
- Department of Renal Medicine, Aarhus University Hospital, Skejby Sygehus, Aarhus, Denmark.
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Boros P, Gondolesi G, Bromberg JS. High dose intravenous immunoglobulin treatment: mechanisms of action. Liver Transpl 2005; 11:1469-80. [PMID: 16315304 DOI: 10.1002/lt.20594] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intravenous immunoglobulin (IVIg) treatment was introduced as replacement therapy for patients with antibody deficiencies, but evidence suggests that a wide range of immune-mediated conditions could benefit from IVIg. The immunoglobulins are precipitated from human plasma by fractionation methods. In conclusion, the differences in basic fractionation methods and the addition of various modifications for purification, stabilization, and virus inactivation result in products significantly different from each other.
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Affiliation(s)
- Peter Boros
- Recanati/Miller Transplantation Institute, The Mount Sinai School of Medicine, PO Box 1504, New York, NY 10029-6574, USA.
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16
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Galarraga MC, Gomez E, de Ona M, Rodriguez A, Laures A, Boga JA, Fernandez JA, Melon S. Ganciclovir prophylasis and beta-herpesvirus in renal transplant recipients. Transpl Int 2005; 18:1016-7. [PMID: 16008754 DOI: 10.1111/j.1432-2277.2005.00105.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Galarraga MC, Gomez E, de Oña M, Rodriguez A, Laures A, Boga JA, Melon S. Influence of Ganciclovir Prophylaxis on Citomegalovirus, Human Herpesvirus 6, and Human Herpesvirus 7 Viremia in Renal Transplant Recipients. Transplant Proc 2005; 37:2124-6. [PMID: 15964357 DOI: 10.1016/j.transproceed.2005.03.123] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Indexed: 10/25/2022]
Abstract
In order to know the influence of ganciclovir (GCV) prophylaxis on cytomegalovirus (CMV) human herpesvirus (HHV)-6 and HHV-7 replication in renal transplant recipients, three groups were studies: 54 patients without GCV; 29, with short-term GCV prophylaxis (less than 30 days); and 51, with long-term GCV prophylaxis (more than 60 days). CMV viremia was more prevalent in the first group (74%, 55%, and 29%, respectively), but CMV replication was also found in 14 patients during therapy, in the other two groups. The antiviral did not affect the prevalence of HHV-6 (67.2%) or HHV-7 (76%), but HHV-6 viremia appeared later (42 +/- 31 vs 21 +/- 25/38 +/- 29 days posttransplant) and was shorter (29 +/- 30 vs 62 +/- 34/41 +/- 33 days) among patients with long-term GCV prophylaxis. On the other hand, CMV viremia was longer when HHV-6 replication was present (40 +/- 25 days vs 18 +/- 16 days). In addition, HHV-7 DNA was detected in all patients with CMV disease.
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Affiliation(s)
- M C Galarraga
- Department of Virology-Microbiology, Hospital Universitaria Central de Asturias, Celestino Villamil, s/n, Oviedo, Asturias 33006, Spain
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Puliyanda DP, Silverman NS, Lehman D, Vo A, Bunnapradist S, Radha RK, Toyoda M, Jordan SC. Successful use of oral ganciclovir for the treatment of intrauterine cytomegalovirus infection in a renal allograft recipient. Transpl Infect Dis 2005; 7:71-4. [PMID: 16150094 DOI: 10.1111/j.1399-3062.2005.00089.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Congenital cytomegalovirus (CMV) infection occurs in approximately 1% of newborns and is the leading infectious cause of congenital birth defects. Female renal allograft recipients who develop CMV infection during pregnancy are at risk for both graft dysfunction and fetal morbidity. DNA-based analysis of amniotic fluid (AF) from at-risk pregnancies has been suggested as an adjunct/substitute for traditional culture. We have shown that CMV-polymerase chain reaction of AF is a useful diagnostic test for congenital CMV infection. Using this test we diagnosed CMV infection in the fetus of a 30-year-old renal transplant recipient. As termination was not an option for the family, the patient was extensively counseled and treated with oral ganciclovir. This resulted in clearance of the virus from the AF and the delivery of a healthy newborn girl, free of CMV disease. This is the first reported case to our knowledge of successful use of maternal ganciclovir to treat intrauterine CMV infection in a pregnant renal transplant recipient.
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Affiliation(s)
- D P Puliyanda
- Center for Kidney Diseases and Transplantation, Cedars Sinai Medical Center, UCLA School of Medicine, Los Angeles, CA 90048, USA.
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Abstract
Cytomegalovirus (CMV) infection remains a serious problem in lung transplant recipients. Development of potent oral antiviral agents, molecular techniques for the detection of infection and its response to therapy and the emergence of isolates with antiviral resistance have had significant impacts on the approach to CMV in these patients. This article discusses the following issues as part of a comprehensive CMV management strategy in lung transplant recipients: (1) Prevention strategies in the era of potent oral antiviral agents, (2) the role of new diagnostic techniques in the management of CMV, (3) treatment regimens for established CMV infection or disease, (4) the potential impact of treatment of CMV on the indirect effects on long-term allograft function, and (5) the incidence, risk factors for and impact of ganciclovir resistance following lung transplantation.
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Affiliation(s)
- Martin R Zamora
- Division of Pulmonary Sciences and Critical Care Medicine, and the Lung Transplant Program, University of Colorado Health Sciences Center, Denver, CO, USA.
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Kotloff RM, Ahya VN, Crawford SW. Pulmonary complications of solid organ and hematopoietic stem cell transplantation. Am J Respir Crit Care Med 2004; 170:22-48. [PMID: 15070821 DOI: 10.1164/rccm.200309-1322so] [Citation(s) in RCA: 231] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The ability to successfully transplant solid organs and hematopoietic stem cells represents one of the landmark medical achievements of the twentieth century. Solid organ transplantation has emerged as the standard of care for select patients with severe vital organ dysfunction and hematopoietic stem cell transplantation has become an important treatment option for patients with a wide spectrum of nonmalignant and malignant hematologic disorders, genetic disorders, and solid tumors. Although advances in surgical techniques, immunosuppressive management, and prophylaxis and treatment of infectious diseases have made long-term survival an achievable goal, transplant recipients remain at high risk for developing a myriad of serious and often life-threatening complications. Paramount among these are pulmonary complications, which arise as a consequence of the immunosuppressed status of the recipient as well as from such factors as the initial surgical insult of organ transplantation, the chemotherapy and radiation conditioning regimens that precede hematopoietic stem cell transplantation, and alloimmune mechanisms mediating host-versus-graft and graft-versus-host responses. As the population of transplant recipients continues to grow and as their care progressively shifts from the university hospital to the community setting, knowledge of the pulmonary complications of transplantation is increasingly germane to the contemporary practice of pulmonary medicine.
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Affiliation(s)
- Robert M Kotloff
- Section of Advanced Lung Disease and Lung Transplantation, Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Medical Center, 838 West Gates, 3400 Spruce Street, Philadelphia, PA 19027, USA.
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21
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Smak Gregoor PJH, van Gelder T, van Riemsdijk-van Overbeeke IC, Vossen ACTM, IJzermans JNM, Weimar W. Unusual presentation of herpes virus infections in renal transplant recipients exposed to high mycophenolic acid plasma concentrations. Transpl Infect Dis 2003; 5:79-83. [PMID: 12974788 DOI: 10.1034/j.1399-3062.2003.00012.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Viral infections constitute an important problem for transplant recipients and their physicians. Often the balance between adequate and over-immunosuppression is hard to find and therapeutic drug monitoring might be a welcome adjunct in the management of transplant patients. We report four renal transplant recipients with extra-ordinary presentations of viral disease who were all treated with mycophenolate mofetil and in whom high mycophenolic acid (MPA) trough levels were found. High MPA levels may reflect over-immunosuppression resulting in infectious complications.
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Affiliation(s)
- P J H Smak Gregoor
- Department of Internal Medicine, Room D-412, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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22
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Limaye AP. Ganciclovir-resistant cytomegalovirus in organ transplant recipients. Clin Infect Dis 2002; 35:866-72. [PMID: 12228824 DOI: 10.1086/342385] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2002] [Revised: 05/01/2002] [Indexed: 01/17/2023] Open
Abstract
Ganciclovir-resistant (GanR) cytomegalovirus (CMV) is an emerging clinical problem in organ transplant recipients, particularly recipients of kidney and pancreas and lung transplants. GanR CMV, a late posttransplantation complication, is observed predominantly among CMV-seronegative recipients of organs from seropositive donors, especially among recipients receiving intensive immunosuppression and having prolonged exposure to ganciclovir. Given the limitations of current diagnostic methods, if GanR CMV is clinically suspected, empirical treatment with intravenously administered foscarnet should be used in conjunction with reductions in immunosuppressive therapy and possibly CMV hyperimmune globulin. Better diagnostic tools and newer, less-toxic antiviral agents with different mechanisms of action are urgently needed to decrease the morbidity associated with this complication in organ transplant recipients.
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Affiliation(s)
- Ajit P Limaye
- Department of Laboratory Medicine, University of Washington Medical Center, Seattle, WA 98195-7110 , USA.
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23
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Zamora MR. Controversies in lung transplantation: management of cytomegalovirus infections. J Heart Lung Transplant 2002; 21:841-9. [PMID: 12163083 DOI: 10.1016/s1053-2498(02)00435-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Martin R Zamora
- Division of Pulmonary Sciences and Critical Care Medicine, Lung Transplant Program, University of Colorado Health Sciences Center, Denver 80262, USA.
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24
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Muheim C, Vogel G, Seydoux C, Gillet M, Mosimann F, Von Segesser L, Sahli R, Estrade C, van Melle G, Meylan PRA. Determinants of protracted cytomegalovirus infection in solid-organ transplant patients. Transplantation 2002; 74:226-36. [PMID: 12151736 DOI: 10.1097/00007890-200207270-00014] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recurrent infection frequently follows the response to the initial treatment of cytomegalovirus (CMV) infection in solid-organ transplant (SOT) recipients. The objective of this study was to describe the course of CMV infection in SOT patients and to identify factors that would predict protracted CMV infection with recurrences. METHODS Quantitative polymerase chain reaction (PCR) assay for CMV DNA in leukocytes and in plasma were used to assess viral load changes retrospectively in consecutive SOT patients, whose CMV infection episodes had been attended therapeutically or preemptively using quantitative blood culture. RESULTS Among 101 SOT patients, CMV infection occurred in 63, of whom 32 developed recurrent infection after the initial episode. In patients with recurrent infection, PCR indicated that a majority (27) of recipients had high level of CMV DNA in peripheral blood leukocytes and plasma throughout a protracted (>/=1 month) period including after preemptive or therapeutic ganciclovir courses. Predictors of protracted high-level infection were increasing age, CMV donor seropositivity, and all measures of viral load during the initial episode. CMV recipient seropositivity protected strongly against protracted infection. End of treatment plasma CMV DNA best discriminated between patients who did or did not develop protracted infection. CONCLUSIONS In SOT patients, protracted CMV infection is associated with increasing age, donor seropositivity, recipient seronegativity, and high viral load during the first episode. End of therapy plasma CMV DNA level best predicts the occurrence of protracted infection. In patients with a high risk of protracted infection, prophylaxis is likely to be particularly cost effective.
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Affiliation(s)
- Carmen Muheim
- Institut de Microbiologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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25
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McGavin JK, Goa KL. Ganciclovir: an update of its use in the prevention of cytomegalovirus infection and disease in transplant recipients. Drugs 2002; 61:1153-83. [PMID: 11465876 DOI: 10.2165/00003495-200161080-00016] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Ganciclovir is a nucleoside guanosine analogue which incorporates ganciclovir triphosphate (the active moiety) into DNA during elongation, thereby inhibiting viral replication. Comparative studies of pre-emptive and prophylactic ganciclovir therapies in bone marrow transplant (BMT) recipients have shown similar rates of cytomegalovirus (CMV) infection, disease and patient mortality. Long term prophylaxis with either oral, or sequential intravenous/oral, ganciclovir has shown efficacy in renal allograft recipients, including high risk patients or those receiving antilymphocyte antibody therapy. A preliminary study indicates that ganciclovir is more efficacious than aciclovir in paediatric patients. Both oral and intravenous prophylactic ganciclovir regimens have shown efficacy compared with no antiviral treatment in lung transplant recipients; initial reports have shown similar efficacy between pre-emptive and prophylactic ganciclovir. Oral ganciclovir monotherapy is as efficacious as sequential intravenous/oral ganciclovir therapy in liver transplant recipients. Pre-emptive treatment was equally as effective as long term ganciclovir prophylaxis in high risk patients. Ganciclovir prophylaxis for 4 weeks appears ineffective in heart allograft recipients treated with antithymocyte globulin. Long term sequential intravenous/ oral ganciclovir therapy has shown greater efficacy in preventing CMV disease than sequential ganciclovir/aciclovir therapy. in these patients. Initial reports indicate that pre-emptive therapy may be beneficial in this patient group. although this remains to be determined. Ganciclovir in therapeutic dosage regimens generally has acceptable tolerability with adverse effects usually of a haematological or neurological nature. Neutropenia, thrombocytopenia and anaemia are the primary dose-limiting toxicities associated with ganciclovir therapy. Overall, neutropenia occurs less frequently with administration of oral ganciclovir than with intravenous ganciclovir. Monitoring of renal function is recommended as serum creatinine levels may rise during ganciclovir therapy. In addition, ganciclovir prophylaxis appears more cost effective than the majority of other currently available therapies for CMV with oral ganciclovir more cost effective than intravenous ganciclovir. In conclusion, it is unlikely that a single strategy will be able to be applied to all transplant patients for the prevention of CMV disease. An optimal strategy will probably be arisk-adapted approach. Prophylactic treatment with ganciclovir appears the best strategy to implement in high risk patients: oral ganciclovir formulations may be best employed where lower toxicity is required. Pre-emptive treatment with ganciclovir appears most efficacious in patients identified as lower risk or, in the case of BMT recipients, where lower toxicity may be desirable. Ganciclovir remains an important therapeutic option for the prevention and treatment of CMV disease in transplant recipients.
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Affiliation(s)
- J K McGavin
- Adis International Limited, Mairangi Bay, Auckland, New Zealand.
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26
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Singh N. Preemptive therapy versus universal prophylaxis with ganciclovir for cytomegalovirus in solid organ transplant recipients. Clin Infect Dis 2001; 32:742-51. [PMID: 11229841 DOI: 10.1086/319225] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2000] [Revised: 10/03/2000] [Indexed: 11/03/2022] Open
Abstract
Whether preemptive therapy or universal prophylaxis with ganciclovir is the optimal approach against cytomegalovirus (CMV) remains unresolved. Controversy abounds with respect to the efficacy of preemptive therapy, the reliability of preemptive therapy tools, the logistical difficulties in conducting surveillance monitoring for CMV, the cost of prophylaxis, the effect of prophylaxis on indirect sequelae of CMV and epidemiology of CMV, and the potential for emergence of ganciclovir-resistant CMV. Although neither approach is wholly adequate, a discussion of the relative merits and limitations of the 2 approaches may guide the selection of a rational approach toward prevention of CMV infection in organ transplant recipients.
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Affiliation(s)
- N Singh
- Veterans Affairs Medical Center and University of Pittsburgh, Thomas E. Starzl Transplantation Institute, Pittsburgh, PA 15240, USA. nis5+@pitt.edu
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27
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Manfredi R, Chiodo F. Management of relapsing cytomegalovirus disease in transplant recipients: diagnostic and therapeutic dilemmas. Transpl Infect Dis 2001; 3:51-3. [PMID: 11429042 DOI: 10.1034/j.1399-3062.2001.003001051.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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28
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Paya CV. Prevention of cytomegalovirus disease in recipients of solid-organ transplants. Clin Infect Dis 2001; 32:596-603. [PMID: 11181123 DOI: 10.1086/318724] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2000] [Revised: 10/02/2000] [Indexed: 01/18/2023] Open
Abstract
The introduction and combination of more-potent immunosuppressive regimens, and the increased transplantation of organs into more severely ill patients, have again placed cytomegalovirus (CMV) disease in the spotlight of posttransplantation complications. Both direct and associated complications related to CMV need to be considered in understanding the pathogenesis of CMV infection after solid-organ transplantation. New diagnostic methods with higher sensitivity for the detection of CMV and the ability to quantify CMV indicate that low levels of CMV replication are present in many patients who don't have clinical symptoms ascribed to CMV infection. How these low levels of CMV replication impact the outcome of the transplanted graft remains unknown. In addition, there needs to be further study regarding whether only patients at high risk for developing CMV disease or, also, those with clinically asymptomatic levels of CMV replication should be the target of effective preventive regimens. This review summarizes our current knowledge of the pathogenesis of CMV infection after solid-organ transplantation, and it outlines different effective preventive regimens and approaches.
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Affiliation(s)
- C V Paya
- Division of Infectious Diseases and Transplant Center, Mayo Clinic, Rochester, MN 55905. USA.
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