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Chung MC, Chen CH, Chang SS, Lee CY, Tian YC, Wu MY, Wang HH, Yu CC, Chen TW, Kao CC, Hsu CY, Chiang YJ, Wu MJ, Chen YT, Wu MS. Prevention and management of cytomegalovirus infection and disease in kidney transplant: A consensus statement of the Transplantation Society of Taiwan. J Formos Med Assoc 2024:S0929-6646(24)00245-6. [PMID: 38777672 DOI: 10.1016/j.jfma.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/24/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Kidney transplant recipients have an increased risk of cytomegalovirus (CMV) infection and disease. A strategy for mitigating the risk of CMV infection in kidney transplant recipients has not yet been established in Taiwan. The Transplantation Society of Taiwan aimed to develop a consensus by expert opinion on the prevention and management of CMV infection. Based on the results of Consensus Conference, we suggested low-dose valganciclovir prophylaxis (450 mg once daily) for kidney transplant recipients. The prophylaxis duration was ≥6 months for high-risk (D+/R-) patients and 3 months for moderate-risk (R+) patients. Even for low-risk (D-/R-) patients, prophylaxis for at least 3 months is recommended because of the high seroprevalence of CMV in Taiwan. CMV prophylaxis was suggested after anti-thymocyte globulin treatment but not after methylprednisolone pulse therapy. Routine surveillance after prophylaxis, secondary prophylaxis after CMV disease treatment, and mTOR inhibitors for primary CMV prophylaxis were not recommended. Letermovir and marabavir are emerging CMV agents used for prophylaxis and refractory CMV disease. CMV immunoglobulins have been used to treat refractory CMV disease in Taiwan. We hope this consensus will help professionals manage patients with CMV in Taiwan to improve the quality of care.
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Affiliation(s)
- Mu-Chi Chung
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Ph.D. Program in Tissue Engineering and Regenerative Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; Department of Life Science, Tunghai University, Taichung, Taiwan
| | - Shen-Shin Chang
- Division of Transplantation, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Yuan Lee
- Department of Surgery, National Taiwan University Hospital, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center and Department of Nephrology Linkou Chang Aging Memorial Hospital, Taiwan
| | - Mei-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan; Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
| | - Hsu-Han Wang
- Department of Urology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Cheng Yu
- Division of Urology, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Teng-Wei Chen
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Chang Kao
- Division of Urology, Department of Surgery, Tri-service General Hospital, National Defense Medical, Taiwan
| | - Chih-Yang Hsu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Taiwan
| | - Yang-Jen Chiang
- Department of Urology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Ju Wu
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yen-Ta Chen
- Division of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan; TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Servais AM, McMullen JS, Bowen R, Kleiboeker SB, Ulloa I, Duncan K, Miles CD. Tailoring cytomegalovirus prophylaxis based on T cell immunity panel assessment in kidney transplant patients at high risk of cytomegalovirus. Transpl Infect Dis 2024:e14291. [PMID: 38708965 DOI: 10.1111/tid.14291] [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: 11/03/2023] [Revised: 04/04/2024] [Accepted: 04/19/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Valganciclovir prophylaxis against cytomegalovirus (CMV) is recommended for solid organ transplant recipients, but is associated with drawbacks, including expense and leukopenia. Our center adopted a strategy of serial assessment with a CMV-specific T cell immunity panel (CMV-TCIP) and cessation of valganciclovir prophylaxis upon demonstration of adequate CD4+ responses in kidney transplant patients at high risk of CMV disease. METHODS We retrospectively reviewed adult recipients of a kidney or pancreas transplant between August 2019 and July 2021 undergoing serial CMV-TCIP monitoring. Included patients were considered high risk for CMV, defined by donor positive (D+)/recipient negative (R-) CMV IgG serostatus, or recipient positive (R+) patients who received induction with a lymphocyte-depleting agent. Prophylaxis was discontinued after a patient's first CMV-specific CD4+ T cell value of ≥0.20%. Risk of clinically significant CMV infection (csCMVi) in those who underwent early discontinuation of CMV prophylaxis and predictors of CMV T cell immunity were analyzed. RESULTS Of 54 included patients, 22 stopped prophylaxis early due to CMV-specific CD4+ T cell immunity at a median of 4.7 (IQR: 3.8-5.4) months after transplant. No instances of csCMVi were observed in the 22 patients who had prophylaxis discontinued early, of whom 19/22 were CMV R+ and 3/22 were CMV D+/R-. Donor/recipient CMV serostatus was predictive of immunity (p <.001). CONCLUSION Early discontinuation of valganciclovir prophylaxis in patients with CMV CD4+ T cellular immunity appears safe and potentially beneficial in this preliminary series, especially in R+ patients. Further study is warranted, given that truncated prophylaxis may yield patient-level benefits.
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Affiliation(s)
- Abigail M Servais
- Department of Pharmaceutical and Nutrition Care, Nebraska Medical Center Omaha, Omaha, Nebraska, USA
| | - John S McMullen
- Department of Pharmaceutical and Nutrition Care, Nebraska Medical Center Omaha, Omaha, Nebraska, USA
| | - Riley Bowen
- University of Nebraska Medical Center College of Pharmacy, Nebraska Medical Center Omaha, Omaha, Nebraska, USA
| | | | | | | | - Clifford D Miles
- Department of Internal Medicine, Division of Nephrology, Nebraska Medical Center, Omaha, Nebraska, USA
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Ishikawa S, Tasaki M, Saito K, Nakagawa Y, Ikeda M, Takahashi K, Tomita Y. Long-term CMV monitoring and chronic rejection in renal transplant recipients. Front Cell Infect Microbiol 2023; 13:1190794. [PMID: 37384223 PMCID: PMC10294236 DOI: 10.3389/fcimb.2023.1190794] [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: 03/30/2023] [Accepted: 05/24/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction Cytomegalovirus (CMV) is well established to be an independent risk factor for graft loss after kidney transplantation (KTx). Monitoring for CMV in the chronic phase is not defined in the current guideline. The effects of CMV infection, including asymptomatic CMV viremia, in the chronic phase are unclear. Methods We performed a single-center retrospective study to investigate incidence of CMV infection in the chronic phase, defined as more than 1 year after KTx. We included 205 patients who received KTx between April 2004 and December 2017. The CMV pp65 antigenemia assays to detect CMV viremia were continuously performed every 1-3 months. Results The median duration of the follow-up was 80.6 (13.1-172.1) months. Asymptomatic CMV infection and CMV disease were observed in 30.7% and 2.9% in the chronic phase, respectively. We found that 10-20% of patients had CMV infections in each year after KTx which did not change over 10 years. The history of CMV infection in the early phase (within 1 year after KTx) and chronic rejection were significantly associated with CMV viremia in the chronic phase. CMV viremia in the chronic phase was significantly associated with graft loss. Discussion This is the first study to examine the incidence of CMV viremia for 10 years post KTx. Preventing latent CMV infection may decrease chronic rejection and graft loss after KTx.
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Affiliation(s)
- Shoko Ishikawa
- Division of Urology, Department of Regenerative & Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Masayuki Tasaki
- Division of Urology, Department of Regenerative & Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Kazuhide Saito
- Division of Urology, Department of Regenerative & Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yuki Nakagawa
- Division of Urology, Department of Regenerative & Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
- Department of Urology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masahiro Ikeda
- Division of Urology, Department of Regenerative & Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | | | - Yoshihiko Tomita
- Division of Urology, Department of Regenerative & Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Wright LR, Wright DL, Weller SK. Viral Nucleases from Herpesviruses and Coronavirus in Recombination and Proofreading: Potential Targets for Antiviral Drug Discovery. Viruses 2022; 14:v14071557. [PMID: 35891537 PMCID: PMC9324378 DOI: 10.3390/v14071557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 02/05/2023] Open
Abstract
In this review, we explore recombination in two very different virus families that have become major threats to human health. The Herpesviridae are a large family of pathogenic double-stranded DNA viruses involved in a range of diseases affecting both people and animals. Coronaviridae are positive-strand RNA viruses (CoVs) that have also become major threats to global health and economic stability, especially in the last two decades. Despite many differences, such as the make-up of their genetic material (DNA vs. RNA) and overall mechanisms of genome replication, both human herpes viruses (HHVs) and CoVs have evolved to rely heavily on recombination for viral genome replication, adaptation to new hosts and evasion of host immune regulation. In this review, we will focus on the roles of three viral exonucleases: two HHV exonucleases (alkaline nuclease and PolExo) and one CoV exonuclease (ExoN). We will review the roles of these three nucleases in their respective life cycles and discuss the state of drug discovery efforts against these targets.
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Affiliation(s)
- Lee R. Wright
- Department of Pharmaceutical Sciences, University of Connecticut School of Pharmacy, Storrs, CT 06269, USA; (L.R.W.); (D.L.W.)
| | - Dennis L. Wright
- Department of Pharmaceutical Sciences, University of Connecticut School of Pharmacy, Storrs, CT 06269, USA; (L.R.W.); (D.L.W.)
| | - Sandra K. Weller
- Department of Molecular Biology and Biophysics, University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030, USA
- Correspondence: ; Tel.: +1-(860)-679-2310; Fax: +1-(860)-679-1239
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Wild M, Hahn F, Brückner N, Schütz M, Wangen C, Wagner S, Sommerer M, Strobl S, Marschall M. Cyclin-Dependent Kinases (CDKs) and the Human Cytomegalovirus-Encoded CDK Ortholog pUL97 Represent Highly Attractive Targets for Synergistic Drug Combinations. Int J Mol Sci 2022; 23:ijms23052493. [PMID: 35269635 PMCID: PMC8910733 DOI: 10.3390/ijms23052493] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/15/2022] [Accepted: 02/22/2022] [Indexed: 12/13/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a pathogenic human herpesvirus associated with serious, potentially life-threatening symptoms in the immunocompromised or immunonaïve host. The limitations encountered by antiviral therapy options currently available include a narrow panel of accessible targets, the induction of viral drug resistance as well as severe drug dosage-mediated side-effects. Improved drug-targeting strategies to resolve these issues are the focus of our investigations. In particular, pharmaceutical kinase inhibitors (PKIs), either directed to host kinases or directed to the viral protein kinase pUL97, have been considered to overcome these restrictions. Recently, we reported the identification of a synergistic combination of two PKIs directed to host cyclin-dependent kinase 7 (CDK7) and viral CDK ortholog pUL97. Here, we substantiate these findings with the following results: (i) true drug synergy was exhibited by various chemical classes of PKI pairs directed to pUL97 and CDK7; (ii) no putative amplification of cytotoxicity by these drug combinations was observed; (iii) a reduction in drug dosage levels for synergistic combinations was defined on a quantitative basis and compared to monotreatments; (iv) the quantities of target proteins CDK7 and pUL97 expressed in HCMV-infected cells were assessed by confocal imaging, indicating a strong down-modulation of CDK7 levels as a result of synergistic drug treatment; (v) the functional importance of these target kinases, both binding to cyclin H, was illustrated by assessing HCMV replication under the viral genomic deletion of ORF-UL97 or cellular cyclin knock-out; (vi) new combinations of HCMV-specific drug synergy were demonstrated for solely host-directed treatments using PKIs against CDK2, CDK7, CDK8 and/or CDK9 and (vii) a triple PKI combination provided further support for the synergy approach. With these combined findings, this study highlights the potential of therapeutic drug combinations of approved, developmental and preclinical PKIs for expanding future options for anti-HCMV therapy.
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Affiliation(s)
- Markus Wild
- Institute for Clinical and Molecular Virology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (F.H.); (N.B.); (M.S.); (C.W.); (S.W.); (M.S.)
| | - Friedrich Hahn
- Institute for Clinical and Molecular Virology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (F.H.); (N.B.); (M.S.); (C.W.); (S.W.); (M.S.)
| | - Nadine Brückner
- Institute for Clinical and Molecular Virology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (F.H.); (N.B.); (M.S.); (C.W.); (S.W.); (M.S.)
| | - Martin Schütz
- Institute for Clinical and Molecular Virology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (F.H.); (N.B.); (M.S.); (C.W.); (S.W.); (M.S.)
| | - Christina Wangen
- Institute for Clinical and Molecular Virology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (F.H.); (N.B.); (M.S.); (C.W.); (S.W.); (M.S.)
| | - Sabrina Wagner
- Institute for Clinical and Molecular Virology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (F.H.); (N.B.); (M.S.); (C.W.); (S.W.); (M.S.)
| | - Mona Sommerer
- Institute for Clinical and Molecular Virology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (F.H.); (N.B.); (M.S.); (C.W.); (S.W.); (M.S.)
| | - Stefan Strobl
- 4SC AG/4SC Discovery GmbH, Fraunhoferstraße 22, 82152 Planegg-Martinsried, Germany;
- BioNTech SE, Am Klopferspitz 19a, 82152 Planegg-Martinsried, Germany
| | - Manfred Marschall
- Institute for Clinical and Molecular Virology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (F.H.); (N.B.); (M.S.); (C.W.); (S.W.); (M.S.)
- Correspondence: ; Tel.: +49-9131-8526089
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Suàrez-Fernández P, Utrero-Rico A, Sandonis V, García-Ríos E, Arroyo-Sánchez D, Fernández-Ruiz M, Andrés A, Polanco N, González-Cuadrado C, Almendro-Vázquez P, Pérez-Romero P, Aguado JM, Paz-Artal E, Laguna-Goya R. Circulatory follicular helper T lymphocytes associate with lower incidence of CMV infection in kidney transplant recipients. Am J Transplant 2021; 21:3946-3957. [PMID: 34153157 DOI: 10.1111/ajt.16725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 01/25/2023]
Abstract
Primary infection and/or reactivation of cytomegalovirus (CMV) in kidney transplant recipients (KTR) favor rejection and mortality. T follicular helper cells (TFH) could contribute to protection against CMV. Circulatory TFH (cTFH) were studied pretransplant and early posttransplant in 90 CMV seropositive KTR not receiving antithymocyte globulin or antiviral prophylaxis, followed-up for 1 year. Patients who presented CMV infection had significantly lower cTFH and activated cTFH pretransplant and early posttransplant. Pretransplant activated cTFH were also lower within patients who developed CMV disease. Pre- and 14 days posttransplant activated cTFH were an independent protective factor for CMV infection (HR 0.41, p = .01; and 0.52, p = .02, respectively). KTR with low cTFH 7 days posttransplant (<11.9%) had lower CMV infection-free survival than patients with high cTFH (28.2% vs. 67.6%, p = .002). cTFH were associated with CMV-specific neutralizing antibodies (Nabs). In addition, IL-21 increased interferon-γ secretion by CMV-specific CD8+ T cells in healthy controls. Thus, we show an association between cTFH and lower incidence of CMV infection, probably through their cooperation in CMV-specific Nab production and IL-21-mediated enhancement of CD8+ T cell activity. Moreover, monitoring cTFH pre- and early posttransplant could improve CMV risk stratification and help select KTR catalogued at low/intermediate risk who could benefit from prophylaxis.
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Affiliation(s)
| | - Alberto Utrero-Rico
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Virginia Sandonis
- National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Majadahonda, Spain
| | - Estéfani García-Ríos
- National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Majadahonda, Spain
| | - Daniel Arroyo-Sánchez
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Immunology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Mario Fernández-Ruiz
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Unit of Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | - Pilar Pérez-Romero
- National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Majadahonda, Spain
| | - José María Aguado
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Unit of Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Estela Paz-Artal
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Immunology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Department of Immunology, Universidad Complutense de Madrid, Madrid, Spain
| | - Rocío Laguna-Goya
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Immunology, Hospital Universitario 12 de Octubre, Madrid, Spain
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Hahn F, Hamilton ST, Wangen C, Wild M, Kicuntod J, Brückner N, Follett JEL, Herrmann L, Kheimar A, Kaufer BB, Rawlinson WD, Tsogoeva SB, Marschall M. Development of a PROTAC-Based Targeting Strategy Provides a Mechanistically Unique Mode of Anti-Cytomegalovirus Activity. Int J Mol Sci 2021; 22:12858. [PMID: 34884662 PMCID: PMC8657773 DOI: 10.3390/ijms222312858] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 12/31/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a major pathogenic herpesvirus that is prevalent worldwide and it is associated with a variety of clinical symptoms. Current antiviral therapy options do not fully satisfy the medical needs; thus, improved drug classes and drug-targeting strategies are required. In particular, host-directed antivirals, including pharmaceutical kinase inhibitors, might help improve the drug qualities. Here, we focused on utilizing PROteolysis TArgeting Chimeras (PROTACs), i.e., hetero-bifunctional molecules containing two elements, namely a target-binding molecule and a proteolysis-inducing element. Specifically, a PROTAC that was based on a cyclin-dependent kinase (CDK) inhibitor, i.e., CDK9-directed PROTAC THAL-SNS032, was analyzed and proved to possess strong anti-HCMV AD169-GFP activity, with values of EC50 of 0.030 µM and CC50 of 0.175 µM (SI of 5.8). Comparing the effect of THAL-SNS032 with its non-PROTAC counterpart SNS032, data indicated a 3.7-fold stronger anti-HCMV efficacy. This antiviral activity, as illustrated for further clinically relevant strains of human and murine CMVs, coincided with the mid-nanomolar concentration range necessary for a drug-induced degradation of the primary (CDK9) and secondary targets (CDK1, CDK2, CDK7). In addition, further antiviral activities were demonstrated, such as the inhibition of SARS-CoV-2 replication, whereas other investigated human viruses (i.e., varicella zoster virus, adenovirus type 2, and Zika virus) were found insensitive. Combined, the antiviral quality of this approach is seen in its (i) mechanistic uniqueness; (ii) future options of combinatorial drug treatment; (iii) potential broad-spectrum activity; and (iv) applicability in clinically relevant antiviral models. These novel data are discussed in light of the current achievements of anti-HCMV drug development.
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Affiliation(s)
- Friedrich Hahn
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Stuart T. Hamilton
- Serology and Virology Division, NSW Health Pathology Microbiology, Prince of Wales Hospital, Schools of Women’s and Children’s Health, Medicine and Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, NSW 2031, Australia; (S.T.H.); (J.E.L.F.); (W.D.R.)
| | - Christina Wangen
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Markus Wild
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Jintawee Kicuntod
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Nadine Brückner
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Jasmine E. L. Follett
- Serology and Virology Division, NSW Health Pathology Microbiology, Prince of Wales Hospital, Schools of Women’s and Children’s Health, Medicine and Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, NSW 2031, Australia; (S.T.H.); (J.E.L.F.); (W.D.R.)
| | - Lars Herrmann
- Institute of Organic Chemistry I, FAU, 91058 Erlangen, Germany; (L.H.); (S.B.T.)
| | - Ahmed Kheimar
- Institute of Virology, Freie Universität Berlin, 14163 Berlin, Germany; (A.K.); (B.B.K.)
| | - Benedikt B. Kaufer
- Institute of Virology, Freie Universität Berlin, 14163 Berlin, Germany; (A.K.); (B.B.K.)
| | - William D. Rawlinson
- Serology and Virology Division, NSW Health Pathology Microbiology, Prince of Wales Hospital, Schools of Women’s and Children’s Health, Medicine and Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, NSW 2031, Australia; (S.T.H.); (J.E.L.F.); (W.D.R.)
| | - Svetlana B. Tsogoeva
- Institute of Organic Chemistry I, FAU, 91058 Erlangen, Germany; (L.H.); (S.B.T.)
| | - Manfred Marschall
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
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Selby PR, Shakib S, Peake SL, Warner MS, Yeung D, Hahn U, Roberts JA. A Systematic Review of the Clinical Pharmacokinetics, Pharmacodynamics and Toxicodynamics of Ganciclovir/Valganciclovir in Allogeneic Haematopoietic Stem Cell Transplant Patients. Clin Pharmacokinet 2021; 60:727-739. [PMID: 33515202 DOI: 10.1007/s40262-020-00982-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ganciclovir (GCV) and valganciclovir (VGCV) are the first-line agents used to prevent and treat cytomegalovirus (CMV) infection in allogeneic haematopoietic stem cell transplant (alloHCT) patients. OBJECTIVE The aim of this work was to describe available data for the clinical pharmacokinetics, pharmacodynamics and toxicodynamics of GCV and VGCV and the potential of a therapeutic drug monitoring strategy to improve outcomes in the alloHCT population. METHODS We systematically reviewed the pharmacokinetics (dose-exposure), pharmacodynamics (exposure-efficacy) and toxicodynamics (exposure-toxicity) of GCV and VGCV in alloHCT patients with CMV infection. Studies including alloHCT patients treated for CMV infection reporting the pharmacokinetics, pharmacodynamics and toxicodynamics of GCV or VGCV were searched for using the PUBMED and EMBASE databases from 1946 to 2019. Only studies involving participants > 12 years of age and available in the English language were included. RESULTS A total of 179 patients were included in the 14 studies that met the inclusion criteria, of which 6 examined GCV pharmacokinetics only, while 8 also examined GCV pharmacodynamics and toxicodynamics. Reported pharmacokinetic parameters showed considerable interpatient variability and were different from other populations, such as solid organ transplant and human immunodeficiency virus-infected patients. Only one study found a correlation between neutropenia and elevated peak and trough GCV concentrations, with no other significant pharmacodynamic and toxicodynamic relationships identified. While therapeutic drug monitoring of GCV is performed in some institutions, no association between GCV therapeutic drug monitoring and clinical outcomes was identified. CONCLUSION Further studies of the pharmacokinetics, pharmacodynamics and toxicodynamics of GCV/VGCV in alloHCT patients are required to identify a more robust therapeutic range and to subsequently quantify the potential value of therapeutic drug monitoring of GCV/VGCV in the alloHCT population.
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Affiliation(s)
- Philip Roland Selby
- School of Medicine, University of Adelaide, Adelaide, SA, Australia. .,Pharmacy Department, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia.
| | - Sepehr Shakib
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Sandra L Peake
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Morgyn S Warner
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,Infectious Diseases Unit, The Queen Elizabeth Hospital, Adelaide, SA, Australia.,SA Pathology, Adelaide, SA, Australia
| | - David Yeung
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,SA Pathology, Adelaide, SA, Australia.,Haematology Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.,Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Uwe Hahn
- School of Medicine, University of Adelaide, Adelaide, SA, Australia.,SA Pathology, Adelaide, SA, Australia.,Haematology Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jason A Roberts
- Faculty of Medicine and Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, St Lucia, QLD, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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9
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Wild M, Kicuntod J, Seyler L, Wangen C, Bertzbach LD, Conradie AM, Kaufer BB, Wagner S, Michel D, Eickhoff J, Tsogoeva SB, Bäuerle T, Hahn F, Marschall M. Combinatorial Drug Treatments Reveal Promising Anticytomegaloviral Profiles for Clinically Relevant Pharmaceutical Kinase Inhibitors (PKIs). Int J Mol Sci 2021; 22:ijms22020575. [PMID: 33430060 PMCID: PMC7826512 DOI: 10.3390/ijms22020575] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 12/11/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a human pathogenic herpesvirus associated with a variety of clinical symptoms. Current antiviral therapy is not always effective, so that improved drug classes and drug-targeting strategies are needed. Particularly host-directed antivirals, including pharmaceutical kinase inhibitors (PKIs), may help to overcome problems of drug resistance. Here, we focused on utilizing a selection of clinically relevant PKIs and determined their anticytomegaloviral efficacies. Particularly, PKIs directed to host or viral cyclin-dependent kinases, i.e., abemaciclib, LDC4297 and maribavir, exerted promising profiles against human and murine cytomegaloviruses. The anti-HCMV in vitro activity of the approved anti-cancer drug abemaciclib was confirmed in vivo using our luciferase-based murine cytomegalovirus (MCMV) animal model in immunocompetent mice. To assess drug combinations, we applied the Bliss independence checkerboard and Loewe additivity fixed-dose assays in parallel. Results revealed that (i) both affirmative approaches provided valuable information on anti-CMV drug efficacies and interactions, (ii) the analyzed combinations comprised additive, synergistic or antagonistic drug interactions consistent with the drugs’ antiviral mode-of-action, (iii) the selected PKIs, especially LDC4297, showed promising inhibitory profiles, not only against HCMV but also other α-, β- and γ-herpesviruses, and specifically, (iv) the combination treatment with LDC4297 and maribavir revealed a strong synergism against HCMV, which might open doors towards novel clinical options in the near future. Taken together, this study highlights the potential of therapeutic drug combinations of current developmental/preclinical PKIs.
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Affiliation(s)
- Markus Wild
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Jintawee Kicuntod
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Lisa Seyler
- Institute of Radiology, University Medical Center Erlangen, FAU, Palmsanlage 5, 91054 Erlangen, Germany; (L.S.); (T.B.)
| | - Christina Wangen
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Luca D. Bertzbach
- Institute of Virology, Freie Universität Berlin, Robert-von-Ostertag-Straße 7-13, 14163 Berlin, Germany; (L.D.B.); (A.M.C.); (B.B.K.)
| | - Andelé M. Conradie
- Institute of Virology, Freie Universität Berlin, Robert-von-Ostertag-Straße 7-13, 14163 Berlin, Germany; (L.D.B.); (A.M.C.); (B.B.K.)
| | - Benedikt B. Kaufer
- Institute of Virology, Freie Universität Berlin, Robert-von-Ostertag-Straße 7-13, 14163 Berlin, Germany; (L.D.B.); (A.M.C.); (B.B.K.)
| | - Sabrina Wagner
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Detlef Michel
- Institute for Virology, Ulm University Medical Center, Albert-Einstein-Allee 11, 89081 Ulm, Germany;
| | - Jan Eickhoff
- Lead Discovery Center GmbH, Otto-Hahn-Str. 15, 44227 Dortmund, Germany;
| | - Svetlana B. Tsogoeva
- Institute of Organic Chemistry I, FAU, Nikolaus-Fiebiger-Straße 10, 91058 Erlangen, Germany;
| | - Tobias Bäuerle
- Institute of Radiology, University Medical Center Erlangen, FAU, Palmsanlage 5, 91054 Erlangen, Germany; (L.S.); (T.B.)
| | - Friedrich Hahn
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Manfred Marschall
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
- Correspondence: ; Tel.: +49-9131-8526-089
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10
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Chan TSY, Cheng SSY, Chen WT, Hsu DC, Chau RWY, Kang SH, Alsumali A, Kwong YL. Cost-effectiveness of letermovir as cytomegalovirus prophylaxis in adult recipients of allogeneic hematopoietic stem cell transplantation in Hong Kong. J Med Econ 2020; 23:1485-1492. [PMID: 33155494 DOI: 10.1080/13696998.2020.1843321] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The cost-effectiveness of letermovir as cytomegalovirus (CMV) prophylaxis in adult seropositive patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT), compared with the conventional strategy of preemptive treatment, has not been evaluated in Asia. METHODS A decision analytical model, simulating the clinical progression of CMV infection on a lifetime horizon, was developed to compare prophylactic strategy with letermovir with preemptive therapy alone as anti-CMV strategies. Prophylaxis comprised administering letermovir for 14 weeks, with clinical outcomes measured at 24 weeks, followed by preemptive therapy if CMV infection occurred. This approach was modeled on outcomes of the letermovir phase 3 clinical study. The model enumerated the cost of letermovir prophylaxis, quality-adjusted life years (QALYs), and incremental cost per QALYs gained with prophylaxis. The opposite arm involved regular monitoring and preemptive therapy for CMV reactivation. Real-world costs from the adult HSCT center at Queen Mary Hospital, Hong Kong, were adopted for analysis. Costs and clinical benefits, expressed as QALYs, were discounted at 3% per year. RESULTS Letermovir prophylaxis compared with preemptive therapy only would lead to an increase of life-year and QALYs at increased costs. Incremental cost-effectiveness analysis showed that letermovir prophylaxis had an associated cost of HKD 193,580 for each life-year gained, and HKD 234,675 for each QALY gained. Probabilistic sensitivity analysis showed that the majority of incremental cost-effectiveness ratio fell below the cost-effectiveness threshold of HKD 382,046 (one gross domestic product per capita) per QALY gained. CONCLUSIONS Letermovir prophylaxis would be cost-effective for preventing CMV infection in adult seropositive allogeneic HSCT recipients in Hong Kong.
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Affiliation(s)
| | | | - Wei-Ting Chen
- Global Medical & Scientific Affairs, MSD, Taipei, Taiwan
| | - Danny Chung Hsu
- Global Medical & Scientific Affairs, MSD, Hong Kong, Hong Kong
| | | | - Suk Hyun Kang
- Centre for Observational and Real-world Evidence, MSD, Seoul, Korea
| | | | - Yok-Lam Kwong
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
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11
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Bruminhent J, Razonable R. Advances in drug therapies for cytomegalovirus in transplantation: a focus on maribavir and letermovir. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1835639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Jackrapong Bruminhent
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - R.R. Razonable
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- William J Von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
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12
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Mullane KM. Human Cytomegalovirus Prophylaxis and Treatment in Lung Transplantation in the Current Era. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00246-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Luo J, Shi X, Lin Y, Cheng N, Shi Y, Wang Y, Wu BQ. Cytomegalovirus Infection in an Adult Patient With Neuromyelitis Optica and Acute Hemorrhagic Rectal Ulcer: Case Report and Literature Review. Front Immunol 2020; 11:1634. [PMID: 32849558 PMCID: PMC7417347 DOI: 10.3389/fimmu.2020.01634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 06/18/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Previous infectious or inflammatory events may be involved in the pathogenesis of neuromyelitis optica (NMO), potentially by triggering an autoimmune response. Cytomegalovirus (CMV)-related NMO (CMV-NMO) is rarely reported. Acute hemorrhagic rectal ulcer (AHRU) is a rare disease with a largely unknown pathogenesis. Herein, we reported a co-NMO and AHRU case associated with CMV infection. In addition, we review previously reported cases of CMV-NMO and CMV-AHRU. Case presentation: A 40-year-old female diagnosed with aquaporin4 (AQP4)-IgG+ NMO and a poor response to high-dose intravenous methylprednisolone and immunoglobulin, followed by three rounds of plasma exchange was transferred to Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. She developed repeated acute lower gastrointestinal hemorrhage from the third day of admission. Abdominal computed tomography angiography (CTA) and interventional angiography did not detect any bleeding vessel. Bedside colonoscopy revealed a large ulcer-like lesion at 10 cm above the anus. Rectal biopsy pathology confirmed a CMV infection on day 23 post-admission, and cerebrospinal fluid (CSF) pathogen gene sequencing detected CMV gene copies on day 25 post-admission. After 2 weeks of treatment with ganciclovir and sodium phosphinate, the patient's lower gastrointestinal bleeding stopped, and her limb muscle strength and visual acuity gradually improved. After 4 weeks of antiviral therapy, colonoscopy showed that the intestinal wall of the original lesion was smooth. Hematoxylin and eosin (HE) staining and immunohistochemistry (IHC) of a biopsy specimen was negative for CMV, her right eye vision was normal, and limb muscle strength had recovered. Serum AQP4-IgG was negative, and lesions on brain magnetic resonance imaging (MRI) manifested shrinkage. Conclusions: The benefits of antiviral therapy remain unclear; however, clinicians should be aware of the possibility of CMV-related NMO, if NMO was refractory to high-dose intravenous methylprednisolone, immunoglobulin, and plasma exchange. Moreover, clinicians should consider the possibility of CMV-related AHRU when recurrent acute lower gastrointestinal bleeding occurs in a patient.
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Affiliation(s)
- Jinmei Luo
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaowei Shi
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Lin
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Na Cheng
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yunfeng Shi
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yanhong Wang
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ben-Quan Wu
- Medical Intensive Care Unit and Division of Respiratory Diseases, Department of Internal Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- *Correspondence: Ben-Quan Wu
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14
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Wu XN, Lightman S, Tomkins‐Netzer O. Viral retinitis: diagnosis and management in the era of biologic immunosuppression: A review. Clin Exp Ophthalmol 2019; 47:381-395. [DOI: 10.1111/ceo.13500] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/08/2019] [Accepted: 02/18/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Xia Ni Wu
- Ophthalmology, Moorfields Eye Hospital London UK
- Faculty of Brain Sciences, Institute of Ophthalmology London UK
| | - Sue Lightman
- Ophthalmology, Moorfields Eye Hospital London UK
- Faculty of Brain Sciences, Institute of Ophthalmology London UK
| | - Oren Tomkins‐Netzer
- Ophthalmology, Moorfields Eye Hospital London UK
- Faculty of Brain Sciences, Institute of Ophthalmology London UK
- Department of OphthalmologyBnai Zion Medical Centre Haifa Israel
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15
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Razonable RR, Humar A. Cytomegalovirus in solid organ transplant recipients-Guidelines of the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13512. [PMID: 30817026 DOI: 10.1111/ctr.13512] [Citation(s) in RCA: 361] [Impact Index Per Article: 72.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 02/11/2019] [Indexed: 12/11/2022]
Abstract
Cytomegalovirus (CMV) is one of the most common opportunistic infections that affect the outcome of solid organ transplantation. This updated guideline from the American Society of Transplantation Infectious Diseases Community of Practice provides evidence-based and expert recommendations for screening, diagnosis, prevention, and treatment of CMV in solid organ transplant recipients. CMV serology to detect immunoglobulin G remains as the standard method for pretransplant screening of donors and transplant candidates. Antiviral prophylaxis and preemptive therapy are the mainstays of CMV prevention. The lack of a widely applicable viral load threshold for diagnosis and preemptive therapy is highlighted, as a result of variability of CMV nucleic acid testing, even in the contemporary era when calibrators are standardized. Valganciclovir and intravenous ganciclovir remain as drugs of choice for CMV management. Strategies for managing drug-resistant CMV infection are presented. There is an increasing use of CMV-specific cell-mediated immune assays to stratify the risk of CMV infection after solid organ transplantation, but their role in optimizing CMV prevention and treatment efforts has yet to be demonstrated. Specific issues related to pediatric transplant recipients are discussed.
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Affiliation(s)
| | - Atul Humar
- University Health Network, Toronto, Ontario, Canada.,Transplant Institute, University of Toronto, Toronto, Ontario, Canada
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