1
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Liu C, Ji S, Gao H, Bi Z, Zhang Q, Shang K, Cao J, Bu B. Efficacy of tacrolimus as long-term immunotherapy for neuronal surface antibody-mediated autoimmune encephalitis. Ther Adv Chronic Dis 2022; 13:20406223211063055. [PMID: 35035868 PMCID: PMC8755929 DOI: 10.1177/20406223211063055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/09/2021] [Indexed: 01/17/2023] Open
Abstract
Aims: We aimed to verify the efficacy and safety of tacrolimus as long-term
immunotherapy for the treatment of neuronal surface antibody-mediated
autoimmune encephalitis (AE) during the first attack. Methods: In this retrospective observational cohort study, patients with neuronal
surface antibody-mediated AE who experienced the first attack were enrolled.
We compared the outcomes of 17 patients who received tacrolimus with those
of 47 patients treated without tacrolimus. Patients were assessed at onset
and 3, 6, and 12 months, as well as at the last follow-up, by using the
modified Rankin scale (mRS) and the Clinical Assessment Scale in Autoimmune
Encephalitis (CASE). The efficacy of tacrolimus was also compared in a
subgroup of patients with anti-NMDA receptor encephalitis. Results: Among all patients with neuronal surface antibody-mediated AE, those
receiving tacrolimus had lower median mRS scores [1 (IQR = 0–1)
versus 2 (IQR = 1–3) in controls, p =
0.001)], CASE scores [2 (IQR = 1–3) versus 3 (IQR = 2–7),
p = 0.006], and more favorable mRS scores (94.1%
versus 68.1%, p = 0.03) at the 3-month
follow-up. No difference was found at the last follow-up. There was no
significant difference in the occurrence of relapse and adverse events
between the two groups (11.8% versus 14.9%,
p = 0.75). In the subgroup of patients with anti-NMDA
receptor encephalitis, patients treated with tacrolimus had a lower median
mRS score at the 3-month follow-up [1 (IQR = 0–2) versus 2
(IQR = 1–3), p = 0.03]; however, no difference in the
outcome was detected at the last follow-up. Conclusion: Tacrolimus can be used as long-term immunotherapy in patients with neuronal
surface antibody-mediated AE during the first attack. Treatment with
tacrolimus appears to accelerate the clinical improvement of neuronal
surface antibody-mediated AE.
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Affiliation(s)
- Chenchen Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suqiong Ji
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huajie Gao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhuajin Bi
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qin Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Shang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Cao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan 430030, China
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2
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Long-term Follow-up of a Randomized Trial of Tacrolimus or Cyclosporine A Microemulsion in Children Post Liver Transplantation. Transplant Direct 2021; 7:e765. [PMID: 34557582 PMCID: PMC8454910 DOI: 10.1097/txd.0000000000001221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 06/22/2021] [Accepted: 07/04/2021] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to determine the long-term efficacy and safety of tacrolimus (Tac) and cyclosporine immunosuppression in pediatric liver transplantation (LTx).
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3
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Zhang Y, Mariani R, Gong M, Kirschmann D, Caparelli E, Wallace N, Turner R, Lu X, Gao J, Yap KL, Gong S. Distinctive Clinicopathologic Features of Monomorphic B-cell Post-transplant Lymphoproliferative Disorders in Children. Pediatr Dev Pathol 2021; 24:318-326. [PMID: 33872109 DOI: 10.1177/10935266211007254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Post-transplant lymphoproliferative disorders (PTLDs) comprise a heterogeneous group of Epstein-Barr virus (EBV)-positive or negative lymphoid or plasmacytic lesions in solid organ or hematopoietic stem cell (HSC) transplant recipients. Although PTLDs in adults have been extensively studied, the clinicopathologic features of monomorphic B-cell PTLD in children, particularly EBV-negative forms, are still poorly understood. METHODS We retrospectively reviewed all our pediatric cases of monomorphic B-cell PTLDs diagnosed in the past 10 years. Clinical data were reviewed. Pathologic data including histologic types and EBV status were analyzed. Additional immunohistochemical stains, FISH studies, and TP53 gene mutational status were performed. RESULTS 4 of 18 cases were EBV-negative. All 4 EBV-negative cases were strikingly confined to the gastrointestinal (GI) tract or abdominal lymph nodes, while tumors in EBV-positive cases were found at various anatomic sites; 2 of 4 EBV-negative cases carried mutations in TP53 gene. Our cohort also included 2 rare types of PTLD, one plasmablastic lymphoma and one high-grade B-cell lymphoma, not otherwise specified (HGBL, NOS). CONCLUSION We report that monomorphic B-cell PTLDs in children have distinctive clinical and pathological features. More studies are needed to clarify whether and how much these pediatric PTLDs differ from their adult counterparts.
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Affiliation(s)
- Yanmin Zhang
- Northwestern Memorial Hospital, Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rachel Mariani
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michelle Gong
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dawn Kirschmann
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Edward Caparelli
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nneka Wallace
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rebekah Turner
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xinyan Lu
- Northwestern Memorial Hospital, Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Juehua Gao
- Northwestern Memorial Hospital, Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kai Lee Yap
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Shunyou Gong
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pathology and Laboratory Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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4
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Job KM, Roberts JK, Enioutina EY, IIIamola SM, Kumar SS, Rashid J, Ward RM, Fukuda T, Sherbotie J, Sherwin CM. Treatment optimization of maintenance immunosuppressive agents in pediatric renal transplant recipients. Expert Opin Drug Metab Toxicol 2021; 17:747-765. [PMID: 34121566 PMCID: PMC10726690 DOI: 10.1080/17425255.2021.1943356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
Introduction: Graft survival in pediatric kidney transplant patients has increased significantly within the last three decades, correlating with the discovery and utilization of new immunosuppressants as well as improvements in patient care. Despite these developments in graft survival for patients, there is still improvement needed, particularly in long-term care in pediatric patients receiving grafts from deceased donor patients. Maintenance immunosuppressive therapies have narrow therapeutic indices and are associated with high inter-individual and intra-individual variability.Areas covered: In this review, we examine the impact of pharmacokinetic variability on renal transplantation and its association with age, genetic polymorphisms, drug-drug interactions, drug-disease interactions, renal insufficiency, route of administration, and branded versus generic drug formulation. Pharmacodynamics are outlined in terms of the mechanism of action for each immunosuppressant, potential adverse effects, and the utility of pharmacodynamic biomarkers.Expert opinion: Acquiring abetter quantitative understanding of immunosuppressant pharmacokinetics and pharmacodynamic components should help clinicians implement treatment regimens to maintain the balance between therapeutic efficacy and drug-related toxicity.
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Affiliation(s)
- Kathleen M Job
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jessica K Roberts
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Sílvia M IIIamola
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Shaun S Kumar
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jahidur Rashid
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robert M Ward
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Tsuyoshi Fukuda
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph Sherbotie
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Catherine M Sherwin
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
- Department of Pediatrics, Boonshoft School of Medicine, Dayton Children’s Hospital, Wright State University, Dayton, OH, USA
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
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5
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Prusinskas B, Ohlsson S, Kathemann S, Pilic D, Kampmann K, Büscher R, Paul A, Pape L, Hoyer PF, Lainka E. Role of Tacrolimus C/D Ratio in the First Year After Pediatric Liver Transplantation. Front Pediatr 2021; 9:659608. [PMID: 34150686 PMCID: PMC8206534 DOI: 10.3389/fped.2021.659608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/27/2021] [Indexed: 12/17/2022] Open
Abstract
Background: The calcineurin inhibitor (CNI) tacrolimus (TAC) is a cornerstone agent in immunosuppressive therapy in pediatric liver transplantation (LTX). Adverse effects limit the use of CNI. In adults, calculating the individual TAC metabolism rate allows to estimate the transplant recipient's risk for therapy-associated complications. Methods: A retrospective, descriptive data analysis was performed in children who had undergone LTX in 2009-2017 and had received TAC twice daily in the first year after LTX. A weight-adjusted concentration/dose ratio (C/D ratio) was calculated [TAC trough level/(daily TAC dose/body weight)] every 3 months after LTX to estimate the average individual TAC metabolism rate. Depending on the C/D ratio, all patients were divided into two groups: fast metabolizers (FM) and slow metabolizers (SM). Clinical and laboratory parameters were analyzed as risk factors in both groups. Results: A total of 78 children (w 34, m 44, median age at LTX 2.4; 0.4-17.0 years) were enrolled in the study. FM (SM) had a mean C/D ratio of <51.83 (≥51.83) ng/ml/(mg/kg). FM were younger at the time of LTX (median age 1.7; 0.4-15.8 years) than SM (5.1, 0.4-17.0), p = 0.008. FM were more likely to have biliary atresia (20/39, 51%) compared to SM (11/39, 28%), p = 0.038, whereas SM were more likely to have progressive familial intrahepatic cholestasis (9/39, 23%) vs. in FM (1/39, 3%), p = 0.014. Epstein-Barr virus (EBV) infection occurred more frequently in FM (27/39, 69%) than SM (13/39, 33%), p = 0.002. Three FM developed post-transplant lymphoproliferative disorder. The annual change of renal function did not differ in both groups (slope FM 1.2 ± 0.6; SM 1.4 ± 0.8 ml/min/1.73 m2 per year, and p = 0.841). Conclusions: Calculation of individual, weight-adjusted TAC C/D ratio is a simple, effective, and cost-efficient tool for physicians to estimate the risk of therapy-associated complications and to initiate individual preventive adjustments after pediatric LTX. Lower TAC levels are tolerable in FM, especially in the presence of EBV infection, reduced renal function, or when receiving a liver transplant in the first 2 years of life.
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Affiliation(s)
- Benas Prusinskas
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany
| | - Sinja Ohlsson
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany
| | - Simone Kathemann
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany
| | - Denisa Pilic
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany
| | - Kristina Kampmann
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany
| | - Rainer Büscher
- Department of Pediatrics II, Pediatric Nephrology and Kidney Transplantation, University Children's Hospital Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral, and Transplantation Surgery, University Medicine Essen, Essen, Germany
| | - Lars Pape
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany.,Department of Pediatrics II, Pediatric Nephrology and Kidney Transplantation, University Children's Hospital Essen, Essen, Germany
| | - Peter F Hoyer
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany.,Department of Pediatrics II, Pediatric Nephrology and Kidney Transplantation, University Children's Hospital Essen, Essen, Germany
| | - Elke Lainka
- Department of Pediatrics II, Pediatric Gastroenterology, Hepatology and Liver Transplantation, University Children's Hospital, Essen, Germany
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Abstract
Lung transplantation is an established therapeutic option for selected patients with advanced lung diseases. As early outcomes after lung transplantation have improved, chronic medical illnesses have emerged as significant obstacles to long-term survival. Among them is post-transplant malignancy, currently representing the 2nd most common cause of death 5–10 years after transplantation. Chronic immunosuppressive therapy and resulting impairment of anti-tumor immune surveillance is thought to have a central role in cancer development after solid organ transplantation (SOT). Lung transplant recipients receive more immunosuppression than other SOT populations, likely contributing to even higher risk of cancer among this group. The most common cancers in lung transplant recipients are non-melanoma skin cancers, followed by lung cancer and post-transplant lymphoproliferative disorder (PTLD). The purpose of this review is to outline the common malignancies following lung transplant, their risk factors, prognosis and current means for both prevention and treatment.
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Affiliation(s)
- Osnat Shtraichman
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Pulmonary Institute, Rabin Medical Center, Affiliated with Sackler School of Medicine Tel Aviv University, Petach Tikva, Israel
| | - Vivek N Ahya
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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7
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Long-lasting chronic high load carriage of Epstein-Barr virus is more common in young pediatric renal transplant recipients. Pediatr Nephrol 2020; 35:427-439. [PMID: 31802220 PMCID: PMC6969008 DOI: 10.1007/s00467-019-04401-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/22/2019] [Accepted: 10/14/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Epstein-Barr virus (EBV) infections can induce post-transplant lymphoproliferative disorder (PTLD). A chronic high load (CHL), as indicated by long-term high EBV DNA levels after transplantation, has been associated with an enhanced risk of PTLD. We aimed to evaluate incidence, time of occurrence, risk factors, and outcome of EBV CHL carrier state after pediatric renal transplantation. METHODS A retrospective study of 58 children aged 1-17 years (median 10), who underwent renal transplantation between January 2004 and June 2017 at a single medical center. EBV IgG antibodies in serum were analyzed before and yearly after transplantation. EBV DNA in whole blood were analyzed weekly for the first 3 months post-transplant, monthly up to 1 year and then at least once yearly. CHL was defined as EBV DNA ≥ 4.2 log10 Geq/ml in > 50% of the samples during ≥ 6 months. RESULTS At transplantation, 31 (53%) patients lacked EBV IgG and 25 (81%) of them developed primary EBV infection post-transplant. Of the 27 seropositive patients, 20 (74%) experienced reactivation of EBV. Altogether, 14 (24%) children developed CHL, starting at a median of 69 days post-transplant and lasting for a median time of 2.3 years (range 0.5-6.5), despite reduction of immunosuppression. Patients with CHL were younger and 11/14 were EBV seronegative at transplantation. No child developed PTLD during median clinical follow-up of 7.8 years (range 0.7-13). CONCLUSIONS CHL was frequent, long lasting, and occurred mainly in young transplant recipients. The absence of PTLD suggests that monitoring of EBV DNA to guide immunosuppression was effective.
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8
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Payet X, Raybaud H, Kipper M, Fino E, Voha C. Lymphoma of the lip after kidney transplantation: a case report. JOURNAL OF ORAL MEDICINE AND ORAL SURGERY 2019. [DOI: 10.1051/mbcb/2019032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Introduction: In transplant recipients, the risk to develop cancer increases 4 fold compared to general population due to the immunosuppressive treatment. Observation: A 68 years old woman, kidney transplanted four years ago, presented with a slowly growing swelling over her left lip since six weeks. The histopathological analyses showed a non Hodgkin lymphoma. Comment: Post-transplant lymphoproliferative disorders (PTLD) is a complication developing after solid organ transplantation or allogenic hematopoietic stem cell transplantation. Immunosuppression due to the immunosuppressives drugs is considered as the most important risk factor and the incidence rate depends of transplant type, age and risk of primary Epstein-Barr virus infection. Conclusion: PTLD is a rare but serious complication. It must be suspected in all cases of intra-oral mass for a transplanted patient and requires a histopathological analysis for early diagnosis and appropriate treatment.
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9
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Francis A, Johnson DW, Teixeira-Pinto A, Craig JC, Wong G. Incidence and predictors of post-transplant lymphoproliferative disease after kidney transplantation during adulthood and childhood: a registry study. Nephrol Dial Transplant 2019; 33:881-889. [PMID: 29342279 DOI: 10.1093/ndt/gfx356] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 12/04/2017] [Indexed: 11/12/2022] Open
Abstract
Background Differences in the epidemiology of post-transplant lymphoproliferative disease (PTLD) between adult and paediatric kidney transplant recipients remain unclear. Methods Using the Australian and New Zealand Dialysis and Transplant Registry (1963-2015), the cumulative incidences of PTLD in children (age <20 years) and adults were calculated using a competing risk of death model and compared with age-matched population-based data using standardized incidence ratios (SIRs). Risk factors for PTLD were assessed using Cox proportional hazards regression. Results Among 23 477 patients (92% adult, 60% male), 505 developed PTLD, with 50 (10%) occurring in childhood recipients. The 25-year cumulative incidence of PTLD was 3.3% [95% confidence interval (CI) 2.9-3.6] for adult recipients and 3.6% (95% CI 2.7-4.8) for childhood recipients. Childhood recipients had a 30-fold increased risk of lymphoma compared with the age-matched general population [SIR 29.5 (95% CI 21.9-38.8)], higher than adult recipients [SIR 8.4 (95% CI 7.7-9.2)]. Epstein-Barr virus (EBV)-negative recipient serology [adjusted hazard ratio (aHR) 3.33 (95% CI 2.21-5.01), P < 0.001], year of transplantation [aHR 0.93 for each year after the year 2000 (95% CI 0.88-0.99), P = 0.02], induction with an agent other than anti-CD25 monoclonal antibody [aHR 2.07 (95% CI 1.16-3.70), P = 0.01] and having diabetes [aHR 3.49 (95% CI 2.26-5.38), P < 0.001] were independently associated with PTLD. Conclusions Lymphoma occurs at similar rates in adult and paediatric recipients, but has been decreasing since the year 2000. EBV-negative patients and those with diabetes or induction agent other than anti-CD25 monoclonal antibody are at substantially increased risk of PTLD.
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Affiliation(s)
- Anna Francis
- Sydney School of Public Health, University of Sydney, Camperdown, Victoria, Australia.,Child and Adolescent Renal Service, Children's Health Queensland, Brisbane, Queensland, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, Diamantina, Translational Research Institute, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | | | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Camperdown, Victoria, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Camperdown, Victoria, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
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10
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Hyun H, Park E, Cho M, Min SI, Ha J, Kang HJ, Shin HY, Ha IS, Cheong HI, Ahn YH, Kang HG. Post-Transplant Lymphoproliferative Diseases in Pediatric Kidney Allograft Recipients with Epstein-Barr Virus Viremia. J Korean Med Sci 2019; 34:e203. [PMID: 31373185 PMCID: PMC6676002 DOI: 10.3346/jkms.2019.34.e203] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 07/07/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disease (PTLD) is one of the major complications of organ transplantation, especially in children with Epstein-Barr virus (EBV) viremia (EV). We performed a retrospective study to evaluate risk factors for PTLD in children with EV. METHODS Among 199 pediatric kidney transplantation (KT) recipients at our center from January 2001 to October 2015, records of those with EBV viral loads of > 1,000 copies/mL and/or PTLD were reviewed. RESULTS Diagnosis of PTLD was made in seven patients (PTLD group), and 39 patients had EV only (EV only group). The median time from KT to EV and PTLD diagnosis was 6.7 (range 0.4-47.8) months and 8.2 (range, 2.8-98.9) months, respectively. There were no significant differences between the groups in terms of sex, age at transplantation, donor type, EBV viral load, or EV-free duration after KT. Higher tacrolimus level before EV (hazard ratio, 44.5; P = 0.003) was an independent risk factor for PTLD in multivariate Cox regression analysis. Six patients with a high EBV load (median 171,639 copies/mL) were treated with preemptive rituximab (RTX) therapy, resulting in transient reduction of EBV load. None of these patients developed PTLD (median follow-up 51.5 months); however, two had neutropenia and two developed infection requiring hospital admission. CONCLUSION In pediatric KT recipients, higher tacrolimus levels were associated with a higher incidence of PTLD. Conversely, those who received preemptive RTX for EV did not develop PTLD.
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Affiliation(s)
- Hyesun Hyun
- Department of Pediatrics, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eujin Park
- Department of Pediatrics, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Myunghyun Cho
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Il Min
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Cancer Research Institute, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Cancer Research Institute, Seoul, Korea
| | - Il Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea.
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11
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Weber J, Hammond N, Yaghmai V, Nikolaidis P, Miller F, Horowitz J. Imaging features of immune-mediated genitourinary disease. Abdom Radiol (NY) 2019; 44:2217-2232. [PMID: 30915493 DOI: 10.1007/s00261-019-01946-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Imaging features of immune-mediated genitourinary diseases often overlap, and the same disease may manifest in different ways, so understanding imaging findings in the context of the patient's entire clinical picture is important in providing the correct diagnosis. METHODS In this article, diseases mediated by the immune system which affect the genitourinary system are reviewed. Examples of immune-mediated genitourinary disease including IgG4-related disease, post-transplant lymphoproliferative disorder, immunodeficiency-associated lymphoproliferative disorder due to immunosuppressive and immunomodulatory medications, lymphoma, leukemia, myeloma, amyloidosis, and histiocytosis. RESULTS Clinical and imaging features will be presented which may help narrow the differential diagnosis for each disease. CONCLUSION Recognition of immune-related genitourinary disease is important for appropriate medical management as they may mimic other diseases both by imaging and clinical presentation.
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Affiliation(s)
- Jonathon Weber
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA.
| | - Nancy Hammond
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
| | - Vahid Yaghmai
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
| | - Paul Nikolaidis
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
| | - Frank Miller
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
| | - Jeanne Horowitz
- Department of Radiology, Northwestern Memorial Hospital, 676 N St. Claire St, Suite 800, Chicago, IL, 60611, USA
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12
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Zhu CY, Zhao SS, Wang XK, Wang L, Wang FY, Fang S, Liu ZX, Guan LX, Liu YC, Ding Y, Dou LP, Wang LL, Gao CJ. Outcome of Rituximab-Based Treatment for Post-Transplant Lymphoproliferative Disorder After Allogeneic Hematopoietic Stem Cell Transplantation: A Single-Center Experience. Ann Transplant 2019; 24:175-184. [PMID: 30940797 PMCID: PMC6463616 DOI: 10.12659/aot.914101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Post-transplant lymphoproliferative disorder (PTLD) is a rare complication following solid organ transplantation and allogeneic hematopoietic stem cell transplantation (Allo-HSCT), which gives rise to high mortality rates. Material/Methods This was a single-center retrospective analysis based on 27 patients who were diagnosed with PTLD following Allo-HSCT between January 1, 2007 and June 2018 at the Chinese PLA General Hospital. The purpose of this analysis was to investigate responses and prognostic factors of rituximab-based treatment. Results Twenty-seven patients were treated with rituximab. Among them, 20 of 27 patients (74.07%) had a complete response, 2 of 27 patients (7.41%) had a partial response, 5 of 27 patients (18.52%) had no response, and 22 of 27 patients (81.48%) cleared Epstein-Barr virus (EBV) copies. There were no obvious side effects. The 1-year overall survival (OS) estimate was 46.8% (95% CI, 23.1–65.5%). Univariate analysis revealed that lower OS was correlated with Eastern Cooperative Oncology Group (ECOG) score standard (3–4), Epstein-Barr virus (EBV) viral load (≥106 copies/mL), bacteria or fungal infection, and EBV reactivation were positive after treatment with 1 or 2 doses of rituximab (P<0.05). Multivariate analysis showed that each of the following were independently associated with lower OS (P<0.05): female, ECOG score standard (3–4), and EBV reactivation were positive after treatment with 1 or 2 doses of rituximab. Conclusions Our results demonstrated that rituximab-based treatment was a safe and effective strategy for patients who were diagnosed with PTLD following Allo-HSCT. The identified prognostic factors may help to detect which PTLD patients are at a higher risk of mortality.
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Affiliation(s)
- Cheng-Ying Zhu
- School of Medicine, Nankai University, Tianjin, China (mainland).,Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Sha-Sha Zhao
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Xiao-Kai Wang
- Department of Orthopedics, Xiqing Hospital, Tianjin, China (mainland)
| | - Li Wang
- Department of Hematology and Oncology, Laoshan Branch, No. 401 Hospital of Chinese People's Liberation Army (PLA), Qingdao, Shandong, China (mainland)
| | - Fei-Yan Wang
- School of Medicine, Nankai University, Tianjin, China (mainland)
| | - Shu Fang
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Zhan-Xiang Liu
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Li-Xun Guan
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yu-Chen Liu
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yi Ding
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Li-Ping Dou
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Li-Li Wang
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Chun-Ji Gao
- School of Medicine, Nankai University, Tianjin, China (mainland).,Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
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13
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A review of adenotonsillar hypertrophy and adenotonsillectomy in children after solid organ transplantation. Int J Pediatr Otorhinolaryngol 2018; 114:29-35. [PMID: 30262363 DOI: 10.1016/j.ijporl.2018.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Paediatric solid organ transplantation is an increasingly successful treatment. Improved survival is paralleled by increased secondary complications of immunosuppression, including post-transplant lymphoproliferative disease (PTLD). PTLD frequently presents in Waldeyer's lymphatic ring. Adenotonsillar hypertrophy (ATH) is common in children, however in children after transplant, ATH may indicate PTLD. We review the literature on ATH and the role of adenotonsillectomy in children after transplantation. METHODS A comprehensive literature search was performed on the 26 th September 2017 of Ovid Medline (1996-September 2017), Embase (1996-2017) and EBM reviews (Cochrane database of systematic reviews 2005-September 20 th 2017). Results were limited to English language publications within the last 20 years. Abstracts were screened for relevance to PTLD and ATH in the paediatric solid organ transplantation population. Screening of the bibliographies identified further articles. RESULTS 85 unique articles were screened to yield 18 relevant publications. 10 were retrospective studies and 8 were prospective studies. CONCLUSION In children, we report a PTLD incidence of up to 15%, with up to 63% of cases presenting in the head and neck. Histological examination of adenotonsillectomy specimens found PTLD in a mean 5.7% (range 0-39%). We found a lack of prospective studies into this topic and further high quality research is needed. Clinical assessment of ATH in children after transplantation and when to perform a diagnostic adenotonsillectomy remains challenging. Children with ATH warrant prompt further investigation and support from colleagues in transplantation and oncology is required. .
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14
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Tanner JE, Hu J, Alfieri C. Construction and Characterization of a Humanized Anti-Epstein-Barr Virus gp350 Antibody with Neutralizing Activity in Cell Culture. Cancers (Basel) 2018; 10:cancers10040112. [PMID: 29642526 PMCID: PMC5923367 DOI: 10.3390/cancers10040112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/30/2018] [Accepted: 04/04/2018] [Indexed: 12/16/2022] Open
Abstract
Acute Epstein-Barr virus (EBV) infection in immunosuppressed transplant patients can give rise to a malignant B-cell proliferation known as post-transplant lymphoproliferative disease (PTLD). The EBV major virion surface glycoprotein (gp)350 is a principal target of naturally occurring neutralizing antibodies and is viewed as the best target to prevent acute infection and PTLD in at-risk transplant recipients. We have constructed a humanized (hu) version of the murine anti-gp350 neutralizing monoclonal antibody 72a1. The hu72a1 IgG1 antibody displayed no significant anti-mouse activity, recognized both gp350 and its splice variant gp220 as well as a gp350 peptide that was shown to constitute the principal EBV gp350 neutralizing epitope when tested in immunoassays. Hu72a1 antibody blocked in vitro EBV infection of B cells at a level which equaled that of a mouse-human chimeric 72a1 antibody construct. This work provides a further structural and immunological understanding of the 72a1 antibody interaction with EBV gp350, and constitutes a launch point for future anti-EBV therapeutic antibodies designed to block EBV infection and prevent PTLD while eliminating the deleterious antigenic murine features of the original 72a1 antibody.
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Affiliation(s)
- Jerome E Tanner
- Laboratory of Viral Pathogenesis, Research Centre, CHU Sainte-Justine, Montréal, QC H3T 1C5, Canada.
| | - Jing Hu
- Laboratory of Viral Pathogenesis, Research Centre, CHU Sainte-Justine, Montréal, QC H3T 1C5, Canada.
| | - Caroline Alfieri
- Laboratory of Viral Pathogenesis, Research Centre, CHU Sainte-Justine, Montréal, QC H3T 1C5, Canada.
- Department of Microbiology, Infectiology and Immunology, University of Montreal, 3175 Côte Ste-Catherine Road, Montreal, QC H3T 1C5, Canada.
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15
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Will BM, Peters SM, Eisig SB, Grbic JT, McKenzie MA, Yoon AJ, Philipone EM. Gingival ulceration in a 63-year-old lung transplant recipient. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 127:364-371. [PMID: 29545078 DOI: 10.1016/j.oooo.2018.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/25/2018] [Accepted: 02/01/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Brian M Will
- DDS Candidate, Class of 2019, Columbia University College of Dental Medicine, New York, NY, USA
| | - Scott M Peters
- Division of Oral and Maxillofacial Pathology, Columbia University College of Dental Medicine, New York, NY, USA
| | - Sidney B Eisig
- Chair, Section of Hospital Dentistry, New York, NY, USA; Director, Division of Oral and Maxillofacial Surgery, New York, NY, USA; Chief, Hospital Dental Service, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - John T Grbic
- Professor, Dental Medicine and Director, Division of Foundational Sciences, Columbia University College of Dental Medicine, New York, NY, USA
| | - Michael A McKenzie
- Instructor, Dental Medicine, Columbia University College of Dental Medicine, New York, NY, USA
| | - Angela J Yoon
- Division of Oral and Maxillofacial Pathology, Columbia University College of Dental Medicine, New York, NY, USA
| | - Elizabeth M Philipone
- Division of Oral and Maxillofacial Pathology, Columbia University College of Dental Medicine, New York, NY, USA.
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Castellsague J, Kuiper JG, Pottegård A, Anveden Berglind I, Dedman D, Gutierrez L, Calingaert B, van Herk-Sukel MP, Hallas J, Sundström A, Gallagher AM, Kaye JA, Pardo C, Rothman KJ, Perez-Gutthann S. A cohort study on the risk of lymphoma and skin cancer in users of topical tacrolimus, pimecrolimus, and corticosteroids (Joint European Longitudinal Lymphoma and Skin Cancer Evaluation - JOELLE study). Clin Epidemiol 2018; 10:299-310. [PMID: 29559812 PMCID: PMC5856050 DOI: 10.2147/clep.s146442] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background There is a concern that topical tacrolimus and pimecrolimus, indicated for second-line treatment of atopic dermatitis, may increase the risk of lymphoma and skin cancer, particularly in children. Objective The aim of this study was to compare incidence rates (IRs) of lymphoma and skin cancer between new users of topical tacrolimus or pimecrolimus and users of moderate- to high-potency topical corticosteroids (TCSs) and untreated subjects. Methods This is a multicenter cohort study with frequency matching by strata of propensity scores in population databases in the Netherlands, Denmark, Sweden, and the UK. IR ratios (IRRs) were estimated using Mantel–Haenszel methods for stratified analysis. Results We included 19,948 children and 66,127 adults initiating tacrolimus, 23,840 children and 37,417 adults initiating pimecrolimus, 584,121 users of TCSs, and 257,074 untreated subjects. IRs of lymphoma per 100,000 person-years were 10.4 events in children and 41.0 events in adults using tacrolimus and 3.0 events in children and 27.0 events in adults using pimecrolimus. The IRR (95% confidence interval [CI]) for lymphoma, tacrolimus versus TCSs, was 3.74 (1.00–14.06) in children and 1.27 (0.94–1.71) in adults. By lymphoma type, the highest IRR was 3.17 (0.58–17.23) for Hodgkin lymphoma in children and 1.76 (95% CI, 0.81–3.79) for cutaneous T-cell lymphoma (CTCL) in adults. For pimecrolimus versus TCSs, the highest IRR was 1.31 (95% CI, 0.33–5.14) for CTCL in adults. Compared with untreated subjects, adults using TCSs had a higher incidence of CTCL (IRR, 10.66; 95% CI, 2.60–43.75). Smaller associations were found between tacrolimus and pimecrolimus use and the risk of malignant melanoma or nonmelanoma skin cancer. Conclusion Use of topical tacrolimus and pimecrolimus was associated with an increased risk of lymphoma. The low IRs imply that even if the increased risk is causal, it represents a small excess risk for individual patients. Residual confounding by severity of atopic dermatitis, increased monitoring of severe patients, and reverse causation could have affected the results.
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Affiliation(s)
| | - Josephina G Kuiper
- Department Research, PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ingegärd Anveden Berglind
- Centre for Pharmacoepidemiology, Unit of Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Daniel Dedman
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Lia Gutierrez
- Department of Epidemiology, RTI Health Solutions, Barcelona, Spain
| | - Brian Calingaert
- Department Epidemiology, RTI Health Solutions, Research Triangle Park, NC
| | | | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anders Sundström
- Centre for Pharmacoepidemiology, Unit of Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Arlene M Gallagher
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - James A Kaye
- Department of Epidemiology, RTI Health Solutions, Waltham, MA, USA
| | - Carolina Pardo
- Pharmacovigilance Department, Astellas Pharma Europe B.V., Leiden, the Netherlands
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Nagle SJ, Reshef R, Tsai DE. Posttransplant Lymphoproliferative Disorder in Solid Organ and Hematopoietic Stem Cell Transplantation. Clin Chest Med 2017; 38:771-783. [DOI: 10.1016/j.ccm.2017.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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18
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Current status of pediatric renal transplant pathology. Pediatr Nephrol 2017; 32:425-437. [PMID: 27221522 DOI: 10.1007/s00467-016-3381-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 03/07/2016] [Accepted: 03/21/2016] [Indexed: 10/21/2022]
Abstract
Histopathology is still an indispensable tool for the diagnosis of kidney transplant dysfunction in adult and pediatric patients. This review presents consolidated knowledge, recent developments and future prospects on the biopsy procedure, the diagnostic work-up, classification schemes, the histopathology of rejection, including antibody-mediated forms, ABO-incompatible transplants, protocol biopsies, recurrent and de novo disease, post-transplant lymphoproliferative disorder, infectious complications and drug-induced toxicity. It is acknowledged that frequently the correct diagnosis can only be reached in consensus with clinical, serological, immunogenetical, bacteriological and virological findings. This review shall enhance the understanding of the pediatric nephrologist for the thought processes of nephropathologists with the aim to facilitate teamwork between these specialist groups for the benefit of the patient.
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19
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Trofe J, Beebe TM, Buell JF, Hanaway MJ, First MR, Alloway RR, Gross TG, Woodle ES. Posttransplant Malignancy. Prog Transplant 2016; 14:193-200. [PMID: 15495778 DOI: 10.1177/152692480401400304] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the past few decades, great advances have been made in the field of solid-organ transplantation. A greater understanding of immune system function, the development of modern immunosuppression, and advancements in surgical technique have led to marked improvements in both recipient and graft survivals, as well as recipients' quality of life. However, improved survival rates have also led to prolonged exposure to chronic immunosuppression, which increases the risk for the development of posttransplant malignancies. In addition, older transplant candidates are being considered, carrying with them the increased likelihood of pre-existing malignancy. Consequently, the potential risk of posttransplant malignancy must be considered. Moreover, as long-term transplant survivors continue to age, posttransplant malignancies will be seen more frequently. This review presents the more commonly encountered posttransplant malignancies and the measures that are currently being utilized to prevent and treat them.
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Affiliation(s)
- Jennifer Trofe
- Israel Penn International Transplant Tumor Registry, University of Cincinnati, Cincinnati, Ohio, USA
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20
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Vincenti F, Rostaing L, Grinyo J, Rice K, Steinberg S, Gaite L, Moal MC, Mondragon-Ramirez GA, Kothari J, Polinsky MS, Meier-Kriesche HU, Munier S, Larsen CP. Belatacept and Long-Term Outcomes in Kidney Transplantation. N Engl J Med 2016; 374:333-43. [PMID: 26816011 DOI: 10.1056/nejmoa1506027] [Citation(s) in RCA: 491] [Impact Index Per Article: 61.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND In previous analyses of BENEFIT, a phase 3 study, belatacept-based immunosuppression, as compared with cyclosporine-based immunosuppression, was associated with similar patient and graft survival and significantly improved renal function in kidney-transplant recipients. Here we present the final results from this study. METHODS We randomly assigned kidney-transplant recipients to a more-intensive belatacept regimen, a less-intensive belatacept regimen, or a cyclosporine regimen. Efficacy and safety outcomes for all patients who underwent randomization and transplantation were analyzed at year 7 (month 84). RESULTS A total of 666 participants were randomly assigned to a study group and underwent transplantation. Of the 660 patients who were treated, 153 of the 219 patients treated with the more-intensive belatacept regimen, 163 of the 226 treated with the less-intensive belatacept regimen, and 131 of the 215 treated with the cyclosporine regimen were followed for the full 84-month period; all available data were used in the analysis. A 43% reduction in the risk of death or graft loss was observed for both the more-intensive and the less-intensive belatacept regimens as compared with the cyclosporine regimen (hazard ratio with the more-intensive regimen, 0.57; 95% confidence interval [CI], 0.35 to 0.95; P=0.02; hazard ratio with the less-intensive regimen, 0.57; 95% CI, 0.35 to 0.94; P=0.02), with equal contributions from the lower rates of death and graft loss. The mean estimated glomerular filtration rate (eGFR) increased over the 7-year period with both belatacept regimens but declined with the cyclosporine regimen. The cumulative frequencies of serious adverse events at month 84 were similar across treatment groups. CONCLUSIONS Seven years after transplantation, patient and graft survival and the mean eGFR were significantly higher with belatacept (both the more-intensive regimen and the less-intensive regimen) than with cyclosporine. (Funded by Bristol-Myers Squibb; ClinicalTrials.gov number, NCT00256750.).
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Affiliation(s)
- Flavio Vincenti
- From the University of California, San Francisco, San Francisco (F.V.), and Sharp Memorial Hospital, San Diego (S.S.) - both in California; University Hospital and INSERM Unité 563, IFR-BMT, Toulouse (L.R.), and Hôpital de La Cavale Blanche, Brest (M.-C.M.) - both in France; University Hospital Bellvitge, Barcelona (J.G.); Baylor University Medical Center, Dallas (K.R.); Clínica de Nefrología, Santa Fe, Argentina (L.G.); Instituto Mexicano de Trasplantes, Morelos, Mexico (G.A.M.-R.); Hinduja Hospital, Hinduja Health Care and Apex Kidney Foundation, Mumbai, India (J.K.); Bristol-Myers Squibb, Princeton, NJ (M.S.P., H.-U.M.-K.); Bristol-Myers Squibb, Braine-l'Alleud, Belgium (S.M.); and Emory University Transplant Center, Atlanta (C.P.L.)
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Vali R, Punnett A, Bajno L, Moineddin R, Shammas A. The value of 18F-FDG PET in pediatric patients with post-transplant lymphoproliferative disorder at initial diagnosis. Pediatr Transplant 2015; 19:932-9. [PMID: 26515450 DOI: 10.1111/petr.12611] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2015] [Indexed: 12/22/2022]
Abstract
PTLD is a serious complication of both solid organ and BMT. This study assessed whether (18) F-FDG PET, when added to CT scan, had additional value in the initial evaluation of PTLD in pediatric patients and whether PET/CT at baseline can reliably guide biopsy. This retrospective study evaluated 34 consecutive pediatric patients (14 female), aged 3.5-17.0 yr (mean age: 9.9 yr, s.d.: 4.9 yr), who had undergone (18) F-FDG PET/CT from May 2007 to December 2014 at initial diagnosis of PTLD following heart (n = 13), lung (n = 8), kidney (n = 4), liver (n = 3), liver and bowel (n = 3), and bone marrow (n = 3) transplantation. PTLD was diagnosed histopathologically in 33 patients and was based on clinical findings, elevated EBV, and imaging and follow-up results in one patient. On lesion-based analysis, (18) F-FDG PET showed more lesions than conventional CT scan (168 vs. 134), but CT revealed 22 lesions negative on PET. On per patient analysis, PET detected more lesions in 13 patients, CT identified more abnormalities in seven, and both showed the same number of lesions in 14. Adding (18) F-FDG PET to CT scans upstaged the disease in seven patients (20.5%). A combination of (18) F-FDG PET and CT was also useful in guiding biopsy, being positive in 36 of 39 samples (92.3%). These findings indicated that (18) F-FDG PET and CT are complementary at initial staging of pediatric PTLD and that (18) F-FDG PET/CT scanning can guide biopsies.
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Affiliation(s)
- R Vali
- Diagnostic Imaging Department, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - A Punnett
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - L Bajno
- Diagnostic Imaging Department, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - R Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - A Shammas
- Diagnostic Imaging Department, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Marques HHDS, Shikanai-Yasuda MA, Azevedo LSFD, Caiaffa-Filho HH, Pierrotti LC, Aquino MZD, Lopes MH, Maluf NZ, Campos SV, Costa SF. Management of post-transplant Epstein-Barr virus-related lymphoproliferative disease in solid organ and hematopoietic stem cell recipients. Rev Soc Bras Med Trop 2014; 47:543-6. [DOI: 10.1590/0037-8682-0036-2014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 07/30/2014] [Indexed: 12/18/2022] Open
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Increased incidence of adenoidectomy and tonsillectomy in children with renal transplantation. Pediatr Nephrol 2014; 29:1441-50. [PMID: 24584665 DOI: 10.1007/s00467-014-2775-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 01/20/2014] [Accepted: 01/24/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Previous studies have found that pediatric solid organ transplant recipients suffer from adenotonsillar hyperplasia. However, as this condition is also common in normal children, it remains unclear whether the incidence is truly increased. The aim of this study was to compare the incidences of surgery on the adenoids and tonsils of normal children with those receiving renal transplants and to define risk factors in the transplant population. METHODS Data on 49 consecutive children from a single renal transplant unit were compared to data from a large governmental survey of healthy German children (KiGGS). For analysis of 'survival without operation', controls were matched for gender, region and immigration status (n = 8,650), as well as for age to compare incidence rates (n = 637). RESULTS The age-matched solid organ transplant recipients had a higher incidence of adenoidectomies [2.3-fold, [95 % confidence interval (CI) for relative risk 1.6-3.3) and a higher incidence of tonsillectomies/tonsillotomies (3.5-fold, 95 % CI 2.1-5.7). The normal peak of adenoidectomies was delayed by 2 years in the pre-school group, and transplanted teenagers showed an extra peak for both operations. Boys and those transplanted at a younger age were significantly more likely to need adenoidectomies. Ciclosporin levels, Epstein-Barr virus and cytomegalovirus infections did not influence the incidence of operations. CONCLUSION Children receiving renal transplants are at markedly increased risk of adenotonsillar hyperplasia requiring surgery, especially males and young recipients.
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Post-transplant lymphoproliferative disease (PTLD): risk factors, diagnosis, and current treatment strategies. Curr Hematol Malig Rep 2014; 8:173-83. [PMID: 23737188 DOI: 10.1007/s11899-013-0162-5] [Citation(s) in RCA: 201] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Post-transplant lymphoproliferative diseases (PTLD) are heterogeneous lymphoid disorders ranging from indolent polyclonal proliferations to aggressive lymphomas that complicate solid organ or hematopoietic transplantation. Risk factors for PTLD include viral infections, degree of immunosuppression, recipient age and race, allograft type, and host genetic variations. Clinically, extra-nodal disease is common including 10-15 % presenting with central nervous system (CNS) disease. Most PTLD cases are B cell (5-10 % T/NK cell or Hodgkin lymphoma), while over one-third are EBV-negative. World Health Organization (WHO) diagnostic categories are: early lesions, polymorphic, and monomorphic PTLD; although in practice, a clear separation is not always possible. Therapeutically, reduction in immunosuppression remains a mainstay, and recent data has documented the importance of rituximab +/- combination chemotherapy. Therapy for primary CNS PTLD should be managed according to immunocompetent CNS paradigms. Finally, novel treatment strategies for PTLD have emerged, including adoptive immunotherapy and rational targeted therapeutics (e.g., anti-CD30 based therapy and downstream signaling pathways of latent membrane protein-2A).
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25
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Benevolo G, Chiappella A, Vitolo U. The risk of CNS involvement in aggressive lymphomas in the rituximab era. Expert Rev Hematol 2013; 6:643-52. [PMID: 24168678 DOI: 10.1586/17474086.2013.850896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The risk of CNS dissemination and CNS prophylaxis strategies in aggressive non-Hodgkin lymphoma (NHL) is still debated. CNS dissemination is a rare but fatal event. A CNS prophylaxis is common for Burkitt and B-cell lymphoblastic lymphoma; however, in other NHLs, prophylactic treatments are not systematically warranted. Current risk models showed low sensitivity in predicting CNS involvement, implying overtreatment in roughly 70% of high-risk patients. Risk models in the rituximab era were modulated for the detection of occult CNS disease at diagnosis using flow cytometry. The optimal regimen for CNS prophylaxis in aggressive lymphoma patients has not been established thus far and should be modulated at different levels of 'intensity' such as standard intrathecal chemotherapy, 'active' intrathecal chemotherapy with liposomal cytarabine or more aggressive systemic treatment with high doses of drugs having good CNS bioavailability reserved for patients who are truly at high risk of CNS dissemination.
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Affiliation(s)
- Giulia Benevolo
- Hematology, Città della Salute e della Scienza Hospital, Corso Bramante 88 10126, Torino, Italy
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27
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Beck-Broichsitter BE, Klapper W, Günther A, Wiltfang J, Becker ST. Gingival ulceration and exposed bone. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115:288-92. [DOI: 10.1016/j.oooo.2011.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 12/11/2011] [Accepted: 12/16/2011] [Indexed: 02/07/2023]
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Rajagopalan S. Post-transplant lymphoproliferative disease. APOLLO MEDICINE 2013. [DOI: 10.1016/j.apme.2013.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Khedmat H, Taheri S. Lymphoproliferative disorders in pediatric liver allograft recipients: a review of 212 cases. Hematol Oncol Stem Cell Ther 2012; 5:84-90. [DOI: 10.5144/1658-3876.2012.84] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Hinrichs C, Wendland S, Zimmermann H, Eurich D, Neuhaus R, Schlattmann P, Babel N, Riess H, Gärtner B, Anagnostopoulos I, Reinke P, Trappe RU. IL-6 and IL-10 in post-transplant lymphoproliferative disorders development and maintenance: a longitudinal study of cytokine plasma levels and T-cell subsets in 38 patients undergoing treatment. Transpl Int 2011; 24:892-903. [PMID: 21668529 DOI: 10.1111/j.1432-2277.2011.01282.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IL-6 and IL-10 have previously been implicated in the pathogenesis of post-transplant lymphoproliferative disorders (PTLD) and, like peripheral lymphocyte populations, are markers of immune status that are amenable to study in vivo. Thus, we analyzed cytokine plasma levels as well as lymphocyte subsets in a longitudinal analysis of 38 adult transplant recipients undergoing treatment for PTLD. Pretherapeutically, we found significantly elevated IL-6 (13.8 pg/ml) and IL-10 plasma levels (54.7 pg/ml) - in the case of IL-10, even higher in treatment nonresponders than in responders (116 vs. 14 pg/ml). Over time, however, IL-10 levels did not correlate with the course of disease, whereas those of IL-6 did, falling in responders and rising in nonresponders. These findings were independent of histological EBV-status, treatment type, and total peripheral T-cell counts, which were significantly reduced in patients with PTLD. Our observations support the idea that although IL-10 is important for creating a permissive environment for post-transplant lymphoma development, IL-6 is associated with PTLD proliferation. The analysis of lymphocyte subsets further identified HLA-DR+ CD8+ lymphocyte numbers as significantly different in non-PTLD controls (33%), treatment responders (44%) and nonresponders (70%). Although the specificity of these cells is unclear, their increase might correlate with the impaired tumor-specific cytotoxic-T-lymphocyte (CTL)-response in PTLD.
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Affiliation(s)
- Carl Hinrichs
- Department of Nephrology and Intensive Care, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
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Koyun M, Hazar V, Akkaya B, Çomak E, Gökçeoğlu A, Doğan Ç, Çubuk S, Akman S. A Case Report: Hepatic Posttransplant Lymphoproliferative Disorder in a Non-Liver Transplant Patient. Transplant Proc 2011; 43:2102-6. [DOI: 10.1016/j.transproceed.2011.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Accepted: 03/01/2011] [Indexed: 11/16/2022]
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Picarsic J, Jaffe R, Mazariegos G, Webber SA, Ellis D, Green MD, Reyes-Múgica M. Post-transplant Burkitt lymphoma is a more aggressive and distinct form of post-transplant lymphoproliferative disorder. Cancer 2011; 117:4540-50. [PMID: 21446044 DOI: 10.1002/cncr.26001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 01/12/2011] [Accepted: 01/14/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although the literature reports a low incidence of Burkitt lymphoma (BL) as a post-transplant lymphoproliferative disorder (PTLD), this entity appears to be different from other monomorphic PTLDs (M-PTLDs), both in its aggressive clinical presentation and its distinct pathologic profile. METHODS Patients with BL, diagnosed in the post-transplant setting, (patients aged ≤ 18 years) were retrieved from the pathology archives at Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center from 1982 to 2010. Clinical outcomes were obtained along with pathologic review. RESULTS Twelve patients with pediatric BL in the post-transplant setting (9 boys, 3 girls) were retrieved. The patients displayed a monomorphic population of small to intermediate-sized, noncleaved, lymphoid elements with a "starry-sky" pattern. The immunophenotype for patients available to the study was CD20+ (n = 9/10), CD10+ (n = 8/8), bcl-6+ (n = 11/11), with a near 100% Ki-67/MIB-1 proliferation index (n = 7/7), and negative for TdT (n = 7/7). Most pretransplant Epstein-Barr virus titers were negative (n = 8/10), with post-transplant titers positive in all tested patients (n = 11), and with positive Epstein-Barr-encoded RNA in situ hybridization in most cases (n = 9/11). The median time from transplantation to diagnosis was 52 months (range, 6-107 months). Nine patients were currently alive after immediate antineoplastic chemotherapy, with median disease-free time of 93 months from diagnosis (range, 2-199 months). CONCLUSIONS BL-PTLD had a higher Epstein-Barr virus incidence compared with sporadic and immunodeficiency-associated BL and represented a distinct monomorphic PTLD. Although some M-PTLDs can be managed less aggressively with decreased immunosuppression alone, immediate lymphoma-specific chemotherapy was associated with a favorable outcome and was strongly recommended.
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Affiliation(s)
- Jennifer Picarsic
- Department of Pediatric Pathology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Aggressive posttransplant lymphoproliferative disease in a renal transplant patient treated with alemtuzumab. Am J Ther 2011; 17:e230-3. [PMID: 19918163 DOI: 10.1097/mjt.0b013e3181c08042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Post transplant lymphoproliferative disease (PTLD) is a rare but potentially fatal complication after solid organ transplantation. The risk of PTLD varies with type of organ transplant, Epstein-Barr virus serostatus of the donor and recipient, age, and intensity of immunosuppression. We report a case of a 45-year-old man who developed aggressive PTLD 7 months after receiving a cadaveric renal transplant. He received 30 mg alemtuzumab intravenously intraoperatively as induction immunosuppression followed by maintenance immunosuppression with tacrolimus and mycophenolate mofetil. The patient presented with intestinal perforation and gastrointestinal bleeding. Histopathology revealed Epstein-Barr virus-positive diffuse large B-cell lymphoma with a high mitotic index involving multiple segments of small and large intestines and leading to perforation of the ileum, jejunum, and cecum. The patient had Stage IV disease and treatment consisted of immunosuppression reduction and 375 mg/m rituximab weekly for four doses. Unfortunately, the patient had recurrent intestinal perforation followed by fatal gastrointestinal bleeding. There have been very few case reports of PTLD after alemtuzumab induction in renal transplant and the case discussed had simultaneous multiple perforations in the small intestine and colon.
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High incidence of cytomegalovirus, human herpesvirus-6, and Epstein-Barr virus reactivation in patients receiving cytotoxic chemotherapy for Adult T cell leukemia. J Med Virol 2011; 83:702-9. [DOI: 10.1002/jmv.22013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Orjuela MA, Alobeid B, Liu X, Siebert AL, Kott ER, Addonizio LJ, Morris E, Garvin JH, Lobritto SJ, Cairo MS. CD20 expression predicts survival in paediatric post-transplant lymphoproliferative disease (PTLD) following solid organ transplantation. Br J Haematol 2011; 152:733-42. [PMID: 21275950 DOI: 10.1111/j.1365-2141.2010.08448.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The prognostic role of CD20 expression and Epstein-Barr virus (EBV) positivity in post-transplant lymphoproliferative disease (PTLD) after solid organ transplantation (SOT) in paediatric patients is poorly understood. We retrospectively examined the relationship of CD20 and EBV with the time interval from SOT to PTLD diagnosis, and PTLD-related event-free (EFS) and overall survival (OS) in 45 consecutive PTLD patients (≤25 years) following SOT. These 45 paediatric SOT patients (28 heart, 11 liver, six kidney) were diagnosed with PTLD 45 months (mean; SD 43; range 4-153; median 24·5) after SOT, with PTLD diagnosis at 118 months (mean) (SD 77; range 14-287) of age. Of 40 evaluable tumours (11 monomorphic, 19 polymorphic, five early lesions, five rare subtypes), 32 (80%) had detectable EBV and 28 (70%) were classified as CD20(+) . Patients whose PTLD expressed CD20 or EBV had shorter intervals between SOT and PTLD onset (28 vs. 64 or 77 months for CD20 and EBV respectively) (P < 0·02), even after adjusting for age at SOT. Patients with CD20(+) tumours had higher 5-year PTLD-related EFS (83·7% vs. 28·6%, P < 0·001) and OS (95·8% vs. 56·3%, P = 0·01). EBV expression was unrelated to PTLD-related EFS or OS. CD20 expression is associated with timing of development of PTLD and predicts survival in PTLD diagnosed following paediatric SOT.
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Affiliation(s)
- Manuela A Orjuela
- Departments of Pediatrics, Columbia University, New York-Presbyterian Morgan Stanley Children's Hospital New York, NY, USA.
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Ratuapli SK, Murarka S, Miller KA, Ferraro JC, Zafar H. Epstein Barr Virus-positive large T-cell lymphoma presenting as acute appendicitis 17 years after cadaveric renal transplant: a case report. J Med Case Rep 2011; 5:5. [PMID: 21226894 PMCID: PMC3024289 DOI: 10.1186/1752-1947-5-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2010] [Accepted: 01/12/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The majority of post-transplant lymphoproliferative disorders in renal transplant patients are of the B-cell phenotype, while the T-cell phenotype is rare. We report a case of Epstein Barr Virus-positive, T-cell lymphoma in a renal transplant patient, presenting unusually as acute appendicitis. CASE PRESENTATION A 45-year-old Hispanic male renal transplant patient presented with right-side abdominal pain 17 years after transplant. The laboratory studies were unremarkable. Laparoscopic exploration showed an inflamed appendix so a laparoscopic appendectomy was performed. Pathology of the appendix showed large cells positive for CD3, CD56 and Epstein Barr Virus-encoded RNA staining, and negative for CD20 and CD30. The tissue tested positive for T-cell receptor gene rearrangement by polymerase chain reaction analysis. Treatment management involved reduction of immunosuppression and initiation of chemotherapy with cisplatin, etoposide, gemcitabine, and solumedrol followed by cyclophosphamide, hydroxydaunorubicin, vincristine and prednisone). He recovered and the allo-grafted kidney is fully functional. CONCLUSION We report a rare case of post-renal transplant large T-cell lymphoma, with an unusual presentation of acute appendicitis and Epstein Barr Virus-positivity, which responded well to chemotherapy.
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Affiliation(s)
- Shiva K Ratuapli
- Department of Medicine, Banner Estrella Medical Center, 9201 W, Thomas Road, Phoenix, AZ 85037, USA.
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Abstract
PURPOSE OF REVIEW Epstein-Barr virus-associated posttransplant lymphoproliferative disease (PTLD) is a life-threatening complication of organ transplantation. As we continue to observe improved outcomes of patients living after solid or hematopoietic stem cell transplantation, we can expect to see a parallel increase in the incidence of PTLD. Several innovative therapeutic approaches are currently under development to add to our arsenal of treatment strategies in this devastating disease. RECENT FINDINGS The past decade has witnessed significant progress in the understanding and treatment of PTLD. The tolerability and effectiveness of standard treatment regimens, such as a reduction in immunosuppression, rituximab, and chemotherapy, have been confirmed and improved upon. Newer options for treatment demonstrating significant promise include antiviral therapy with arginine butyrate, as well as Epstein-Barr virus-specific cytotoxic T-cell therapy. SUMMARY Both the heterogeneous PTLD population and the lack of standardized and evidence-based treatment approaches make treatment a difficult decision for the clinician. This article reviews and updates the evidence behind accepted strategies such as reduction in immunosuppression, rituximab, and chemotherapy, as well as explores novel and effective therapeutic modalities including antiviral therapy with arginine butyrate and adoptive allogeneic T-cell therapy.
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Albright JB, Bonatti H, Stauffer J, Dickson RC, Nguyen J, Harnois D, Jeanpierre C, Hinder R, Steers J, Chua H, Aranda-Michel J. Colorectal and anal neoplasms following liver transplantation. Colorectal Dis 2010; 12:657-66. [PMID: 19508543 DOI: 10.1111/j.1463-1318.2009.01840.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Liver transplantation (LT) is the treatment of choice for end-stage liver disease. The required immunosuppression increases the risk for developing malignancies. Some viruses play a crucial role. Data on neoplasms of the colon, rectum and anus in LT are limited. METHOD A retrospective evaluation of the incidence and clinical course of colorectal and anal malignancies and colonic polyps in a series of 467 consecutive LTs in 402 individuals between 1998 and 2001 was performed. Standard immunosuppression included Tacrolimus, Mycophenolic acid and steroids. RESULTS During a median follow up of 5.2 years, three colon adenocarcinomas, one EBV associated cecal posttransplant lymphoproliferative tumour and two HPV associated anal tumours were identified. Pre-LT colonoscopy was performed in 161 patients (40%), and of 153 evaluable individuals, 53 (34.9%) had polyps. Colonoscopy was performed in 186 patients (46.3%) median 14.8 (range 0.2-77.8) months post-LT and 55 (29.3%) had polyps. Post-LT adenomatous polyps were detected in 47.3% of patients with pre-LT polyps vs 6.7% of patients without pre-LT polyps (P < 0.001). Patients with alcoholic liver disease had a significantly higher rate of adenoma formation (50.0% vs 11.1%, P < 0.001). No patient died from colorectal/anal malignancy. CONCLUSION The incidence of metachronous and new polyp formation in our study is similar to people who are not immunocompromised, but subgroups are at increased risk. Viral-associated malignancies, including post-transplant lymphoproliferative disorders and anal cancer, are important entities in the LT population suggesting that complete screening of the colon, rectum and anus including pre-LT and post-LT colonoscopy should be utilized.
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Affiliation(s)
- J B Albright
- Department of Surgery, South Bay Medical Center, Harbor City, California, USA
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Inoue T, Satoh S, Saito M, Horikawa Y, Tsuchiya N, Habuchi T. Post-transplant lymphoproliferative disorder involving the ovary as an initial manifestation: a case report. J Med Case Rep 2010; 4:184. [PMID: 20565880 PMCID: PMC2896377 DOI: 10.1186/1752-1947-4-184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Accepted: 06/18/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Because the normal ovary is assumed to be devoid of lymphoid tissue, it is unusual for it to be an initial manifestation of malignant lymphoma. This case is the first report, to our knowledge, of post-transplant lymphoproliferative disorder involving the ovary as an initial manifestation. CASE PRESENTATION Twenty-nine weeks after a living renal transplantation, a 38-year-old Japanese female, whose ethnic origin was Asian, presented with abdominal pain and a chronic high fever. Computed tomography revealed a right ovarian tumor and liver metastases. The patient underwent oophrectomy based on the clinical diagnosis of liver metastasis from the primary ovarian tumor. The pathological diagnosis was Epstein-Barr Virus-associated post-transplant lymphoproliferative disorder. While ovarian malignant lymphoma has a poor prognosis, complete remission of liver involvement in this case was achieved only with a reduction of immunosuppressants. CONCLUSION Clinicians should remember that malignant lymphoma could initially involve the ovary, especially if the patient is immunosuppressed after transplantation therapy.
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Affiliation(s)
- Takamitsu Inoue
- Department of Urology, Akita University School of Medicine, Akita 010-8543, Japan.
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Affiliation(s)
| | - Philippa Harris
- Department of Oncology, Chelsea & Westminster Hospital, London SW10 9NH
| | - Mark Bower
- Department of Oncology, Chelsea & Westminster Hospital, London SW10 9NH
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Impact of HLA Mismatching on Incidence of Posttransplant Non-Hodgkin Lymphoma After Kidney Transplantation. Transplantation 2010; 89:567-72. [DOI: 10.1097/tp.0b013e3181c69855] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Epidemiology of pretransplant EBV and CMV serostatus in relation to posttransplant non-Hodgkin lymphoma. Transplantation 2010; 88:962-7. [PMID: 19855238 DOI: 10.1097/tp.0b013e3181b9692d] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND.: Despite the importance of non-Hodgkin lymphoma (NHL) as a posttransplant complication, the relationship between NHL and recipient seropositivity for Epstein-Barr virus (EBV) or cytomegalovirus (CMV) is incompletely understood. METHODS.: Kidney, heart, and liver transplant recipients reported to the Collaborative Transplant Study with known pretransplant EBV and CMV serostatus were analyzed in terms of clinically manifest NHL. Cox multivariate regression analysis was performed to account for a wide range of possible confounders. RESULTS.: In total, 18,682 kidney, 2042 heart, and 2616 liver transplant recipients were analyzed. Regardless of age, pretransplant EBV serostatus was significantly associated with risk of NHL in kidney transplant recipients (P<0.001). There was no significant difference in lymphoma rates according to CMV and CMV serostatus among EBV and EBV recipients (log-rank P=0.55 and P=0.57, respectively), but hospitalization for CMV disease during year 1 posttransplant was associated with subsequent NHL (hazard ratio [HR] 6.1; 95% confidence interval [CI] 2.0-18.4; P=0.001). EBV serostatus was also associated with increased risk of NHL in heart transplant patients (HR 3.6; 95% CI 1.1-11.3; P=0.031) but, contrary to expectation, not in liver recipients (HR 0.6; 95% CI 0.1-1.7; P=0.32). CONCLUSIONS.: In view of the striking increase in risk of NHL in EBV kidney transplant recipients of all ages, EBV serostatus should be determined pretransplant in all age groups. CMV serostatus was not independently associated with risk of NHL after kidney transplantation. Surprisingly, in liver transplantation, the risk of NHL was virtually unaffected by EBV serostatus.
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Le Coutre P, Reinke P, Neuhaus R, Trappe R, Ringel F, Lalancette M, Hemmati PG, Dörken B, Daniel PT. BCR-ABL positive cells and chronic myeloid leukemia in immune suppressed organ transplant recipients. Eur J Haematol 2010; 84:26-33. [DOI: 10.1111/j.1600-0609.2009.01357.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kalinova L, Indrakova J, Bachleda P. POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2009; 153:251-7. [DOI: 10.5507/bp.2009.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Nabors LB, Palmer CA, Julian BA, Przekwas AM, Kew CE. Isolated central nervous system posttransplant lymphoproliferative disorder treated with high-dose intravenous methotrexate. Am J Transplant 2009; 9:1243-8. [PMID: 19422350 DOI: 10.1111/j.1600-6143.2009.02598.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) is an uncommon neoplastic complication of kidney transplantation, affecting about 1% of recipients. It is generally associated with Epstein-Barr virus (EBV) infection of B-lineage lymphocytes. Central nervous system (CNS) involvement is rare. There is little clinical experience with treatment of CNS PTLD due to the relative rarity of the disease other than reduction or withdrawal of immunosuppression, but it is usually fatal. We describe six patients with renal allografts and histologically proven isolated CNS PTLD. Tissue analysis from the biopsy specimens was positive for EBV material in five of the six patients. All six patients were treated with high-dose intravenous methotrexate (HD IV MTX). Methotrexate was initiated at 8 g/m2, with later adjustments for creatinine clearance. With MTX therapy, four patients have had a sustained complete response, and two had progressive disease and were referred for radiation therapy. This finding suggests a subgroup of patients may benefit from MTX but our case series is inadequate to describe overall efficacy. No unexpected toxicities were encountered in 37 courses of treatment. HD IV MTX chemotherapy should be considered as an alternative for treatment of CNS PTLD.
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Affiliation(s)
- L B Nabors
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.
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Schauer E, Webber S, Kingsley L, Green M, Rowe D. Increased Ig-null B lymphocytes in the peripheral blood of pediatric solid organ transplant recipients with elevated Epstein-Barr viral loads. Pediatr Transplant 2009; 13:311-8. [PMID: 18564309 DOI: 10.1111/j.1399-3046.2008.00918.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In this study, the characteristics of Ig-null B cells in high viral load carriers were examined by four-color flow cytometry. The frequency of Ig-null B cells in patients with high, low or undetectable virus loads was found that while patients with a high load had more Ig-null cells, these cells were also present in the low and undetectable load groups. As Ig-null cells from patients with no viral load were EBV-negative, EBV infection was not absolutely required for the generation or survival of Ig-null cells. Ig-null cells were CD19(+), sIg(-), CD5(-), CD10(-), CD27(-), CD23(-), CD38(-), and CD69(-) with variable surface expression of CD20 and CD40. Ig-null cells did not have a proliferating cell phenotype (Ki67(-)) and a high proportion were HLA class I(-) and class II(-). Virus copy number in CD19(+) Ig-null cell populations may be much higher than in CD19(+) Ig(+) cell populations. EBV infected Ig-null cells were common in blood specimens from pediatric solid organ transplant recipients and infected Ig-null cells may pose potential problems for immunotherapies that target infected B cells directly.
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Affiliation(s)
- Elizabeth Schauer
- Department of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Vila L, Moreno L, Andrés MDM, Fernández JM, Verdeguer A, Pérez-Valle S, Sangüesa C, Berbel O, Castel V. Could other viruses cause pediatric posttransplant lymphoproliferative disorder? Clin Transl Oncol 2008; 10:422-5. [DOI: 10.1007/s12094-008-0225-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sato T, Fujieda M, Tanaka E, Miyamura M, Chikamoto H, Hisano M, Akioka Y, Ishiura Y, Dohno S, Maeda A, Hattori M, Wakiguchi H. Monitoring of Epstein-Barr virus load and antibody in pediatric renal transplant patients. Pediatr Int 2008; 50:454-8. [PMID: 19143966 DOI: 10.1111/j.1442-200x.2008.02579.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Epstein-Barr virus (EBV) infection can lead to life-threatening post-transplant lymphoproliferative disorder (PTLD). The aim of the present study was to establish EBV monitoring methods to prevent PTLD. METHODS EBV-DNA load was investigated, using real-time polymerase chain reaction (PCR) and anti-EBV antibody titers, in peripheral blood mononuclear cells of 21 renal transplant patients (seven recipients who were EBV-seronegative, R[-]; 14 who were EBV-seropositive, R[+]) before grafting. The mean age at entry and the mean follow-up period was 7.8 years of age (range, 3.3-12.0 years) and 1.8 years (range, 0.4-4.0 years), respectively, in the R(-) group, and 12.5 years of age (range, 3.9-17.7 years) and 3.8 years (range, 0.8-8.2 years) in the R(+) group, respectively. RESULTS The mean maximum load of the EBV genome was 1071 copies/microg DNA (range, 106-20700 copies/microg DNA) in the R(-) group, and 61 copies/microg DNA (range, <50-552 copies/microg DNA) in the R(+) group. During follow up no patient in the R(+) group had any noticeable symptoms that could be related to EBV, but three recipients in the R(-) group developed EBV-related symptoms including adenoid hypertrophy, cervical lymphadenopathy, and PTLD (B cell lymphoma), in one patient each. In the R(-) group the first leukocyte-associated viremia was detected at 30-180 days, and seroconversion at 43-266 days after transplantation. CONCLUSIONS Viral DNA detection using PCR is a useful tool for EBV surveillance, but the maximum EBV load was not markedly elevated (2474 copies/microg DNA) in a patient with PTLD. Therefore, EBV surveillance using only monitoring of EBV load in peripheral leukocyte may be insufficient. Histology may therefore be necessary to accurately diagnose PTLD.
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Affiliation(s)
- Tetsuya Sato
- Department of Pediatrics, Kochi Medical School, Kochi University, Kohasu Oko, Nankoku, Kochi, Japan
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Post-transplant lymphoproliferative disorders of oral cavity. ACTA ACUST UNITED AC 2008; 105:589-96. [DOI: 10.1016/j.tripleo.2007.11.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Revised: 11/21/2007] [Accepted: 11/28/2007] [Indexed: 11/24/2022]
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