1
|
The current therapeutic approach for anaemia after kidney transplant. Curr Opin Nephrol Hypertens 2023; 32:35-40. [PMID: 36250458 DOI: 10.1097/mnh.0000000000000842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Anaemia after kidney transplantation is a common finding with no uniform management guideline. Most approaches are derived from the chronic kidney disease (CKD) population. Recent advances for the treatment of anaemia in patients with CKD/End stage renal disease include hypoxia-inducible factor-prolyl hydroxylase inhibitor (HIF-PHi), a novel class of oral erythropoietin-stimulating agents (ESAs). We present relevant studies of HIF-PHi in the transplant population and its implications on the management of posttransplant anaemia. RECENT FINDINGS Data on HIF-PHi use in the kidney transplant population are promising. Limited data demonstrate a significant increase in haemoglobin, with a comparable safety profile to epoetin. Reported adverse effects include overcorrection and low iron stores. SUMMARY Current therapeutic approaches to anaemia in the kidney transplant population is mostly derived from the CKD population. More studies are needed on HIF-Phi, a novel class of ESAs that has thus far demonstrated promise in the kidney transplant population.
Collapse
|
2
|
Marini I, Uzun G, Jamal K, Bakchoul T. Treatment of drug-induced immune thrombocytopenias. Haematologica 2022; 107:1264-1277. [PMID: 35642486 PMCID: PMC9152960 DOI: 10.3324/haematol.2021.279484] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Several therapeutic agents can cause thrombocytopenia by either immune-mediated or non-immune-mediated mechanisms. Non-immune-mediated thrombocytopenia is due to direct toxicity of drug molecules to platelets or megakaryocytes. Immune-mediated thrombocytopenia, on the other hand, involves the formation of antibodies that react to platelet-specific glycoprotein complexes, as in classic drug-induced immune thrombocytopenia (DITP), or to platelet factor 4, as in heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT). Clinical signs include a rapid drop in platelet count, bleeding or thrombosis. Since the patient's condition can deteriorate rapidly, prompt diagnosis and management are critical. However, the necessary diagnostic tests are only available in specialized laboratories. Therefore, the most demanding step in treatment is to identify the agent responsible for thrombocytopenia, which often proves difficult because many patients are taking multiple medications and have comorbidities that can themselves also cause thrombocytopenia. While DITP is commonly associated with an increased risk of bleeding, HIT and VITT have a high mortality rate due to the high incidence of thromboembolic complications. A structured approach to drug-associated thrombocytopenia/thrombosis can lead to successful treatment and a lower mortality rate. In addition to describing the treatment of DITP, HIT, VITT, and vaccine-associated immune thrombocytopenia, this review also provides the pathophysiological and clinical information necessary for correct patient management.
Collapse
Affiliation(s)
- Irene Marini
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Gunalp Uzun
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Kinan Jamal
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen.
| |
Collapse
|
3
|
Kuter DJ. Treatment of chemotherapy-induced thrombocytopenia in patients with non-hematologic malignancies. Haematologica 2022; 107:1243-1263. [PMID: 35642485 PMCID: PMC9152964 DOI: 10.3324/haematol.2021.279512] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of the treatment of non-hematologic malignancies. Many patient-related variables (e.g., age, tumor type, number of prior chemotherapy cycles, amount of bone marrow tumor involvement) determine the extent of CIT. CIT is related to the type and dose of chemotherapy, with regimens containing gemcitabine, platinum, or temozolomide producing it most commonly. Bleeding and the need for platelet transfusions in CIT are rather uncommon except in patients with platelet counts below 25x109/L in whom bleeding rates increase significantly and platelet transfusions are the only treatment. Nonetheless, platelet counts below 70x109/L present a challenge. In patients with such counts, it is important to exclude other causes of thrombocytopenia (medications, infection, thrombotic microangiopathy, post-transfusion purpura, coagulopathy and immune thrombocytopenia). If these are not present, the common approach is to reduce chemotherapy dose intensity or switch to other agents. Unfortunately decreasing relative dose intensity is associated with reduced tumor response and remission rates. Thrombopoietic growth factors (recombinant human thrombopoietin, pegylated human megakaryocyte growth and development factor, romiplostim, eltrombopag, avatrombopag and hetrombopag) improve pretreatment and nadir platelet counts, reduce the need for platelet transfusions, and enable chemotherapy dose intensity to be maintained. National Comprehensive Cancer Network guidelines permit their use but their widespread adoption awaits adequate phase III randomized, placebo-controlled studies demonstrating maintenance of relative dose intensity, reduction of platelet transfusions and bleeding, and possibly improved survival. Their potential appropriate use also depends on consensus by the oncology community as to what constitutes an appropriate pretreatment platelet count as well as identification of patient-related and treatment variables that might predict bleeding.
Collapse
Affiliation(s)
- David J Kuter
- Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
4
|
Teschner D, Knop J, Piehl C, Junker S, Witzke O. Cytomegalovirus infection and rehospitalization rates after allogeneic hematopoietic stem cell and solid organ transplantation: a retrospective cohort study using German claims data. Infection 2022; 50:1543-1555. [PMID: 35633464 PMCID: PMC9705421 DOI: 10.1007/s15010-022-01847-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/03/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aimed to describe the cytomegalovirus (CMV) infection rate, rehospitalizations, and comorbidities following allogeneic hematopoietic stem cell transplantation (allo-HSCT) and solid organ transplantation (SOT). METHODS Patients who received allo-HSCT or SOT in 01/07/2015-30/06/2018 were identified using anonymized German claims data. The transplantation-related hospital admission date was defined as the index date, and patients were followed for up to 12 months (or death, first event relevant). The frequency of CMV infections (confirmed outpatient/inpatient diagnoses, ICD-10-GM codes: B25.-/B27.1) and the rate, number, and duration of all-cause rehospitalizations in the follow-up period were evaluated. RESULTS A total of 226 allo-HSCT and 250 SOT patients were identified (mean age 52.8 years, 38.9% female). During the 12 months after transplantation, 29.2% of allo-HSCT patients and 16.8% of SOT patients received a CMV diagnosis. The majority of these diagnoses were given during the initial hospitalization or within the following 3 months. Across transplantation types, CMV patients had more hospital readmission days per patient-year (allo-HSCT 93.3 vs. 49.4, p = 0.001; SOT 42.0 vs. 20.7, p = 0.005), with a longer mean duration of readmissions (allo-HSCT 22.4 vs. 15.4 days, p < 0.001; SOT 11.6 vs. 7.5 days, p = 0.003). Comorbidity burden in transplantation patients was substantial, with several diagnoses being significantly more common among patients with CMV vs. non-CMV. One-year mortality did not differ significantly between patients with/without CMV. CONCLUSION Burden of transplant recipients with CMV in terms of rehospitalizations and comorbidities is substantial, highlighting the need for improved CMV prevention and treatment.
Collapse
Affiliation(s)
- Daniel Teschner
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany.,Department of Hematology, Medical Oncology, and Pneumology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jana Knop
- Takeda Pharma Vertrieb GmbH & Co. KG, Berlin, Germany
| | | | - Sophia Junker
- Ingress-Health HWM GmbH, A Wholly Owned Subsidiary of Cytel Inc., Berlin, Germany.
| | - Oliver Witzke
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, Essen, Germany.,University Duisburg-Essen, Duisburg, Germany
| |
Collapse
|
5
|
Charlotte R, François P, Jonathan M, Véronique B, Olivier B, Tristan D, Séverine F, Jérôme L, Adrien T, Claire D, Espérie B, Eve C, Antoine R. Use of anti-CMV immunoglobulins in lung transplant recipients: The French experience. Transpl Infect Dis 2021; 23:e13754. [PMID: 34723405 DOI: 10.1111/tid.13754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 09/28/2021] [Accepted: 10/11/2021] [Indexed: 02/05/2023]
Abstract
RATIONAL Pending the authorization of new anti-CMV drugs with fewer adverse effects, exploring the possibilities offered by CMV immunoglobulins (CMVIG) seems necessary. In France, access to CMVIG requires official authorization by the national Health authority and is restricted to second line rescue therapy for CMV infection/disease. The aim of this multicenter retrospective study is to describe the indications and clinical situations that justified its use in France. METHODS A multicenter retrospective study included 22 lung transplant patients over a 3-year period. Data on clinical indication, tolerance and efficacy were collected. RESULTS The main indication for CMVIG initiation, which was documented in 17 of them (82%) was complex clinical situations resulting from side effects to antiviral drug. CMVIG indication was documented as treatment for 15 patients (68%) and as a secondary prophylaxis for 7 patients (32%). Only one side effect (pruritus during infusion with no anaphylactic symptoms) attributable to CMVIG was reported. After CMVIG initiation, no recurrence of infection or disease was observed during a median follow-up of 174 (12-682) days after treatment initiation for respectively 68% and 66% of the patients. CONCLUSION This study describes an unusual indication of CMVIG use as a last resort treatment in complex situations, based on clinical needs. CMVIG could be useful to change the course of CMV infection with minimal adverse effects or comorbidity.
Collapse
Affiliation(s)
- Roy Charlotte
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | | | - Messika Jonathan
- Pulmonology Department and Lung Transplant Centre, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Boussaud Véronique
- Pulmonology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Brugière Olivier
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, Suresnes, France
| | - Degot Tristan
- Department of Respiratory Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Feuillet Séverine
- Department of Cardio-Thoracic Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Lepavec Jérôme
- Department of Cardio-Thoracic Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Tissot Adrien
- Pulmonology Department, Institut du Thorax, Nantes University Hospital, Nantes, France
| | - Dromer Claire
- Pulmonology Department, Bordeaux University Hospital, Bordeaux, France
| | - Burnet Espérie
- Pulmonology Department, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Camps Eve
- Pharmacy Department, Foch Hospital, Suresnes, France
| | - Roux Antoine
- Pulmonology Department, Adult Cystic Fibrosis Centre and Lung Transplantation Department, Foch Hospital, Suresnes, France.,Versailles-Saint-Quentin-en-Yvelines University, Versailles, France
| |
Collapse
|
6
|
Flores-Martínez YA, Le-Trilling VTK, Trilling M. Nedd8-Activating Enzyme Is a Druggable Host Dependency Factor of Human and Mouse Cytomegalovirus. Viruses 2021; 13:v13081610. [PMID: 34452475 PMCID: PMC8402636 DOI: 10.3390/v13081610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022] Open
Abstract
Human cytomegalovirus causes diseases in individuals with insufficient immunity. Cytomegaloviruses exploit the ubiquitin proteasome pathway to manipulate the proteome of infected cells. The proteasome degrades ubiquitinated proteins. The family of cullin RING ubiquitin ligases (CRL) regulates the stability of numerous important proteins. If the cullin within the CRL is modified with Nedd8 ("neddylated"), the CRL is enzymatically active, while CRLs lacking Nedd8 modifications are inactive. The Nedd8-activating enzyme (NAE) is indispensable for neddylation. By binding to NAE and inhibiting neddylation, the drug MLN4924 (pevonedistat) causes CRL inactivation and stabilization of CRL target proteins. We showed that MLN4924 elicits potent antiviral activity against cytomegaloviruses, suggesting that NAE might be a druggable host dependency factor (HDF). However, MLN4924 is a nucleoside analog related to AMP, and the antiviral activity of MLN4924 may have been influenced by off-target effects in addition to NAE inhibition. To test if NAE is indeed an HDF, we assessed the novel NAE inhibitor TAS4464 and observed potent antiviral activity against mouse and human cytomegalovirus. Additionally, we raised an MLN4924-resistant cell clone and showed that MLN4924 as well as TAS4464 lose their antiviral activity in these cells. Our results indicate that NAE, the neddylation process, and CRLs are druggable HDFs of cytomegaloviruses.
Collapse
|
7
|
Müskens KF, Lindemans CA, Belderbos ME. Hematopoietic Dysfunction during Graft-Versus-Host Disease: A Self-Destructive Process? Cells 2021; 10:cells10082051. [PMID: 34440819 PMCID: PMC8392486 DOI: 10.3390/cells10082051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
Graft-versus-host disease (GvHD) is a major complication of allogeneic hematopoietic (stem) cell transplantation (HCT). Clinically, GvHD is associated with severe and long-lasting hematopoietic dysfunction, which may contribute to the high mortality of GvHD after HCT. During GvHD, excessive immune activation damages both hematopoietic stem and progenitor cells and their surrounding bone marrow niche, leading to a reduction in cell number and functionality of both compartments. Hematopoietic dysfunction can be further aggravated by the occurrence—and treatment—of HCT-associated complications. These include immune suppressive therapy, coinciding infections and their treatment, and changes in the microbiome. In this review, we provide a structured overview of GvHD-mediated hematopoietic dysfunction, including the targets in the bone marrow, the mechanisms of action and the effect of GvHD-related complications and their treatment. This information may aid in the identification of treatment options to improve hematopoietic function in patients, during and after GvHD.
Collapse
Affiliation(s)
- Konradin F. Müskens
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (K.F.M.); (C.A.L.)
| | - Caroline A. Lindemans
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (K.F.M.); (C.A.L.)
- Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands
| | - Mirjam E. Belderbos
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (K.F.M.); (C.A.L.)
- Correspondence:
| |
Collapse
|
8
|
Shragai T, Lebel E, Deshet D, Varon D, Avivi I, Kirgner I, Sarid N. Characteristics and outcomes of adults with cytomegalovirus‐associated thrombocytopenia: a case series and literature review. Br J Haematol 2020; 191:863-867. [DOI: 10.1111/bjh.17017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/09/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Tamir Shragai
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Eyal Lebel
- Department of Hematology Hadassah‐Hebrew University Medical Center Jerusalem Israel
| | - Dana Deshet
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- Department of Hematology Edith Wolfson Medical Center Holon Israel
| | - David Varon
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Irit Avivi
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Ilya Kirgner
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Nadav Sarid
- Department of Hematology Tel Aviv Sourasky Medical Center Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| |
Collapse
|
9
|
Marschall M, Häge S, Conrad M, Alkhashrom S, Kicuntod J, Schweininger J, Kriegel M, Lösing J, Tillmanns J, Neipel F, Eichler J, Muller YA, Sticht H. Nuclear Egress Complexes of HCMV and Other Herpesviruses: Solving the Puzzle of Sequence Coevolution, Conserved Structures and Subfamily-Spanning Binding Properties. Viruses 2020; 12:v12060683. [PMID: 32599939 PMCID: PMC7354485 DOI: 10.3390/v12060683] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022] Open
Abstract
Herpesviruses uniquely express two essential nuclear egress-regulating proteins forming a heterodimeric nuclear egress complex (core NEC). These core NECs serve as hexameric lattice-structured platforms for capsid docking and recruit viral and cellular NEC-associated factors that jointly exert nuclear lamina as well as membrane-rearranging functions (multicomponent NEC). The regulation of nuclear egress has been profoundly analyzed for murine and human cytomegaloviruses (CMVs) on a mechanistic basis, followed by the description of core NEC crystal structures, first for HCMV, then HSV-1, PRV and EBV. Interestingly, the highly conserved structural domains of these proteins stand in contrast to a very limited sequence conservation of the key amino acids within core NEC-binding interfaces. Even more surprising, although a high functional consistency was found when regarding the basic role of NECs in nuclear egress, a clear specification was identified regarding the limited, subfamily-spanning binding properties of core NEC pairs and NEC multicomponent proteins. This review summarizes the evolving picture of the relationship between sequence coevolution, structural conservation and properties of NEC interaction, comparing HCMV to α-, β- and γ-herpesviruses. Since NECs represent substantially important elements of herpesviral replication that are considered as drug-accessible targets, their putative translational use for antiviral strategies is discussed.
Collapse
Affiliation(s)
- Manfred Marschall
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Medical Center, 91054 Erlangen, Germany; (S.H.); (J.K.); (J.L.); (J.T.); (F.N.)
- Correspondence: ; Tel.: +49-9131-85-26089
| | - Sigrun Häge
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Medical Center, 91054 Erlangen, Germany; (S.H.); (J.K.); (J.L.); (J.T.); (F.N.)
| | - Marcus Conrad
- Division of Bioinformatics, Institute of Biochemistry, Friedrich-Alexander University of Erlangen-Nürnberg, 91054 Erlangen, Germany; (M.C.); (H.S.)
| | - Sewar Alkhashrom
- Division of Medicinal Chemistry, Department of Chemistry and Pharmacy, Friedrich-Alexander University of Erlangen-Nürnberg, 91058 Erlangen, Germany; (S.A.); (J.E.)
| | - Jintawee Kicuntod
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Medical Center, 91054 Erlangen, Germany; (S.H.); (J.K.); (J.L.); (J.T.); (F.N.)
| | - Johannes Schweininger
- Division of Biotechnology, Department of Biology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91052 Erlangen, Germany; (J.S.); (M.K.); (Y.A.M.)
| | - Mark Kriegel
- Division of Biotechnology, Department of Biology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91052 Erlangen, Germany; (J.S.); (M.K.); (Y.A.M.)
| | - Josephine Lösing
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Medical Center, 91054 Erlangen, Germany; (S.H.); (J.K.); (J.L.); (J.T.); (F.N.)
| | - Julia Tillmanns
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Medical Center, 91054 Erlangen, Germany; (S.H.); (J.K.); (J.L.); (J.T.); (F.N.)
| | - Frank Neipel
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Medical Center, 91054 Erlangen, Germany; (S.H.); (J.K.); (J.L.); (J.T.); (F.N.)
| | - Jutta Eichler
- Division of Medicinal Chemistry, Department of Chemistry and Pharmacy, Friedrich-Alexander University of Erlangen-Nürnberg, 91058 Erlangen, Germany; (S.A.); (J.E.)
| | - Yves A. Muller
- Division of Biotechnology, Department of Biology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91052 Erlangen, Germany; (J.S.); (M.K.); (Y.A.M.)
| | - Heinrich Sticht
- Division of Bioinformatics, Institute of Biochemistry, Friedrich-Alexander University of Erlangen-Nürnberg, 91054 Erlangen, Germany; (M.C.); (H.S.)
| |
Collapse
|
10
|
The Cytomegalovirus Protein Kinase pUL97:Host Interactions, Regulatory Mechanisms and Antiviral Drug Targeting. Microorganisms 2020; 8:microorganisms8040515. [PMID: 32260430 PMCID: PMC7232230 DOI: 10.3390/microorganisms8040515] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/02/2020] [Accepted: 04/02/2020] [Indexed: 12/25/2022] Open
Abstract
Human cytomegalovirus (HCMV) expresses a variety of viral regulatory proteins that undergo close interaction with host factors including viral-cellular multiprotein complexes. The HCMV protein kinase pUL97 represents a viral cyclin-dependent kinase ortholog (vCDK) that determines the efficiency of HCMV replication via phosphorylation of viral and cellular substrates. A hierarchy of functional importance of individual pUL97-mediated phosphorylation events has been discussed; however, the most pronounced pUL97-dependent phenotype could be assigned to viral nuclear egress, as illustrated by deletion of the UL97 gene or pharmacological pUL97 inhibition. Despite earlier data pointing to a cyclin-independent functionality, experimental evidence increasingly emphasized the role of pUL97-cyclin complexes. Consequently, the knowledge about pUL97 involvement in host interaction, viral nuclear egress and additional replicative steps led to the postulation of pUL97 as an antiviral target. Indeed, validation experiments in vitro and in vivo confirmed the sustainability of this approach. Consequently, current investigations of pUL97 in antiviral treatment go beyond the known pUL97-mediated ganciclovir prodrug activation and henceforward include pUL97-specific kinase inhibitors. Among a number of interesting small molecules analyzed in experimental and preclinical stages, maribavir is presently investigated in clinical studies and, in the near future, might represent a first kinase inhibitor applied in the field of antiviral therapy.
Collapse
|
11
|
Phoompoung P, Ferreira VH, Tikkanen J, Husain S, Viswabandya A, Kumar D, Humar A. Letermovir as Salvage Therapy for Cytomegalovirus Infection in Transplant Recipients. Transplantation 2020; 104:404-409. [PMID: 32000236 DOI: 10.1097/tp.0000000000002785] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Letermovir, a new viral terminase complex inhibitor, has been approved for the prevention of cytomegalovirus (CMV) infection in hematopoietic stem cell transplant patients. However, data on the efficacy and safety of letermovir for the treatment of CMV infection in transplant recipients remain scarce. METHODS We performed a single-center retrospective study of stem cell and organ transplant recipients who received letermovir for the treatment of CMV infection from November 2017 to October 2018. RESULTS Six patients were included, and 5 were evaluable. All received letermovir in the context of a refractory or resistant CMV infection including asymptomatic CMV viremia (n = 3), CMV syndrome (n = 1), and CMV pneumonitis and colitis (n = 1). The 3 asymptomatic patients experienced a decrease of the viral load (VL) to <200 IU/mL after letermovir therapy. One patient displayed a partial VL response (2-log of VL reduction) but a good clinical response, and one who received a suboptimal dose of letermovir experienced an increase of viremia. There were no treatment-related adverse effects. CONCLUSIONS We demonstrate mixed efficacy in patients with refractory CMV infection suggesting that letermovir may be a useful therapeutic adjunct, potentially in combination with other antivirals.
Collapse
Affiliation(s)
- Pakpoom Phoompoung
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
- Division of Infectious Disease and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Victor H Ferreira
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Jussi Tikkanen
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Shahid Husain
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Auro Viswabandya
- Hans Messner Allogeneic Transplant Program, University Health Network, Toronto, ON, Canada
| | - Deepali Kumar
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Atul Humar
- Transplant Infectious Diseases, University Health Network, Toronto, ON, Canada
| |
Collapse
|
12
|
Tague LK, Scozzi D, Wallendorf M, Gage BF, Krupnick AS, Kreisel D, Byers D, Hachem R, Gelman AE. Lung transplant outcomes are influenced by severity of neutropenia and granulocyte colony-stimulating factor treatment. Am J Transplant 2020; 20:250-261. [PMID: 31452317 PMCID: PMC6940547 DOI: 10.1111/ajt.15581] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 08/01/2019] [Accepted: 08/10/2019] [Indexed: 01/25/2023]
Abstract
Although neutropenia is a common complication after lung transplant, its relationship with recipient outcomes remains understudied. We evaluated a retrospective cohort of 228 adult lung transplant recipients between 2008 and 2013 to assess the association of neutropenia and granulocyte colony-stimulating factor (GCSF) treatment with outcomes. Neutropenia was categorized as mild (absolute neutrophil count 1000-1499), moderate (500-999), or severe (<500) and as a time-varying continuous variable. Associations with survival, acute rejection, and chronic lung allograft dysfunction (CLAD) were assessed with the use of Cox proportional hazards regression. GCSF therapy impact on survival, CLAD, and acute rejection development was analyzed by propensity score matching. Of 228 patients, 101 (42.1%) developed neutropenia. Recipients with severe neutropenia had higher mortality rates than those of recipients with no (adjusted hazard ratio [aHR] 2.97, 95% confidence interval [CI] 1.05-8.41, P = .040), mild (aHR 14.508, 95% CI 1.58-13.34, P = .018), or moderate (aHR 3.27, 95% CI 0.89-12.01, P = .074) neutropenia. Surprisingly, GCSF treatment was associated with a higher risk for CLAD in mildly neutropenic patients (aHR 3.49, 95% CI 0.93-13.04, P = .063), although it did decrease death risk in severely neutropenic patients (aHR 0.24, 95% CI 0.07-0.88, P = .031). Taken together, our data point to an important relationship between neutropenia severity and GCSF treatment in lung transplant outcomes.
Collapse
Affiliation(s)
- Laneshia K. Tague
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri
| | - Davide Scozzi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St. Louis, Missouri
| | | | - Brian F. Gage
- Division of General Medical Sciences, Washington University, St. Louis, Missouri
| | - Alexander S. Krupnick
- Department of Surgery and Carter Center for Immunology, University of Virginia, Charlottesville, Virginia
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St. Louis, Missouri
| | - Derek Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri
| | - Andrew E. Gelman
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St. Louis, Missouri
- Department of Pathology & Immunology Washington University, St. Louis, Missouri
| |
Collapse
|
13
|
El Helou G, Razonable RR. Safety considerations with current and emerging antiviral therapies for cytomegalovirus infection in transplantation. Expert Opin Drug Saf 2019; 18:1017-1030. [PMID: 31478398 DOI: 10.1080/14740338.2019.1662787] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Human cytomegalovirus (HCMV) is a major contributor of morbidity and mortality, and its management is essential for the successful outcome of solid organ and hematopoietic stem cell transplantation. Areas covered: This review discusses the safety profiles of currently available and emerging antiviral drugs and the other strategies for HCMV prevention and treatment after transplantation. Expert opinion: Strategies for management of HCMV rely largely on the use of antiviral agents that inhibit viral DNA polymerase (ganciclovir/valganciclovir, foscarnet, and cidofovir/brincidofovir) and viral terminase complex (letermovir), with different types and degrees of adverse effects. An investigational agent, maribavir, exerts its anti-CMV effect through UL97 inhibition, and its safety profile is under clinical evaluation. In choosing the antiviral medication to use, it is important to consider these safety profiles in addition to overall efficacy. In addition to antiviral drugs, reduction of immunosuppression is often generally needed in the management of HCMV infection, but with a potential risk of allograft rejection or graft-versus-host disease. The use of HCMV-specific or non-specific intravenous immunoglobulins remains debated, while adoptive HCMV-specific T cell therapy remains investigational, and associated with unique set of adverse effects.
Collapse
Affiliation(s)
- Guy El Helou
- Division of Infectious Diseases, Department of Medicine, and William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, and William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| |
Collapse
|
14
|
Cellular Cullin RING Ubiquitin Ligases: Druggable Host Dependency Factors of Cytomegaloviruses. Int J Mol Sci 2019; 20:ijms20071636. [PMID: 30986950 PMCID: PMC6479302 DOI: 10.3390/ijms20071636] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 12/20/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a ubiquitous betaherpesvirus that frequently causes morbidity and mortality in individuals with insufficient immunity, such as transplant recipients, AIDS patients, and congenitally infected newborns. Several antiviral drugs are approved to treat HCMV infections. However, resistant HCMV mutants can arise in patients receiving long-term therapy. Additionally, side effects and the risk to cause birth defects limit the use of currently approved antivirals against HCMV. Therefore, the identification of new drug targets is of clinical relevance. Recent work identified DNA-damage binding protein 1 (DDB1) and the family of the cellular cullin (Cul) RING ubiquitin (Ub) ligases (CRLs) as host-derived factors that are relevant for the replication of human and mouse cytomegaloviruses. The first-in-class CRL inhibitory compound Pevonedistat (also called MLN4924) is currently under investigation as an anti-tumor drug in several clinical trials. Cytomegaloviruses exploit CRLs to regulate the abundance of viral proteins, and to induce the proteasomal degradation of host restriction factors involved in innate and intrinsic immunity. Accordingly, pharmacological blockade of CRL activity diminishes viral replication in cell culture. In this review, we summarize the current knowledge concerning the relevance of DDB1 and CRLs during cytomegalovirus replication and discuss chances and drawbacks of CRL inhibitory drugs as potential antiviral treatment against HCMV.
Collapse
|
15
|
Khalil MAM, Khalil MAU, Khan TFT, Tan J. Drug-Induced Hematological Cytopenia in Kidney Transplantation and the Challenges It Poses for Kidney Transplant Physicians. J Transplant 2018; 2018:9429265. [PMID: 30155279 PMCID: PMC6093016 DOI: 10.1155/2018/9429265] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 06/04/2018] [Accepted: 06/25/2018] [Indexed: 12/14/2022] Open
Abstract
Drug-induced hematological cytopenia is common in kidney transplantation. Various cytopenia including leucopenia (neutropenia), thrombocytopenia, and anemia can occur in kidney transplant recipients. Persistent severe leucopenia or neutropenia can lead to opportunistic infections of various etiologies. On the contrary, reducing or stopping immunosuppressive medications in these events can provoke a rejection. Transplant clinicians are often faced with the delicate dilemma of balancing cytopenia and rejection from adjustments of immunosuppressive regimen. Differentials of drug-induced cytopenia are wide. Identification of culprit medication and subsequent modification is also challenging. In this review, we will discuss individual drug implicated in causing cytopenia and correlate it with corresponding literature evidence.
Collapse
Affiliation(s)
| | | | - Taqi F. Taufeeq Khan
- King Salman Armed Forces Hospital, Tabuk King Abdul Aziz Rd., Tabuk 47512, Saudi Arabia
| | - Jackson Tan
- RIPAS Hospital, Bandar Seri Begawan BA1710, Brunei Darussalam
| |
Collapse
|
16
|
Hematologic Manifestations of Childhood Illness. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
|
17
|
Dunn SP, Horslen S. Posttransplant Complications and Comorbidities. SOLID ORGAN TRANSPLANTATION IN INFANTS AND CHILDREN 2018. [PMCID: PMC7123596 DOI: 10.1007/978-3-319-07284-5_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Stephen P. Dunn
- Department of Surgery, Jefferson Medical College, Wilmington, Delaware USA
| | - Simon Horslen
- Division of Gastroenterology, Seattle Children’s Hospital, Seattle, Washington USA
| |
Collapse
|
18
|
Nakaharai K, Miyajima M, Kobayashi H, Shimizu A, Hosaka Y, Horino T, Hori S. Severe Thrombocytopenia During Dolutegravir-containing Antiretroviral Therapy. Intern Med 2017; 56:2229-2232. [PMID: 28781310 PMCID: PMC5596289 DOI: 10.2169/internalmedicine.8377-16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 56-year-old Japanese man diagnosed with acquired immunodeficiency syndrome, Pneumocystis jirovecii pneumonia and cytomegalovirus infection presented with thrombocytopenia after starting antiretroviral therapy, which included dolutegravir (DTG). Although good control of the human immunodeficiency virus and cytomegalovirus infections was achieved, the patient's thrombocytopenia persisted. The patient's platelet count decreased to ≤50,000/μL even after the cessation of valganciclovir, which can cause bone marrow suppression. At five months after starting antiretroviral therapy, DTG was replaced by ritonavir-boosted darunavir. Soon after, his platelet count improved and was maintained at a level of >100,000/μL. This is the first reported case of severe thrombocytopenia during DTG-containing antiretroviral therapy.
Collapse
Affiliation(s)
- Kazuhiko Nakaharai
- Department of Infectious Diseases and Infection Control, Jikei University School of Medicine, Japan
| | - Makiko Miyajima
- Department of Infectious Diseases and Infection Control, Jikei University School of Medicine, Japan
| | - Hiroaki Kobayashi
- Department of Infectious Diseases and Infection Control, Jikei University School of Medicine, Japan
| | - Akihiro Shimizu
- Department of Infectious Diseases and Infection Control, Jikei University School of Medicine, Japan
| | - Yumiko Hosaka
- Department of Infectious Diseases and Infection Control, Jikei University School of Medicine, Japan
| | - Tetsuya Horino
- Department of Infectious Diseases and Infection Control, Jikei University School of Medicine, Japan
| | - Seiji Hori
- Department of Infectious Diseases and Infection Control, Jikei University School of Medicine, Japan
| |
Collapse
|
19
|
Jafari A, Najivash P, Khatami MR, Dashti-Khavidaki S. Cytopenia Occurrence in Kidney Transplant Recipients Within Early Post-transplant Period. J Res Pharm Pract 2017; 6:31-39. [PMID: 28331864 PMCID: PMC5348855 DOI: 10.4103/2279-042x.200983] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objective: This study assessed incidence, severity, and time to occurrence of drug-induced leukopenia/thrombocytopenia within 1st month after kidney transplantation. Methods: This cross-sectional study was conducted on newly kidney transplant recipients from two hospitals, Iran. Patients with thrombocytopenia due to acute antibody-mediated rejection were excluded from the study. Demographic, clinical, and laboratory data of patients within the 1st month after transplantation were collected. Findings: Of 213 patients, 14.1% and 66.2% experienced leukopenia and thrombocytopenia, respectively. Cytopenia happened more commonly among patients with thymoglobulin-containing regimen (for leukopenia: 24.6% vs. 0%, P < 0.001; for thrombocytopenia 84.4% vs. 41.8%, P < 0.001). Most leukopenia patients experienced Grades 1 and 2 of leukopenia (46.6% and 40% of patients). Most thrombocytopenic patients showed Grade 1 of thrombocytopenia (78.7%). Cumulative dose of thymoglobulin did not differ between patients with and without leukopenia (5.57 ± 1.13 vs. 5.9 ± 1.96 mg/kg; P = 0.613) or with and without thrombocytopenia (5.87 ± 1.86 vs. 5.56 ± 1.38 mg/kg; P = 0.29). Cytopenia were more common among recipients from deceased compared with from living donors (91.3% vs. 8.7% for leukopenia patients, P = 0.001; 69.9% vs. 33.1% for thrombocytopenia, P = 0.02). More patients with kidney from deceased donors received thymoglobulin in their immunosuppressive regimen (82% vs. 37%; P < 0.001). The median time to leukopenia and thrombocytopenia were 3 days and 1 day, respectively. Conclusion: Among immunosuppressive and prophylactic antimicrobial agents, thymoglobulin is more related to cytopenia; therefore, thymoglobulin dose reduction is recommended as the first intervention to manage cytopenia without need for reduction of its cumulative dose. The higher prevalence of cytopenia among recipients from deceased donors may be related to the higher use of thymoglobulin in these patients.
Collapse
Affiliation(s)
- Atefeh Jafari
- Department of Clinical Pharmacy, Guilan University of Medical Sciences, Rasht, Iran
| | - Parisa Najivash
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Khatami
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran; Center of Excellence in Nephrology, Tehran University of Medical Sciences, Tehran, Iran
| | - Simin Dashti-Khavidaki
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran; Center of Excellence in Nephrology, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
20
|
|
21
|
Chanques G, Jaber S. Treating HSV and CMV reactivations in critically ill patients who are not immunocompromised: con. Intensive Care Med 2014; 40:1950-3. [PMID: 25361592 DOI: 10.1007/s00134-014-3521-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/11/2014] [Indexed: 12/19/2022]
Affiliation(s)
- G Chanques
- Departement d'Anesthésie-Réanimation (DAR) Hôpital Saint Eloi, Centre Hospitalier Universitaire de Montpellier, 80 avenue Augustin Fliche, 34295, Montpellier Cedex 5, France
| | | |
Collapse
|
22
|
Human cytomegalovirus resistance to deoxyribosylindole nucleosides maps to a transversion mutation in the terminase subunit-encoding gene UL89. Antimicrob Agents Chemother 2014; 59:226-32. [PMID: 25348532 DOI: 10.1128/aac.03686-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Human cytomegalovirus (HCMV) infection can cause severe illnesses, including encephalopathy and mental retardation, in immunocompromised and immunologically immature patients. Current pharmacotherapies for treating systemic HCMV infections include ganciclovir, cidofovir, and foscarnet. However, long-term administration of these agents can result in serious adverse effects (myelosuppression and/or nephrotoxicity) and the development of viral strains with reduced susceptibility to drugs. The deoxyribosylindole (indole) nucleosides demonstrate a 20-fold greater activity in vitro (the drug concentration at which 50% of the number of plaques was reduced with the presence of drug compared to the number in the absence of drug [EC50] = 0.34 μM) than ganciclovir (EC50 = 7.4 μM) without any observed increase in cytotoxicity. Based on structural similarity to the benzimidazole nucleosides, we hypothesize that the indole nucleosides target the HCMV terminase, an enzyme responsible for packaging viral DNA into capsids and cleaving the DNA into genome-length units. To test this hypothesis, an indole nucleoside-resistant HCMV strain was isolated, the open reading frames of the genes that encode the viral terminase were sequenced, and a G766C mutation in exon 1 of UL89 was identified; this mutation resulted in an E256Q change in the amino acid sequence of the corresponding protein. An HCMV wild-type strain, engineered with this mutation to confirm resistance, demonstrated an 18-fold decrease in susceptibility to the indole nucleosides (EC50 = 3.1 ± 0.7 μM) compared to that of wild-type virus (EC50 = 0.17 ± 0.04 μM). Interestingly, this mutation did not confer resistance to the benzimidazole nucleosides (EC50 for wild-type HCMV = 0.25 ± 0.04 μM, EC50 for HCMV pUL89 E256Q = 0.23 ± 0.04 μM). We conclude, therefore, that the G766C mutation that results in the E256Q substitution is unique for indole nucleoside resistance and distinct from previously discovered substitutions that confer both indole and benzimidazole nucleoside resistance (D344E and A355T).
Collapse
|
23
|
Vanhove T, Kuypers D, Claes KJ, Evenepoel P, Meijers B, Naesens M, Vanrenterghem Y, Cornelis T, Bammens B. Reasons for dose reduction of mycophenolate mofetil during the first year after renal transplantation and its impact on graft outcome. Transpl Int 2013; 26:813-21. [PMID: 23746202 DOI: 10.1111/tri.12133] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/11/2013] [Accepted: 05/15/2013] [Indexed: 11/29/2022]
Abstract
UNLABELLED Mycophenolate mofetil (MMF) decreases the risk of acute rejection and is associated with improved graft survival in renal transplant recipients. However, MMF-related side effects often necessitate dose reduction, which may expose patients to a higher risk of acute rejection and graft loss. This study's aim was to examine the reasons for MMF dose reduction during the first post-transplant year and its impact on acute rejection, overall and death-censored graft loss. METHODS Single-center retrospective analysis of 749 renal transplant recipients treated with MMF in their initial maintenance immunosuppressive protocol. RESULTS In 365 patients (48.7%) a total of 530 MMF dose reductions were done. Reasons for reduction were hematologic toxicity (46.5%), infection (16.1%), gastrointestinal side effects (12.3%), malignancy (2.1%), study protocol (14.6%), and unknown (13.5%). MMF dose reduction as such was not an independent predictor of acute rejection or graft survival, although reductions in ≥ 50% of initial dose were significantly associated with acute rejection. CONCLUSIONS In this retrospective cohort, by far the most important reason for MMF dose reduction during the first post-transplantation year was hematologic. MMF dose reductions in ≥ 50% increased the risk of acute rejection but did not compromise graft survival.
Collapse
Affiliation(s)
- Thomas Vanhove
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospitals Leuven, Belgium
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
The Seville expert workshop for progress in posttransplant lymphoproliferative disorders. Transplantation 2012; 94:784-93. [PMID: 22992767 DOI: 10.1097/tp.0b013e318269e64f] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
: Posttransplant lymphoproliferative disorders (PTLDs) are associated with significant morbidity and mortality among solid-organ transplant patients, but approaches to diagnosis and management vary considerably. An international multidisciplinary panel evaluated current understanding of risk factors and classification systems and developed recommendations to aid in PTLD prevention. We considered evidence on PTLD risk factors including Epstein-Barr virus serostatus and immunosuppression and identified knowledge gaps for future research. Recommendations address prophylactic and preemptive strategies to minimize PTLD development, including modulation of immunosuppression and antiviral drug regimens. Finally, new classification criteria were outlined that may help facilitate standardized reporting and improve our understanding of PTLD.
Collapse
|
25
|
Labro MT. Immunomodulatory effects of antimicrobial agents. Part I: antibacterial and antiviral agents. Expert Rev Anti Infect Ther 2012; 10:319-40. [PMID: 22397566 DOI: 10.1586/eri.12.11] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite impressive therapeutic progresses in the battle against infections, microorganisms are still a threat to mankind. With hundreds of antibacterial molecules, major concerns remain about the emergence of resistant and multidrug-resistant pathogens. On the other hand, the antiviral drug armamentarium is comprised of only a few dozens of compounds which are highly pathogen specific, and resistance is also a concern. According to Arturo Casadevall (Albert Einstein College of Medicine, NY, USA), we have now entered the third era of anti-infective strategy, which intends to favor the interplay between active molecules and the immune system. The first part of this review focuses on the potential immunomodulating properties of anti-infective agents, beginning with antibacterial and antiviral agents.
Collapse
Affiliation(s)
- Marie-Thérèse Labro
- Inserm SC14 Centre d'Expertise Collective, Université Paris Diderot Paris, 7 Faculté de Médecine Site Bichat, 16 rue Henri Huchard, 75890, Paris Cedex 18, France.
| |
Collapse
|
26
|
Fujimoto D, Matsushima A, Nagao M, Takakura S, Ichiyama S. Risk factors associated with elevated blood cytomegalovirus pp65 antigen levels in patients with autoimmune diseases. Mod Rheumatol 2012; 23:345-50. [PMID: 22534885 DOI: 10.1007/s10165-012-0651-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To further assess the relationship between elevated levels of cytomegalovirus (CMV) pp65 antigen in blood, as indicative of viral load, during treatment-free follow-up and CMV diseases in patients with autoimmune diseases and to identify any risk factors associated with elevated viral loads. METHODS This was a retrospective review of the electronic medical charts of 148 patients with autoimmune diseases who tested positive for CMV pp65 antigen in the blood. RESULTS A total of 106 patients were analyzed. During follow-up, elevated viral loads were detected in 35 patients who were not on antiviral therapy, of whom five developed CMV diseases. Elevated viral load was significantly associated with CMV diseases [5/35 vs. 0/71 (no elevated viral load); P = 0.001). Multivariate analysis revealed that lymphopenia [lymphocyte numbers <700/mm(3), odds ratio (OR) 34.44, 95 % confidence interval (CI), 7.82-151.66; P < 0.001], systemic lupus erythematosus (SLE) (OR 6.71, 95 % CI, 1.23-36.49; P = 0.028), and polymyositis/dermatomyositis (PM/DM) (OR 10.62, 95 % CI 1.41-79.77; P = 0.022) were significantly associated with elevated viral load. CONCLUSIONS Elevated viral load was significantly associated with CMV diseases. Patients with SLE or PM/DM and lymphopenia would therefore benefit from a detailed viral load follow-up and careful physical examination.
Collapse
Affiliation(s)
- Daichi Fujimoto
- Department of Infection Control and Prevention, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, Kyoto 606-8507, Japan
| | | | | | | | | |
Collapse
|
27
|
Manuel O, Perrottet N, Pascual M. Valganciclovir to prevent or treat cytomegalovirus disease in organ transplantation. Expert Rev Anti Infect Ther 2012; 9:955-65. [PMID: 22029513 DOI: 10.1586/eri.11.116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cytomegalovirus (CMV) is generally considered the most significant pathogen to infect patients following organ transplantation. Significant improvements have been achieved in the management of CMV disease over recent years, especially since the introduction of oral drugs such as oral ganciclovir followed by valganciclovir (VGC), a prodrug of ganciclovir with enhanced bioavailability. Several randomized controlled trials have shown that VGC is an efficacious and convenient oral drug to prevent or treat CMV disease in solid-organ transplant recipients. In this article, we discuss the clinical and pharmacological experience with the use of VGC for the management of CMV in solid-organ transplant recipients. Finally, novel strategies to further reduce the incidence of CMV disease after transplantation are also reviewed.
Collapse
Affiliation(s)
- Oriol Manuel
- Transplantation Center, University Hospital of Lausanne (CHUV), 1011 Lausanne, Switzerland.
| | | | | |
Collapse
|
28
|
Fisher RA, Kistler KD, Ulsh P, Bergman GE, Morris J. The association between cytomegalovirus immune globulin and long-term recipient and graft survival following liver transplantation. Transpl Infect Dis 2011; 14:121-31. [PMID: 21883757 DOI: 10.1111/j.1399-3062.2011.00664.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The association between cytomegalovirus (CMV) immune globulin (CMVIG) and long-term clinical outcomes has not been well defined. We examined the association between CMVIG and long-term recipient and graft survival in liver transplant recipients. Data were from the Scientific Registry of Transplant Recipients and included recipients transplanted between January 1995 and October 2008; follow-up was through March 2009. All recipients≤80 years of age with primary, single-organ liver transplants, given CMVIG with (n=2350) or without antivirals (n=455), antivirals without CMVIG (n = 32,939), or no CMV prophylaxis (n=28,508) before discharge were included. Kaplan-Meier analysis was used to examine rates of acute rejection (AR), graft loss, and death, over 7 years post transplantation. The adjusted risk of AR, graft loss, and death associated with CMVIG with and without antivirals vs. no prophylaxis was estimated using the Cox proportional hazards regression. In the univariate analysis, CMVIG, with and without antivirals, was associated with increased AR rates, but decreased mortality; CMVIG with antivirals was also associated with decreased graft loss compared with no prophylaxis. From the multivariable model, CMVIG with antivirals was associated with increased risk for AR, but decreased risk for graft loss and death; after adjustment, the association between CMVIG alone and mortality was not significant. CMVIG with antivirals is associated with increased risk of AR but greater long-term patient and graft survival after liver transplantation.
Collapse
Affiliation(s)
- R A Fisher
- Virginia Commonwealth University Medical Center, Medical College of Virginia Hospitals, Richmond, Virginia, USA
| | | | | | | | | |
Collapse
|
29
|
Martin JM, Danziger-Isakov LA. Cytomegalovirus risk, prevention, and management in pediatric solid organ transplantation. Pediatr Transplant 2011; 15:229-36. [PMID: 21199215 DOI: 10.1111/j.1399-3046.2010.01454.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Cytomegalovirus (CMV) is an important cause of morbidity and mortality in children who have received organ transplants. Patients have been reported to be at differential risk for CMV disease based on the serostatus of the donor and recipient with highest risk reported for CMV seronegative recipients who receive an organ from a CMV seropositive donor. Prophylaxis with ganciclovir and/or oral valganciclovir is reasonable to attempt to prevent CMV infections. A hybrid strategy bridging prophylaxis and pre-emptive therapy appears to be emerging as an additional method to prevent CMV disease. However, there is no agreement on the optimal schedule of testing, duration and dosing of antiviral medications or the role of immunoglobulin therapy. This manuscript will review the most recent literature and recommendations for the prophylaxis and treatment of CMV infections and disease in pediatric transplant recipients. Multicenter, randomized, clinical studies involving several pediatric transplant centers are needed to determine the best strategies to prevent and treat CMV infections in these patients.
Collapse
Affiliation(s)
- Judith M Martin
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA 15224, USA.
| | | |
Collapse
|
30
|
Choquette M, Goebel JW, Campbell KM. Nonimmune complications after transplantation. Pediatr Clin North Am 2010; 57:505-21, table of contents. [PMID: 20371049 DOI: 10.1016/j.pcl.2010.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
As posttransplant longevity has increased, nonimmune complications related to the transplant and posttransplant course have emerged as important factors in defining long-term outcomes. The incidence of, and risk factors for these complications may vary by transplanted organ based on immunosuppressive protocols and preexisting risk factors. This article discusses the relevant nonimmune complications associated with posttransplant care, with a focus on risk factors and management strategies.
Collapse
Affiliation(s)
- Monique Choquette
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Research Foundation, Cincinnati, OH 45229, USA
| | | | | |
Collapse
|