1
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McCort M, MacKenzie E, Pursell K, Pitrak D. Bacterial infections in lung transplantation. J Thorac Dis 2022; 13:6654-6672. [PMID: 34992843 PMCID: PMC8662486 DOI: 10.21037/jtd-2021-12] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 02/18/2021] [Indexed: 12/30/2022]
Abstract
Lung transplantation has lower survival rates compared to other than other solid organ transplants (SOT) due to higher rates of infection and rejection-related complications, and bacterial infections (BI) are the most frequent infectious complications. Excess morbidity and mortality are not only a direct consequence of these BI, but so are subsequent loss of allograft tolerance, rejection, and chronic lung allograft dysfunction due to bronchiolitis obliterans syndrome (BOS). A wide variety of pathogens can cause infections in lung transplant recipients (LTRs), including a number of nosocomial pathogens and other multidrug-resistant (MDR) pathogens. Although pneumonia and intrathoracic infections predominate, LTRs are at risk of a number of types of infections. Risk factors include altered anatomy and function of airways, impaired immunity, the microbial flora of the donor and recipient, underlying medical conditions, and genetic factors. Further work on immune monitoring has the potential to improve outcomes. The infecting agents can be derived from the donor lung, pre-existing recipient flora, or acquired from the environment over time. Certain infections may preclude lung transplantation, but this varies from center to center, and more recent studies suggest fewer patients should be disqualified. New molecular methods allow microbiome studies of the lung, gut, and other sites that may further our knowledge of how airway colonization can result in infection and allograft loss. Surveillance, early diagnosis, and aggressive antimicrobial therapy of BI is critical in LTRs. Antibiotic resistance is a major barrier to successful management of these infections. The availability of new agents for MDR Gram-negatives may improve outcomes. Other new therapies, such as bacteriophage therapy, show promise for the future. Finally, it is important to prevent infections through peri-transplant prophylaxis, vaccination, and infection control measures.
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Affiliation(s)
- Margaret McCort
- Albert Einstein College of Medicine, Division of Infectious Disease, New York, NY, USA
| | - Erica MacKenzie
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
| | - Kenneth Pursell
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
| | - David Pitrak
- University of Chicago Medicine, Section of Infectious Diseases and Global Health, Chicago, IL, USA
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2
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Hoang J, Krisl J, Moaddab M, Nguyen DT, Graviss EA, Hussain I, Kassi M, Yousefzai R, Kim J, Trachtenberg B, Bhimaraj A, Guha A. Intravenous Immunoglobulin in Heart Transplant Recipients with Mild to Moderate Hypogammaglobulinemia and Infection. Clin Transplant 2021; 36:e14571. [DOI: 10.1111/ctr.14571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Johnny Hoang
- Department of Pharmacy Houston Methodist Hospital Houston Texas
| | - Jill Krisl
- Department of Pharmacy Houston Methodist Hospital Houston Texas
| | - Mozhgon Moaddab
- Department of Pharmacy Houston Methodist Hospital Houston Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Houston Texas
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Houston Texas
- Department of Surgery Houston Methodist Hospital Houston Texas
| | - Imad Hussain
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Mahwash Kassi
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Rayan Yousefzai
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Ju Kim
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Barry Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Arvind Bhimaraj
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
| | - Ashrith Guha
- Houston Methodist DeBakey Heart and Vascular Center Houston Methodist Hospital Houston Texas
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3
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Pavlakou P, Papasotiriou M, Ntrinias T, Kourakli A, Bratsiakou A, Goumenos DS, Papachristou E. Case Report: Kidney Transplantation in a Patient With Acquired Agammaglobulinemia and SLE. Issues and Challenges. Front Med (Lausanne) 2021; 8:665475. [PMID: 33777986 PMCID: PMC7994764 DOI: 10.3389/fmed.2021.665475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
Lupus nephritis in the context of Systemic Lupus Erythematosus (SLE) is characterized by an unpredicted course with remissions and flare-ups. Among others, it remains a significant cause of end-stage kidney disease (ESKD) in relatively young patients. Therapeutic regimens with newer immunosuppressive agents have been introduced in order to control SLE clinical manifestations more efficiently and limit organ damage induced by immune complex formation and sustained inflammation. Treatment is usually long-term, and the cumulative impact of immunosuppression is expressed through the increased frequency of infections and neoplasms. However, if the observed immunity dysregulation is secondary and pharmaceutically induced or there is a pre-existing, primary immunodeficiency that shares common pathogenetic pathways with SLE's autoimmunity is not always clear. Herein, we present the case of a 39-year-old woman, that reached ESKD due to lupus nephritis. After an upper respiratory cytomegalovirus (CMV) infection and concomitant CMV reactivations the investigation revealed significant immunodeficiency. Not long after the initiation of intravenous immunoglobulin (IVIG) administration, patient received a cadaveric kidney transplant. IVIG was continued along with standard immunosuppression so that both recurrent infections and allograft rejection are avoided. Patient is closely monitored, and her post-transplant course is remarkably satisfying so far. ESKD patients with immunodeficiency syndromes should not be excluded by definition from kidney transplantation.
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Affiliation(s)
- Paraskevi Pavlakou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Marios Papasotiriou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Theodoros Ntrinias
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Alexandra Kourakli
- Hematology Division, Department of Internal Medicine, University Hospital of Patras, Achaia, Greece
| | - Adamantia Bratsiakou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Dimitrios S Goumenos
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
| | - Evangelos Papachristou
- Department of Nephrology and Renal Transplantation, University Hospital of Patras, Achaia, Greece
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4
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Stachel MW, Gidea CG, Reyentovich A, Mehta SA, Moazami N. COVID-19 pneumonia in a dual heart-kidney recipient. J Heart Lung Transplant 2020; 39:612-614. [PMID: 32503728 PMCID: PMC7165097 DOI: 10.1016/j.healun.2020.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 01/29/2023] Open
Affiliation(s)
- Maxine W Stachel
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Health, New York, New York.
| | - Claudia G Gidea
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Health, New York, New York
| | - Alex Reyentovich
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Health, New York, New York
| | - Sapna A Mehta
- Department of Medicine, Transplant Infectious Disease Service, New York University Langone Health, New York, New York
| | - Nader Moazami
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
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5
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Newman M, Gregg K, Estes R, Pursell K, Pitrak D. Acquired hypogammaglobulinemia and pathogen-specific antibody depletion after solid organ transplantation in human immunodeficiency virus infection: A brief report. Transpl Infect Dis 2019; 21:e13188. [PMID: 31587457 DOI: 10.1111/tid.13188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/15/2019] [Accepted: 09/15/2019] [Indexed: 01/04/2023]
Abstract
Hypogammaglobulinemia (HGG) frequently occurs in recipients after types of (SOT). The incidence and significance of HGG in HIV+ recipients of SOT are just being explored. We reported that 12% of the recipients in the SOT in multi-center HIV-TR (HIV-TR) Study developed moderate or severe HGG at 1 year. In LT recipients, this was associated with serious infections and death. We have now further characterized the decreased antibodies in HIV+ SOT recipients who developed HGG. We measured the levels of pathogen-specific antibodies and poly-specific self-reactive antibodies (PSA) in relation to total IgG levels from serial serum samples for 20 HIV+ SOT recipients who developed moderate to severe HGG following SOT. Serum antibody levels to measles, tetanus toxoid, and HIV-1 were determined by EIA. Levels of PSAs were determined by incubating control lymphocytes with patient serum, staining with anti-human IgG Fab-FITC, and analysis by flow cytometry. Levels of PSA were higher compared to healthy, HIV-uninfected controls at pre-transplant baseline and increased by weeks 12 and 26, but the changes were not significant. Likewise, anti-HIV antibody levels remained unchanged over time. In contrast, antibody levels against measles and tetanus were significantly reduced from baseline by week 12, and did not return to baseline, even after 2 years. For HIV patients who develop moderate to severe HGG after transplant, the reduction in IgG levels is associated with a significant decrease in pathogen-specific antibody titers, while PSA levels and anti-HIV antibodies are unchanged. This may contribute to infectious complications and other clinical endpoints.
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Affiliation(s)
- Margaret Newman
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL
| | - Kevin Gregg
- Division of Infectious Diseases, University of Michigan, Ann Arbor, MI
| | - Randee Estes
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL
| | - Kenneth Pursell
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL
| | - David Pitrak
- Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL
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6
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Bourassa-Blanchette S, Patel V, Knoll GA, Hutton B, Fergusson N, Bennett A, Tay J, Cameron DW, Cowan J. Clinical outcomes of polyvalent immunoglobulin use in solid organ transplant recipients: A systematic review and meta-analysis - Part II: Non-kidney transplant. Clin Transplant 2019; 33:e13625. [PMID: 31162852 DOI: 10.1111/ctr.13625] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/26/2019] [Accepted: 05/30/2019] [Indexed: 12/17/2022]
Abstract
Immunoglobulin (IG) is commonly used to desensitize and treat antibody-mediated rejection in solid organ transplant (SOT) recipients. The impact of IG on other outcomes such as infection, all-cause mortality, graft rejection, and graft loss is not clear. We conducted a similar systematic review and meta-analysis to our previously reported Part I excluding kidney transplant. A comprehensive literature review found 16 studies involving the following organ types: heart (6), lung (4), liver (4), and multiple organs (2). Meta-analysis could only be performed on mortality outcome in heart and lung studies due to inadequate data on other outcomes. There was a significant reduction in mortality (OR 0.34 [0.17-0.69]; 4 studies, n = 455) in heart transplant with hypogammaglobulinemia receiving IVIG vs no IVIG. Mortality in lung transplant recipients with hypogammaglobulinemia receiving IVIG was comparable to those of no hypogammaglobulinemia (OR 1.05 [0.49, 2.26]; 2 studies, n = 887). In summary, IVIG targeted prophylaxis may decrease mortality in heart transplant recipients as compared to those with hypogammaglobulinemia not receiving IVIG, or improve mortality to the equivalent level with those without hypogammaglobulinemia in lung transplant recipients, but there is a lack of data to support physicians in making decisions around using immunoglobulins in all SOT recipients for infection prophylaxis.
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Affiliation(s)
- Samuel Bourassa-Blanchette
- Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Vishesh Patel
- Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Greg A Knoll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Renal Transplantation, Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nicholas Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alexandria Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jason Tay
- Blood and Marrow Transplant Program, Alberta Health Sciences, Calgary, Alberta, Canada
| | - D William Cameron
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Juthaporn Cowan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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7
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Patel SY, Carbone J, Jolles S. The Expanding Field of Secondary Antibody Deficiency: Causes, Diagnosis, and Management. Front Immunol 2019; 10:33. [PMID: 30800120 PMCID: PMC6376447 DOI: 10.3389/fimmu.2019.00033] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022] Open
Abstract
Antibody deficiency or hypogammaglobulinemia can have primary or secondary etiologies. Primary antibody deficiency (PAD) is the result of intrinsic genetic defects, whereas secondary antibody deficiency may arise as a consequence of underlying conditions or medication use. On a global level, malnutrition, HIV, and malaria are major causes of secondary immunodeficiency. In this review we consider secondary antibody deficiency, for which common causes include hematological malignancies, such as chronic lymphocytic leukemia or multiple myeloma, and their treatment, protein-losing states, and side effects of a number of immunosuppressive agents and procedures involved in solid organ transplantation. Secondary antibody deficiency is not only much more common than PAD, but is also being increasingly recognized with the wider and more prolonged use of a growing list of agents targeting B cells. SAD may thus present to a broad range of specialties and is associated with an increased risk of infection. Early diagnosis and intervention is key to avoiding morbidity and mortality. Optimizing treatment requires careful clinical and laboratory assessment and may involve close monitoring of risk parameters, vaccination, antibiotic strategies, and in some patients, immunoglobulin replacement therapy (IgRT). This review discusses the rapidly evolving list of underlying causes of secondary antibody deficiency, specifically focusing on therapies targeting B cells, alongside recent advances in screening, biomarkers of risk for the development of secondary antibody deficiency, diagnosis, monitoring, and management.
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Affiliation(s)
- Smita Y. Patel
- Clinical Immunology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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8
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The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. Transplantation 2019; 102:900-931. [PMID: 29596116 DOI: 10.1097/tp.0000000000002191] [Citation(s) in RCA: 684] [Impact Index Per Article: 136.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite recent advances, cytomegalovirus (CMV) infections remain one of the most common complications affecting solid organ transplant recipients, conveying higher risks of complications, graft loss, morbidity, and mortality. Research in the field and development of prior consensus guidelines supported by The Transplantation Society has allowed a more standardized approach to CMV management. An international multidisciplinary panel of experts was convened to expand and revise evidence and expert opinion-based consensus guidelines on CMV management including prevention, treatment, diagnostics, immunology, drug resistance, and pediatric issues. Highlights include advances in molecular and immunologic diagnostics, improved understanding of diagnostic thresholds, optimized methods of prevention, advances in the use of novel antiviral therapies and certain immunosuppressive agents, and more savvy approaches to treatment resistant/refractory disease. The following report summarizes the updated recommendations.
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9
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Lichvar AB, Ensor CR, Zeevi A, Morrell MR, Pilewski JM, Hayanga JWA, D'Cunha J, McDyer JF, Petrov AA. Detrimental Association of Hypogammaglobulinemia With Chronic Lung Allograft Dysfunction and Death Is Not Mitigated by On-Demand Immunoglobulin G Replacement After Lung Transplantation. Prog Transplant 2018; 29:1526924818817028. [PMID: 30537897 DOI: 10.1177/1526924818817028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND: Hypogammaglobulinemia (HGG), immunoglobulin G (IgG) <700 mg/dL, is associated with infections, chronic lung allograft dysfunction, and death following lung transplantation. This study evaluates the use of on-demand intravenous IgG in lung transplant recipients with HGG. MATERIALS AND METHODS: This single-center retrospective cohort study of adult lung recipients evaluated 3 groups, no, untreated (u), or treated (t) HGG at first IgG administration or a matched time posttransplant. Primary outcome was freedom from allograft dysfunction. Secondary outcomes included development of advanced dysfunction, rejection, infection burden, and mortality. RESULTS: Recipients included 484 (no HGG: 76, uHGG: 192, tHGG: 216). Freedom from chronic allograph dysfunction was highest in the non-HGG group 2 years post-enrollment (no HGG 77.9% vs uHGG 56.4% vs tHGG 52.5%; P = .002). Freedom from advanced dysfunction was significantly different 2 years post-enrollment (no HGG 90.5% vs uHGG 84.7% vs tHGG 75.4%; P = .017). Patients without HGG and those with uHGG had less mortality at 2 years post-enrollment (no HGG 84.2% vs uHGG 81.3% vs tHGG 64.8%; P < .001). Gram-negative pneumonias occurred more often in the tHGG group ( P = .02). CONCLUSIONS: Development of chronic lung allograft dysfunction, patient survival, rejection burden, and key infectious outcomes in lung transplant recipients were still problematic in the context of on-demand IgG therapy. Prospective studies are warranted.
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Affiliation(s)
- Alicia B Lichvar
- 1 Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Christopher R Ensor
- 2 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adriana Zeevi
- 3 Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew R Morrell
- 2 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph M Pilewski
- 2 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - J W Awori Hayanga
- 4 Division of Lung Transplant/Lung Failure, Department of Cardiothoracic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan D'Cunha
- 4 Division of Lung Transplant/Lung Failure, Department of Cardiothoracic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John F McDyer
- 2 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrej A Petrov
- 2 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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10
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Avery RK, Lonze BE, Kraus ES, Marr KA, Montgomery RA. Severe chronic norovirus diarrheal disease in transplant recipients: Clinical features of an under-recognized syndrome. Transpl Infect Dis 2017; 19. [PMID: 28176463 DOI: 10.1111/tid.12674] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/27/2016] [Accepted: 11/06/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Norovirus (NV) infection has been reported as a cause of severe chronic diarrhea in transplant recipients, but this entity remains under-recognized in clinical practice, leading to diagnostic delays. Transplant clinicians should become familiar with this syndrome in order to facilitate early detection and management. METHODS Demographic, clinical, and outcomes variables were summarized from a series of transplant recipients with positive stool NV reverse transcription polymerase chain reaction (RT-PCR) assays at Johns Hopkins in 2013-2014. Factors associated with longer duration of symptoms were compared using random forest analysis. RESULTS Thirty-one of 193 (16%) transplant recipients who were tested for NV had positive stool RT-PCRs. Symptoms included diarrhea (100%), nausea/vomiting (58%), abdominal pain (52%), and wasting (35%). Acute kidney injury occurred in 23%, and persisted in 21% after 6 months. Median duration of diarrheal symptoms was 4 months (range, <1-20) and 11/31 (35.4%) patients had relapses after improvement. Wasting, incompatible kidney transplant status, and plasmapheresis were associated with longer diarrhea durations. Treatments included nitazoxanide (in 74%), reduction of immunosuppression (58%), and intravenous immunoglobulin (32%). Six patients died, but no deaths were attributed to NV. CONCLUSIONS It is important for clinicians to recognize that NV can cause severe chronic diarrhea in transplant recipients. In this series, receipt of a human leukocyte antigen- and/or blood type-incompatible kidney transplant, and plasmapheresis were associated with longer symptom duration.
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Affiliation(s)
- Robin K Avery
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bonnie E Lonze
- Division of Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward S Kraus
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kieren A Marr
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Robert A Montgomery
- Division of Transplantation, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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11
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Sarmiento E, Diez P, Arraya M, Jaramillo M, Calahorra L, Fernandez-Yañez J, Palomo J, Sousa I, Hortal J, Barrio J, Alonso R, Muñoz P, Navarro J, Vicario J, Fernandez-Cruz E, Carbone J. Early intravenous immunoglobulin replacement in hypogammaglobulinemic heart transplant recipients: results of a clinical trial. Transpl Infect Dis 2016; 18:832-843. [DOI: 10.1111/tid.12610] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 05/16/2016] [Accepted: 06/29/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Elizabeth Sarmiento
- Transplant Immunology Group; Clinical Immunology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Pablo Diez
- Cardiology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Mauricio Arraya
- Transplant Immunology Group; Clinical Immunology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Maria Jaramillo
- Transplant Immunology Group; Clinical Immunology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Leticia Calahorra
- Transplant Immunology Group; Clinical Immunology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Juan Fernandez-Yañez
- Cardiology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Jesus Palomo
- Cardiology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Iago Sousa
- Cardiology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Javier Hortal
- Anesthesiology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Jose Barrio
- Cardiology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Roberto Alonso
- Microbiology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Patricia Muñoz
- Microbiology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Joaquin Navarro
- Transplant Immunology Group; Clinical Immunology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Jose Vicario
- Transfusion Center of the Community of Madrid; Madrid Spain
| | - Eduardo Fernandez-Cruz
- Transplant Immunology Group; Clinical Immunology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
| | - Javier Carbone
- Transplant Immunology Group; Clinical Immunology Department; Hospital General Universitario Gregorio Marañon; Madrid Spain
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12
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Hoffman TW, van Kessel DA, van Velzen-Blad H, Grutters JC, Rijkers GT. Antibody replacement therapy in primary antibody deficiencies and iatrogenic hypogammaglobulinemia. Expert Rev Clin Immunol 2015; 11:921-33. [DOI: 10.1586/1744666x.2015.1049599] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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13
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Florescu DF. Solid organ transplantation: hypogammaglobulinaemia and infectious complications after solid organ transplantation. Clin Exp Immunol 2015; 178 Suppl 1:54-6. [PMID: 25546761 DOI: 10.1111/cei.12510] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- D F Florescu
- Transplant Infectious Diseases Division, Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE, USA
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14
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Sarmiento E, Arraya M, Jaramillo M, Diez P, Fernandez-Yañez J, Palomo J, Navarro J, Carbone J. Intravenous immunoglobulin as an intervention strategy of risk factor modification for prevention of severe infection in heart transplantation. Clin Exp Immunol 2015; 178 Suppl 1:156-8. [PMID: 25546803 DOI: 10.1111/cei.12552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- E Sarmiento
- Transplant Immunology Group, Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
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15
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Jolles S, Jordan SC, Orange JS, van Schaik IN. Immunoglobulins: current understanding and future directions. Clin Exp Immunol 2015; 178 Suppl 1:163-8. [PMID: 25546806 DOI: 10.1111/cei.12555] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- S Jolles
- University Hospital of Wales, Cardiff, UK
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16
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Origüen J, Fernández-Ruiz M, Lumbreras C, Orellana MÁ, López-Medrano F, Ruiz-Merlo T, San Juan R, García-Reyne A, González E, Polanco N, Paz-Artal E, Andrés A, Aguado JM. Potential role of post-transplant hypogammaglobulinemia in the risk of Clostridium difficile infection after kidney transplantation: a case-control study. Infection 2015; 43:413-22. [PMID: 25676130 DOI: 10.1007/s15010-015-0737-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 01/27/2015] [Indexed: 12/16/2022]
Abstract
PURPOSE To identify reversible risk factors for Clostridium difficile infection (CDI) after kidney transplantation (KT) that could lead to a reduction in its incidence and associated complications. METHODS We performed a single-center case-control study in which 41 patients undergoing KT between February 2009 and July 2013 who developed a first episode of post-transplant CDI were included as cases. Patients transplanted at the same calendar day (± 2 weeks) as each case with no evidence of CDI and comparable risk exposure period were chosen as controls (2:1 ratio). Serum immunoglobulin and complement levels were systematically measured at baseline and months 1 and 6 after transplantation. RESULTS Multivariate regression analysis identified age-adjusted Charlson comorbidity index (odds ratio [OR] per unitary increment 1.31; P value = 0.043), delayed graft function (OR 2.76; P value = 0.039), prior cytomegalovirus (CMV) disease (OR 6.85; P value = 0.011) and prior acute graft rejection (OR 5.92; P value = 0.008) as risk factors for post-transplant CDI. Cases with their first episode of CDI occurring beyond the first month were more likely to have IgG hypogammaglobulinemia (HGG) at month 1 (P value = 0.002), whereas cases with CDI beyond the sixth month were more likely to have HGG of any class at month 6 (P value = 0.003). Poor outcome (graft loss and/or all-cause mortality) was more common among cases (adjusted hazard ratio 5.69; P value = 0.001). CONCLUSION The occurrence of CDI exerts a detrimental effect on graft and patient outcome. Post-transplant HGG was a potentially modifiable risk factor for CDI in KT recipients.
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Affiliation(s)
- Julia Origüen
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre" (Centro de Actividades Ambulatorias, 2ª planta, bloque D, Avda. de Córdoba, s/n, 28041), Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain,
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Kerr J, Quinti I, Eibl M, Chapel H, Späth PJ, Sewell WAC, Salama A, van Schaik IN, Kuijpers TW, Peter HH. Is dosing of therapeutic immunoglobulins optimal? A review of a three-decade long debate in europe. Front Immunol 2014; 5:629. [PMID: 25566244 PMCID: PMC4263903 DOI: 10.3389/fimmu.2014.00629] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/25/2014] [Indexed: 12/13/2022] Open
Abstract
The consumption of immunoglobulins (Ig) is increasing due to better recognition of antibody deficiencies, an aging population, and new indications. This review aims to examine the various dosing regimens and research developments in the established and in some of the relevant off-label indications in Europe. The background to the current regulatory settings in Europe is provided as a backdrop for the latest developments in primary and secondary immunodeficiencies and in immunomodulatory indications. In these heterogeneous areas, clinical trials encompassing different routes of administration, varying intervals, and infusion rates are paving the way toward more individualized therapy regimens. In primary antibody deficiencies, adjustments in dosing and intervals will depend on the clinical presentation, effective IgG trough levels and IgG metabolism. Ideally, individual pharmacokinetic profiles in conjunction with the clinical phenotype could lead to highly tailored treatment. In practice, incremental dosage increases are necessary to titrate the optimal dose for more severely ill patients. Higher intravenous doses in these patients also have beneficial immunomodulatory effects beyond mere IgG replacement. Better understanding of the pharmacokinetics of Ig therapy is leading to a move away from simplistic "per kg" dosing. Defective antibody production is common in many secondary immunodeficiencies irrespective of whether the causative factor was lymphoid malignancies (established indications), certain autoimmune disorders, immunosuppressive agents, or biologics. This antibody failure, as shown by test immunization, may be amenable to treatment with replacement Ig therapy. In certain immunomodulatory settings [e.g., idiopathic thrombocytopenic purpura (ITP)], selection of patients for Ig therapy may be enhanced by relevant biomarkers in order to exclude non-responders and thus obtain higher response rates. In this review, the developments in dosing of therapeutic immunoglobulins have been limited to high and some medium priority indications such as ITP, Kawasaki' disease, Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, myasthenia gravis, multifocal motor neuropathy, fetal alloimmune thrombocytopenia, fetal hemolytic anemia, and dermatological diseases.
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Affiliation(s)
- Jacqueline Kerr
- Section Poly- and Monoclonal Antibodies, Paul Ehrlich Institut, Langen, Germany
| | - Isabella Quinti
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Helen Chapel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Peter J. Späth
- Institute of Pharmacology, University of Bern, Bern, Switzerland
| | | | - Abdulgabar Salama
- Zentrum für Transfusionsmedizin u. Zelltherapie, Charité, Berlin, Germany
| | - Ivo N. van Schaik
- Department of Neurology, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Taco W. Kuijpers
- Department of Pediatric Hematology, Immunology and Infectious disease, Academic Medical Center (AMC), University of Amsterdam, Amsterdam, Netherlands
| | - Hans-Hartmut Peter
- Centrum für chronische Immunodeficienz (CCI), University Medical Centre, University of Freiburg, Freiburg im Breisgau, Germany
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Compagno N, Malipiero G, Cinetto F, Agostini C. Immunoglobulin replacement therapy in secondary hypogammaglobulinemia. Front Immunol 2014; 5:626. [PMID: 25538710 PMCID: PMC4259107 DOI: 10.3389/fimmu.2014.00626] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 11/24/2014] [Indexed: 12/02/2022] Open
Abstract
Immunoglobulin (Ig) replacement therapy dramatically changed the clinical course of primary hypogammaglobulinemias, significantly reducing the incidence of infectious events. Over the last two decades its use has been extended to secondary antibody deficiencies, particularly those related to hematological disorders as lymphoproliferative diseases (LPDs) and multiple myeloma. In these malignancies, hypogammaglobulinemia can be an intrinsic aspect of the disease or follow chemo-immunotherapy regimens, including anti-CD20 treatment. Other than in LPDs the broadening use of immunotherapy (e.g., rituximab) and immune-suppressive therapy (steroids, sulfasalazine, and mycophenolate mofetil) has extended the occurrence of iatrogenic hypogammaglobulinemia. In particular, in both autoimmune diseases and solid organ transplantation Ig replacement therapy has been shown to reduce the rate of infectious events. Here, we review the existing literature about Ig replacement therapy in secondary hypogammaglobulinemia, with special regard for subcutaneous administration route, a safe, effective, and well-tolerated treatment approach, currently well established in primary immunodeficiencies and secondary hypogammaglobulinemias.
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Affiliation(s)
- Nicolò Compagno
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Giacomo Malipiero
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Francesco Cinetto
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
| | - Carlo Agostini
- Department of Medicine, Clinical Immunology and Hematology, University of Padova , Padova , Italy
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Florescu DF, Kalil AC, Qiu F, Grant W, Morris MC, Schmidt CM, Florescu MC, Poole JA. Does increasing immunoglobulin levels impact survival in solid organ transplant recipients with hypogammaglobulinemia? Clin Transplant 2014; 28:1249-55. [PMID: 25203509 DOI: 10.1111/ctr.12458] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Severe hypogammaglobulinemia (IgG < 400 mg/dL) has adverse impact on mortality during the first year post-transplantation. The aim of the study was to determine whether increasing IgG levels to ≥400 mg/dL improved outcomes. METHODS Kaplan-Meier analyses were performed to estimate survival, log-rank test to compare survival distributions between groups, and Fisher's exact test to determine the association between hypogammaglobulinemia and rejection or graft loss. RESULTS Thirty-seven solid organ transplant (SOT) recipients were included. Hypogammaglobulinemia was diagnosed at median of 5.6 months (range: 0-291.8 months) post-transplantation. Types of transplants: liver-small bowel (17); liver-small bowel-kidney (2); liver (5); small bowel (4); liver-kidney (1); kidney/kidney-pancreas (3); heart (3); heart-kidney (1); and heart-lung (1). The three-yr survival after the diagnosis of hypogammaglobulinemia was 49.5% (95% CI: 32.2-64.6%). Patients were dichotomized based upon IgG level at last follow-up: IgG ≥ 400 mg/dL (23 patients) and IgG < 400 mg/dL (14 patients). There was no evidence of a difference in survival (p = 0.44), rejection rate (p = 0.44), and graft loss censored for death (p = 0.99) at one yr between these two groups. There was no difference in survival between patients receiving or not immunoglobulin (p = 0.99) or cytomegalovirus hyperimmunoglobulin (p = 0.14). CONCLUSION Severe hypogammaglobulinemia after SOT is associated with high mortality rates, but increasing IgG levels to ≥400 mg/dL did not seem to translate in better patient or graft survival in this cohort.
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Affiliation(s)
- Diana F Florescu
- Transplant Infectious Diseases Program, University of Nebraska Medical Center, Omaha, NE, USA; Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE, USA
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Clinical immune-monitoring strategies for predicting infection risk in solid organ transplantation. Clin Transl Immunology 2014; 3:e12. [PMID: 25505960 PMCID: PMC4232060 DOI: 10.1038/cti.2014.3] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 01/28/2014] [Accepted: 01/28/2014] [Indexed: 02/06/2023] Open
Abstract
Infectious complications remain a leading cause of morbidity and mortality after solid organ transplantation (SOT), and largely depend on the net state of immunosuppression achieved with current regimens. Cytomegalovirus (CMV) is a major opportunistic viral pathogen in this setting. The application of strategies of immunological monitoring in SOT recipients would allow tailoring of immunosuppression and prophylaxis practices according to the individual's actual risk of infection. Immune monitoring may be pathogen-specific or nonspecific. Nonspecific immune monitoring may rely on either the quantification of peripheral blood biomarkers that reflect the status of a given arm of the immune response (serum immunoglobulins and complement factors, lymphocyte sub-populations, soluble form of CD30), or on the functional assessment of T-cell responsiveness (release of intracellular adenosine triphosphate following a mitogenic stimulus). In addition, various methods are currently available for monitoring pathogen-specific responses, such as CMV-specific T-cell-mediated immune response, based on interferon-γ release assays, intracellular cytokine staining or main histocompatibility complex-tetramer technology. This review summarizes the clinical evidence to date supporting the use of these approaches to the post-transplant immune status, as well as their potential limitations. Intervention studies based on validated strategies for immune monitoring still need to be performed.
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