1
|
Dulek DE. Update on Epidemiology and Outcomes of Infection in Pediatric Organ Transplant Recipients. Infect Dis Clin North Am 2023; 37:561-575. [PMID: 37532391 DOI: 10.1016/j.idc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Pediatric solid organ transplant (SOT) recipients are at risk for infection following transplantation. Data from adult SOT recipients are often used to guide prevention and treatment of infections associated with organ transplantation in children. This article highlights key recent pediatric SOT-specific publications for an array of infectious complications of organ transplantation. Attention is given to areas of need for future study.
Collapse
Affiliation(s)
- Daniel E Dulek
- Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
| |
Collapse
|
2
|
Dulek DE, Ardura MI. "Weight-ing" for an answer on optimal valganciclovir prophylaxis dosing in pediatric solid organ transplantation recipients. Pediatr Transplant 2023; 27:e14494. [PMID: 36945839 DOI: 10.1111/petr.14494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/17/2023] [Indexed: 03/23/2023]
Affiliation(s)
- D E Dulek
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Tennessee, Nashville, USA
| | - M I Ardura
- Department of Pediatrics, Division of Infectious Diseases & Host Defense, Nationwide Children's Hospital & The Ohio State University College of Medicine, Ohio, Columbus, USA
| |
Collapse
|
3
|
Walabh P, Moore DP, Paget G, Meyer A, Moshesh PNM, Walabh P, Palweni ST, Hajinicolaou C. Healthcare disparity and its associations with cytomegalovirus disease in pediatric liver transplant recipients in South Africa. Transpl Infect Dis 2022; 24:e13917. [PMID: 35870126 PMCID: PMC10078342 DOI: 10.1111/tid.13917] [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: 05/01/2022] [Revised: 06/30/2022] [Accepted: 07/03/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection and disease are preventable complications following pediatric liver transplantation (PLT), despite the use of prophylaxis to minimize the risk of CMV disease. We evaluated the incidence and complications of CMV disease in PLT recipients in South Africa (SA), with particular reference to potential differences in outcome between state and private sector patients. METHODS Medical records of patients younger than 16 years of age who received liver transplants between January 1, 2012, and August 31, 2018 were analyzed. RESULTS Records of all 150 PLT patients were retrieved. The median age at transplant was 29.2 months (95% confidence interval 15.6-58.4) and follow-up was 46.3 months (interquartile range 27.6-63.1). Sixty-six (44%) patients were high risk, 79 (52.7%) were intermediate risk, and five (3.3%) were low risk for CMV infection. Forty-three (28.9%) patients had CMV DNAemia following transplantation, and 30 (20.1%) developed CMV disease. Receipt of care in the private sector was consistently associated with a lower hazard of CMV disease (adjusted hazard ratio [aHR] ranging from 0.36 to 0.43) and a consistently lower hazard of death among recipients at high risk for CMV disease and/or those who developed CMV disease (aHR ranging from 0.28 to 0.33). CONCLUSION Receipt of care in the private health sector was associated with a consistently lower hazard of CMV disease and death in individuals with CMV disease and/or at high risk for CMV disease. Policies aimed at creating a more equitable healthcare system in SA may mitigate the differential burden of illness associated with CMV in PLT recipients.
Collapse
Affiliation(s)
- Priya Walabh
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Paediatric Gastroenterology and Hepatology Unit, Charlotte Maxeke Johannesburg Hospital, University of Witwatersrand, Johannesburg, South Africa.,Gauteng Provincial Solid Organ Transplant Division, Gauteng, South Africa
| | - David P Moore
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Paediatrics and Child Health, Chris Hani Baragwanath Hospital, University of Witwatersrand, Johannesburg, South Africa.,Medical Research Council, Vaccines and Infectious Diseases Analytics (VIDA) Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Graham Paget
- Gauteng Provincial Solid Organ Transplant Division, Gauteng, South Africa.,Division of Nephrology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Anja Meyer
- Gauteng Provincial Solid Organ Transplant Division, Gauteng, South Africa.,Department of Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Porai Nthabaleng M Moshesh
- School of Clinical Medicine, Faculty of Health Sciences, Paediatric Intensive Care Unit, Nelson Mandela Children's Hospital, University of Witwatersrand, Johannesburg, South Africa
| | | | - Sechaba T Palweni
- Gauteng Provincial Solid Organ Transplant Division, Gauteng, South Africa.,Department of Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of Witwatersrand, Johannesburg, South Africa.,Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Christina Hajinicolaou
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Paediatrics and Child Health, Chris Hani Baragwanath Hospital, University of Witwatersrand, Johannesburg, South Africa.,Divisional Head Paediatric Gastroenterology, Department of Paediatrics and Child Health, Chris Hani Baragwanath Hospital, University of Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
4
|
Onpoaree N, Sanpavat A, Sintusek P. Cytomegalovirus infection in liver-transplanted children. World J Hepatol 2022; 14:338-353. [PMID: 35317177 PMCID: PMC8891677 DOI: 10.4254/wjh.v14.i2.338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/17/2021] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
Abstract
Cytomegalovirus (CMV) infection is a common complication of liver trans-plantation in children. The CMV serostatus of recipients and donors is the primary risk factor, and prophylaxis or pre-emptive strategies are recommended for high-risk patients. Graft rejection, coinfection and Epstein-Bar virus reactivation, which can lead to post-transplant lymphoproliferative disease, are indirect effects of CMV infection. Assessment of CMV infection viral load should be routinely performed upon clinical suspicion. However, tissue-invasive CMV disease is not associated with CMV viraemia and requires confirmation by tissue pathology. Oral valganciclovir and intravenous ganciclovir are equivalent treatments, and the duration of treatment depends on factors including CMV viral load, tissue pathology, and clinical response. Risk stratification by donor and recipient status prior to transplantation and post-transplantation antiviral prophylaxis or pre-emptive therapy are recommended. Adult guidelines have been established but additional study of the effectiveness of the preventive guidelines in children is needed. This review summarizes the burden, risk factors, clinical manifestations, laboratory evaluation, treatment, and prevention of CMV infection in children after liver transplantation.
Collapse
Affiliation(s)
- Norrapat Onpoaree
- Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Anapat Sanpavat
- Division of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Thai Paediatric Gastroenterology, Hepatology and Immunology Research Unit, Chulalongkorn University, Bangkok 10330, Thailand
| | - Palittiya Sintusek
- Thai Paediatric Gastroenterology, Hepatology and Immunology Research Unit, Chulalongkorn University, Bangkok 10330, Thailand
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
| |
Collapse
|
5
|
Jarasvaraparn C, Choudhury S, Rusch C, Nadler M, Liss KH, Stoll J, Hmiel S, Khan A, Doyle M, Kulkarni S. Characteristics, risk factors, and outcomes of neutropenia after liver or kidney transplantation in children. Pediatr Transplant 2022; 26:e14131. [PMID: 34494348 PMCID: PMC10591294 DOI: 10.1111/petr.14131] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND While prior adult studies have shown that approximately 20%-38% of subjects undergoing solid-organ transplant develop neutropenia, similar analyses in pediatric subjects are scarce. METHODS We conducted a retrospective chart review of liver transplant (LT) and kidney transplant (KT) recipients at our center during the period 2008-2018. All of the KT and none of the LT subjects during this time period had induction with either anti-thymocyte globulin (ATG) or basiliximab at time of transplant. Neutropenia was defined as absolute neutrophil count (ANC) value ≤1000/mm3 . RESULTS One hundred subjects with LT and 82 subjects with KT were included. The incidence of neutropenia within the first year of transplant in KT was higher compared to LT (54.8% vs 39%, p = .01). The median number of hospitalizations (p = .001) and infectious complications (p = .04) was significantly higher only in the KT subjects who developed neutropenia (compared to those who did not). Multivariate analysis identified factors associated with severity of liver disease at transplant, namely h/o upper gastrointestinal bleeding (p = .02), weight deficit (p = .01), and pre-LT ANC (p = .01), along with high or moderate risk cytomegalovirus status (p = .05) as predictors of neutropenia in LT subjects. Female gender (p = .03) predicted neutropenia, while BK virus infection was protective for neutropenia (p = .04) in KT subjects. CONCLUSIONS The incidence of and morbidity associated with neutropenia within 1 year post-transplant is higher in KT subjects compared to LT subjects. The likely reason for this is the use of induction therapy (ATG, basiliximab) at the time of transplant in KT subjects.
Collapse
Affiliation(s)
- Chaowapong Jarasvaraparn
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Shelley Choudhury
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Courtney Rusch
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michelle Nadler
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kim H.H. Liss
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Janis Stoll
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stanley Hmiel
- Department of Pediatrics, Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Adeel Khan
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Maria Doyle
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sakil Kulkarni
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Washington University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
6
|
Valencia Deray KG, Hosek KE, Chilukuri D, Dunson JR, Spielberg DR, Swartz SJ, Spinner JA, Leung DH, Moulton EA, Munoz FM, Demmler-Harrison GJ, Bocchini CE. Epidemiology and long-term outcomes of cytomegalovirus DNAemia and disease in pediatric solid organ transplant recipients. Am J Transplant 2022; 22:187-198. [PMID: 34467658 DOI: 10.1111/ajt.16822] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/08/2021] [Accepted: 08/28/2021] [Indexed: 01/25/2023]
Abstract
Despite prevention strategies, cytomegalovirus (CMV) remains a common infection in pediatric solid organ transplant recipients (SOTR). We sought to determine the frequency, associations with, and long-term outcomes of CMV DNAemia in pediatric SOTR. We performed a single-center retrospective cohort study, including 687 first time SOTR ≤21 years receiving universal prophylaxis from 2011 to 2018. Overall, 159 (23%) developed CMV DNAemia, the majority occurring after completing primary prophylaxis. CMV disease occurred in 33 (5%) SOTR, 25 (4%) with CMV syndrome and 10 (1%) with proven/probable tissue-invasive disease. CMV contributed to the death of three (0.4%) patients (all lung). High-risk (OR 6.86 [95% CI, 3.6-12.9]) and intermediate-risk (4.36 [2.3-8.2]) CMV status and lung transplantation (4.63 [2.33-9.2]) were associated with DNAemia on multivariable analysis. DNAemia was associated with rejection in liver transplant recipients (p < .01). DNAemia was not associated with an increase in graft failure, all-cause mortality, or other organ-specific poor outcomes. We report one of the lowest rates of CMV disease after SOTR, showing that universal prophylaxis is effective and should be continued. However, we observed CMV morbidity and mortality in a subset of patients, highlighting the need for research on optimal prevention strategies. This study was IRB approved.
Collapse
Affiliation(s)
- Kristen G Valencia Deray
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Kathleen E Hosek
- Department of Pediatrics, Section of Quality, Texas Children's Hospital, Houston, Texas, USA
| | - Divya Chilukuri
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jordan R Dunson
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - David R Spielberg
- Department of Pediatrics, Section of Pulmonology, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph A Spinner
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel H Leung
- Department of Pediatrics, Section of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Elizabeth A Moulton
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Flor M Munoz
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Gail J Demmler-Harrison
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Claire E Bocchini
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|