1
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Reusing JO, Agena F, Kotton CN, Campana G, Pierrotti LC, David-Neto E. QuantiFERON-CMV as a Predictor of CMV Events During Preemptive Therapy in CMV-seropositive Kidney Transplant Recipients. Transplantation 2024; 108:985-995. [PMID: 37990351 DOI: 10.1097/tp.0000000000004870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
BACKGROUND Prevention of cytomegalovirus (CMV) infection after kidney transplantation is costly and burdensome. METHODS Given its promising utility in risk stratification, we evaluated the use of QuantiFERON-CMV (QFCMV) and additional clinical variables in this prospective cohort study to predict the first clinically significant CMV infection (CS-CMV, ranging from asymptomatic viremia requiring treatment to CMV disease) in the first posttransplant year. A cost-effectiveness analysis for guided prevention was done. RESULTS One hundred adult kidney transplant recipients, CMV IgG + , were given basiliximab induction and maintained on steroid/mycophenolate/tacrolimus with weekly CMV monitoring. Thirty-nine patients developed CS-CMV infection (viral syndrome, n = 1; end-organ disease, n = 9; and asymptomatic viremia, n = 29). A nonreactive or indeterminate QFCMV result using the standard threshold around day 30 (but not before transplant) was associated with CS-CMV rates of 50% and 75%, respectively. A higher QFCMV threshold for reactivity (>1.0 IU interferon-γ/mL) outperformed the manufacturer's standard (>0.2 IU interferon-γ/mL) in predicting protection but still allowed a 16% incidence of CS-CMV. The combination of recipient age and type of donor, along with posttransplant QFCMV resulted in a prediction model that increased the negative predictive value from 84% (QFCMV alone) to 93%. QFCMV-guided preemptive therapy was of lower cost than preemptive therapy alone ( P < 0.001, probabilistic sensitivity analysis) and was cost-effective (incremental net monetary benefit of 210 USD) assuming willingness-to-pay of 2000 USD to avoid 1 CMV disease. CONCLUSIONS Guided CMV prevention by the prediction model with QFCMV is cost-effective and would spare from CMV surveillance in 42% of patients with low risk for CS-CMV.
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Affiliation(s)
- José O Reusing
- Renal Transplant Service, Instituto Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fabiana Agena
- Renal Transplant Service, Instituto Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Camille N Kotton
- Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Ligia Camera Pierrotti
- Medical Director Department, Dasa, Barueri, Brazil
- Division of Infectious Disease, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Elias David-Neto
- Renal Transplant Service, Instituto Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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2
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Koch M. [Kidney transplantation]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:129-134. [PMID: 37973621 DOI: 10.1007/s00104-023-01991-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 11/19/2023]
Abstract
Every patient with kidney failure requiring dialysis in Germany has the right to at least be evaluated for a transplantation. When an affected person can be considered for a transplantation, it must be clarified which allocation program is the right one for the person and whether a living organ donor can be considered. It should also be individually discussed with patients which type of donor organ should be accepted. Following a transplantation an individualized immunosuppression is relevant not only for the long-term survival of the transplant but also for the adherence of the patient.
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Affiliation(s)
- Martina Koch
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
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3
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Maenaka A, Kinoshita K, Hara H, Cooper DKC. The case for the therapeutic use of mechanistic/mammalian target of rapamycin (mTOR) inhibitors in xenotransplantation. Xenotransplantation 2023; 30:e12802. [PMID: 37029499 DOI: 10.1111/xen.12802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/23/2023] [Indexed: 04/09/2023]
Abstract
The mechanistic/mammalian target of rapamycin (mTOR) is one of the systems that are necessary to maintain cell homeostasis, such as survival, proliferation, and differentiation. mTOR inhibitors (mTOR-Is) are utilized as immunosuppressants and anti-cancer drugs. In organ allotransplantation, current regimens infrequently include an mTOR-I, which are positioned more commonly as alternative immunosuppressants. In clinical allotransplantation, long-term efficacy has been established, but there is a significant incidence of adverse events, for example, inhibition of wound healing, buccal ulceration, anemia, hyperglycemia, dyslipidemia, and thrombocytopenia, some of which are dose-dependent. mTOR-Is have properties that may be especially beneficial in xenotransplantation. These include suppression of T cell proliferation, increases in the number of T regulatory cells, inhibition of pig graft growth, and anti-inflammatory, anti-viral, and anti-cancer effects. We here review the potential benefits and risks of mTOR-Is in xenotransplantation and suggest that the benefits exceed the adverse effects.
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Affiliation(s)
- Akihiro Maenaka
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Kohei Kinoshita
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Hidetaka Hara
- College of Veterinary Medicine, Yunnan Agricultural University, Kunming, Yunnan, China
| | - David K C Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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4
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Tang Y, Guo J, Li J, Zhou J, Mao X, Qiu T. Risk factors for cytomegalovirus infection and disease after kidney transplantation: A meta-analysis. Transpl Immunol 2022; 74:101677. [PMID: 35901951 DOI: 10.1016/j.trim.2022.101677] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To investigate the risk factors for cytomegalovirus (CMV) infection and disease in kidney transplantation recipient, and provide references for the prevention and control of CMV infection and disease in kidney transplantation patients. METHODS Chinese and international literature related to risk factors for CMV infection and disease in renal transplant recipients was searched using databases, including China National Knowledge Infrastructure; WanFang Data; Wiper; Chinese Biomedical Literature database; PubMed; Embase; Web of Science, and the Cochrane Register of Controlled Trials. Two researchers independently screened the literature, extracted the data, and evaluated the quality of the literature according to published standards. A meta-analysis was performed using RevMan 5.4 software to extract the risk factors for CMV infection and disease in renal transplant recipients. RESULTS A total of 59,847 subjects were included in 24 studies. The risk factors for CMV infection were ATG [OR = 2.76, 95% CI (2.10, 3.63), P < 0.00001], Donor (D) CMV-IgG(+) Receptor (R)(-): (D+/R-) [OR = 2.97, 95% CI (1.63, 5.44), P = 0.004 < 0.05], recipient age [OR = 1.96, 95% CI (1.50, 2.54), P < 0.00001], lymphocytopenia [OR = 3.26, 95% CI (1.46, 7.31), P < 0.00001], and mycophenolate [OR = 3.22, 95% CI (2.02, 5.46), P < 0.00001]. The protective factor for CMV infection was glomerular filtration rate (GFR) [OR = 0.98, 95% CI (0.97, 0.99), P < 0.00001], and the uncertain factors were the use of tacrolimus [OR = 0.91, 95% CI (0.64, 1.28), P = 0.58 > 0.05], rejection [OR = 1.32, 95% CI (0.49, 3.53), P = 0.58 > 0.05], donor age [OR = 1.00, 95% CI (0.99, 1.01), P = 0.67 > 0.5], and preemptive therapy [OR = 0.51, 95% CI (0.11, 2.36), P = 0.86 > 0.05]. The risk factors for CMV disease were D+/R- [OR = 4.78, 95% CI (3.76, 6.07), P < 0.00001], ATG [OR = 1.83, 95% CI (1.25, 2.67), P < 0.00001], rejection [OR = 1.42, 95% CI (1.26, 1.59), P < 0.00001], mycophenolate [OR = 1.67, 95% CI (1.38, 2.02), P < 0.00001], recipient age [OR = 1.03, 95% CI (1.02, 1.03), P < 0.00001], donor age [OR = 1.01, 95% CI (1.00, 1.01), P = 0.001 < 0.05], Donor (D) CMV-IgG(+) Receptor(R)(+): (D+/R+) [OR = 1.92, 95% CI (1.49, 2.46), P < 0.00001], the use of prednisolone [OR = 1.59, 95% CI (1.32, 1.92), P < 0.00001], and diabetes mellitus[OR = 1.18, 95% CI (1.01, 1.37), P = 0.03 < 0.05], and the uncertain factors were donor type [OR = 4.10, 95% CI (0.28, 59.79), P = 0.30 > 0.05], time of transplantation [OR = 0.95, 95% CI (0.78, 1.16), P = 0.64 > 0.05], and the use of cyclosporine [OR = 1.50, 95% CI (0.62, 3.64), P = 0.37 > 0.05]. CONCLUSION There are many factors influencing CMV infection and disease in kidney transplant patients. Risk factors should be carefully monitored, protective factors strengthened, and more attention paid to uncertain factors.
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Affiliation(s)
- Yan Tang
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Jiayu Guo
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Jinke Li
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Jiangqiao Zhou
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China
| | - Xiaolan Mao
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
| | - Tao Qiu
- Department of Organ Transplantation, Renmin's Hospital of Wuhan University, Wuhan University, Wuhan 430060, China.
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5
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Bikhet M, Iwase H, Yamamoto T, Jagdale A, Foote JB, Ezzelarab M, Anderson DJ, Locke JE, Eckhoff DE, Hara H, Cooper DKC. What Therapeutic Regimen Will Be Optimal for Initial Clinical Trials of Pig Organ Transplantation? Transplantation 2021; 105:1143-1155. [PMID: 33534529 DOI: 10.1097/tp.0000000000003622] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We discuss what therapeutic regimen might be acceptable/successful in the first clinical trial of genetically engineered pig kidney or heart transplantation. As regimens based on a calcineurin inhibitor or CTLA4-Ig have proved unsuccessful, the regimen we administer to baboons is based on induction therapy with antithymocyte globulin, an anti-CD20 mAb (Rituximab), and cobra venom factor, with maintenance therapy based on blockade of the CD40/CD154 costimulation pathway (with an anti-CD40 mAb), with rapamycin, and a corticosteroid. An anti-inflammatory agent (etanercept) is administered for the first 2 wk, and adjuvant therapy includes prophylaxis against thrombotic complications, anemia, cytomegalovirus, and pneumocystis. Using this regimen, although antibody-mediated rejection certainly can occur, we have documented no definite evidence of an adaptive immune response to the pig xenograft. This regimen could also form the basis for the first clinical trial, except that cobra venom factor will be replaced by a clinically approved agent, for example, a C1-esterase inhibitor. However, none of the agents that block the CD40/CD154 pathway are yet approved for clinical use, and so this hurdle remains to be overcome. The role of anti-inflammatory agents remains unproven. The major difference between this suggested regimen and those used in allotransplantation is the replacement of a calcineurin inhibitor with a costimulation blockade agent, but this does not appear to increase the complications of the regimen.
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Affiliation(s)
- Mohamed Bikhet
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Takayuki Yamamoto
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Abhijit Jagdale
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL
| | - Mohamed Ezzelarab
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas J Anderson
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Devin E Eckhoff
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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6
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Hauser IA, Marx S, Sommerer C, Suwelack B, Dragun D, Witzke O, Lehner F, Schiedel C, Porstner M, Thaiss F, Neudörfl C, Falk CS, Nashan B, Sester M. Effect of everolimus-based drug regimens on CMV-specific T-cell functionality after renal transplantation: 12-month ATHENA subcohort-study results. Eur J Immunol 2020; 51:943-955. [PMID: 33306229 DOI: 10.1002/eji.202048855] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/15/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023]
Abstract
Post-transplant cytomegalovirus (CMV) infections and increased viral replication are associated with CMV-specific T-cell anergy. In the ATHENA-study, de-novo everolimus (EVR) with reduced-exposure tacrolimus (TAC) or cyclosporine (CyA) showed significant benefit in preventing CMV infections in renal transplant recipients as compared to standard TAC + mycophenolic acid (MPA). However, immunomodulatory mechanisms for this effect remain largely unknown. Ninety patients from the ATHENA-study completing the 12-month visit on-treatment (EVR + TAC n = 28; EVR + CyA n = 19; MPA + TAC n = 43) were included in a posthoc analysis. Total lymphocyte subpopulations were quantified. CMV-specific CD4 T cells were determined after stimulation with CMV-antigen, and cytokine-profiles and various T-cell anergy markers were analyzed using flow cytometry. While 25.6% of MPA + TAC-treated patients had CMV-infections, no such events were reported in EVR-treated patients. Absolute numbers of lymphocyte subpopulations were comparable between arms, whereas the percentage of regulatory T cells was significantly higher with EVR + CyA versus MPA + TAC (p = 0.019). Despite similar percentages of CMV-specific T cells, their median expression of CTLA-4 and PD-1 was lower with EVR + TAC (p < 0.05 for both) or EVR + CyA (p = 0.045 for CTLA-4) compared with MPA + TAC. Moreover, mean percentages of multifunctional CMV-specific T cells were higher with EVR + TAC (27.2%) and EVR + CyA (29.4%) than with MPA + TAC (19.0%). In conclusion, EVR-treated patients retained CMV-specific T-cell functionality, which may contribute to enhanced protection against CMV infections.
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Affiliation(s)
- Ingeborg A Hauser
- Department of Nephrology, Goethe-University Frankfurt, Frankfurt, Germany
| | - Stefanie Marx
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Claudia Sommerer
- Nephrology Unit, University Hospital Heidelberg, Heidelberg, Germany
| | - Barbara Suwelack
- Department of Internal Medicine, Transplant Nephrology, University Hospital of Münster, Münster, Germany
| | - Duska Dragun
- Department of Nephrology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, West German Centre of Infectious Diseases, Universitätsmedizin Essen, University Duisburg-Essen, Duisburg-Essen, Germany
| | - Frank Lehner
- Clinic for General, Abdominal and Transplant Surgery, Hannover Medical School, Hannover, Germany.,Helios Hospital Hildesheim, Department of General- and Visceral Surgery, Academic Teaching Hospital of the Hannover Medical School, Hildesheim, Germany
| | | | | | - Friedrich Thaiss
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Neudörfl
- Institute of Transplant Immunology, Hannover Medical School MHH, Hannover, Germany
| | - Christine S Falk
- Institute of Transplant Immunology, Hannover Medical School MHH, Hannover, Germany.,German Center for Infection Research DZIF, Hannover, Germany
| | - Björn Nashan
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, Hefei, China
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
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7
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Raval AD, Kistler KD, Tang Y, Murata Y, Snydman DR. Epidemiology, risk factors, and outcomes associated with cytomegalovirus in adult kidney transplant recipients: A systematic literature review of real-world evidence. Transpl Infect Dis 2020; 23:e13483. [PMID: 33012092 DOI: 10.1111/tid.13483] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/21/2022]
Abstract
Kidney transplant recipients (KTRs) have increased risk for cytomegalovirus (CMV) infection/disease given the necessity of drug-induced immunosuppression. A comprehensive review of published literature reporting real-world data on prevention strategies utilized and associated CMV burden outcomes is limited. Such data could help inform future clinical practice and identify unmet needs in CMV management. We conducted a systematic review of observational studies published in Medline or EMBASE from January 2008 to November 2018 to identify current real-world CMV management approaches, CMV infection/disease risk factors, and outcomes associated with CMV infection. Descriptive statistics and pooled quantitative analyses were conducted. From 1608 records screened, 86 citations, including 69 803 adult KTR, were included. Prophylaxis and preemptive therapy (PET) were predominant approaches among D+/R- and R + CMV serostatus transplants, respectively. Valganciclovir and ganciclovir were frequently utilized across CMV risk strata. Despite prevention approaches, approximately one-fourth of KTR developed CMV infection. Age and D+/R- CMV serostatus were consistent risk factors for CMV infection/disease. CMV infection/disease was associated with increased mortality and graft loss. CMV was similarly associated with acute rejection (AR) risk, but with high heterogeneity among studies. Limited data were available on CMV and opportunistic infections (OIs) risk. CMV remains a significant issue. New strategies may be needed to optimize CMV management.
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8
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Laub MR, Byrns J, Gommer J, Ellis M, Harris M. Delayed vs initial cytomegalovirus prophylaxis after kidney transplantation. Clin Transplant 2020; 34:e13854. [PMID: 32163619 DOI: 10.1111/ctr.13854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/28/2020] [Accepted: 03/06/2020] [Indexed: 12/13/2022]
Abstract
It is recommended to start cytomegalovirus (CMV) prophylaxis within 10 days of solid organ transplant, if indicated. Our center underwent a cost-savings initiative to delay CMV prophylaxis initiation from postoperative day zero to postoperative day 7 or upon discharge, hypothesizing this would not affect clinical outcomes but could impact costs. The purpose of this retrospective study was to determine the effects of early vs delayed (<72 vs >72 hours after transplant) CMV prophylaxis in kidney and kidney/pancreas transplant recipients transplanted between June 2014 and January 2017. The primary endpoint was incidence of CMV infection within 1 year. Secondary endpoints included CMV disease, CMV testing, and valganciclovir cost during index hospitalization. A total of 173 patients (114 early, 59 delayed) were included. CMV infection occurred in 61% vs 54% in the early vs delayed group (P = .5). Excluding low-level DNAemia (QNAT < 200 IU/mL), infection occurred in 30% vs 22% in the early vs late group (P = .4). The median days to starting prophylaxis were 0 and 6 in the early and delayed group (P < .05), which led to a median cost savings of $497.00 per patient during index hospitalization (P < .05). Delaying prophylaxis initiation did not impact CMV outcomes in this cohort and decreased costs.
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Affiliation(s)
- Melissa R Laub
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina
| | - Jennifer Byrns
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina
| | - Jennifer Gommer
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina
| | - Matthew Ellis
- Department of Medicine, Duke University Hospital, Durham, North Carolina
| | - Matt Harris
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina
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9
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Jehn U, Schütte-Nütgen K, Bautz J, Pavenstädt H, Suwelack B, Thölking G, Heinzow H, Reuter S. Cytomegalovirus Viremia after Living and Deceased Donation in Kidney Transplantation. J Clin Med 2020; 9:jcm9010252. [PMID: 31963515 PMCID: PMC7019428 DOI: 10.3390/jcm9010252] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 12/14/2022] Open
Abstract
Despite screening, effective anti-viral drugs and risk-balanced prophylaxis, cytomegalovirus (CMV) remains a major cause of morbidity in transplant patients. The objective of this study was to retrospectively analyze the risk factors associated with CMV viremia after kidney transplantation in a large European cohort with standardized valganciclovir prophylaxis in the present era. A special focus was placed on the comparison of living and postmortal donation. We conducted a longitudinal observational study involving 723 adult patients with a total of 3292 patient-years who were transplanted at our center between 2007 and 2015. Valganciclovir prophylaxis was administered over 100 days for CMV+ donors (D) or recipients (R), over 200 days for D+/R−, and none in D−/R−. A CMV+ donor, rejection episodes, and deceased donor transplantation were identified to be associated with increased incidences of CMV viremia. Although we did not find a reduced overall survival rate for patients with CMV viremia, it was associated with worse graft function. Since we observed a relevant number of CMV infections despite prescribing valganciclovir prophylaxis, a pre-emptive strategy in patients with (suspected) adherence restrictions could be favored. Our data can help transplant physicians educate their patients about their individual CMV risk and choose the most appropriate CMV treatment approach.
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Affiliation(s)
- Ulrich Jehn
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany; (U.J.); (K.S.-N.); (J.B.); (H.P.); (B.S.); (G.T.)
| | - Katharina Schütte-Nütgen
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany; (U.J.); (K.S.-N.); (J.B.); (H.P.); (B.S.); (G.T.)
| | - Joachim Bautz
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany; (U.J.); (K.S.-N.); (J.B.); (H.P.); (B.S.); (G.T.)
| | - Hermann Pavenstädt
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany; (U.J.); (K.S.-N.); (J.B.); (H.P.); (B.S.); (G.T.)
| | - Barbara Suwelack
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany; (U.J.); (K.S.-N.); (J.B.); (H.P.); (B.S.); (G.T.)
| | - Gerold Thölking
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany; (U.J.); (K.S.-N.); (J.B.); (H.P.); (B.S.); (G.T.)
| | - Hauke Heinzow
- Department of Medicine B, Division of Gastroenterology and Hepatology, University Hospital of Muenster, 48149 Muenster, Germany;
| | - Stefan Reuter
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, 48149 Muenster, Germany; (U.J.); (K.S.-N.); (J.B.); (H.P.); (B.S.); (G.T.)
- Correspondence: ; Tel.: +49-251-83-47540; Fax: +49-251-83-56973
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10
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Bedreli S, Straub K, Achterfeld A, Willuweit K, Katsounas A, Saner F, Wedemeyer H, Herzer K. The Effect of Immunosuppression on Coagulation After Liver Transplantation. Liver Transpl 2019; 25:1054-1065. [PMID: 31021493 DOI: 10.1002/lt.25476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 03/30/2019] [Indexed: 12/24/2022]
Abstract
Everolimus (EVR) is a mammalian target of rapamycin (mTOR) inhibitor commonly used for immunosuppression (IS) after liver transplantation (LT). However, there are concerns about whether mTOR inhibitors may move the hemostatic balance toward a higher likelihood of thrombosis. The present study aimed to investigate potential coagulation disorders after the administration of EVR. We evaluated 54 patients after conversion to an EVR-based IS regimen (n = 26) and compared those patients with patients who were switched to extended-release tacrolimus (TAC) but had never received EVR (n = 28). At baseline and again at 1 month and 6 months after conversion, we measured international normalized ratio, activated partial thromboplastin time, and anticoagulation and fibrinolysis factors, and we performed rotational thromboelastometry (ROTEM). Data were analyzed with a Mann-Whitney U test, a repeated-measure analysis of variance, and a Fisher's exact test. Statistical significance was set at the level of P ≤ 0.05. Plasma levels of von Willebrand factor, fibrinogen, and factor VIII were significantly higher than baseline levels at 1 month and 6 months after conversion of IS to EVR (P < 0.001); plasma levels of protein C, protein S, and plasminogen also increased significantly (P < 0.001). ROTEM confirmed a significant increase in maximum clot firmness in EXTEM, INTEM, and FIBTEM assays (P < 0.001). In all assays, maximum lysis was significantly lower than baseline levels at 1 month and 6 months after conversion to EVR. Patients converted to IS with extended-release TAC exhibited no significant changes in coagulation variables. Retrospective analysis showed a significantly higher incidence of thromboembolic complications among patients treated with EVR-based IS than among those treated with extended-release TAC (P < 0.01). In conclusion, the administration of EVR after LT seems to modify hemostasis to a procoagulant state. Thrombophilia screening before conversion may determine which patients will benefit from conversion to EVR-based IS.
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Affiliation(s)
- Sotiria Bedreli
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katja Straub
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Anne Achterfeld
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katharina Willuweit
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Antonios Katsounas
- Department of Gastroenterology, Hepatology and Infectious Diseases, University of Magdeburg, Magdeburg, Germany
| | - Fuat Saner
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Kerstin Herzer
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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11
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International Liver Transplantation Society Consensus Statement on Immunosuppression in Liver Transplant Recipients. Transplantation 2019; 102:727-743. [PMID: 29485508 DOI: 10.1097/tp.0000000000002147] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Effective immunosupression management is central to achieving optimal outcomes in liver transplant recipients. Current immunosuppression regimens and agents are highly effective in minimizing graft loss due to acute and chronic rejection but can also produce a substantial array of toxicities. The utilization of immunosuppression varies widely, contributing to the wide disparities in posttransplant outcomes reported between transplant centers. The International Liver Transplantation Society (ILTS) convened a consensus conference, comprised of a global panel of expert hepatologists, transplant surgeons, nephrologists, and pharmacologists to review the literature and experience pertaining to immunosuppression management to develop guidelines on key aspects of immunosuppression. The consensus findings and recommendations of the ILTS Consensus guidelines on immunosuppression in liver transplant recipients are presented in this article.
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12
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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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13
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Analysis of Risk Factors for Allograft Outcome Comparing 2 Kidneys From the Same Donor in Separate Recipients. Transplant Proc 2018; 50:3211-3215. [PMID: 30577187 DOI: 10.1016/j.transproceed.2018.08.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/31/2018] [Accepted: 08/16/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND An analysis of 2 kidney transplants from the same donor at the same center enables us to analyze the influence of risk factors on the outcome of the grafts in different recipients. METHODS We retrospectively analyzed 88 kidneys from 44 donors that were implanted in 88 recipients at our institution between 2007-2016. We defined unsatisfactory outcome as glomerular filtration rate <30 mL/min/1.73 m2 allograft loss or recipient death within the first year after transplantation. Fifty-three kidneys were allocated and age-matched to donors above the age of 65 years (via Eurotransplant Senior Program or center offer). We compared kidney pairs with satisfactory outcome in both recipients (group A) to pairs with divergent outcome (group B) and unsatisfactory outcome in both recipients (group C). RESULTS Thirty-four grafts (17 donors) had a satisfactory outcome for both recipients (group A), and 16 grafts (8 donors) had an unsatisfactory outcome for both recipients (group C). Donor age was significantly higher in group C vs group A (67.5 ± 6.7 vs 56.4 ± 16.0 years, P = .010). The 19 donors donating 1 kidney with satisfactory and the other with unsatisfactory outcome were 67.4 ± 10.7 years old (group B). A severe surgical complication occurred more often in recipients with an unsatisfactory outcome in comparison to patients with a satisfactory outcome. CONCLUSION Donor age is an important risk factor for an unsatisfactory outcome, either in one or both kidneys of the same donor.
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14
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Tan L, Sato N, Shiraki A, Yanagita M, Yoshida Y, Takemura Y, Shiraki K. Everolimus delayed and suppressed cytomegalovirus DNA synthesis, spread of the infection, and alleviated cytomegalovirus infection. Antiviral Res 2018; 162:30-38. [PMID: 30543830 DOI: 10.1016/j.antiviral.2018.12.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 12/26/2022]
Abstract
Everolimus is an inhibitor of mammalian target of rapamycin (mTOR) and reduces the risk of cytomegalovirus (CMV) infection in transplant recipients. Everolimus inhibits mTOR complex 1, which regulates factors involved in several crucial cellular functions and is required for CMV replication. However, it is not clear how everolimus regulates CMV replication and prevents and alleviates CMV infection. Effects of everolimus on CMV infection, spread, and DNA synthesis and release from infected cells were assessed by plaque formation, infectious centre assay, real-time PCR of infected cells, and culture supernatant in CMV-infected cultures with and without everolimus. Everolimus enhanced plaque formation by 3.6 times, but the size of the plaques was reduced to 36.4% of untreated cultures in the absence of a pretreatment period. Everolimus reduced viral adsorption but enhanced the replication efficiency of inoculated virus, resulting in an increase in plaque number in the early phase of infection. Preinfection treatment of cells with everolimus efficiently exhibited its antiviral efficacy, and everolimus delayed and suppressed viral DNA synthesis and release from infected cells. Everolimus had suppressed the spread of infection and reduced the number of total infected cells to 40% of untreated cells on day 9, indicating reduction of the size of CMV lesions to one-sixth in 2-3 replication cycles. Preinfection treatment of the cells with everolimus augmented its suppressive effect on CMV infection and replication. Everolimus reduced the total number of infected cells and limited the CMV lesions, and this reduction in the spread of CMV infection would alleviate CMV infection in transplant recipients.
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Affiliation(s)
- Long Tan
- Department of Virology, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Noriaki Sato
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Atsuko Shiraki
- Department of Anesthesiology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoshihiro Yoshida
- Department of Virology, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Yoshinori Takemura
- Department of Anesthesiology, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Kimiyasu Shiraki
- Department of Virology, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
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15
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Li J, Koch M, Kramer K, Kloth K, Abu Ganim AR, Scheidat S, Rinninger F, Thaiss F, Gulati A, Herden U, Achilles E, Fischer L, Nashan B. Dual antibody induction and de novo use of everolimus enable low-dose tacrolimus with early corticosteroid withdrawal in simultaneous pancreas-kidney transplantation. Transpl Immunol 2018; 50:26-33. [DOI: 10.1016/j.trim.2018.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 05/27/2018] [Accepted: 06/01/2018] [Indexed: 12/28/2022]
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16
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Cowan J, Bennett A, Fergusson N, McLean C, Mallick R, Cameron DW, Knoll G. Incidence Rate of Post-Kidney Transplant Infection: A Retrospective Cohort Study Examining Infection Rates at a Large Canadian Multicenter Tertiary-Care Facility. Can J Kidney Health Dis 2018; 5:2054358118799692. [PMID: 30224973 PMCID: PMC6136109 DOI: 10.1177/2054358118799692] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 08/04/2018] [Indexed: 11/16/2022] Open
Abstract
Background Reducing post-operative infections among kidney transplant patients is critical to improve long-term outcomes. With shifting disease demographics and implementation of new transplantation protocols, frequent evaluation of infection rate and type is necessary. Objective Our objectives were to assess the incidence and types of post-operative infections in kidney transplant recipients at a large tertiary-care facility and determine sample sizes needed for future intervention trials. Design Retrospective cohort study. Setting The Ottawa Hospital, Ottawa, Ontario. Patients Adult kidney transplant patients, N = 142. Measurements Demographic data, transplant protocol, infections up to 2 years following transplantation. Methods Infections within 2 years following transplantation in all kidney transplant recipients between January 2011 and December 2012 were reviewed. Sample sizes were determined using all-cause infection rates and infection-free survival data. Results Of 142 patients, 44 (31.0%) had at least one infection. The incidence of infection was 36.2 per 100 patient-years by 2 years post-transplant. A total of 32 (22.5%) patients had 56 infection-related hospitalizations with 73.2% occurring in the first year. In the first 2 years, urinary tract infections had the highest incidence (18.1 per 100 patient-years) followed by skin (3.9 per 100 patient-years), cytomegalovirus (3.9 per 100 patient-years), and bacteremia (3.9 per 100 patient-years). Results indicate that 206 patients per study arm would be needed to show a 30% reduction in the 2-year incidence of infection post-transplantation. Limitations Infection rates may be slightly underestimated due to the relatively short 2-year follow-up; however, the highest infection-risk period was captured within this time frame. Conclusions Infections post-kidney transplant are still common, particularly urinary tract infections. They are associated with significant morbidity and hospitalization. Given the feasible sample sizes calculated in this study, intervention trials are indicated to further reduce infection rates within the first 2 years post-kidney transplantation.
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Affiliation(s)
- Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, ON, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada.,Department of Biochemistry, Microbiology and Immunology, University of Ottawa, ON, Canada
| | - Alexandria Bennett
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, ON, Canada
| | - Nicholas Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada
| | | | - Ranjeeta Mallick
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, ON, Canada
| | - D William Cameron
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, ON, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada.,Department of Biochemistry, Microbiology and Immunology, University of Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, ON, Canada
| | - Greg Knoll
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, ON, Canada.,Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
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17
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Rohn H, Tomoya Michita R, Schwich E, Dolff S, Gäckler A, Trilling M, Le-Trilling VTK, Wilde B, Korth J, Heinemann FM, Horn PA, Kribben A, Witzke O, Rebmann V. The Donor Major Histocompatibility Complex Class I Chain-Related Molecule A Allele rs2596538 G Predicts Cytomegalovirus Viremia in Kidney Transplant Recipients. Front Immunol 2018; 9:917. [PMID: 29867932 PMCID: PMC5953334 DOI: 10.3389/fimmu.2018.00917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/13/2018] [Indexed: 01/14/2023] Open
Abstract
The interaction of major histocompatibility complex class I chain-related protein A (MICA) and its cognate activating receptor natural killer (NK) group 2 member D (NKG2D) receptor plays a significant role in viral immune control. In the context of kidney transplantation (KTx), cytomegalovirus (CMV) frequently causes severe complications. Hypothesizing that functional polymorphisms of the MICA/NKG2D axis might affect antiviral NK and T cell responses to CMV, we explored the association of the MICA-129 Met/Val single nucleotide polymorphism (SNP) (affecting the binding affinity of MICA with the NKG2D receptor), the MICA rs2596538 G/A SNP (influencing MICA transcription), and the NKG2D rs1049174 G/C SNP (determining the cytotoxic potential of effector cells) with the clinical outcome of CMV during the first year after KTx in a cohort of 181 kidney donor-recipients pairs. Univariate analyses identified the donor MICA rs2596538 G allele status as a protective prognostic determinant for CMV disease. In addition to the well-known prognostic factors CMV high-risk sero-status of patients and the application of lymphocyte-depleting drugs, the donor MICA rs2596538 G allele carrier status was confirmed by multivariate analyses as novel-independent factor predicting the development of CMV infection/disease during the first year after KTx. The results of our study emphasize the clinical importance of the MICA/NKG2D axis in CMV control in KTx and point out that the potential MICA transcription in the donor allograft is of clinically relevant importance for CMV immune control in this allogeneic situation. Furthermore, they provide substantial evidence that the donor MICA rs2596538 G allele carrier status is a promising genetic marker predicting CMV viremia after KTx. Thus, in the kidney transplant setting, donor MICA rs2596538 G may help to allow the future development of personal CMV approaches within a genetically predisposed patient cohort.
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Affiliation(s)
- Hana Rohn
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Rafael Tomoya Michita
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Esther Schwich
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Anja Gäckler
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Mirko Trilling
- Institute for Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | | | - Benjamin Wilde
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Johannes Korth
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Falko M Heinemann
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Peter A Horn
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Vera Rebmann
- Institute for Transfusion Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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18
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Devresse A, Leruez-Ville M, Scemla A, Avettand-Fenoel V, Morin L, Lebreton X, Tinel C, Amrouche L, Lamhaut L, Timsit MO, Zuber J, Legendre C, Anglicheau D. Reduction in late onset cytomegalovirus primary disease after discontinuation of antiviral prophylaxis in kidney transplant recipients treated with de novo everolimus. Transpl Infect Dis 2018; 20:e12846. [DOI: 10.1111/tid.12846] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 09/30/2017] [Accepted: 11/02/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Arnaud Devresse
- Service de Transplantation Rénale et Unité de Soins Intensifs; Hôpital Necker-Enfants Malades; AP-HP; Paris France
- Service de Néphrologie des Cliniques Universitaires Saint-Luc; Bruxelles Belgique
- Institut de Recherche Expérimentale et Clinique; Université Catholique de Louvain; Bruxelles Belgique
| | - Marianne Leruez-Ville
- Faculté de Médecine; Université Paris Descartes; Paris France
- Département de Virologie; Hôpital Necker-Enfants Malades; AP-HP; Paris France
| | - Anne Scemla
- Service de Transplantation Rénale et Unité de Soins Intensifs; Hôpital Necker-Enfants Malades; AP-HP; Paris France
| | - Véronique Avettand-Fenoel
- Faculté de Médecine; Université Paris Descartes; Paris France
- Département de Virologie; Hôpital Necker-Enfants Malades; AP-HP; Paris France
| | - Lise Morin
- Service de Transplantation Rénale et Unité de Soins Intensifs; Hôpital Necker-Enfants Malades; AP-HP; Paris France
| | - Xavier Lebreton
- Service de Transplantation Rénale et Unité de Soins Intensifs; Hôpital Necker-Enfants Malades; AP-HP; Paris France
| | - Claire Tinel
- Service de Transplantation Rénale et Unité de Soins Intensifs; Hôpital Necker-Enfants Malades; AP-HP; Paris France
| | - Lucile Amrouche
- Service de Transplantation Rénale et Unité de Soins Intensifs; Hôpital Necker-Enfants Malades; AP-HP; Paris France
- Faculté de Médecine; Université Paris Descartes; Paris France
| | - Lionel Lamhaut
- Service d'anesthésie; Hôpital Necker-Enfants Malades; AP-HP; Paris France
| | | | - Julien Zuber
- Service de Transplantation Rénale et Unité de Soins Intensifs; Hôpital Necker-Enfants Malades; AP-HP; Paris France
- Faculté de Médecine; Université Paris Descartes; Paris France
| | | | - Dany Anglicheau
- Service de Transplantation Rénale et Unité de Soins Intensifs; Hôpital Necker-Enfants Malades; AP-HP; Paris France
- Faculté de Médecine; Université Paris Descartes; Paris France
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19
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Gaudre N, Cougoul P, Bartolucci P, Dörr G, Bura-Riviere A, Kamar N, Del Bello A. Improved Fetal Hemoglobin With mTOR Inhibitor-Based Immunosuppression in a Kidney Transplant Recipient With Sickle Cell Disease. Am J Transplant 2017; 17:2212-2214. [PMID: 28276629 DOI: 10.1111/ajt.14263] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 01/25/2023]
Abstract
Fetal hemoglobin induction is a key point in the management of sickle cell disease (SCD). We report the case of a kidney transplant recipient with SCD who was treated with everolimus, a mammalian target of rapamycin inhibitor. At 10 months after initiating therapy, the patient's fetal hemoglobin level was dramatically increased (from 4.8% to 15%) and there was excellent tolerance to treatment.
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Affiliation(s)
- N Gaudre
- Department of Vascular Medicine, CHU Rangueil, Toulouse, France
| | - P Cougoul
- Department of Internal Medicine, Cancer University Institute of Toulouse-Oncopole, Toulouse, France
| | - P Bartolucci
- AP-HP, Groupe Hospitalier Henri Mondor-Albert Chenevier, Centre de Référence des Syndromes Drépanocytaires Majeurs, Créteil, France.,Laboratoire d'Excellence GRex, Département Hospitalo-Universitaire Ageing-Thorax-Vessels-Blood, Institut Mondor de Recherche Biomédicale, Université Paris-Est-Créteil, Créteil, France.,Service de Médecine Interne, AP-HP, Groupe Hospitalier Henri Mondor-Albert Chenevier, Créteil, France
| | - G Dörr
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - A Bura-Riviere
- Department of Vascular Medicine, CHU Rangueil, Toulouse, France
| | - N Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France
| | - A Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
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20
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Abstract
Solid-organ transplantation in pediatrics can be a life-saving procedure, but it cannot be accomplished without risk of infection-related morbidity and mortality. Evaluation of the recipient during candidacy and donor during evaluation can assist with identification of risk. Further, risk of infection from the surgical procedure can be mitigated through careful planning and attention to infection prevention processes. Finally, early recognition of infection posttransplant can limit the impact of these events.
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Affiliation(s)
- Elizabeth Doby Knackstedt
- Division of Pediatric Infectious Disease, University of Utah, Salt Lake City, Utah; Division of Transplant/Immunocompromised Infectious Diseases, Primary Children's Hospital, Salt Lake City, Utah
| | - Lara Danziger-Isakov
- Division of Pediatric Infectious Diseases, University of Cincinnati, Immunocompromised Host Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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21
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Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients: A Guidance Report and Clinical Checklist by the Consensus on Managing Modifiable Risk in Transplantation (COMMIT) Group. Transplantation 2017; 101:S1-S56. [PMID: 28328734 DOI: 10.1097/tp.0000000000001651] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Short-term patient and graft outcomes continue to improve after kidney and liver transplantation, with 1-year survival rates over 80%; however, improving longer-term outcomes remains a challenge. Improving the function of grafts and health of recipients would not only enhance quality and length of life, but would also reduce the need for retransplantation, and thus increase the number of organs available for transplant. The clinical transplant community needs to identify and manage those patient modifiable factors, to decrease the risk of graft failure, and improve longer-term outcomes.COMMIT was formed in 2015 and is composed of 20 leading kidney and liver transplant specialists from 9 countries across Europe. The group's remit is to provide expert guidance for the long-term management of kidney and liver transplant patients, with the aim of improving outcomes by minimizing modifiable risks associated with poor graft and patient survival posttransplant.The objective of this supplement is to provide specific, practical recommendations, through the discussion of current evidence and best practice, for the management of modifiable risks in those kidney and liver transplant patients who have survived the first postoperative year. In addition, the provision of a checklist increases the clinical utility and accessibility of these recommendations, by offering a systematic and efficient way to implement screening and monitoring of modifiable risks in the clinical setting.
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22
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Feng S, Yang J, Wang W, Hu X, Liu H, Qian X, Feng D, Zhang X. Incidence and Risk Factors for Cytomegalovirus Infection in Patients With Kidney Transplantation: A Single-Center Experience. Transplant Proc 2017; 48:2695-2699. [PMID: 27788803 DOI: 10.1016/j.transproceed.2016.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/03/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is deemed to be a major cause of morbidity and mortality in patients after kidney transplantation. The purpose of this study was to analyze the incidence of CMV infection and risk factors for CMV infection in our center, to help in determination of its impact on the kidney function in this patient population, and to provide new ideas for the prevention and treatment of CMV infection. METHODS A total of 319 kidney transplant recipients from our center were studied between January 2000 and December 2015. The CMV viral load in each kidney transplant patients was monitored with the use of CMV quantitative nucleic acid testing (CMV-QNAT). Laboratory data and other medical records were also collected. RESULTS The incidence of CMV infection was 8.8% in our studied patients. The patients within 3 to 6 months and 5 to 10 years after transplantation had a higher risk of CMV infection. CMV infection was probably correlated with lower white blood cell counts but elevated hemoglobin, serum creatinine, blood urea nitrogen, potassium, and estimated glomerular filtration rate (eGFR). Anti-CMV immunoglobulin (Ig)G and history of allograft rejection were also associated with CMV infection. In multivariate regression analysis, white blood cells, eGFR, anti-CMV IgG, and history of allograft rejection were the independent risk factors associated with CMV infection in kidney transplantation patients. CONCLUSIONS CMV infection was an important complication after kidney transplantation, particularly in these patients with allograft impairment.
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Affiliation(s)
- S Feng
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - J Yang
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - W Wang
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - X Hu
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - H Liu
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - X Qian
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - D Feng
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - X Zhang
- Institute of Uro-Nephrology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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23
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Modification of immunosuppressive therapy as risk factor for complications after liver transplantation. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624108 DOI: 10.1016/j.bpg.2017.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Management of complications post-liver transplantation (LT) includes immunosuppressive manipulations with the aim to reduce the overall burden of immunologic suppression and compensate for renal, cardiovascular, metabolic toxicities, and for the increased oncologic risk. Two approaches can be implemented to reduce immunosuppression-related adverse events: upfront schedules tailored to the pretransplant individual patient's risk profile versus downstream modifications in the event of immunosuppression-related complications. Upfront strategies are supported by evidence originating from prospective randomized trials and consist of triple/quadruple schedules whereby calcineurin inhibitors (CNI)-exposure is reduced with combination of anti-CD25 monoclonal antibodies, antimetabolites and corticosteroids. Quadruple regimens allow for staggering of CNI introduction and higher renal function in the early term, but their superiority in the long term has not yet been established. A more recent upfront schedule contemplates early (4 weeks) introduction of mammalian target of rapamycin inhibitor (mTORi) everolimus and allows for reduction of CNI up to 4 years posttransplantation. Incorporation of mTORi has the potential to prolong time to recurrence for patients with hepatocellular carcinoma. However, as suggested by the available evidence, downstream immunosuppressive manipulations are more frequently adopted in clinical practice. These encompass CNI replacement and immunosuppression withdrawal. Switching CNI to mTORi monotherapy is the option most commonly adopted to relieve renal function and compensate for posttransplant malignancies. Its impact is dependent on interval from transplantation and underlying severity of renal impairment. Introduction of mTORi is associated with longer overall survival for patients with extrahepatic posttransplant malignancies, but results are awaited for recurrences of hepatocellular carcinoma. Immunosuppression withdrawal seems feasible (70%) in very long term survivors (>10 years), but is not associated with reversal of immunosuppression-related complications. Awaiting novel immunosuppressive drug categories, integration of upfront strategies with the aim to reduce CNI-exposure and a low threshold for adjustment in the posttransplant course are both advisable to improve long-term outcomes of LT.
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24
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Arav-Boger R. Is drug repurposing the answer for cytomegalovirus treatment or prevention? Future Virol 2017. [DOI: 10.2217/fvl-2016-0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Medical progress has placed cytomegalovirus (CMV) as one of the most important viral pathogens for which treatment is limited and a vaccine is not yet available. The limited treatment options for CMV triggered efforts to discover new antivirals. Drug screening raised hope but also uncertainties as to whether drug repurposing may be a practical approach for infectious diseases in general and CMV in particular. I summarize here several of such agents as well as an approach to advance repurposing for CMV therapy.
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Affiliation(s)
- Ravit Arav-Boger
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Ji YD, Aboalela A, Villa A. Everolimus-associated stomatitis in a patient who had renal transplant. BMJ Case Rep 2016; 2016:bcr-2016-217513. [PMID: 27797804 DOI: 10.1136/bcr-2016-217513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Everolimus is used as an immunosuppressant in renal allograft transplant rejection and in metastatic breast cancer treatment. One side effect of everolimus is stomatitis, referred to as mammalian target of rapamycin inhibitor-associated stomatitis. This side effect can affect treatment course and contribute to discontinuation of therapy or dose reduction, previously reported in the treatment of metastatic breast cancer. Here, we present a case of everolimus-associated stomatitis with a novel management method with intralesional triamcinolone that allows for continuous course of everolimus.
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Affiliation(s)
- Yisi D Ji
- Harvard School of Dental Medicine, Boston, Massachusetts, USA
| | - Ali Aboalela
- Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Alessandro Villa
- Department of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, Massachusetts, USA
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