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Patterson CM, Shaw TD, Gerovasili V, Khatana U, Jose RJ. Emerging therapies and respiratory infections: Focus on the impact of immunosuppressants and immunotherapies. Clin Med (Lond) 2024; 24:100015. [PMID: 38387208 PMCID: PMC11024833 DOI: 10.1016/j.clinme.2024.100015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
Host defences to infection are based upon an integrated system of physical and biochemical barriers, innate and adaptive immunity. Weakness in any of these defensive elements leads to increased susceptibility to specific pathogens. Understanding how medical therapies disrupt host defences is key to the successful prevention, diagnosis and management of respiratory infection in the immunocompromised host.
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Affiliation(s)
- Caroline M Patterson
- Consultant in Respiratory Transplant Medicine, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
| | - Timothy D Shaw
- Academic Clinical Lecturer in Infectious Diseases and Medical Microbiology, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - Vicky Gerovasili
- Consultant in Respiratory Transplant Medicine, Royal Brompton and Harefield hospital, part of Guys and St Thomas NHS Foundation trust, London, UK
| | - Usman Khatana
- Specialty Trainee in Respiratory Medicine, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Ricardo J Jose
- Consultant in Host Defence, Royal Brompton and Harefield hospital, part of Guys and St Thomas NHS Foundation trust, London, UK
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2
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Patterson CM, Jolly EC, Burrows F, Ronan NJ, Lyster H. Conventional and Novel Approaches to Immunosuppression in Lung Transplantation. Clin Chest Med 2023; 44:121-136. [PMID: 36774159 DOI: 10.1016/j.ccm.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Most therapeutic advances in immunosuppression have occurred over the past few decades. Although modern strategies have been effective in reducing acute cellular rejection, excess immunosuppression comes at the price of toxicity, opportunistic infection, and malignancy. As our understanding of the immune system and allograft rejection becomes more nuanced, there is an opportunity to evolve immunosuppression protocols to optimize longer term outcomes while mitigating the deleterious effects of traditional protocols.
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Affiliation(s)
- Caroline M Patterson
- Transplant Continuing Care Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Elaine C Jolly
- Division of Renal Medicine, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Fay Burrows
- Department of Pharmacy, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Nicola J Ronan
- Transplant Continuing Care Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Haifa Lyster
- Cardiothoracic Transplant Unit, Royal Brompton and Harefield Hospitals, Part of Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom; Kings College, London, United Kingdom; Pharmacy Department, Royal Brompton and Harefield Hospitals, Part of Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom.
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3
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Rabbani A, Aliabbar S, Nikeghbalian S, Malek-hosseini A, Baziboroun M. Immunosuppressive regimens on conversion of cytomegalovirus infection to disease in liver transplant recipients. CASPIAN JOURNAL OF INTERNAL MEDICINE 2022; 13:721-727. [PMID: 36420336 PMCID: PMC9659840 DOI: 10.22088/cjim.13.4.721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 05/09/2021] [Accepted: 07/05/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) disease is one of the most common infectious complications after liver transplantation. It is the cause of numerous morbidity and mortalities. Intensity of immunosuppression defined as overall immunosuppressive drug dosage seems to affect infectious complications. The main purpose of this study is to investigate the intensity of immunosuppression on conversion of CMV infection to disease in this population. METHODS In this cross-sectional study, we retrospectively evaluated and analyzed the data of all recipients who underwent orthotopic liver transplantation (OLT) between March 2014 and March 2016 and had positive serum PCR for CMV after transplantation in follow- up course. Of 134 recipients, only 66 adult liver transplant recipients were eligible to be studied. Multiple variables such as MELD score, cold ischemic time, warm ischemic time, operative data, immunosuppressive drugs and regimen, plasma CMV viral load, donor and recipient CMV IgG serostatus were recorded and analyzed. RESULTS of the 66 patients, 50 (76%) had CMV infection and 16 (24%) had disease. There was significant association between donor CMV IgG serostatus, extra corticosteroid pulse therapy, acute cellular rejection, serum tacrolimus level and conversion of CMV infection to CMV disease (P=0.005, 0.001, 0.031, 0.031). CONCLUSION It seems that the intensity of immunosuppression has influence on conversion rate of CMV infection to disease in liver recipients.
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Affiliation(s)
- Amirhassan Rabbani
- Taleghani Hospital, Department of Transplant and Hepatobiliary Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran,Correspondence: Amirhassan Rabbani, Taleghani Hospital, Department of Transplant and Hepatobiliary Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail: , Tel: 0098 2122439963, Fax: 0098 2122439964
| | - Shiva Aliabbar
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saman Nikeghbalian
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Malek-hosseini
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mana Baziboroun
- Infectious Disease and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Cancer Research Center, Health Research Institue, Babol University of Medical Sciences, Babol, Iran
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4
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Ahlenstiel-Grunow T, Pape L. Novel ways to monitor immunosuppression in pediatric kidney transplant recipients-underlying concepts and emerging data. Mol Cell Pediatr 2021; 8:8. [PMID: 34309698 PMCID: PMC8313639 DOI: 10.1186/s40348-021-00118-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022] Open
Abstract
After pediatric kidney transplantation, immunosuppressive therapy is given to avoid acute and chronic rejections. However, the immunosuppression causes an increased risk of severe viral complications and bacterial infections and is associated with serious side effects. It is therefore crucial to achieve the optimal individual balance between over- and under-immunosuppression and thereby avoid unnecessary exposure to immunosuppressive drugs. In routine use, steering of immunosuppressants is performed primarily by monitoring of trough levels that mirror pharmacokinetics (although not, however, pharmacodynamics). Other diagnostic and prognostic markers to assess the individual intensity of immunosuppression are missing. Potential methods to determine immune function and grade of immunosuppression, such as analysis of the torque teno virus (TTV) load, QuantiFERON Monitor®, and ImmuKnow® as well as virus-specific T cells (Tvis), are currently being evaluated. In some studies TTV load, QuantiFERON Monitor® and ImmuKnow® were associated with the risk for post-transplant rejections and infections, but randomized controlled trials after pediatric kidney transplantation are not available. Post-transplant monitoring of Tvis levels seem to be promising because Tvis control virus replication and have been shown to correlate with virus-specific as well as general cellular immune defense, which represents the individual’s susceptibility to infections. Additional Tvis-monitoring provides an innovative opportunity to personalize the antiviral management and the dosing of the immunosuppressive therapy after pediatric kidney transplantation to avoid unnecessary therapeutic interventions and identify over-immunosuppression.
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Affiliation(s)
- Thurid Ahlenstiel-Grunow
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Pape
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Hufelandstraße 55, 45147, Essen, Germany.
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5
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Ahlenstiel-Grunow T, Liu X, Schild R, Oh J, Taylan C, Weber LT, Staude H, Verboom M, Schröder C, Sabau R, Großhennig A, Pape L. Steering Transplant Immunosuppression by Measuring Virus-Specific T Cell Levels: The Randomized, Controlled IVIST Trial. J Am Soc Nephrol 2021; 32:502-516. [PMID: 33323473 PMCID: PMC8054884 DOI: 10.1681/asn.2020050645] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 10/10/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Pharmacokinetic monitoring is insufficient to estimate the intensity of immunosuppression after transplantation. Virus-specific T cells correlate with both virus-specific and general cellular immune defense. Additional steering of immunosuppressive therapy by virus-specific T cell levels might optimize dosing of immunosuppressants. METHODS In a multicenter, randomized, controlled trial, we randomized 64 pediatric kidney recipients to a control group with trough-level monitoring of immunosuppressants or to an intervention group with additional steering of immunosuppressive therapy by levels of virus-specific T cells (quantified by cytokine flow cytometry). Both groups received immunosuppression with cyclosporin A and everolimus in the same target range of trough levels. Primary end point was eGFR 2 years after transplantation. RESULTS In the primary analysis, we detected no difference in eGFR for the intervention and control groups 2 years after transplantation, although baseline eGFR 1 month after transplantation was lower in the intervention group versus the control group. Compared with controls, patients in the intervention group received significantly lower daily doses of everolimus and nonsignificantly lower doses of cyclosporin A, resulting in significantly lower trough levels of everolimus (3.5 versus 4.5 µg/L, P<0.001) and cyclosporin A (47.4 versus 64.1 µg/L, P<0.001). Only 20% of patients in the intervention group versus 47% in the control group received glucocorticoids 2 years after transplantation (P=0.04). The groups had similar numbers of donor-specific antibodies and serious adverse events. CONCLUSIONS Steering immunosuppressive therapy by virus-specific T cell levels in addition to pharmacokinetic monitoring seems safe, results in a similar eGFR, and personalizes immunosuppressive therapy by lowering exposure to immunosuppressive drugs, likely resulting in lower drug costs. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER IVIST trial, https://www.clinicaltrialsregister.eu/ctr-search/search?query=2009-012436-32 and ISRCTN89806912.
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Affiliation(s)
- Thurid Ahlenstiel-Grunow
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- Department of Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Xiaofei Liu
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Raphael Schild
- Department of Pediatric Nephrology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jun Oh
- Department of Pediatric Nephrology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Taylan
- Department of Pediatric Nephrology, Children’s and Adolescents’ University Hospital, University of Cologne, Cologne, Germany
| | - Lutz T. Weber
- Department of Pediatric Nephrology, Children’s and Adolescents’ University Hospital, University of Cologne, Cologne, Germany
| | - Hagen Staude
- Department of Pediatric Nephrology, University Children’s Hospital, University Hospital of Rostock, Rostock, Germany
| | - Murielle Verboom
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Christoph Schröder
- Department of Pharmacovigilance, Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany
| | - Ruxandra Sabau
- Department of Pharmacovigilance, Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany
| | - Anika Großhennig
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Lars Pape
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
- Department of Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
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6
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Virus-specific T cells in pediatric renal transplantation. Pediatr Nephrol 2021; 36:789-796. [PMID: 32221706 PMCID: PMC7910244 DOI: 10.1007/s00467-020-04522-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 12/15/2022]
Abstract
After pediatric kidney transplantation, immunosuppressive therapy causes an increased risk of severe viral complications, especially from cytomegalovirus (CMV), BK polyomavirus (BKPyV) or Epstein-Barr virus (EBV), and less frequent from adenovirus (ADV). However, suitable predictive markers for the individual outcome of viral infections are missing and the therapeutic management remains a challenge to the success of pediatric kidney transplantation. Virus-specific T cells are known for controlling viral replication and there is growing evidence that virus-specific T cells may serve as a prognostic marker to identify patients at risk for viral complications. This review provides an overview of the usability of virus-specific T cells for improving diagnostic and therapeutic management of viral infections with reference to the necessity of antiviral prophylaxis, timing of pre-emptive therapy, and dosing of immunosuppressive medication after pediatric kidney transplantation. Several studies demonstrated that high levels of virus-specific T cells are associated with decrease of virus load and favorable outcome, whereas lack of virus-specific T cells coincided with virus-induced complications. Accordingly, the additional monitoring of virus-specific T cells aims to personalize the management of antiviral therapy, identify overimmunosuppression, and avoid unnecessary therapeutic interventions. Prospective randomized trials in pediatric kidney recipients comparing standard antiviral and immunosuppressive regimens with T cell-guided therapeutic interventions are needed, before monitoring of virus-specific T cells is implemented in the routine care of pediatric kidney graft recipients.
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Ehren R, Schijvens AM, Hackl A, Schreuder MF, Weber LT. Therapeutic drug monitoring of mycophenolate mofetil in pediatric patients: novel techniques and current opinion. Expert Opin Drug Metab Toxicol 2020; 17:201-213. [PMID: 33107768 DOI: 10.1080/17425255.2021.1843633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction: Mycophenolate mofetil (MMF) is an ester prodrug of the immunosuppressant mycophenolic acid (MPA) and is recommended and widely used for maintenance immunosuppressive therapy in solid organ and stem-cell transplantation as well as in immunological kidney diseases. MPA is a potent, reversible, noncompetitive inhibitor of the inosine monophosphate dehydrogenase (IMPDH), a crucial enzyme in the de novo purine synthesis in T- and B-lymphocytes, thereby inhibiting cell-mediated immunity and antibody formation. The use of therapeutic drug monitoring (TDM) of MMF is still controversial as outcome data of clinical trials are equivocal. Areas covered: This review covers in great depth the existing literature on TDM of MMF in the field of pediatric (kidney) transplantation. In addition, the relevance of TDM in immunological kidney diseases, in particular childhood nephrotic syndrome is highlighted. Expert opinion: TDM of MMF has the potential to optimize therapy in pediatric transplantation as well as in nephrotic syndrome. Limited sampling strategies to estimate MPA exposure increase its feasibility. Future perspectives rather encompass approaches reflecting total immunosuppressive load than single drug TDM.
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Affiliation(s)
- Rasmus Ehren
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne , Cologne, Germany
| | - Anne M Schijvens
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center , Nijmegen, The Netherlands
| | - Agnes Hackl
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne , Cologne, Germany
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center , Nijmegen, The Netherlands
| | - Lutz T Weber
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne , Cologne, Germany
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8
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Ahlenstiel-Grunow T, Pape L. Immunosuppression, BK polyomavirus infections, and BK polyomavirus-specific T cells after pediatric kidney transplantation. Pediatr Nephrol 2020; 35:625-631. [PMID: 31858227 DOI: 10.1007/s00467-019-04408-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/02/2019] [Accepted: 10/29/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND After kidney transplantation, immunosuppressive therapy increases risk of BK polyomavirus-associated nephropathy (BKPyVAN). Outcomes of BKPyV viremia are various and prognostic markers are missing. The impact of different immunosuppressive regimens on BKPyV infections is currently under discussion. METHODS We analyzed immunosuppressive therapy and BKPyV-specific cellular immunity to distinguish patients at risk of BKPyVAN from those with self-limiting viremia for purposes of risk-stratified BKPyV management. In a retrospective analysis, 46 pediatric kidney recipients with BKPyV viremia were analyzed with regard to duration of BKPyV viremia and immunosuppressive therapy; in addition, in 37/46 patients, BKPyV-specific CD4 and CD8 T cells were measured. RESULTS Nine patients showed persistent BKPyV viremia and BKPyVAN, and required therapeutic intervention, while 37 patients had asymptomatic, self-limiting viremia. At onset of viremia, 78% of patients with persistent viremia and BKPyVAN were treated with tacrolimus, whereas tacrolimus therapy was significantly less frequent in patients with self-limiting viremia (14%). The majority of patients with transient, self-limiting viremia received cyclosporine A (81%) and/or mTOR inhibitors (81%). Patients with persistent BKPyV viremia and BKPyVAN showed lack of BKPyV-specific CD4 and CD8 T cells (6/6), whereas the majority of patients with self-limiting viremia (27/31) had detectable BKPyV-specific CD4 and/or CD8 T cells ≥ 0.5 cells/μl (p < 0.001). CONCLUSIONS These results indicate that tacrolimus enhances risk of BKPyVAN with need of therapeutic intervention, whereas under cyclosporine A and mTOR inhibitors, the majority of pediatric kidney recipients showed self-limiting viremia. In patients at risk of BKPyV infections, combination of cyclosporine A and mTOR inhibitor may be advantageous.
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Affiliation(s)
- Thurid Ahlenstiel-Grunow
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
| | - Lars Pape
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
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9
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Pape L. State-of-the-art immunosuppression protocols for pediatric renal transplant recipients. Pediatr Nephrol 2019; 34:187-194. [PMID: 29067527 DOI: 10.1007/s00467-017-3826-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 09/08/2017] [Accepted: 10/06/2017] [Indexed: 01/28/2023]
Abstract
Immunosuppressive protocols used in pediatric kidney transplantation have changed substantially within the last decade. Many transplant centers now focus on the use of tacrolimus and mycophenolate mofetil in combination with early steroid withdrawal, frequently combined with antibody induction therapy. However, this approach is mainly based on treatment efficacy and-compared to other immunosuppressive regimens used in this context-leads to higher rates of viral infections in patients. In this review I assess data from prospective, interventional trials of immunosuppressive therapy in pediatric kidney transplantation. However, since there is a paucity of randomized controlled trials, I also describe the results of studies with weaker designs. The advantages and disadvantages of different immunosuppressive strategies are discussed. Within this framework I suggest ideas for individualized immunosuppressive regimens based on different stratificators that could effect a change from a 'one size fits all' to a tailored approach for initial and maintenance immunosuppressive therapy after renal transplantation in the pediatric setting.
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Affiliation(s)
- Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany.
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10
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Weiler N, Trötschler S, Vermehren J, Schnitzbauer AA, Bechstein WO, Herrmann E, Zeuzem S, Welker MW. Risk-guided strategy to prevent cytomegalovirus associated complications after liver transplantation. Future Virol 2018. [DOI: 10.2217/fvl-2018-0045] [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
Aim: We evaluated a risk-guided strategy to prevent cytomegalovirus-associated complications (CMV-ac) after liver transplantation (LT). Patients & methods: Forty liver graft recipients were stratified according to their CMV risk status to prophylactic (high risk, HR and group) or pre-emptive antiviral treatment (intermediate, IR, and low risk, LR and group). A detailed analysis of clinical and virological data was performed. Results: 8/40 patients were classified within the HR, 28/40 within the IR and 4/40 within the LR group. Incidence of CMV viremia was 3/8 (38%) in the HR, 9/28 (32%) in the IR and 0/5 in the LR group. Mortality rate of CMV-ac was 0%. Conclusion: A risk-guided antiviral strategy is effective to prevent severe CMV-ac up to 1 year after LT.
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Affiliation(s)
- Nina Weiler
- Medizinische Klinik 1, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Sven Trötschler
- Medizinische Klinik 1, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Johannes Vermehren
- Medizinische Klinik 1, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Andreas A Schnitzbauer
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Eva Herrmann
- Institut für Biostatistik und Mathematische Modellierung, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Martin-Walter Welker
- Medizinische Klinik 1, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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11
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Banas B, Steubl D, Renders L, Chittka D, Banas MC, Wekerle T, Koch M, Witzke O, Mühlfeld A, Sommerer C, Habicht A, Hugo C, Hünig T, Lindemann M, Schmidt T, Rascle A, Barabas S, Deml L, Wagner R, Krämer BK, Krüger B. Clinical validation of a novel enzyme-linked immunosorbent spot assay-basedin vitrodiagnostic assay to monitor cytomegalovirus-specific cell-mediated immunity in kidney transplant recipients: a multicenter, longitudinal, prospective, observational study. Transpl Int 2018; 31:436-450. [DOI: 10.1111/tri.13110] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/17/2017] [Accepted: 12/19/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Bernhard Banas
- Department of Nephrology; University Medical Center Regensburg; Regensburg Germany
| | - Dominik Steubl
- Department of Nephrology; Klinikum rechts der Isar; Technical University Munich; Munich Germany
| | - Lutz Renders
- Department of Nephrology; Klinikum rechts der Isar; Technical University Munich; Munich Germany
| | - Dominik Chittka
- Department of Nephrology; University Medical Center Regensburg; Regensburg Germany
| | - Miriam C. Banas
- Department of Nephrology; University Medical Center Regensburg; Regensburg Germany
| | - Thomas Wekerle
- Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Martina Koch
- Transplantation Immunology Research Group; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - Oliver Witzke
- Departments of Nephrology and of Infectious Disease; University Hospital Essen; Essen Germany
| | | | - Claudia Sommerer
- Division of Nephrology; University Hospital Heidelberg; Heidelberg Germany
| | - Antje Habicht
- Transplantation Center; Ludwig-Maximilians-University Medical Center Munich; Munich Germany
| | - Christian Hugo
- Department of Nephrology; Carl Gustav Carus University Medical Center Dresden; Dresden Germany
| | - Thomas Hünig
- Institute of Virology and Immunobiology; University Medical Center Würzburg; Würzburg Germany
| | - Monika Lindemann
- Institute for Transfusion Medicine; University Hospital Essen; Essen Germany
| | | | | | | | | | - Ralf Wagner
- Lophius Biosciences; Regensburg Germany
- Institute of Clinical Microbiology and Hygiene; University Medical Center Regensburg; Regensburg Germany
| | - Bernhard K. Krämer
- Vth Department of Medicine; University Medical Center Mannheim; Mannheim Germany
| | - Bernd Krüger
- Vth Department of Medicine; University Medical Center Mannheim; Mannheim Germany
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12
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Sester M, Leboeuf C, Schmidt T, Hirsch HH. The "ABC" of Virus-Specific T Cell Immunity in Solid Organ Transplantation. Am J Transplant 2016; 16:1697-706. [PMID: 26699950 DOI: 10.1111/ajt.13684] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 01/25/2023]
Abstract
Transplant patients are at increased risk of viral complications due to impaired control of viral replication, resulting from HLA mismatching between graft and host and the immunosuppression needed to avert alloimmune reactions. In the past decade, quantitative viral load measurements have become widely available to identify patients at risk and to inform treatment decisions with respect to immunosuppressive drugs and antiviral therapies. Because viral loads are viewed as the result of viral replication and virus-specific immune control, virus-specific T cell monitoring has been explored to optimize management of adenovirus, BK polyomavirus and cytomegalovirus ("ABC") in transplant patients. Although most studies are descriptive using different technologies, the overall results show that the quantity and quality of virus-specific T cells inversely correlate with viral replication, whereby strong cellular immune responses are associated with containment of viral replication. The key obstacles to the introduction of assays for virus-specific T cells into clinical practice is the definition of reliable cutoffs for clinical decision making, the poor negative predictive value of some assays, and the absence of interventional trials justifying changes of antiviral treatment or immunosuppression. More clinical research is needed using optimized assays and targets before standardization and commutability can be envisaged as achieved for viral load testing.
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Affiliation(s)
- M Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - C Leboeuf
- Transplantation & Clinical Virology, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland
| | - T Schmidt
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - H H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland.,Division Infection Diagnostics, Department Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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13
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Carbone J. The Immunology of Posttransplant CMV Infection: Potential Effect of CMV Immunoglobulins on Distinct Components of the Immune Response to CMV. Transplantation 2016; 100 Suppl 3:S11-8. [PMID: 26900990 PMCID: PMC4764014 DOI: 10.1097/tp.0000000000001095] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 12/14/2022]
Abstract
The immune response to cytomegalovirus (CMV) infection is highly complex, including humoral, cellular, innate, and adaptive immune responses. Detection of CMV by the innate immune system triggers production of type I IFNs and inflammatory cytokines which initiate cellular and humoral responses that are critical during the early viremic phase of CMV infection. Sustained control of CMV infection is largely accounted for by cellular immunity, involving various T-cell and B-cell subsets. In solid organ transplant patients, global suppression of innate and adaptive immunities by immunosuppressive agents limits immunological defense, including inhibition of natural killer cell activity with ongoing lowering of Ig levels and CMV-specific antibody titers. This is coupled with a short-term suppression of CMV-specific T cells, the extent and duration of which can predict risk of progression to CMV viremia. CMV immunoglobulin (CMVIG) preparations have the potential to exert immunomodulatory effects as well as providing passive immunization. Specific CMVIG antibodies and virus neutralization might be enhanced by modulation of dendritic cell activity and by a decrease in T-cell activation, effects which are of importance during the initial phase of infection. In summary, the role of CMVIG in reconstituting specific anti-CMV antibodies may be enhanced by some degree of modulation of the innate and adaptive immune responses, which could help to control some of the direct and indirect effects of CMV infection.
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Affiliation(s)
- Javier Carbone
- Clinical Immunology Department, General University Hospital Gregorio Marañon, Complutense University, Madrid, Spain
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