Preemptive antiviral therapy in lung transplantation from hepatitis C donors results in a rapid and sustained virologic response

Objective

The study objective was to assess the safety and efficacy of a preemptive direct-acting antiviral therapy in lung transplants from hepatitis C virus donors to uninfected recipients.

Methods

This study is a prospective, open-label, nonrandomized, pilot trial. Recipients of hepatitis C virus nucleic acid test positive donor lungs underwent preemptive direct-acting antiviral therapy with glecaprevir 300 mg/pibrentasvir 120 mg for 8 weeks from January 1, 2019, to December 31, 2020. Recipients of nucleic acid test positive lungs were compared with recipients of lungs from nucleic acid test negative donors. Primary end points were Kaplan-Meier survival and sustained virologic response. Secondary outcomes included primary graft dysfunction, rejection, and infection.

Results

Fifty-nine lung transplantations were included: 16 nucleic acid test positive and 43 nucleic acid test negative. Twelve nucleic acid test positive recipients (75%) developed hepatitis C virus viremia. Median time to clearance was 7 days. All nucleic acid test positive patients had undetectable hepatitis C virus RNA by week 3, and all alive patients (n = 15) remained negative during follow-up with 100% sustained virologic response at 12 months. One nucleic acid test positive patient died of primary graft dysfunction and multiorgan failure. Three of 43 nucleic acid test negative patients (7%) had hepatitis C virus antibody positive donors. None of them developed hepatitis C virus viremia. One-year survival was 94% for nucleic acid test positive recipients and 91% for nucleic acid test negative recipients. There was no difference in primary graft dysfunction, rejection, or infection. One-year survival for nucleic acid test positive recipients was similar to a historical cohort of the Scientific Registry of Transplant Recipients (89%).

Conclusions

Recipients of hepatitis C virus nucleic acid test positive lungs have similar survival as recipients of nucleic acid test negative lungs. Preemptive direct-acting antiviral therapy results in rapid viral clearance and sustained virologic response at 12 months. Preemptive direct-acting antiviral may partially prevent hepatitis C virus transmission.

Pharmacist Expansion to Tele-Health Visits in Heart Transplant Clinic

Purpose

During the COVID-19 pandemic, inpatient cardiothoracic transplant pharmacists expanded clinical services to include remote telehealth visits to increase patient access to pharmacy services and streamline visits for providers. Pharmacist visit activities included adherence and medication access assessments, adverse effect assessment and management, chart reviews, and medication reconciliation.

Methods

A single center retrospective chart review of 80 heart transplant recipients transplanted between January 2020 and December 2020 was completed. From July 2020 - March 2021, pharmacists called patients within the first year of transplant prior to scheduled provider clinic visits. Patients were not called if they had been called within the prior 4 weeks. Activities from clinic visits before and after pharmacist involvement were compared at 1 month, 3 months, 6 months, and 12 months post-transplant. The goal of this analysis was to describe the number and types of interventions made by the pharmacist.

Results

A total of 100 patients and 272 clinic visits were analyzed, baseline clinical characteristics did not differ in the two cohorts. Pharmacists performed 233 tele-health visits which resulted in 394 interventions from July 2020 - March 2021, summarized in Figure 1. The most common interventions included adverse effect management (34%) and renal dose adjustment (17.8%). An analysis of outpatient visits before and after pharmacist involvement found no significant difference in reported adherence, appropriate renal dosing of medications or reported neurotoxicity (Table 1).

Conclusion

Close to 400 interventions were made by our transplant pharmacy team through tele-health visits over a period of 8 months. Use of pre-visit pharmacist tele-health assessments allowed for expansion of clinical pharmacy services while facilitating more focused provider clinic visits. more consistency in clinic may yield improved post-pharmacist outcomes, though further analysis is warranted.

Impact analysis of virtual ambulatory transplant pharmacists during COVID-19

INTRODUCTION

During the coronavirus disease 2019 (COVID-19) pandemic, transplant centers were challenged to meet the demand for new telemedicine strategies. The ability of lung transplant providers (LTP) to conduct face-to-face clinic visits for high-risk immunocompromised patients, such as lung transplant recipients (LTR), was limited. Through the implementation of comprehensive medication management visits, pharmacists were able to assist LTP in the transition to telemedicine.

METHODS

A retrospective chart review of telephone encounters from cardiothoracic (CT) transplant pharmacists at our center from March to September 2020 was completed. LTR scheduled for clinic visits with LTP were called prior to the visit by CT transplant pharmacists who conducted medication list reviews, adherence assessments, and medication access assistance. Clinical recommendations were communicated directly to the LTP and documented in patient electronic medical records. The primary outcome was the number of pharmacist-driven clinical interventions. Secondary endpoints included the clinical severity and value of service of each intervention, percentage of accepted recommendations, patient cost savings interventions, prevention of adverse events, and avoidance of inappropriate doses.

RESULTS

From March to September 2020, the CT transplant pharmacists conducted 385 virtual visits on 157 LTR with a median of 20 minutes spent per visit. There were 891 total interventions made by CT transplant pharmacists, including 778 medication discrepancies identified. Over 60% of encounters demonstrated some form of medication error and over 55% of encounters exhibited value of pharmacy services.

CONCLUSION

Implementation of CT transplant pharmacist telehealth visits has potential for increased patient access to pharmacy care and improved accuracy of medication lists. When focusing on the severity of errors and value of services, most demonstrated a level of significance. Further investigation is needed to analyze the impact of this service on patient outcomes as well as cost-effectiveness.

Utilization of direct-acting oral anticoagulation in solid organ transplant patients: A national survey of institutional practices

The safety and efficacy of direct-acting oral anticoagulants (DOACs) and reversal strategies are not well established in the solid organ transplant population. This was a survey of pharmacists to assess DOAC and urgent reversal practices among adult transplant programs in the United States. A 27-question survey was distributed to members of transplant pharmacy organization listservs between 5/28/19 and 6/30/19. A total of 115 responses were received from kidney (43.5%), heart (20.0%), lung (18.3%), liver (13.9%), and pancreas (4.4%) transplant programs. DOAC use prior to transplant was mostly prohibited in thoracic programs (77.3%) but more permissive in kidney transplant programs (64.0%). If permitted, apixaban (57.8%) was most preferred. At transplant surgery, reversal of DOAC was performed "as needed" (20.9%) or was not routine (18.3%). DOAC use post-transplant was more permissive (94.3%). A majority of responders follow FDA recommended dosing in the setting of drug-drug interactions (51.1%). Major factors influencing DOAC prescribing decisions included renal function, drug-drug interactions, and insurance. High clinical practice variability exists regarding DOAC utilization and urgent reversal strategies in pre-, peri-, and post-transplant stages. While more research is needed to refine the clinical landscape, many institutions are using DOAC therapy under the perception that they pose a similar risk of bleeding compared to a non-transplant population.

Successful optimization of antiretroviral regimens in treatment-experienced people living with HIV undergoing liver transplantation

Modern antiretroviral therapy (ART) extends life expectancy for people living with HIV (PLWH). However, most older PLWH (≥50 years) "aged" with HIV and were exposed to historical HIV care practices and older, more toxic ART. In PLWH with exposure to older and multiple ART regimens, the drug interactions between ART frequently used in treatment-experienced persons and commonly used immunosuppressants remain a significant challenge. However, the advent of newer ART classes (eg, integrase non-strand transfer inhibitors) and more advanced HIV genetic resistance testing may allow optimization of ART regimens with minimal drug interactions. Here, we present a case series of three PLWH whose complicated ART interacted (or was at risk for interacting) with their post-liver transplant immunosuppression. After a review of their proviral DNA resistance testing, they successfully transitioned onto safer integrase non-strand transfer inhibitor-containing ART regimens without viral blips or evidence of organ rejection.

Outcomes of Lung Transplantation for Cystic Fibrosis in the Setting of Extensively Drug-Resistant Organisms

Introduction:

Since the largest study on extensively drug-resistant organisms and lung transplantation in patients with cystic fibrosis, there have been innovations and advancements in the treatment of Pseudomonas aeruginosa.

Research Question:

What differences exist for patients with cystic fibrosis with a history of extensively drug-resistant infections who undergo lung transplantation despite treatment advances with antimicrobial therapy?

Study Design:

Two-center, retrospective, cohort study conducted in 44 patients with cystic fibrosis chronically infected with extensively drug-resistant organisms who received a lung transplant from January 2008 through August 2016. Patients in the resistant cohort were chronically infected with pan-resistant P aeruginosa, polymyxin-sensitive only, or sensitive to 2 antibiotic classes (polymyxin plus one other); remaining patients with more susceptible P aeruginosa or no P aeruginosa remained in the control cohort. The primary outcome is a composite of patient survival, retransplantation, chronic lung allograft dysfunction, and acute rejection 12 months posttransplant. Categorical variables were analyzed using χ2 testing. The independent samples t test was utilized for continuous variables.

Results:

There was no difference in the primary outcome (40% vs 37%, P = .831). Differences between patient survival (84% vs 95%, P = .487), the incidence of acute rejection (20% vs 33%, P = .323), and the incidence of chronic lung allograft rejection (12% vs 5%, P = .441) were not different between groups.

Discussion:

Recipients chronically infected with an extensively resistant P aeruginosa had similar outcomes compared to those infected with more sensitive organisms.

The West Nile virus encephalitis outbreak in the United States (1999-2000): from Flushing, New York, to beyond its borders

Viruses cause most forms of encephalitis. The two main types responsible for epidemic encephalitis are enteroviruses and arboviruses. The City of New York reports about 10 cases of encephalitis yearly. Establishing a diagnosis is often difficult. In August 1999, a cluster of five patients with fever, confusion, and weakness were admitted to a community hospital in Flushing, New York. Flaccid paralysis developed in four of the five patients, and they required ventilatory support. Three, less severe, cases presented later in the same month. An investigation was conducted by the NewYork City (NYC) and New York State (NYS) health departments and the national Centers for Disease Control and Prevention (CDC). The West Nile virus (WNV) was identified as the etiologic agent. WNV is an arthropod-borne flavivirus, with a geographic distribution in Africa, the Middle East, and southwestern Asia. It has also been isolated in Australia and sporadically in Europe but never in the Americas. The majority of people infected have no symptoms. Fever, severe myalgias, headache, conjunctivitis, lymphadenopathy, and a roseolar rash can occur. Rarely, encephalitis or meningitis is seen. The NYC outbreak resulted in the first cases of WNV infection in the Western Hemisphere and the first arboviral infection in NYC since yellow fever in the nineteenth century. The WNV is now a public health concern in the United States.

The West Nile Virus outbreak of 1999 in New York: the Flushing Hospital experience

West Nile Virus (WNV) is a mosquito-borne flavivirus, which has been known to cause human infection in Africa, the Middle East, and southwestern Asia. It has also been isolated in Australia and sporadically in Europe but never in the Americas. Clinical features include acute fever, severe myalgias, headache, conjunctivitis, lymphadenopathy, and a roseolar rash. Rarely is encephalitis or meningitis seen. During the month of August 1999, a cluster of 5 patients with fever, confusion, and weakness were admitted to the intensive care unit of the same hospital in New York City. Ultimately 4 of the 5 developed flaccid paralysis and required ventilatory support. Three patients with less-severe cases presented shortly thereafter. With the assistance of the New York City and New York State health departments and the Centers for Disease Control and Prevention, these were documented as the first cases of WNV infection on this continent.

Relationships of nutrient intake to lipids and lipoproteins in 1234 white children. The Lipid Research Clinics Prevalence Study

Using the geographically and socioeconomically varied collaborative Lipid Research Clinics Prevalence Study data, this report focuses upon relationships between dietary intake and plasma lipids and lipoproteins in 1234 white children, 661 boys and 573 girls, aged 6-19 years who were sampled in a random recall (Visit 2) from large populations in six Lipid Research Clinics. Using multiple regression analysis, we found that in 6- to 12-year-old boys the dietary polyunsaturated-to-saturated fat ratio was inversely associated with plasma total and low density lipoprotein cholesterol and dietary cholesterol was positively associated with plasma high density lipoprotein cholesterol. In 13- to 19-year-old boys, high density lipoprotein cholesterol and the ratio of high density lipoprotein cholesterol to total cholesterol were inversely related to sucrose intake. In 6- to 12-year-old girls, plasma triglycerides were positively related to dietary sucrose. Using analysis of covariance in children having the lowest, middle, and top decile nutrient intakes, we found that higher carbohydrate intakes were associated with lower plasma total cholesterol in boys. The highest polyunsaturated fat intake (in 6- to 12-year-old girls) was associated with the lowest plasma cholesterol and very low density lipoprotein cholesterol. The highest cholesterol intake (in 6- to 12-year-old boys) was associated with the highest high density lipoprotein cholesterol levels. In girls, the highest sucrose intakes were associated with the highest plasma triglyceride levels. We conclude that the weak, but statistically significant, associations that we observed were meaningful relative to etiologies of nutrient-lipoprotein interrelationships, and should be useful in forming new hypotheses for focused metabolic ward studies.