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Background: Cytomegalovirus (CMV) is a driver of negative outcomes after lung transplant (LTX) and primary prophylaxis (PPX) with valganciclovir (VGC) is standard‐of‐care. VGC is associated with myelosuppression, prompting interest in letermovir (LTV). Methods: Adults receiving LTX between April 1, 2015, and July 30, 2022, at our institution were evaluated. Patients were excluded if low CMV risk (D‐/R‐), survived <90 days post‐LTX, or transferred care before PPX withdrawal. Primary outcomes were leukopenia (white blood cell count [WBC] ≤ 3.0 × 109/L), severe leukopenia (WBC ≤ 2.0 × 109/L), and neutropenia (absolute neutrophil count ≤ 1500 cells/µL) requiring granulocyte‐colony stimulating factor (GCSF) on PPX. Secondary outcomes included breakthrough CMV infection and post‐PPX CMV infection. Results: 204 patients met inclusion criteria: 175 patients on VGC and 29 patients on LTV (after VGC conversion). Most patients received bilateral LTX (62.7%) with non‐lymphocyte‐depleting induction (96.6%) and moderate‐risk serostatus (D+/R+, 48.5%). Patients transitioned from VGC to LTV after a mean of 178 days (SD 80.8 days) post‐transplant. Patients on VGC experienced significantly more leukopenia (82.3% vs. 58.6%, p = 0.008), severe leukopenia (57.1% vs. 31.0%, p = 0.016), and neutropenia requiring GCSF (70.9% vs. 51.7%, p = 0.048). Breakthrough (5.7% vs. 3.4%, p = 0.955) and post‐PPX (24.6% vs. 37.9%, p = 0.199) infections were similar. A subgroup analysis of patients with high‐risk serostatus showed similar trends, though did not reach statistical significance. Conclusions: In this single‐center study, the incidence of leukopenia and neutropenia requiring GCSF were reduced with LTV compared to VGC. Breakthrough and post‐PPX infections were not significantly different. This evidence suggests that LTV has comparable efficacy with reduced myelosuppression compared to VGC in LTX recipients, and may be an appropriate alternative for PPX. [ABSTRACT FROM AUTHOR]

The article discusses the efficacy of dose-reduced glecaprevir-pibrentasvir in lung transplant recipients on maintenance cyclosporine from donors with hepatitis C viremia. It highlights the successful treatment of two lung transplant recipients with HCV viremic donors using glecaprevir-pibrentasvir while on cyclosporine maintenance immunosuppression. The study emphasizes the importance of utilizing dose-reduced GLE-PIB to effectively treat HCV infection transmitted by donors in lung transplantation, providing a flexible and individualized approach to post-operative care. The collaborative effort of various specialists is crucial for the success of such treatment strategies in expanding the donor pool and increasing transplantation accessibility. [Extracted from the article]

Background: While presumably less common with modern molecular diagnostic and imaging techniques, fever of unknown origin (FUO) remains a challenge in kidney transplant recipients (KTRs). Additionally, the impact of FUO on patient and graft survival is poorly described. Methods: A cohort of adult KTRs between January 1, 1995 and December 31, 2018 was followed at the University of Wisconsin Hospital. Patients transplanted from January 1, 1995 to December 31, 2005 were included in the "early era"; patients transplanted from January 1, 2006 to December 31, 2018 were included in the "modern era". The primary objective was to describe the epidemiology and etiology of FUO diagnoses over time. Secondary outcomes included rejection, graft and patient survival. Results: There were 5590 kidney transplants at our center during the study window. FUO was identified in 323 patients with an overall incidence rate of.8/100 person‐years. Considering only the first 3 years after transplant, the incidence of FUO was significantly lower in the modern era than in the early era, with an Incidence Rate Ratio (IRR) per 100 person‐years of.48; 95% CI:.35–.63; p <.001. A total of 102 (31.9%) of 323 patients had an etiology determined within 90 days after FUO diagnosis: 100 were infectious, and two were malignancies. In the modern era, FUO remained significantly associated with rejection (HR = 44.1; 95% CI: 16.6–102; p <.001) but not graft failure (HR = 1.21; 95% CI:.68–2.18; p =.52) total graft loss (HR = 1.17; 95% CI:.85–1.62; p =.34), or death (HR = 1.17; 95% CI:.79–1.76; p =.43. Conclusions: FUO is less common in KTRs during the modern era. Our study suggests infection remains the most common etiology. FUO remains associated with significant increases in risk of rejection, warranting further inquiry into the management of immunosuppressive medications in SOT recipients in the setting of FUO. [ABSTRACT FROM AUTHOR]

This article discusses a case report of a lung transplant recipient who developed multi-drug resistant cytomegalovirus (CMV), including resistance to ganciclovir (GCV) and maribavir (MARI). The patient received various antiviral treatments, including valganciclovir (VGC), cidofovir (CDV), and foscarnet (FOS), but experienced adverse effects and fluctuating CMV viral load. The case highlights the emerging issue of MARI resistance in solid organ transplant recipients and the challenges in managing CMV infections in this population. The document also discusses the risks and considerations associated with the use of MARI, including the need for careful initiation and monitoring for resistance. The authors emphasize the need for further research on the effectiveness and nuances of MARI as a treatment for CMV infections. [Extracted from the article]

Purpose: Studies conducted in the northern United States found cytomegalovirus (CMV) disease after liver transplantation follows a seasonal pattern, with increased incidence in fall and winter. This has not been evaluated in kidney transplant recipients. Improved understanding of CMV seasonality may help guide use of preventative therapies. Methods: We evaluated adult patients receiving a kidney transplant at our center in Wisconsin from January 1, 1995 to December 31, 2018. CMV event was defined as quantifiable viral replication with clinical signs or symptoms suspicious for CMV per current consensus recommendations. Seasons were divided as follows: winter (December–February), spring (March–May), summer (June–August), and fall (September–November). The primary objective was to evaluate the annual distribution of CMV disease and determine whether this differed by season. Results: There were 6151 kidney transplants in the study period. A total of 913 patients had 1492 episodes of CMV. Median time from transplant to first detection was 5.51 months (interquartile range [IQR] 2.87–11.7). The observed overall incidence exceeded the expected incidence in winter (+.7%), spring (+5.5%), and fall (+3.4%) and was less than expected in summer (−9.5%) (p =.18). The incidence of CMV during summer, however, was 21% less than expected (p =.001) in recipients who were CMV positive (R+) at the time of transplantation. No such difference was observed in CMV negative recipients (R−; p =.58). Conclusion: CMV after kidney transplant appears to be less common during the summer season in patients who were R+ at transplant but does not follow seasonal variation in R−. Reasons for this are unclear but are likely related to CMV‐specific cell‐mediated immunity. These findings may have clinical implications, particularly the use of non‐pharmacologic strategies to improve response to antiviral therapy. [ABSTRACT FROM AUTHOR]

Myalgia in liver transplant recipients after receiving tixagevimab/cilgavimab for pre-exposure prophylaxis of COVID-19: A case series At our center, three of 77 liver transplant recipients who have received tixagevimab/cilgavimab (3.9%) have reported myalgia; by contrast, 139 kidney transplant recipients and 101 lung transplant recipients have received tixagevimab/cilgavimab without any reports of myalgia. [Extracted from the article]

Purpose: To evaluate epidemiology, risk‐factors, and outcomes of high‐level (HL) cytomegalovirus (CMV) viremia in liver transplant recipients. Methods: Adult patients receiving a liver transplant between 1/1/2017 and 9/30/2020 were evaluated. Viral loads at University of Wisconsin Health Clinical Laboratories were required to allow for numerical comparison. Primary objective was incidence and outcomes of HL CMV viremia (viral‐load > 100 000 IU/ml). Secondary objective was to elucidate risk factors to allow targeted interventions. Results: Two hundred nine patients met inclusion criteria; 175 kept their graft for at least 240 days. Of these nine patients developed HL CMV, 28 developed low‐level (LL CMV, viral‐load 250–100 000 IU/ml), and 138 did not develop CMV viremia. When comparing these three groups via classic statistical methods time from transplant to viremia was similar (HL 158 ± 77 days, LL 150 ± 76 days). Clinical factors were also similar with the exception of donor seropositivity (HL 87.5%, LL 70.4%, No CMV 49.6%, p = 0.025). HL CMV was significantly associated with graft loss (p < 0.0001) on Kaplan–Meier analysis; graft loss in the LL CMV group did not differ from the no CMV group (p = 0.96). To allow valid assessment of risk factors in the total study population (n = 209), models of time‐varying covariates were used, and Cox proportional hazards ratios were calculated. In this analysis, HL CMV was associated with a significantly increased risk of graft loss (HR 5.6, p = 0.0016). When investigating risk factors associated with HL CMV, donor seropositivity significantly increased risk (HR 8.85, 95% CI 1.13–71.43, p = 0.038). Pretransplant total bilirubin (HR 1.04, 95% CI 0.998–1.07, p = 0.06) trended toward significance. Recipient seronegativity, liver disease, clinical and allocation model for end‐stage liver disease (MELD), transplant surgery duration, age, sex, induction immunosuppression, and maintenance immunosuppression were not significantly associated with development of HL CMV. Conclusion: HL CMV after liver transplant is uncommon but is associated with a significantly increased risk of graft loss that is not present in those patients who develop LL CMV or do not develop CMV viremia. Given these negative graft effects, CMV stewardship interventions targeting recipients of CMV seropositive allografts are warranted. Future larger scale studies evaluating the potential role of other factors in risk stratification are needed. [ABSTRACT FROM AUTHOR]

A recently published report titled "Increased incidence and unusual presentations of CMV disease in kidney transplant recipients after conversion to belatacept" by Chavarot et al. observed that patients converted to belatacept have a sevenfold higher incidence of cytomegalovirus (CMV) disease and atypical, aggressive disease phenotype.1 These results coincided with earlier published studies that similarly observed that belatacept-based maintenance immunosuppression regimens in kidney transplant recipients are associated with increased rates of opportunistic infections, particularly primary CMV infections with prolonged viral replication in high-risk (seronegative recipient receiving a graft from seropositive donor, D+/R-) patients.2,3 We concur with these findings and propose the etiology may be attributed to a prolonged inhibitory effect of belatacept on CMV-specific cell-mediated immunity (CMI), which persists beyond discontinuation, based on our experience with the following case (Figure 1). Increased incidence and unusual presentations of CMV disease in kidney transplant recipients after conversion to belatacept. CMV high-risk status and posttransplant outcomes in kidney transplant recipients treated with belatacept. [Extracted from the article]

Background: Cytomegalovirus (CMV) is associated with detrimental outcomes after lung transplantation (LTX); primary prophylaxis (PPX) with valganciclovir (VGC) is guideline-recommended. VGC is associated with myelosuppression, spurring interest in letermovir (LTV)., Methods: Adults undergoing LTX between January 1, 2021, and July 30, 2022 at our institution who were converted from VGC to LTV for PPX were evaluated. Outcomes included antimetabolite dosing during PPX, the incidence and frequency of myelosuppressive events, and the time to the first myelosuppressive event., Results: Twenty-nine LTX recipients met the inclusion criteria. Most patients received non-lymphocyte-depleting induction (96.6%) and had moderate risk CMV serostatus (D+/R+, 48.3%). Patients transitioned from VGC to LTV 177 days (IQR 102 days) post-transplant. After conversion to LTV, patients tolerated higher daily doses of mycophenolate (721 mg vs. 1000 mg, p = 0.008) or azathioprine (33.3 mg vs. 62.5 mg, p = 0.478). The incidence of myelosuppressive events was reduced (100.0% vs. 62.1%, p < 0.001) including leukopenia (96.6% vs. 58.6%, p = 0.001), severe leukopenia (82.8% vs 31.0%, p < 0.001) and neutropenia requiring GCSF (96.6% vs. 48.3%, p < 0.001) while on VGC compared to LTV. While on LTV, patients had a reduced rate of myelosuppressive events compared to VGC (1 event per 6.2 patient days vs. 1 event per 14.7 patient days, p < 0.001). While on LTV, one patient had breakthrough viremia (3.4%) that was treated with (val)ganciclovir., Conclusions: In this single-center study, patients tolerated higher doses of antimetabolite immunosuppression, and the incidence and frequency of myelosuppressive events were reduced while on LTV compared to VGC. This evidence expands upon the current literature demonstrating improved tolerability of LTV in LTX recipients., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)