Curr Infect Dis Rep (2013) 15:453–454 DOI 10.1007/s11908-013-0379-4
INVITED COMMENTARY
Current Issues in Transplant Infectious Diseases Nicole Theodoropoulos & Michael G. Ison
Published online: 19 October 2013 # Springer Science+Business Media New York 2013
Solid organ transplantation (SOT) represents a significant advance in medicine and currently represents the preferred treatment for most patients with end-stage organ failure. SOT results in improved quality and quantity of life for more than 25,000 patients each year in the United States [1]. Significant advances in the potency of immunosuppressive agents, improvement in surgical techniques, and expanded use of antimicrobial prophylaxis have resulted in greater patient and graft survival rates over time [2]. Despite these advances, infections remain a leading cause of morbidity and mortality among transplant recipients [2–4]. Likewise, hematopoietic stem cell transplantation (HSCT) has made great strides in curing many previously incurable malignancies. Although improvements to the transplantation process, use of prophylaxis and screening measures, and employment of supportive care have decreased the infectious complications of HSCT, they remain a serious threat to good patient outcomes [5]. To address these significant challenges to successful transplantation, the field of transplant infectious diseases (TID) has grown to be an integral part of all major transplant programs in N. Theodoropoulos Department of Internal Medicine, Division of Infectious Diseases, The Ohio State University, Columbus, OH, USA N. Theodoropoulos : M. G. Ison Northwestern University Transplant Outcomes Research Collaborative, Northwestern University Feinberg School of Medicine, Chicago, IL, USA M. G. Ison Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA N. Theodoropoulos (*) Division of Infectious Diseases, The Ohio State University, N1121 Doan Hall 410 W. 10th Ave, Columbus, OH 43210, USA e-mail: [email protected]
the developed world. TID experts have advanced transplantation by defining the epidemiology of the infectious complications of both SOT and HSCT. BK virus nephropathy and novovirus gastroenteritis, for example, have recently been recognized to be significant causes of graft failure and chronic diarrhea, respectively. Most significant, the knowledge of posttransplant infections is being applied to develop and implement novel antimicrobials for the prevention and treatment of these complications. These advances are having a meaningful impact in reducing the frequency and severity of posttransplant infections and improving outcomes associated with SOT and HSCT. For this issue, we invited leaders in the field of TID to summarize the advances in recent research that have resulted in improved understanding of the epidemiology, prevention, and management of the specific infections. Multidrug-resistant organisms (MDROs) are an emerging threat in SOT. While it has long been recognized that transplant patients are among the highest risk groups for becoming colonized and developing serious infections, the frequency with which MDROs cause infection in transplant recipients has increased significantly in the past several years. Gopi Patel, Meenakshi M. Rana, and Shirish Huprikar from the Icahn School of Medicine at Mount Sinai have detailed our understanding of the mechanism of resistance, the risk factors for acquiring MDRO infections, and the optimal strategies for preventing acquisition of and treating these challenging infections. Immunomodulatory agents are increasingly used in transplant and other specialties to minimize inflammation and improve graft survival and to minimize the symptoms and impact of a number of immune-mediated diseases, including psoriasis, inflammatory bowel diseases, and multiple sclerosis. These agents cause specific defects in the immune system that result in enhanced risk of infectious complications, particularly the reactivation of latent infections in the host.
454
Ricardo M. La Hoz and John W. Baddley from the University of Alabama at Birmingham have summarized our current understanding of the specific risks of infectious complications associated with the use of these agents and the measures that help ensure optimal patient outcomes. Since the 2009 influenza A/H1N1 pandemic, the important impact of influenza on transplant populations has been recognized by the medical community. Vaccination remains the mainstay of prevention of influenza infections, but questions about the safety and efficacy of influenza vaccination contribute to the poor utilization of this important preventative strategy among transplant recipients. Aliyah Baluch and Yanina Pasikhova from the University of South Florida College of Medicine and H. Lee Moffitt Cancer Center and Research Institute summarize the current data on the safety and efficacy of influenza vaccination among patients undergoing therapy for cancer. Mechanical circulatory support is increasingly important in the routine therapy of patients with end-stage heart failure. While advances in these devices have resulted in improved clinical outcomes, infections remain a substantial limitation to this form of therapy. Stanley I. Martin from The Ohio State University provides a comprehensive review of techniques for infection prevention and the ideal approach to diagnostic and therapeutic strategies to managing mechanical circulatory support infections. Cytomegalovirus (CMV) remains the most common infection after solid organ and hematopoietic stem cell transplant. Advances in antiviral prophylaxis strategies have reduced the incidence of CMV infections but remain limited by toxicity and the frequency of late-onset CMV infections. Oriol Manuel from University of Lausanne has provided a comprehensive review of clinically meaningful methods of measuring CMVspecific T-cell responses and has highlighted the potential role that these powerful tools may have in optimizing the prevention and management of CMV infections following transplantation. Recently completed multicenter studies of kidney and liver transplantation has demonstrated that this life-saving intervention can be safely applied to patients living with HIV infection. These studies have further demonstrated that graft and patient outcomes are acceptable in this unique population and have led to more HIV-infected patients being offered transplantation. Furthermore, recent advances in our understanding of the pool of HIV-positive donors and the ability to safely use selected HIV-infected donor organs for HIV-infected candidates have resulted in Congress reconsidering the prohibition of the use of HIV-infected donors for SOT. Valentina Stosor of the Northwestern University Feinberg School of Medicine provides a complete and up-to-date review of the optimal
Curr Infect Dis Rep (2013) 15:453–454
selection of HIV-infected donors and candidates for SOT. Furthermore, she summarizes the lessons learned and outlines the multidisciplinary approach required for the successful outcomes of these patients. Fungal infections are a persistent threat to transplant recipients and are increasingly recognized as an important contributor to the morbidity and mortality in patients with compromised immunity. Peter Chin-Hong of the University of California at San Francisco summarizes our current understanding of the epidemiology, prevention, and management of endemic mycoses. These regionally limited infections are a growing challenge, given the increased use of donors from distant regions and the increase in travel of transplant patients preand posttransplant. Since lung transplant grafts are in direct contact with the environment, they remain at a unique and exceptionally high risk of developing a range of fungal infections posttransplant. Fortunately, several studies have identified a number of strategies that can significantly reduce the incidence of these important complications. Furthermore, contemporary antifungal medications are allowing for treatment of fungal infections among lung transplant recipients with far less treatmentassociated toxicity and improved clinical outcomes. Shahid Husain of the University of Toronto has detailed our current understanding of the optimal strategies to prevent and treat fungal complications after lung transplantation. Compliance with Ethics Guidelines Conflict of Interest Nicole Theodoropoulos and Michael Ison declare that they have no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
References 1. Israni AK, Zaun DA, Rosendale JD, Snyder JJ, Kasiske BL. OPTN/ SRTR 2011 Annual data report: deceased organ donation. Am J Transplant. 2013;13:179–98. 2. Fishman JA. Infection in solid-organ transplant recipients. The New England journal of medicine. 2007;357(25):2601–14. 3. Halloran PF. Immunosuppressive drugs for kidney transplantation. The New England journal of medicine. 2004;351(26):2715–29. 4. Villacian JS, Paya CV. Prevention of infections in solid organ transplant recipients. Transplant infectious disease : an official journal of the Transplantation Society. 1999;1(1):50–64. 5. Marr KA. Delayed opportunistic infections in hematopoietic stem cell transplantation patients: a surmountable challenge. Hematology Am Soc Hematol Educ Program. 2012;2012:265–70.
INVITED COMMENTARY
Current Issues in Transplant Infectious Diseases Nicole Theodoropoulos & Michael G. Ison
Published online: 19 October 2013 # Springer Science+Business Media New York 2013
Solid organ transplantation (SOT) represents a significant advance in medicine and currently represents the preferred treatment for most patients with end-stage organ failure. SOT results in improved quality and quantity of life for more than 25,000 patients each year in the United States [1]. Significant advances in the potency of immunosuppressive agents, improvement in surgical techniques, and expanded use of antimicrobial prophylaxis have resulted in greater patient and graft survival rates over time [2]. Despite these advances, infections remain a leading cause of morbidity and mortality among transplant recipients [2–4]. Likewise, hematopoietic stem cell transplantation (HSCT) has made great strides in curing many previously incurable malignancies. Although improvements to the transplantation process, use of prophylaxis and screening measures, and employment of supportive care have decreased the infectious complications of HSCT, they remain a serious threat to good patient outcomes [5]. To address these significant challenges to successful transplantation, the field of transplant infectious diseases (TID) has grown to be an integral part of all major transplant programs in N. Theodoropoulos Department of Internal Medicine, Division of Infectious Diseases, The Ohio State University, Columbus, OH, USA N. Theodoropoulos : M. G. Ison Northwestern University Transplant Outcomes Research Collaborative, Northwestern University Feinberg School of Medicine, Chicago, IL, USA M. G. Ison Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA N. Theodoropoulos (*) Division of Infectious Diseases, The Ohio State University, N1121 Doan Hall 410 W. 10th Ave, Columbus, OH 43210, USA e-mail: [email protected]
the developed world. TID experts have advanced transplantation by defining the epidemiology of the infectious complications of both SOT and HSCT. BK virus nephropathy and novovirus gastroenteritis, for example, have recently been recognized to be significant causes of graft failure and chronic diarrhea, respectively. Most significant, the knowledge of posttransplant infections is being applied to develop and implement novel antimicrobials for the prevention and treatment of these complications. These advances are having a meaningful impact in reducing the frequency and severity of posttransplant infections and improving outcomes associated with SOT and HSCT. For this issue, we invited leaders in the field of TID to summarize the advances in recent research that have resulted in improved understanding of the epidemiology, prevention, and management of the specific infections. Multidrug-resistant organisms (MDROs) are an emerging threat in SOT. While it has long been recognized that transplant patients are among the highest risk groups for becoming colonized and developing serious infections, the frequency with which MDROs cause infection in transplant recipients has increased significantly in the past several years. Gopi Patel, Meenakshi M. Rana, and Shirish Huprikar from the Icahn School of Medicine at Mount Sinai have detailed our understanding of the mechanism of resistance, the risk factors for acquiring MDRO infections, and the optimal strategies for preventing acquisition of and treating these challenging infections. Immunomodulatory agents are increasingly used in transplant and other specialties to minimize inflammation and improve graft survival and to minimize the symptoms and impact of a number of immune-mediated diseases, including psoriasis, inflammatory bowel diseases, and multiple sclerosis. These agents cause specific defects in the immune system that result in enhanced risk of infectious complications, particularly the reactivation of latent infections in the host.
454
Ricardo M. La Hoz and John W. Baddley from the University of Alabama at Birmingham have summarized our current understanding of the specific risks of infectious complications associated with the use of these agents and the measures that help ensure optimal patient outcomes. Since the 2009 influenza A/H1N1 pandemic, the important impact of influenza on transplant populations has been recognized by the medical community. Vaccination remains the mainstay of prevention of influenza infections, but questions about the safety and efficacy of influenza vaccination contribute to the poor utilization of this important preventative strategy among transplant recipients. Aliyah Baluch and Yanina Pasikhova from the University of South Florida College of Medicine and H. Lee Moffitt Cancer Center and Research Institute summarize the current data on the safety and efficacy of influenza vaccination among patients undergoing therapy for cancer. Mechanical circulatory support is increasingly important in the routine therapy of patients with end-stage heart failure. While advances in these devices have resulted in improved clinical outcomes, infections remain a substantial limitation to this form of therapy. Stanley I. Martin from The Ohio State University provides a comprehensive review of techniques for infection prevention and the ideal approach to diagnostic and therapeutic strategies to managing mechanical circulatory support infections. Cytomegalovirus (CMV) remains the most common infection after solid organ and hematopoietic stem cell transplant. Advances in antiviral prophylaxis strategies have reduced the incidence of CMV infections but remain limited by toxicity and the frequency of late-onset CMV infections. Oriol Manuel from University of Lausanne has provided a comprehensive review of clinically meaningful methods of measuring CMVspecific T-cell responses and has highlighted the potential role that these powerful tools may have in optimizing the prevention and management of CMV infections following transplantation. Recently completed multicenter studies of kidney and liver transplantation has demonstrated that this life-saving intervention can be safely applied to patients living with HIV infection. These studies have further demonstrated that graft and patient outcomes are acceptable in this unique population and have led to more HIV-infected patients being offered transplantation. Furthermore, recent advances in our understanding of the pool of HIV-positive donors and the ability to safely use selected HIV-infected donor organs for HIV-infected candidates have resulted in Congress reconsidering the prohibition of the use of HIV-infected donors for SOT. Valentina Stosor of the Northwestern University Feinberg School of Medicine provides a complete and up-to-date review of the optimal
Curr Infect Dis Rep (2013) 15:453–454
selection of HIV-infected donors and candidates for SOT. Furthermore, she summarizes the lessons learned and outlines the multidisciplinary approach required for the successful outcomes of these patients. Fungal infections are a persistent threat to transplant recipients and are increasingly recognized as an important contributor to the morbidity and mortality in patients with compromised immunity. Peter Chin-Hong of the University of California at San Francisco summarizes our current understanding of the epidemiology, prevention, and management of endemic mycoses. These regionally limited infections are a growing challenge, given the increased use of donors from distant regions and the increase in travel of transplant patients preand posttransplant. Since lung transplant grafts are in direct contact with the environment, they remain at a unique and exceptionally high risk of developing a range of fungal infections posttransplant. Fortunately, several studies have identified a number of strategies that can significantly reduce the incidence of these important complications. Furthermore, contemporary antifungal medications are allowing for treatment of fungal infections among lung transplant recipients with far less treatmentassociated toxicity and improved clinical outcomes. Shahid Husain of the University of Toronto has detailed our current understanding of the optimal strategies to prevent and treat fungal complications after lung transplantation. Compliance with Ethics Guidelines Conflict of Interest Nicole Theodoropoulos and Michael Ison declare that they have no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
References 1. Israni AK, Zaun DA, Rosendale JD, Snyder JJ, Kasiske BL. OPTN/ SRTR 2011 Annual data report: deceased organ donation. Am J Transplant. 2013;13:179–98. 2. Fishman JA. Infection in solid-organ transplant recipients. The New England journal of medicine. 2007;357(25):2601–14. 3. Halloran PF. Immunosuppressive drugs for kidney transplantation. The New England journal of medicine. 2004;351(26):2715–29. 4. Villacian JS, Paya CV. Prevention of infections in solid organ transplant recipients. Transplant infectious disease : an official journal of the Transplantation Society. 1999;1(1):50–64. 5. Marr KA. Delayed opportunistic infections in hematopoietic stem cell transplantation patients: a surmountable challenge. Hematology Am Soc Hematol Educ Program. 2012;2012:265–70.
