It remains uncertain whether immunocompromised patients including solid organ transplant (SOT) recipients will have a robust antibody response to SARS‐CoV‐2 infection. We enrolled all adult SOT recipients at our center with confirmed SARS‐CoV‐2 infection who underwent antibody testing with a single commercially available anti‐nucleocapsid antibody test at least 7 days after diagnosis in a retrospective cohort. 70 SOT recipients were studied (56% kidney, 19% lung, 14% liver +/‐ kidney, and 11% heart +/‐ kidney recipients). 36 (51%) had positive anti‐nucleocapsid antibody testing, and 34 (49%) were negative. Recipients of a kidney allograft were less likely to have positive antibody testing compared those who did not receive a kidney (p=0.04). In the final multivariable model, the years from transplant to diagnosis (OR 1.26, p=0.002) and baseline immunosuppression with more than 2 agents (OR 0.26, p=0.03) were significantly associated with the antibody test result, controlling for kidney transplantation. In conclusion, among SOT recipients with confirmed infection, only 51 % of patients had detectable anti‐nucleocapsid antibodies, and transplant‐related variables including the level and nature of immunosuppression are important predictors. These findings raise the concern that SOT recipients with COVID‐19 may be less likely to form SARS‐CoV‐2 antibodies.
Background Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) is highly effective. However, people who inject drugs face significant barriers to DAA access. Methods We describe a program that colocates HCV management within a syringe service program in New York City. We performed a retrospective chart review of all patients with confirmed HCV viremia. Results From 2015 to 2018, 102 patients with viremia completed intake. Fifty-eight patients started DAAs. Nine patients discontinued treatment or were lost to follow-up before completion; 1 is continuing DAA treatment. Of 48 patients who completed therapy, sustained virologic response (SVR) was achieved in 43 (89.6%). Age and established mental health treatment at intake were associated with SVR. Regular cocaine use was negatively associated with SVR in univariate analysis, but this association was not significant after adjustment for age. Of 30 patients completing DAA therapy with active illicit opioid use at intake, 14 (46.4%) engaged in opioid use disorder (OUD) treatment during therapy, and 9 remained in OUD treatment after completion of DAA treatment. Conclusions Loss to follow-up is a challenge for people who inject drugs, but among those who completed treatment, SVR was achieved at a high rate. Mental health treatment may facilitate HCV cure. Conversely, HCV therapy may facilitate engagement in OUD treatment and other services.
Recipients of ex vivo T-cell depleted (TCD) HCT are at risk of infection by double stranded (ds) DNA viruses. We report rates of dsDNA viremia, end-organ disease (EOD), infection-related mortality, and overall survival (OS) in a contemporary cohort of adult TCD HCT recipients routinely monitored for cytomegalovirus (CMV), adenovirus (ADV), human herpesvirus 6 (HHV6) and Epstein-Barr virus (EBV). Health care utilization in the first 6 months post HCT was compared between patients with dsDNA viremia versus no viremia. Observational study of adult patients with acute leukemia and myelodysplastic syndrome who received CD34+ selected, peripheral blood HCT at Memorial Sloan Kettering Cancer Center from March 2012 through December 2014. Patients were prospectively monitored by quantitative polymerase chain (qPCR) assays for CMV, ADV, HHV6 and EBV in whole blood or plasma. The cumulative incidence of viremia(s) at day +180, end-organ disease (EOD) at 1 year, and overall survival at 1 year were estimated by the Kaplan-Meier method and compared by the log-rank test among patient with and without viremia/EOD. Standardized incidence ratios (SIR) were used to compare overall length of hospital stay (LOS), number of readmissions after HCT and length of readmissions through day +180. Of 156 patients, 96 (62%) were CMV recipient seropositive. Patients received grafts from matched related 42 (27%), matched unrelated 86 (55%) or mismatched 28 (18%) donors. Overall, 132 (85%) patients had ≥1viremia, and 52 (33%) patients had ≥2 viremias by day +180. The cumulative incidences for CMV, HHV6, ADV, and EBV viremia were 44%, 61%, 7% and 16%, respectively with median [interquartile range(IQR)] time of onset 28 (25–33), 33(25–47), 60(19–84), and 79 (54–106) days post HCT, respectively. Twenty-eight (18%) patients developed EOD by ds DNA viruses at 1 year post HCT. Treatment for CMV accounted for 91% total antiviral treatment-days. Compared to patients with no viremia, patients with CMV viremia, HHV6 viremia, or ≥ 2 viremias experienced longer LOS (P<0.001) and a higher number of readmissions (P<0.001) by day+ 180. OS at 1-year was 79% and similar between patients with or without ds DNA viremias. EOD was associated with lower 1-year OS (63.4%) vs without EOD (81.1%) (P=0.02). Of 33 patients that died, 10 died due to infection and 7 of the 10 infection-related deaths were due to dsDNA viruses. Viremia by dsDNA viruses occurred in 85% of CD34+ HCT recipients by day +100 and 33% of patients experienced ≥2 viremias by day +180. CMV accounted for the majority of antiviral use. CMV, HHV6 or ≥2 viremias were associated with more readmissions and longer LOS. Overall, one-year OS was 78%. EOD by dsDNA viruses was associated with decreased one-year OS. Infections by ds DNA viruses pose a substantial burden after TCD HCT.
We quantified cytomegalovirus (CMV) antiviral use and hospital length of stay (LOS) associated with CMV infection in a contemporary cohort of conventional (CONV) and CD34-selected (T D 1 0 8 X XcellÀD 1 0 9 X Xdepleted) hematopoietic cell transplantation (HCT) recipients managed by preemptive therapy (PET) in a single US center. Adults who received first allogeneic HCT at Memorial Sloan Kettering D 1 1 0 X XCancer Center from June 2010 through December 2014 were analyzed. Days on PET, number of readmissions, and readmission LOS by day 180 post-D 1 1 1 X XHCT were summarized. Estimated unit value (EUV) was defined as the expected number of PET days for a cohort of 100 HCT with characteristics as the analyzed cohort. Standardized incidence ratio D 1 1 2 X Xwas calculated as the ratio of observed outcomes of patients with CMV viremia over the outcomes of patients without CMV viremia. Of 318 patients, 88 received CONV and 230 CD34-selected HCT. Rates of CMV viremia were 26.3% for CONV and 41.9% for CD34selected (P = D 1 1 3 X X.003). Among D 1 1 4 X Xpatients with viremia 68.2% CONV and 97.9% CD34-selected received PET. EUV for PET was 852 days and 2D 1 1 5 X X821 days for CONV and CD34-selected, respectively. The standardized incidence ratios D 1 1 6 X Xfor number of readmission and readmission LOS were 1.7 D 1 1 7 X X(95% confidence interval [CI], D 1 1 8 X X1.4 to D 1 1 9 X X2.1D 1 2 0 X X) and 1.2 (95% CI, 1.1 to D 1 2 1 X X1.3), respectively, for CONV HCT and 1.7 (95% CI, 1.3 to D 1 2 2 X X2.1) and 1.6 (95% CI, 1.5 to D 1 2 3 X X1.7), respectively, for CD34selected HCT. Overall survival D 1 2 4 X Xwas similar between patients with and without CMV viremia by HCT type. CMV end-organ disease was associated with lower overall survival D 1 2 5 X Xonly in CD34-selected HCT (P = .0007). CMV infection managed by PET requires substantial antiviral useD 1 2 6 X X and is associated with longer readmission LOS more, particularly among CD34-selected HCT.
HIV transmission via solid organ transplant is a rare but serious complication. Here, we describe long-term outcomes in a case of living donor-derived transmission of HIV in a kidney transplant recipient. After 11 years since transplant surgery, the donor shows no evidence of abnormal renal function, while the recipient continues to have a functioning graft. HIV is well controlled in both individuals. This single case report highlights the possibility of acceptable long-term outcomes in living kidney donors with HIV as well as in donor-derived HIV transmission to kidney transplant recipients. K E Y W O R D Sdonor derived infection, HIV, kidney transplant, outcomes INTRODUCTIONHIV transmission via solid organ donation to an HIV negative recipient is a rare but serious complication. Additionally, long-term consequences to HIV positive kidney donors are unknown. This report describes long-term follow-up of a kidney transplant donor unknown to be infected with HIV who subsequently transmitted HIV to the recipient via the allograft in 2009. Both recipient and donor have consented to this report. The details of the case were initially outlined in a Morbidity and Mortality Weekly Report (MMWR) report in 2011. 1 Briefly, a hemodialysis-dependent patient with systemic lupus erythematosus and antiphospholipid syndrome underwent a living donor kidney transplant in October 2009. HIV antibody testing in the recipient was negative 2 weeks prior to transplant. The immediate postoperative course was uncomplicated, but starting 3 months posttransplant, the recipient developed acute graft dysfunction, fevers, and recurrent oral Abbreviations: ESRD, end-stage renal disease; HIV, human immunodeficiency virus; MMWR, morbidity and mortality weekly report; NAT, nucleic acid test; PSH, Public Health Service and esophageal candidiasis. Approximately 1 year after transplant, the recipient was found to have HIV infection, and further investigation by the New York City Department of Health (DOH) ultimately established that the donor had acquired HIV a few weeks prior to organ donation and unknowingly transmitted the virus to the recipient. Recipient follow-upAt the time of diagnosis of HIV in October 2010, the recipient's viral load was 29,996 RNA copies/ml, and the CD4 count was 54 cells/µl (CD4+ 4%). Pneumocystis prophylaxis with trimethoprim/sulfamethoxazole was promptly initiated, and after a genotype demonstrated no resistance mutations, the recipient was started on a regimen of renally-adjusted lamivudine, abacavir, and efavirenz. The recipient tolerated therapy without any side effects, and the viral load became undetectable by January 2011. The CD4 count also responded positively, reaching above 200 cells/µl (CD4+ 12%) within 7 months of initiation of therapy. Since then, there have been no
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