Barbara G. Werner

Use of Cytomegalovirus Immune Globulin to Prevent Cytomegalovirus Disease in Renal-Transplant Recipients

We undertook a prospective randomized trial to examine whether an intravenous cytomegalovirus (CMV) immune globulin would prevent primary CMV disease in renal-transplant recipients. Fifty-nine CMV-seronegative patients who received kidneys from donors who had antibodies against CMV were assigned to receive either intravenous CMV immune globulin or no treatment. The immune globulin was administered in multiple doses over the first four months after transplantation. The incidence of virologically confirmed CMV-associated syndromes was reduced from 60 percent in controls to 21 percent in recipients of CMV immune globulin (P less than 0.01). Fungal or parasitic superinfections were not seen in globulin recipients but occurred in 20 percent of controls (P = 0.05). Only 4 percent of globulin recipients had marked leukopenia (reflecting serious CMV disease), as compared with 37 percent of the controls (P less than 0.01). There was a concomitant but not statistically significant reduction in the incidence of CMV pneumonia (17 percent of controls as compared with 4 percent of globulin recipients). A significant reduction in serious CMV-associated disease was observed even when patients were stratified according to therapy for transplant rejection (P = 0.04). We observed no effect of immune globulin on rates of viral isolation or seroconversion, suggesting that treated patients often harbored the virus but that clinically evident disease was much less likely to develop in them. We conclude that CMV immune globulin provides effective prophylaxis in renal-transplant recipients at risk for primary CMV disease.

The Independent Role of Cytomegalovirus as a Risk Factor for Invasive Fungal Disease in Orthotopic Liver Transplant Recipients

PURPOSE To assess impact of cytomegalovirus (CMV) donor-recipient serostatus, infection, or disease on development of invasive fungal infection in orthotopic liver transplant recipients. PATIENTS AND METHODS An analysis of prospectively collected data in 146 liver transplant recipients (intention to treat cohort) from 4 tertiary care, university-affiliated transplant centers in Boston (Boston Center for Liver Transplantation). Patients were observed for 1 year after transplantation for the development of CMV infection, CMV disease, CMV pneumonia, as well as for the development of opportunistic fungal infections, graft survival, and mortality. Weekly cultures were taken of urine and throat and every other week of buffy coat for CMV for 2 months, then monthly for 6 months, at 1 year, and at the time of any clinical illness. Pre- and posttransplant variables including CMV-serostatus of donor and recipient, fungal isolation from sterile body sites, fungemia, bacteremia, antibiotic use, immunosuppression, treatment for rejection, and volumes of blood products were measured. RESULTS Survival analysis demonstrated that 36% of patients with CMV disease developed invasive fungal disease within the first year post-transplant compared with 8% of those without CMV disease (P < 0.0001). One-year mortality in patients with invasive fungal disease was 15 of 22 (68%) compared with 23 of 124 (19%) in those without invasive fungal disease (P < 0.001). A multivariable, time-dependent analysis demonstrated that being a CMV-seronegative recipient of a CMV-seropositive donor organ (P < 0.001), having bacteremia (P = 0.001), UNOS (United Network for Organ Sharing) status 4 (need for life support measures) at transplant (P = 0.002), and volume of platelets (P = 0.002) were independently associated with invasive fungal disease. Restriction of cases of invasive fungal disease to those that occurred more than 2 weeks after transplant demonstrated an association with CMV disease (P = 0.003), bacteremia (P = 0.003), need for life support (P = 0.03), and volume of blood products transfused (P = 0.02). CONCLUSION CMV disease or being a CMV-seronegative recipient of a CMV-seropositive donor organ is an important predictor for invasive fungal disease following orthotopic liver transplantation.

Accidental Hepatitis-B-Surface-Antigen-Positive Inoculations: Use of e Antigen to Estimate Infectivity

We assessed the ability of radioimmunoassay for hepatitis B e antigen (HBeAg) to predict infectivity in exposed medical personnel by analyzing 390 samples of sera positive for hepatitis B surface antigen (HBsAg) that were implicated in accidental inoculations of known outcome. The radioimmunoassay detected HBeAg or its antibody (anti-HBe) in 91% of the donor sera. The incidence of hepatitis B was 19% (44 of 234) in recipients of HBeAg-positive sera but was only 2.5% (three of 121) in recipients of sera positive for anti-HBe, and nil (none of 35) in recipients of sera negative for HBeAg and anti-HBe. The known relation of HBeAg and infectivity was quantified by radioimmunoassay as a risk ratio of 10:1 (HBeAg-positive to HBeAg-negative) for this type of exposure. The sensitivity of the radioimmunoassay also showed that a large proportion (55%) of donor sera not producing hepatitis were positive for HBeAg; therefore, even the most flagrant needlestick exposures to HBsAg-positive sera often must involve subthreshold amounts of infective material.

Nonresponsiveness to hepatitis B vaccine in health care workers. Results of revaccination and genetic typings.

Twenty-eight health care workers who had a poor antibody response when initially vaccinated with hepatitis B vaccine were revaccinated with three additional 20-microgram doses. Eight of the twenty nonresponders, who had levels of antibody to hepatitis B surface antigen (anti-HBs) of less than 8 estimated radioimmunoassay (RIA) units, and all 8 of the hyporesponders, who had anti-HBs levels of 8 or 16 RIA units, attained anti-HBs levels of 36 RIA units or more after revaccination. Tests for HLA-A, B, C, and DR; for complement proteins C2, C4A, C4B, and BF; and for the erythrocyte enzyme glyoxalase I were done in 17 nonresponders and 3 hyporesponders. Nine (45%) had HLA-DR7 and 8 (40%) had HLA-DR3, compared with an expected rate of 23% in the general population. At least one of two extended haplotypes (B44, DR7, FC31 or B8, DR3, SCO1) were detected in 6 of the 9 who did not respond to revaccination, compared with 2 of 11 who responded to a second course of vaccine. Poor responders to vaccine may benefit from revaccination, and genetic factors may modulate the immune response to vaccination.

Hepatitis B Vaccine in Health Care Personnel: Safety, lmmunogenicity, and Indicators of Efficacy

In a double-blind trial, we randomly assigned 1330 high-risk health care personnel to receive three 20-micrograms doses of hepatitis B vaccine or placebo. Among vaccine recipients 58% responded within 1 month and 97% within 9 months; there was no difference in immune response to the vaccine between men and women. Efficacy was evaluated after a mean follow-up of only 13.2 months, just before the vaccine was released commercially. Five hepatitis B infections were identified in placebo recipients and one in a vaccine recipient. Although the number of infections was too small to allow confident conclusions about protective efficacy of the vaccine, we saw a 67% reduction in the need for hepatitis B immune globulin after accidental hepatitis B inoculation in the vaccine group (relative risk, 5.08; 95% confidence intervals, 1.3 to 19.9). Minor side effects occurred with equal frequency after vaccine (28.7%) and placebo (27.2%) injections; no participant had a severe adverse reaction. Vaccination with the 20-micrograms hepatitis B vaccine was highly immunogenic and safe in health care workers.

Human Herpesvirus 6 Reactivation Is Associated with Cytomegalovirus Infection and Syndromes in Kidney Transplant Recipients at Risk for Primary Cytomegalovirus Infection

A potential association between human herpesvirus 6 (HHV-6) and cytomegalovirus (CMV) following kidney transplantation was explored by retrospectively testing serial serum specimens for HHV-6 IgG and IgM antibody. HHV-6 reactivation occurred in 35 (66%) of 53 transplant recipients. Fungal or parasitic opportunistic infections, graft rejection or loss, and mortality were not associated with HHV-6 reactivation. HHV-6 reactivation was associated with primary CMV infection (P=.001) and CMV syndrome (P=.003) and with trends for CMV-related hepatitis (P=.095), CMV-related neutropenia (P=.104), and serious CMV disease (P=.085). After controlling for CMV immune globulin (CMVIG) prophylaxis, the association between HHV-6 reactivation and primary CMV infection and syndrome remained significant (P=.002 and 0.006, respectively). The reduction in CMV syndrome among those receiving CMVIG prophylaxis remained significant (P=.007) after controlling for HHV-6 reactivation. HHV-6 reactivation in kidney transplant recipients at risk for primary CMV infection is associated with CMV infection and CMV-related disease, and these effects are independent of CMVIG prophylaxis.

Effect of Cytomegalovirus Infection Status on First-Year Mortality Rates among Orthotopic Liver Transplant Recipients

Improvements in surgical technique, the introduction of immunosuppressive agents that have more specific immunomodulatory effects, and accumulated experience in the management of liver transplant recipients have led to an increase in early and late survival among patients receiving orthotopic liver transplants [1]. However, 1-year mortality rates of 20% to 30% continue to be reported from most centers [1, 2]. The identification of risk factors associated with death in liver transplant recipients is important because of the benefit that might be derived through risk modification. Previous studies of predictors of death in liver transplant recipients have focused on the urgency of liver transplantation, concomitant illness before surgery, surgical risk factors, bacterial and fungal infections after transplantation, rejection of the transplanted organ, and the need for retransplantation [3-9]. Cytomegalovirus (CMV) is known to cause illness in liver transplant recipients [1, 10], and a trend for an association between CMV disease and decreased survival has been reported [10]. Evidence among heart and lung transplant recipients indicates that CMV infection is associated with decreased graft and patient survival [11, 12]. However, no data obtained using multivariate analysis are available for examination of the association between death and the status of CMV infection in liver transplant recipients. We explore the possible effect of the CMV serologic status of donor and recipient on 1-year mortality rates in a cohort of liver transplant recipients after controlling for pretransplantation characteristics; post-transplantation interventions, such as the immunosuppressive regimen; and other outcomes, such as rejection of the transplanted organ and bacterial and fungal infections. All of the factors have been known to affect survival. Methods Patients We did an intention-to-treat analysis of prospectively gathered data from a cohort of 146 liver transplant recipients enrolled in a multicenter, randomized, placebo-controlled, double-blind trial of CMV immune globulin. We analyzed data from patients who were followed for 1 year in that study, which was done from December 1987 though June 1990 in four transplant centers in Boston, Massachusetts (the participating centers of the Boston Center for Liver Transplantation). Details of enrollment; follow-up; clinical management; all microbiological studies, including cultures and studies of serologic status for CMV; and immunosuppressive therapy and the definitions of CMV infection, CMV disease, bacteremia, and invasive fungal disease have been reported elsewhere [13, 14]. Statistical Analysis Pretransplantation, intratransplantation, and post-transplantation variables were analyzed for their association with death. In the univariate analysis, we used a log-rank test from Kaplan-Meier survival analysis for discrete pretransplantation variables, a Wald chi-square from Cox proportional-hazards survival analysis for continuous pretransplantation and intratransplantation variables, and a Wald chi-square from time-dependent Cox proportional-hazards survival analysis for post-transplantation variables [15]. Post-transplantation variables were analyzed as time-dependent covariates, except for the total amount of solumedrol and murine monoclonal antibody (Orthoclone OKT3, Ortho Biotech, Inc., Raritan, New Jersey) and the development of CMV infection or CMV viremia, which were analyzed as time-independent covariates. Only variables that showed a statistical association (P < 0.05) with the 1-year mortality rate on univariate analysis were included as candidate variables for stepwise selection in the Cox proportional-hazards models. To explore the possible role of donor and recipient CMV serologic status on mortality rates, we constructed a model for multivariate analysis that did not include variables that were highly correlated with donor and recipient CMV serologic status. Multivariate analysis of pretransplantation and intratransplantation variables alone was also done. Results Univariate Analysis Thirty-eight of 146 (26%) patients died within the first year after liver transplantation. The 1-year mortality rate was 25.4% (31 of 122 patients) in adults and 29.2% (7 of 24 patients) in children. In this intention-to-treat analysis, we included 5 patients who had had retransplantation after the first 30 days after enrollment and who had been censored from the original report after loss of the first graft. We also included 5 patients who had been excluded from analysis because they had received fewer than two doses of the study medication [13]. Univariate analysis showed a highly statistically significant increase in the relative risk for death associated with CMV disease, invasive fungal disease, bacteremia, retransplantation, number of units of blood products administered during transplantation, abdominal surgery (excluding retransplantation) after liver transplantation, CMV serologic status of donor and recipient before transplantation, and fungal isolation (colonization or invasive fungal disease) (Table 1). When analyzed individually, the number of units of each type of blood product (red blood cells, fresh frozen plasma, and platelets) administered during transplantation was also associated with higher mortality rates (Table 1). Table 1. Univariate Analysis of Predictors of 1-Year Mortality for 146 Orthotopic Liver Transplant Recipients Analyzed as an Intention-To-Treat Cohort* We saw highly statistically significant differences in 1-year mortality rates among the four combinations of donor and recipient CMV serologic status before transplantation. One-year mortality rates by CMV serologic status were as follows: 11% if donor and recipient were both seronegative, 22% if donor was seronegative and recipient was seropositive, 30% if donor and recipient were both seropositive, and 44% if donor was seropositive and recipient was seronegative (P = 0.0091) (Table 1). This difference was seen for patients who received either CMV immune globulin or placebo (data not shown). Stratified analysis by donor CMV serologic status showed a 2.7-fold increase in relative risk for death up to 1 year for recipients of livers from CMV-seropositive donors compared with CMV-seronegative donors (95% CI, 1.4 to 5.3; P = 0.003). Multivariate Analysis In a multivariate analysis of pretransplantation variables only, the CMV serologic status of donor and recipient was the only variable that was significantly associated with survival (P = 0.0091) (Table 2). A Cox proportional-hazards model was used to analyze possible associations of pretransplantation and intratransplantation characteristics with death. This analysis showed that the number of units of blood products administered during transplantation (relative risk, 1.007 per unit; P < 0.001) and the combination of donor and recipient CMV serologic status (relative risks compared with seronegative donors and recipients were as follows: 1.94 for seronegative donor and seropositive recipient [P = 0.24], 3.17 for seropositive donor and recipient [P = 0.051], and 4.61 for seropositive donor and seronegative recipient [P = 0.0034]) were the only variables independently associated with a higher 1-year mortality rate. Table 2. Multivariate Analysis of Independent Predictors of 1-Year Mortality in Orthotopic Liver Transplant Recipients* A multivariate, time-dependent Cox proportional-hazards model with stepwise selection using the eight pretransplantation, intratransplantation, and post-transplantation variables that had a significant (P < 0.05) association on univariate analysis showed that retransplantation (relative risk, 4.6 [CI, 1.9 to 10.7]; P < 0.001), total number of units of blood products administered during transplantation (relative risk, 1.006 per unit [CI, 1.003 to 1.010]; P < 0.001), presence of CMV disease (relative risk, 3.9 [CI, 1.8 to 8.5]; P < 0.001), presence of invasive fungal disease (relative risk, 3.3 [CI, 1.5 to 7.1]; P = 0.0020), and presence of bacteremia (relative risk, 2.5 [CI, 1.2 to 5.2]; P = 0.0136) were independently associated with higher mortality rates (Table 2). Variables that were independently associated with survival in the main model remained unchanged in a subset analysis of the 124 adult liver transplant recipients (data not shown). To fully explore the effect of donor and recipient CMV serologic status before transplantation on 1-year mortality rates, we studied the correlation between the four CMV serologic strata and the post-transplantation variables that were found to be independently associated with higher 1-year mortality rates. Donor and recipient CMV serologic status before transplantation was associated with presence of CMV disease (P < 0.001), invasive fungal disease (P < 0.001), and bacteremia (P = 0.0153). In another multivariate analysis that included CMV serologic status as a candidate variable but did not include the three post-transplantation characteristics that were highly associated with CMV serologic status, the combination of donor and recipient CMV serologic status was found to be independently associated with higher 1-year mortality rates (relative risks compared with seronegative donor and recipient were 2.23 [CI, 0.71 to 6.99] for seronegative donor and seropositive recipient, 5.15 [CI, 1.55 to 17.0] for seropositive donor and recipient, and 5.0 [CI, 1.8 to 13.9] for seropositive donor and seronegative recipient; global P value for differences among groups, 0.002). In that model, the total number of units of blood products administered during transplantation (relative risk, 1.01 per unit; P = 0.001) and retransplantation (relative risk, 3.50; P = 0.0012) remained highly associated with increased mortality rates. Discussion We show that the development of CMV disease in a multicenter, prospectively followed cohort of 146 recipients of orthotopic liver transplants is associated with almost a fourfold

Cytomegalovirus disease is associated with increased cost and hospital length of stay among orthotopic liver transplant recipients.

Cytomegalovirus (CMV) is a cause of considerable morbidity and mortality among orthotopic liver transplant (OLT) recipients. To study the impact of CMV on cost and hospital length of stay in this population, we undertook an analysis of a cohort of OLT recipients from four transplant centers in Boston who participated in a CMV prophylaxis trial. First posttransplant year hospital length of stay (including the hospital stay after transplantation and readmissions within 1 year after transplantation) was available for all 141 patients included in the study. In a multiple linear regression model bacteremia (P=0.0001), CMV disease (P=0.0007), abdominal reexploration (excluding retransplantation) (P=0.0070), recipient age < or = 16 years (P=0.0352), and the number of units of blood products (red blood cells, platelets, or fresh frozen plasma) administered during transplantation (P=0.0523) were shown to be independently associated with longer first posttransplant year hospital length of stay. Cost data for in-hospital care for the year beginning with admission for liver transplantation were available for 66 OLT recipients. Using a multiple linear regression model, development of CMV disease (P=0.0001), the number of units of blood products administered during transplantation (P=0.0001), bacteremia (P=0.0002), decreased pretransplant renal function (estimated by creatinine clearance) (P=0.0109), and need for retransplantation (P=0.0619) were shown to be independently associated with higher cost. These data strongly suggest that CMV disease has a direct impact on cost and hospital length of stay in liver transplantation.

Association of Human Herpesvirus 6 Reactivation with Severe Cytomegalovirus-Associated Disease in Orthotopic Liver Transplant Recipients

To explore the possible interaction between human herpesvirus 6 (HHV-6) and cytomegalovirus (CMV) in patients who have undergone organ transplantation, stored serum samples from 139 orthotopic liver transplant recipients were tested for HHV-6 immunoglobulin (Ig) G and IgM antibodies. HHV-6 reactivation occurred in 87 patients (62.6%) and was associated with CMV disease (P=.01), severe CMV-associated disease (P=.01), older age (P=.005), and use of muromonab-CD3 (Orthoclone; Orthobiotech) as treatment for rejection (P=.02). Trends for an association between HHV-6 reactivation and invasive fungal disease (P=.12), bacteremia (P=.10), and graft loss (P=.12) were seen. In a multivariate analysis of risk factors for severe CMV-associated disease, HHV-6 reactivation (relative risk [RR], 3.5; 95% confidence interval [CI], 1.2-10.2; P=.02), CMV donor-positive-recipient-negative match (RR, 5.7; 95% CI, 2.5-13.2; P<.001), and elevated serum creatinine level (P<.0001) were independent predictors. HHV-6 reactivation is associated with severe CMV-associated disease in liver transplant recipients.

SIGNIFICANCE OF CYTOMEGALOVIRUS FOR LONG-TERM SURVIVAL AFTER ORTHOTOPIC LIVER TRANSPLANTATION: A Prospective Derivation and Validation Cohort Analysis1

BACKGROUND Cytomegalovirus (CMV) infection and disease has been found to be associated with decreased graft and patient survival among heart transplant recipients. We sought to explore the effect of CMV infection and disease on long-term survival in orthotopic liver transplant (OLT) recipients using a derivation and validation cohort. METHODS For derivation-validation modeling, we used data collected from two prospectively followed cohorts as the basis for multivariate analyses: 167 OLT recipients from the Boston Center for Liver Transplantation (the derivation set; median follow-up: 5.5 years, mortality: 40%) and an independent cohort of 294 OLT recipients from the Mayo Clinic (the validation set; median follow-up: 4.8 years, mortality: 27%). RESULTS Underlying liver disease other than primary biliary cirrhosis or sclerosing cholangitis, number of units of red blood cells administered during transplantation, and donor CMV seropositivity were the pre- and intratransplant variables independently associated (P<0.01) with decreased long-term survival in the derivation cohort. For variables collected up to 1 year after transplantation, the need for retransplan. tation, CMV pneumonia, invasive fungal disease, and underlying liver disease other than primary biliary cirrhosis or sclerosing cholangitis were independently associated (P<0.01) with decreased long-term survival in the derivation cohort. The magnitude of the relationship of each pre-, intra-, and posttransplant factor with survival, as measured by the relative risk, did not significantly differ between the derivation and validation cohorts. The derivation model, incorporating pre-, intra-, and posttransplant factors, had receiver operating characteristic areas of 73% and 74% for 5-year mortality in the derivation and validation cohorts, respectively. CONCLUSIONS Data from a derivation and an independent validation cohort demonstrate that CMV factors (reflected by either donor CMV seropositivity at transplantation, CMV pneumonia, or CMV disease within the first posttransplant year) are independently associated with decreased long-term survival in OLT recipients.