Ebens Christen L, Smith Angela R, Verghese Priya S
Department of Pediatrics, Division of Blood and Marrow Transplant, University of Minnesota, Minneapolis, MN, USA.
Department of Pediatrics, Division of Nephrology, University of Minnesota, Minneapolis, MN, USA.
Pediatr Transplant. 2017 Aug;21(5). doi: 10.1111/petr.12929. Epub 2017 Apr 27.
Pediatric patients requiring kidney transplant after hematopoietic cell transplant receive multiple courses of immunosuppression placing them at risk for infection. To elucidate potential risk factors for infection, we compared the immunosuppressive regimens and infectious complications of pediatric kidney transplant recipients at a single institution who had previously undergone hematopoietic cell transplant from different donors to similar patients reported in the literature. Among the initial four post-hematopoietic cell transplant kidney transplant patients reviewed, viremia episodes were universal, including BK virus, Epstein-Barr virus, and human herpesvirus-6, with one death from presumed BK virus encephalitis. No viremia was reported in five similar cases in the literature. Risk factors for increased infection include use of lymphodepleting serotherapy in HCT conditioning, multiple HCTs, limited immune reconstitution time between transplants, increased pre-KTx viral burden, and use of T-cell-depleting versus -suppressive induction immunosuppression for KTx. These findings suggest that pediatric post-HCT KTx recipients are at increased risk for viral infections, likely benefitting from thorough pre-KTx evaluation of immune reconstitution and preferential use of non-T-cell-depleting induction therapy for KTx. We applied these recommendations to one subsequent post-HCT patient requiring KTx at our institution with excellent outcomes one year post-KTx.
造血细胞移植后需要进行肾移植的儿科患者接受多疗程免疫抑制治疗，这使他们面临感染风险。为了阐明潜在的感染风险因素，我们比较了一家机构中曾接受来自不同供体的造血细胞移植的儿科肾移植受者的免疫抑制方案和感染并发症，并与文献中报道的类似患者进行了对比。在最初审查的4例造血细胞移植后肾移植患者中，病毒血症发作普遍存在，包括BK病毒、EB病毒和人类疱疹病毒6型，其中1例因疑似BK病毒脑炎死亡。文献中报道的5例类似病例均未出现病毒血症。感染增加的风险因素包括在造血细胞移植预处理中使用淋巴细胞清除性血清疗法、多次造血细胞移植、移植之间免疫重建时间有限、肾移植前病毒载量增加以及在肾移植中使用耗竭T细胞而非抑制T细胞的诱导免疫抑制。这些发现表明，造血细胞移植后肾移植的儿科受者病毒感染风险增加，可能受益于肾移植前对免疫重建的全面评估以及优先使用非耗竭T细胞的肾移植诱导治疗。我们将这些建议应用于我们机构随后1例需要进行肾移植的造血细胞移植后患者，肾移植后1年效果良好。
