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The effect of induction immunosuppression for kidney transplant on the latent HIV reservoir

Benner, Sarah E; Eby, Yolanda; Zhu, Xianming; Fernandez, Reinaldo E; Patel, Eshan U; Ruff, Jessica E; Habtehyimer, Feben; Schmidt, Haley A; Kirby, Charles S; Hussain, Sarah; Ostrander, Darin; Desai, Niraj M; Florman, Sander; Rana, Meenakshi M; Friedman-Moraco, Rachel; Pereira, Marcus R; Mehta, Shikha; Stock, Peter; Gilbert, Alexander; Morris, Michele I; Stosor, Valentina; Mehta, Sapna A; Small, Catherine B; Ranganna, Karthik; Santos, Carlos Aq; Aslam, Saima; Husson, Jennifer; Malinis, Maricar; Elias, Nahel; Blumberg, Emily A; Doby, Brianna L; Massie, Allan B; Smith, Melissa L; Odim, Jonah; Quinn, Thomas C; Laird, Gregory M; Siliciano, Robert F; Segev, Dorry L; Redd, Andrew D; Durand, Christine M; Tobian, Aaron Ar
The HIV latent viral reservoir (LVR) remains a major challenge in the effort to find a cure for HIV. There is interest in lymphocyte-depleting agents, used in solid organ and bone marrow transplantation to reduce the LVR. This study evaluated the LVR and T cell receptor repertoire in HIV-infected kidney transplant recipients using intact proviral DNA assay and T cell receptor sequencing in patients receiving lymphocyte-depleting or lymphocyte-nondepleting immunosuppression induction therapy. CD4+ T cells and intact and defective provirus frequencies decreased following lymphocyte-depleting induction therapy but rebounded to near baseline levels within 1 year after induction. In contrast, these biomarkers were relatively stable over time in the lymphocyte-nondepleting group. The lymphocyte-depleting group had early TCRβ repertoire turnover and newly detected and expanded clones compared with the lymphocyte-nondepleting group. No differences were observed in TCRβ clonality and repertoire richness between groups. These findings suggest that, even with significant decreases in the overall size of the circulating LVR, the reservoir can be reconstituted in a relatively short period of time. These results, while from a relatively unique population, suggest that curative strategies aimed at depleting the HIV LVR will need to achieve specific and durable levels of HIV-infected T cell depletion.
PMID: 36345940
ISSN: 2379-3708
CID: 5357162

Remdesivir resistance in transplant recipients with persistent COVID-19

Hogan, John I; Duerr, Ralf; Dimartino, Dacia; Marier, Christian; Hochman, Sarah E; Mehta, Sapna; Wang, Guiqing; Heguy, Adriana
New mutations conferring resistance to SARS-CoV-2 therapeutics have important clinical implications. We describe the first cases of an independently acquired V792I RNA-dependent RNA polymerase mutation developing in renal transplant recipients after remdesivir exposure. Our work underscores the need for augmented efforts to identify concerning mutations and address their clinical implications.
PMID: 36156117
ISSN: 1537-6591
CID: 5333962

Next steps for the xenotransplantation of pig organs into humans

Montgomery, Robert A; Mehta, Sapna A; Parent, Brendan; Griesemer, Adam
PMID: 35941375
ISSN: 1546-170x
CID: 5286742

National Landscape of HIV+ Deceased Organ Donors in the United States

Werbel, William A; Brown, Diane M; Kusemiju, Oyinkansola T; Doby, Brianna L; Seaman, Shanti M; Redd, Andrew D; Eby, Yolanda; Fernandez, Reinaldo E; Desai, Niraj M; Miller, Jernelle; Bismut, Gilad A; Kirby, Charles S; Schmidt, Haley A; Clarke, William A; Seisa, Michael; Petropoulos, Christos J; Quinn, Thomas C; Florman, Sander S; Huprikar, Shirish; Rana, Meenakshi M; Friedman-Moraco, Rachel J; Mehta, Aneesh K; Stock, Peter G; Price, Jennifer C; Stosor, Valentina; Mehta, Shikha G; Gilbert, Alexander J; Elias, Nahel; Morris, Michele I; Mehta, Sapna A; Small, Catherine B; Haidar, Ghady; Malinis, Maricar; Husson, Jennifer S; Pereira, Marcus R; Gupta, Gaurav; Hand, Jonathan; Kirchner, Varvara A; Agarwal, Avinash; Aslam, Saima; Blumberg, Emily A; Wolfe, Cameron R; Myer, Kevin; Wood, R Patrick; Neidlinger, Nikole; Strell, Sara; Shuck, Marion; Wilkins, Harry; Wadsworth, Matthew; Motter, Jennifer D; Odim, Jonah; Segev, Dorry L; Durand, Christine M; Tobian, Aaron A R
BACKGROUND:Organ transplantation from donors with HIV to recipients with HIV (HIV D+/R+) presents risks of donor-derived infections. Understanding clinical, immunologic, and virologic characteristics of HIV+ donors is critical for safety. METHODS:We performed a prospective study of donors with HIV-positive and HIV false-positive (FP) testing within the HOPE in Action studies of HIV D+/R+ transplantation (ClinicalTrials.gov NCT02602262; NCT03500315; NCT03734393). We compared clinical characteristics in HIV+ versus FP donors. We measured CD4+ T cells, HIV viral load (VL), drug resistance mutations (DRMs), co-receptor tropism, and serum antiretroviral therapy (ART) detection using mass spectrometry in HIV+ donors. RESULTS:Between 03/2016-03/2020, 92 donors (58 HIV+, 34 FP), representing 98.9% of all US HOPE donors during this period, donated 177 organs (131 kidney, 46 liver). Each year the number of donors increased. Prevalence of hepatitis B (16% vs. 0%), syphilis (16% vs. 0%), and cytomegalovirus (91% vs. 58%) was higher in HIV+ versus FP donors; hepatitis C viremia was similar (2% vs. 6%). Most HIV+ donors (71%) had known HIV diagnosis, of whom 90% were prescribed ART and 68% had VL<400 copies/mL. Median CD4 count was 194 cells/uL (IQR=77-331); median CD4% was 27.0 (IQR=16.8-36.1). Major HIV DRMs were detected in 42%, including non-nucleoside reverse transcriptase inhibitors (33%), integrase strand transfer inhibitor (INSTI, 4%), and multiclass (13%). Serum ART was detected in 46% and matched ART by history. CONCLUSION/CONCLUSIONS:Utilization of HIV+ donor organs is increasing. HIV DRMs are common, yet resistance that would compromise INSTI-based regimens is rare, which is reassuring regarding safety.
PMID: 34453519
ISSN: 1537-6591
CID: 5127552

Results of Two Cases of Pig-to-Human Kidney Xenotransplantation [Case Report]

Montgomery, Robert A; Stern, Jeffrey M; Lonze, Bonnie E; Tatapudi, Vasishta S; Mangiola, Massimo; Wu, Ming; Weldon, Elaina; Lawson, Nikki; Deterville, Cecilia; Dieter, Rebecca A; Sullivan, Brigitte; Boulton, Gabriella; Parent, Brendan; Piper, Greta; Sommer, Philip; Cawthon, Samantha; Duggan, Erin; Ayares, David; Dandro, Amy; Fazio-Kroll, Ana; Kokkinaki, Maria; Burdorf, Lars; Lorber, Marc; Boeke, Jef D; Pass, Harvey; Keating, Brendan; Griesemer, Adam; Ali, Nicole M; Mehta, Sapna A; Stewart, Zoe A
BACKGROUND:Xenografts from genetically modified pigs have become one of the most promising solutions to the dearth of human organs available for transplantation. The challenge in this model has been hyperacute rejection. To avoid this, pigs have been bred with a knockout of the alpha-1,3-galactosyltransferase gene and with subcapsular autologous thymic tissue. METHODS:We transplanted kidneys from these genetically modified pigs into two brain-dead human recipients whose circulatory and respiratory activity was maintained on ventilators for the duration of the study. We performed serial biopsies and monitored the urine output and kinetic estimated glomerular filtration rate (eGFR) to assess renal function and xenograft rejection. RESULTS:in Recipient 2. In both recipients, the creatinine level, which had been at a steady state, decreased after implantation of the xenograft, from 1.97 to 0.82 mg per deciliter in Recipient 1 and from 1.10 to 0.57 mg per deciliter in Recipient 2. The transplanted kidneys remained pink and well-perfused, continuing to make urine throughout the study. Biopsies that were performed at 6, 24, 48, and 54 hours revealed no signs of hyperacute or antibody-mediated rejection. Hourly urine output with the xenograft was more than double the output with the native kidneys. CONCLUSIONS:Genetically modified kidney xenografts from pigs remained viable and functioning in brain-dead human recipients for 54 hours, without signs of hyperacute rejection. (Funded by Lung Biotechnology.).
PMID: 35584156
ISSN: 1533-4406
CID: 5230812

Upper gastrointestinal bleeding in a lung transplant recipient

Sivasailam, Barathi; Rudym, Darya; Latorre, Melissa; Mehta, Sapna A
PMID: 35373524
ISSN: 1600-6143
CID: 5201562

HOPE in action: A prospective multicenter pilot study of liver transplantation from donors with HIV to recipients with HIV

Durand, Christine M; Florman, Sander; Motter, Jennifer D; Brown, Diane; Ostrander, Darin; Yu, Sile; Liang, Tao; Werbel, William A; Cameron, Andrew; Ottmann, Shane; Hamilton, James P; Redd, Andrew D; Bowring, Mary G; Eby, Yolanda; Fernandez, Reinaldo E; Doby, Brianna; Labo, Nazzarena; Whitby, Denise; Miley, Wendell; Friedman-Moraco, Rachel; Turgeon, Nicole; Price, Jennifer C; Chin-Hong, Peter; Stock, Peter; Stosor, Valentina; Kirchner, Varvara A; Pruett, Timothy; Wojciechowski, David; Elias, Nahel; Wolfe, Cameron; Quinn, Thomas C; Odim, Jonah; Morsheimer, Megan; Mehta, Sapna A; Rana, Meenakshi M; Huprikar, Shirish; Massie, Allan; Tobian, Aaron A R; Segev, Dorry L
Liver transplantation (LT) from donors-with-HIV to recipients-with-HIV (HIV D+/R+) is permitted under the HOPE Act. There are only three international single-case reports of HIV D+/R+ LT, each with limited follow-up. We performed a prospective multicenter pilot study comparing HIV D+/R+ to donors-without-HIV to recipients-with-HIV (HIV D-/R+) LT. We quantified patient survival, graft survival, rejection, serious adverse events (SAEs), human immunodeficiency virus (HIV) breakthrough, infections, and malignancies, using Cox and negative binomial regression with inverse probability of treatment weighting. Between March 2016-July 2019, there were 45 LTs (8 simultaneous liver-kidney) at 9 centers: 24 HIV D+/R+, 21 HIV D-/R+ (10 D- were false-positive). The median follow-up time was 23 months. Median recipient CD4 was 287 cells/µL with 100% on antiretroviral therapy; 56% were hepatitis C virus (HCV)-seropositive, 13% HCV-viremic. Weighted 1-year survival was 83.3% versus 100.0% in D+ versus D- groups (p = .04). There were no differences in one-year graft survival (96.0% vs. 100.0%), rejection (10.8% vs. 18.2%), HIV breakthrough (8% vs. 10%), or SAEs (all p > .05). HIV D+/R+ had more opportunistic infections, infectious hospitalizations, and cancer. In this multicenter pilot study of HIV D+/R+ LT, patient and graft survival were better than historical cohorts, however, a potential increase in infections and cancer merits further investigation.
PMID: 34741800
ISSN: 1600-6143
CID: 5116832

Delayed mortality among solid organ transplant recipients hospitalized for COVID-19

Heldman, Madeleine R; Kates, Olivia S; Safa, Kassem; Kotton, Camille N; Multani, Ashrit; Georgia, Sarah J; Steinbrink, Julie M; Alexander, Barbara D; Blumberg, Emily A; Haydel, Brandy; Hemmige, Vagish; Hemmersbach-Miller, Marion; La Hoz, Ricardo M; Moni, Lisset; Condor, Yesabeli; Flores, Sandra; Munoz, Carlos G; Guitierrez, Juan; Diaz, Esther I; Diaz, Daniela; Vianna, Rodrigo; Guerra, Giselle; Loebe, Matthias; Yabu, Julie M; Kramer, Kailey Hughes; Tanna, Sajal D; Ison, Michael G; Rakita, Robert M; Malinis, Maricar; Azar, Marwan M; McCort, Margaret E; Singh, Pooja P; Velioglu, Arzu; Mehta, Sapna A; van Duin, David; Goldman, Jason D; Lease, Erika D; Wald, Anna; Limaye, Ajit P; Fisher, Cynthia E
INTRODUCTION/BACKGROUND:Most studies of solid organ transplant (SOT) recipients with COVID-19 focus on outcomes within one month of illness onset. Delayed mortality in SOT recipients hospitalized for COVID-19 has not been fully examined. METHODS:We used data from a multicenter registry to calculate mortality by 90 days following initial SARS-CoV-2 detection in SOT recipients hospitalized for COVID-19 and developed multivariable Cox proportional-hazards models to compare risk factors for death by days 28 and 90. RESULTS:Vital status at day 90 was available for 936 of 1117 (84%) SOT recipients hospitalized for COVID-19: 190 of 936 (20%) died by 28 days and an additional 56 of 246 deaths (23%) occurred between days 29 and 90. Factors associated with mortality by day 90 included: age > 65 years [aHR 1.8 (1.3-2.4), p =<0.001], lung transplant (vs. non-lung transplant) [aHR 1.5 (1.0-2.3), p=0.05], heart failure [aHR 1.9 (1.2-2.9), p=0.006], chronic lung disease [aHR 2.3 (1.5-3.6), p<0.001] and body mass index ≥ 30 kg/m 2 [aHR 1.5 (1.1-2.0), p=0.02]. These associations were similar for mortality by day 28. Compared to diagnosis during early 2020 (March 1-June 19, 2020), diagnosis during late 2020 (June 20-December 31, 2020) was associated with lower mortality by day 28 [aHR 0.7 (0.5-1.0, p=0.04] but not by day 90 [aHR 0.9 (0.7-1.3), p=0.61]. CONCLUSIONS:In SOT recipients hospitalized for COVID-19, >20% of deaths occurred between 28 and 90 days following SARS-CoV-2 diagnosis. Future investigations should consider extending follow-up duration to 90 days for more complete mortality assessment.
PMID: 35212363
ISSN: 1537-6591
CID: 5172472

Immunogenicity after heterologous third dose COVID-19 vaccination in a heart transplant recipient [Letter]

Mehta, Sapna A; Reyentovich, Alex; Montgomery, Robert A; Segev, Dorry L; Gebel, Howard M; Bray, Robert A; Samanovic, Marie I; Cornelius, Amber R; Mulligan, Mark J; Herati, Ramin S
PMID: 35107835
ISSN: 1399-0012
CID: 5153612

Development and evaluation of a structured guide to assess the preventability of hospital-onset bacteremia and fungemia

Schrank, Gregory M; Sick-Samuels, Anna; Bleasdale, Susan C; Jacob, Jesse T; Dantes, Raymund; Gokhale, Runa H; Mayer, Jeanmarie; Mehrotra, Preeti; Mehta, Sapna A; Mena Lora, Alfredo J; Ray, Susan M; Rhee, Chanu; Salinas, Jorge L; Seo, Susan K; Shane, Andi L; Nadimpalli, Gita; Milstone, Aaron M; Robinson, Gwen; Brown, Clayton H; Harris, Anthony D; Leekha, Surbhi
OBJECTIVE:To assess preventability of hospital-onset bacteremia and fungemia (HOB), we developed and evaluated a structured rating guide accounting for intrinsic patient and extrinsic healthcare-related risks. DESIGN/METHODS:HOB preventability rating guide was compared against a reference standard expert panel. PARTICIPANTS/METHODS:A 10-member panel of clinical experts was assembled as the standard of preventability assessment, and 2 physician reviewers applied the rating guide for comparison. METHODS:The expert panel independently rated 82 hypothetical HOB scenarios using a 6-point Likert scale collapsed into 3 categories: preventable, uncertain, or not preventable. Consensus was defined as concurrence on the same category among ≥70% experts. Scenarios without consensus were deliberated and followed by a second round of rating.Two reviewers independently applied the rating guide to adjudicate the same 82 scenarios in 2 rounds, with interim revisions. Interrater reliability was evaluated using the κ (kappa) statistic. RESULTS:Expert panel consensus criteria were met for 52 scenarios (63%) after 2 rounds.After 2 rounds, guide-based rating matched expert panel consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewers 1 and 2, respectively. Agreement rates between the 2 reviewers were 84% overall (κ, 0.76; 95% confidence interval [CI], 0.64-0.88]) and 87% (κ, 0.79; 95% CI, 0.65-0.94) for the 52 scenarios with expert consensus. CONCLUSIONS:Preventability ratings of HOB scenarios by 2 reviewers using a rating guide matched expert consensus in most cases with moderately high interreviewer reliability. Although diversity of expert opinions and uncertainty of preventability merit further exploration, this is a step toward standardized assessment of HOB preventability.
PMID: 35086601
ISSN: 1559-6834
CID: 5154752