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Vol. 34, No. 6, 2011
Issue release date: November 2011
Section title: Original Paper
Kidney Blood Press Res 2011;34:382–386
(DOI:10.1159/000328730)

Varicella Zoster Infection in Renal Transplant Recipients: Prevalence, Complications and Outcome

Mustapic Z.a · Basic-Jukic N.a · Kes P.a · Lovcic V.a · Bubic-Filipi Lj.a · Mokos I.b · Kastelan Z.b · Zekan S.c
Departments of aNephrology, Arterial Hypertension and Dialysis, and bUrology, Clinical Hospital Centre Zagreb and School of Medicine, University of Zagreb, and cClinical Hospital for Infectious Diseases ‘Fran Mihaljevic’, Zagreb, Croatia
email Corresponding Author

Abstract

Varicella zoster virus (VZV) is an important pathogen after renal transplantation. In the present study, we examined the prevalence, clinical presentation and outcome of VZV infections in renal transplant recipients. Charts and medical records of adult renal allotransplant recipients were investigated to find patients with VZV infection. From December 1972 until July 2010, 1,139 patients received kidney allograft at our institution. VZV infection was diagnosed in 40 patients (3.51%). 28 patients (70%) had intensified immunosuppression prior to VZV infection occurrence. Median time of onset was 2.13 years after transplantation (range 9 days to 19.2 years). 35 patients developed VZV during the first post-transplant year (median 0.61 years). Four patients developed VZV infection more than 12 years after transplantation. 33 patients (82.5%) had dermatomal distribution, 5 (12.5%) disseminated herpes zoster (HZ), and 2 patients (5%) who were VZV IgG-negative before transplantation, developed chickenpox. Immunosuppression was reduced and patients received acyclovir. Cutaneous scarring was recorded in 7 cases (17.5%). Two patients developed post-herpetic neuralgia, which was accompanied by scarring and skin depigmentation in 1 of them. Five patients (12.5%) experienced relapse of HZ. Timely initiation of therapy may prevent development of complications and the visceral form of disease. Based on our experience with development of chickenpox, we suggest active immunization for all seronegative patients before organ transplantation.

© 2011 S. Karger AG, Basel


  

Key Words

  • Renal transplantation
  • Immunosuppression
  • Varicella zoster
  • Mycophenolate mofetil
  • Varicella zoster virus infection

References

  1. Fishman JA: Infection in renal transplant recipients. Semin Nephrol 2007;27:445–461.
  2. Fehr T, Bossart W, Wahl C, Binswanger U: Disseminated varicella infection in adult renal allograft recipients: four cases and a review of the literature. Transplantation 2002;73:608–611.
  3. Rodriguez-Moreno A, Sanchez-Fructuoso AI, Calvo N, Ridao N, Conesa J, Marques M, Prats D, Barrientos A: Varicella infection in adult renal allograft recipients: experience at one center. Transplant Proc 2006;38:2416–2418.
  4. Lauzurica R, Bayés B, Frías C, Fontseré N, Hernandez A, Matas L, Jimenez A, Bonet J, Romero R: Disseminated varicella infection in adult renal allograft recipients: role of mycophenolate mofetil. Transplant Proc 2003;35:1758–1759.
  5. Gourishankar S, McDermid JC, Jhangri GS, Preiksaitis JK: Herpes zoster infection following solid organ transplantation: incidence, risk factors and outcomes in the current immunosuppressive era. Am J Transplant 2004;4:108–115.
  6. Miller GG, Dummer JS: Herpes simplex and varicella zoster viruses: forgotten but not gone. Am J Transplant 2007;7:741–747.
  7. Arness T, Pedersen R, Dierkhising R, Kremers W, Patel R: Varicella zoster virus-associated disease in adult kidney transplant recipients: incidence and risk-factor analysis. Transpl Infect Dis 2008;10:260–268.
  8. Fishman JA: Infection in solid-organ transplant recipients. N Engl J Med 2007;57:2601–2614.

    External Resources

  9. The Tricontinental Mycophenolate Mofetil Renal Transplantation Study Group: A blinded, randomized clinical trial of mycophenolate mofetil for the prevention of acute rejection in cadaveric renal transplantation. Transplantation 1996;61:1029–1037.
  10. European Mycophenolate Mofetil Cooperative Study Group: Placebo-controlled study of mycophenolate mofetil combined with cyclosporin and corticosteroids for prevention of acute rejection. Lancet 1995;345:1321–1325.
  11. Basic-Jukic N, Kes P, Bubic-Filipi LJ, Puretic Z, Brunetta B, Pasini J: Does mycophenolate mofetil increase the incidence of cytomegalovirus disease compared with azathioprine after cadaveric kidney transplantation? Transplant Proc 2005;37:850–851.
  12. Basic-Jukic N, Racki S, Kes P, Mustapic Z: Cytomegalovirus infection in renal transplant recipients (in Croatian). Acta Med Croatica 2008;62:69–75.

    External Resources

  13. Marcén R: Immunosuppressive drugs in kidney transplantation: impact on patient survival, and incidence of cardiovascular disease, malignancy and infection. Drugs 2009;69:2227–2243.
  14. Satoh S, Tada H, Murakami M, Tsuchiya N, Inoue T, Togashi H, Matsuura S, Hayase Y, Suzuki T, Habuchi T: The influence of mycophenolate mofetil versus azathioprine and mycophenolic acid pharmacokinetics on the incidence of acute rejection and infectious complications after renal transplantation. Transplant Proc 2005;37:1751–1753.
  15. Rothwell WS, Gloor JM, Morgenstern BZ, Milliner DS: Disseminated varicella infection in pediatric renal transplant recipients treated with mycophenolate mofetil. Transplantation 1999;68:158–161.
  16. Buell C, Koo J: Long-term safety of mycophenolate mofetil and cyclosporine: a review. J Drugs Dermatol 2008;7:741–748.
  17. Cox VC, Ensom MH: Mycophenolate mofetil for solid organ transplantation: does the evidence support the need for clinical pharmacokinetic monitoring? Ther Drug Monit 2003;25:137–157.
  18. Gnann JW: Other herpesviruses: herpes simplex virus, varicella-zoster virus, human herpes types 6,7 and 8; in Transplant Infections, ed 1. Philadelphia, Lippincott-Raven, 1998, pp 265–286.
  19. Gilden D, Cohrs RJ, Mahalingam R, Nagel MA: Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment. Lancet Neurol 2009;8:731–740.
  20. Rogers SY, Irving W, Harris A, Russell NH: Visceral varicella zoster infection after bone marrow transplantation without skin involvement and the use of PCR for diagnosis. Bone Marrow Transplant 1995;15:805–807.
  21. Jantsch J, Schmidt B, Bardutzky J, Bogdan C, Eckardt KU, Raff U: Lethal varicella-zoster virus reactivation without skin lesions following renal transplantation. Nephrol Dial Transplant 2011;26:365–368.
  22. Peterson LR, Ferguson RM: Fatal central nervous system infection with varicella- zoster virus in renal transplant recipients. Transplantation 1984;37:366–368.
  23. Herrero JI, Quiroga J, Sangro B, Pardo F, Rotellar F, Alvarez-Cienfuegos J, Prieto J: Herpes zoster after liver transplantation: incidence, risk factors, and complications. Liver Transpl 2004;10:1140–1143.
  24. Litjens NH, Huisman M, Baan CC, van Druningen CJ, Betjes MG: Hepatitis B vaccine-specific CD4+ T cells can be detected and characterised at the single cell level: limited usefulness of dendritic cells as signal enhancers. J Immunol Methods 2008;330:1–11.
  25. Crosnier J: Hepatitis B in haemodialysis: vaccination against HBS antigen. Proc Eur Dial Transplant Assoc 1981;18:231–240.

  

Author Contacts

Nikolina Basic-Jukic, MD, PhD
Department of Nephrology, Arterial Hypertension and Dialysis
Clinical Hospital Centre Zagreb
Kispaticeva 12, HR–10000 Zagreb (Croatia)
Tel. +385 1 2312 517, E-Mail nina_basic@net.hr

  

Article Information

Received: October 15, 2010
Accepted: April 13, 2011
Published online: June 7, 2011
Number of Print Pages : 5
Number of Figures : 1, Number of Tables : 1, Number of References : 25

  

Publication Details

Kidney and Blood Pressure Research

Vol. 34, No. 6, Year 2011 (Cover Date: November 2011)

Journal Editor: Tesar V. (Prague)
ISSN: 1420-4096 (Print), eISSN: 1423-0143 (Online)

For additional information: http://www.karger.com/KBR


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Varicella zoster virus (VZV) is an important pathogen after renal transplantation. In the present study, we examined the prevalence, clinical presentation and outcome of VZV infections in renal transplant recipients. Charts and medical records of adult renal allotransplant recipients were investigated to find patients with VZV infection. From December 1972 until July 2010, 1,139 patients received kidney allograft at our institution. VZV infection was diagnosed in 40 patients (3.51%). 28 patients (70%) had intensified immunosuppression prior to VZV infection occurrence. Median time of onset was 2.13 years after transplantation (range 9 days to 19.2 years). 35 patients developed VZV during the first post-transplant year (median 0.61 years). Four patients developed VZV infection more than 12 years after transplantation. 33 patients (82.5%) had dermatomal distribution, 5 (12.5%) disseminated herpes zoster (HZ), and 2 patients (5%) who were VZV IgG-negative before transplantation, developed chickenpox. Immunosuppression was reduced and patients received acyclovir. Cutaneous scarring was recorded in 7 cases (17.5%). Two patients developed post-herpetic neuralgia, which was accompanied by scarring and skin depigmentation in 1 of them. Five patients (12.5%) experienced relapse of HZ. Timely initiation of therapy may prevent development of complications and the visceral form of disease. Based on our experience with development of chickenpox, we suggest active immunization for all seronegative patients before organ transplantation.

© 2011 S. Karger AG, Basel


  

Author Contacts

Nikolina Basic-Jukic, MD, PhD
Department of Nephrology, Arterial Hypertension and Dialysis
Clinical Hospital Centre Zagreb
Kispaticeva 12, HR–10000 Zagreb (Croatia)
Tel. +385 1 2312 517, E-Mail nina_basic@net.hr

  

Article Information

Received: October 15, 2010
Accepted: April 13, 2011
Published online: June 7, 2011
Number of Print Pages : 5
Number of Figures : 1, Number of Tables : 1, Number of References : 25

  

Publication Details

Kidney and Blood Pressure Research

Vol. 34, No. 6, Year 2011 (Cover Date: November 2011)

Journal Editor: Tesar V. (Prague)
ISSN: 1420-4096 (Print), eISSN: 1423-0143 (Online)

For additional information: http://www.karger.com/KBR


Article / Publication Details

First-Page Preview
Abstract of Original Paper

Received: 10/15/2010 10:11:11 AM
Accepted: 4/13/2011
Published online: 6/7/2011
Issue release date: November 2011

Number of Print Pages: 5
Number of Figures: 1
Number of Tables: 1

ISSN: 1420-4096 (Print)
eISSN: 1423-0143 (Online)

For additional information: http://www.karger.com/KBR


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Fishman JA: Infection in renal transplant recipients. Semin Nephrol 2007;27:445–461.
  2. Fehr T, Bossart W, Wahl C, Binswanger U: Disseminated varicella infection in adult renal allograft recipients: four cases and a review of the literature. Transplantation 2002;73:608–611.
  3. Rodriguez-Moreno A, Sanchez-Fructuoso AI, Calvo N, Ridao N, Conesa J, Marques M, Prats D, Barrientos A: Varicella infection in adult renal allograft recipients: experience at one center. Transplant Proc 2006;38:2416–2418.
  4. Lauzurica R, Bayés B, Frías C, Fontseré N, Hernandez A, Matas L, Jimenez A, Bonet J, Romero R: Disseminated varicella infection in adult renal allograft recipients: role of mycophenolate mofetil. Transplant Proc 2003;35:1758–1759.
  5. Gourishankar S, McDermid JC, Jhangri GS, Preiksaitis JK: Herpes zoster infection following solid organ transplantation: incidence, risk factors and outcomes in the current immunosuppressive era. Am J Transplant 2004;4:108–115.
  6. Miller GG, Dummer JS: Herpes simplex and varicella zoster viruses: forgotten but not gone. Am J Transplant 2007;7:741–747.
  7. Arness T, Pedersen R, Dierkhising R, Kremers W, Patel R: Varicella zoster virus-associated disease in adult kidney transplant recipients: incidence and risk-factor analysis. Transpl Infect Dis 2008;10:260–268.
  8. Fishman JA: Infection in solid-organ transplant recipients. N Engl J Med 2007;57:2601–2614.

    External Resources

  9. The Tricontinental Mycophenolate Mofetil Renal Transplantation Study Group: A blinded, randomized clinical trial of mycophenolate mofetil for the prevention of acute rejection in cadaveric renal transplantation. Transplantation 1996;61:1029–1037.
  10. European Mycophenolate Mofetil Cooperative Study Group: Placebo-controlled study of mycophenolate mofetil combined with cyclosporin and corticosteroids for prevention of acute rejection. Lancet 1995;345:1321–1325.
  11. Basic-Jukic N, Kes P, Bubic-Filipi LJ, Puretic Z, Brunetta B, Pasini J: Does mycophenolate mofetil increase the incidence of cytomegalovirus disease compared with azathioprine after cadaveric kidney transplantation? Transplant Proc 2005;37:850–851.
  12. Basic-Jukic N, Racki S, Kes P, Mustapic Z: Cytomegalovirus infection in renal transplant recipients (in Croatian). Acta Med Croatica 2008;62:69–75.

    External Resources

  13. Marcén R: Immunosuppressive drugs in kidney transplantation: impact on patient survival, and incidence of cardiovascular disease, malignancy and infection. Drugs 2009;69:2227–2243.
  14. Satoh S, Tada H, Murakami M, Tsuchiya N, Inoue T, Togashi H, Matsuura S, Hayase Y, Suzuki T, Habuchi T: The influence of mycophenolate mofetil versus azathioprine and mycophenolic acid pharmacokinetics on the incidence of acute rejection and infectious complications after renal transplantation. Transplant Proc 2005;37:1751–1753.
  15. Rothwell WS, Gloor JM, Morgenstern BZ, Milliner DS: Disseminated varicella infection in pediatric renal transplant recipients treated with mycophenolate mofetil. Transplantation 1999;68:158–161.
  16. Buell C, Koo J: Long-term safety of mycophenolate mofetil and cyclosporine: a review. J Drugs Dermatol 2008;7:741–748.
  17. Cox VC, Ensom MH: Mycophenolate mofetil for solid organ transplantation: does the evidence support the need for clinical pharmacokinetic monitoring? Ther Drug Monit 2003;25:137–157.
  18. Gnann JW: Other herpesviruses: herpes simplex virus, varicella-zoster virus, human herpes types 6,7 and 8; in Transplant Infections, ed 1. Philadelphia, Lippincott-Raven, 1998, pp 265–286.
  19. Gilden D, Cohrs RJ, Mahalingam R, Nagel MA: Varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment. Lancet Neurol 2009;8:731–740.
  20. Rogers SY, Irving W, Harris A, Russell NH: Visceral varicella zoster infection after bone marrow transplantation without skin involvement and the use of PCR for diagnosis. Bone Marrow Transplant 1995;15:805–807.
  21. Jantsch J, Schmidt B, Bardutzky J, Bogdan C, Eckardt KU, Raff U: Lethal varicella-zoster virus reactivation without skin lesions following renal transplantation. Nephrol Dial Transplant 2011;26:365–368.
  22. Peterson LR, Ferguson RM: Fatal central nervous system infection with varicella- zoster virus in renal transplant recipients. Transplantation 1984;37:366–368.
  23. Herrero JI, Quiroga J, Sangro B, Pardo F, Rotellar F, Alvarez-Cienfuegos J, Prieto J: Herpes zoster after liver transplantation: incidence, risk factors, and complications. Liver Transpl 2004;10:1140–1143.
  24. Litjens NH, Huisman M, Baan CC, van Druningen CJ, Betjes MG: Hepatitis B vaccine-specific CD4+ T cells can be detected and characterised at the single cell level: limited usefulness of dendritic cells as signal enhancers. J Immunol Methods 2008;330:1–11.
  25. Crosnier J: Hepatitis B in haemodialysis: vaccination against HBS antigen. Proc Eur Dial Transplant Assoc 1981;18:231–240.