Pre-transplant screening - Revision history

Aidan: /* CMV */

2020-09-19T21:13:51Z

CMV

Aidan at 19:50, 13 August 2019

2019-08-13T19:50:54Z

← Older revision		Revision as of 19:50, 13 August 2019
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	= Pre-tranplant screening =

	* Screen for latent infections that may reactivate, and for risk for future infections		* Screen for latent infections that may reactivate, and for risk for future infections

	== Approach ==		= Approach =

	=== History ===		== History ==

	* Look for primary infections, based on epidemiology		* Look for primary infections, based on epidemiology
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	* Dental assessment		* Dental assessment

	=== Physical Exam ===		== Physical Exam ==

	* Signs of active infections		* Signs of active infections

	=== Investigations ===		== Investigations ==

	* Chest and abdomeinal CT for staging and signs of active infection		* Chest and abdomeinal CT for staging and signs of active infection
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	** Tuberculosis, thought TST may be negative depending on their immunosuppression and IGRA is unstudied		** Tuberculosis, thought TST may be negative depending on their immunosuppression and IGRA is unstudied

	== Specific Diseases ==		= Specific Diseases =

	=== CMV ===		== CMV ==

	* Donor and recipient are both screened with serology		* Donor and recipient are both screened with serology
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	\|}		\|}

	==== Treatment ====		== Treatment ==

	* Start treatment, repeat the viral load at 2 weeks		* Start treatment, repeat the viral load at 2 weeks
	* Monitor for failure with a 1-log decrease at 2 weeks		* Monitor for failure with a 1-log decrease at 2 weeks

	=== EBV ===		== EBV ==

	* 90% of adults are IgG positive		* 90% of adults are IgG positive
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	** Rituximab is a treatment option		** Rituximab is a treatment option

	=== HSV/VZV ===		== HSV/VZV ==

	* Can cause morbidity		* Can cause morbidity
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	* In SOT, depends on centre and specific organ, but likely prophylaxed with acyclovir at least until off prednisone		* In SOT, depends on centre and specific organ, but likely prophylaxed with acyclovir at least until off prednisone

	=== Hepatitis B ===		== Hepatitis B ==

	* Risk factors for reactivation		* Risk factors for reactivation
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	* If donor is positive, recipient should be given HBIg immediately and at 1 months, then reimmunized as well as the routine prophylaxis		* If donor is positive, recipient should be given HBIg immediately and at 1 months, then reimmunized as well as the routine prophylaxis

	=== Hepatitis C ===		== Hepatitis C ==

	* If serology positive, get HCV-RNA		* If serology positive, get HCV-RNA
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	* ''May'' be able to donate HCV-positive donor organs, though still early developments		* ''May'' be able to donate HCV-positive donor organs, though still early developments

	=== HTLV-I/II ===		== HTLV-I/II ==

	* Testing is for both, does not distinguish		* Testing is for both, does not distinguish
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	** Send testing to public health for HTLV-I, and if positive, precludes donation		** Send testing to public health for HTLV-I, and if positive, precludes donation

	=== Other Routine ===		== Other Routine ==

	* VDRL, ideally treat before transplantation		* VDRL, ideally treat before transplantation
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	* WNV NAT/PCR in donor only, and precludes HSCT		* WNV NAT/PCR in donor only, and precludes HSCT

	=== Other Optional ===		== Other Optional ==

	==== Toxoplasmosis ====		== Toxoplasmosis ==

	* Consider it in undocooked meat, especially game animals, or lots of cats		* Consider it in undocooked meat, especially game animals, or lots of cats
	* Concern is for reactivation in alloHSCT		* Concern is for reactivation in alloHSCT

	==== HPV ====		== HPV ==

	* Talk to the women about it		* Talk to the women about it
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	* Ensure they get Pap smears routinely, and likely more frequently than normal-risk populations		* Ensure they get Pap smears routinely, and likely more frequently than normal-risk populations

	=== Travel-specific Screening ===		== Travel-specific Screening ==

	==== Trypansoma cruzi ====		== Trypansoma cruzi ==

	* Screen high-risk populations with Trypanosoma cruzi antibody		* Screen high-risk populations with Trypanosoma cruzi antibody
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	** Thatched roof		** Thatched roof

	==== Strongyloides ====		== Strongyloides ==

	* Present in southern US and eastern Europe		* Present in southern US and eastern Europe
	* Low threshold for screening and treating		* Low threshold for screening and treating

	==== Malaria ====		== Malaria ==

	* Can be transmited via graft in alloHSCT		* Can be transmited via graft in alloHSCT
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	* If donor has infection, treat them first		* If donor has infection, treat them first

	==== Endemic fungi ====		== Endemic fungi ==

	* Coccidioides in recipient does have a higher risk of reactivation		* Coccidioides in recipient does have a higher risk of reactivation
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	* Many recipients get prophylaxis for other fungi anyway		* Many recipients get prophylaxis for other fungi anyway

	== Contraindications ==		= Contraindications =

	* HIV infection		* HIV infection
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	* Chronic, active hepatitis B or C is relative contraindication		* Chronic, active hepatitis B or C is relative contraindication

	== Vaccination ==		= Vaccination =

	=== Pre-transplantation ===		== Pre-transplantation ==

	* Can give inactivated, non-live vaccines		* Can give inactivated, non-live vaccines
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	* Will need to be repeated post-engraftment		* Will need to be repeated post-engraftment

	=== Post-transplantation ===		== Post-transplantation ==

	* Need to be reviewed as		* Need to be reviewed as

			[[Category:Transplant patients]]

Aidan: Aidan moved page Special Pre-transplant screening to Pre-transplant screening without leaving a redirect

2019-08-13T19:50:22Z

Aidan moved page Special Pre-transplant screening to Pre-transplant screening without leaving a redirect

← Older revision		Revision as of 19:50, 13 August 2019
(No difference)

Maintenance script: Imported from text file

2019-08-11T18:05:59Z

Imported from text file

New page

= Pre-tranplant screening =

* Screen for latent infections that may reactivate, and for risk for future infections

== Approach ==

=== History ===

* Look for primary infections, based on epidemiology
** e.g. Chagas in higher risk people from South America
* What is the planned transplantation, and for stem cell transplants, what is the planned conditioning regimen?
** e.g. ATG prolongs T-cell dysfunction
* Prolonged neutropenia
* Recent live vaccines within 4 weeks of transplantation
* Travel or exposure history
** Tuberculosis
** Strongyloidiasis
** Malaria
* Sexual history
** Many patients have unknown STIs
* Dental assessment

=== Physical Exam ===

* Signs of active infections

=== Investigations ===

* Chest and abdomeinal CT for staging and signs of active infection
* Routine
** HIV serology & p24 antigen, followed by NAT if positive
*** Donor may be screened with NAT/PCR depending on the centre
*** Positive donor precludes transplant
*** Positive recipients have higher risk of HCV reactivation, but otherwise seem to do okay
**** Should get control of HIV before transplant if possible
** CMV, EBV, HSV, VZV, HBV, HCV, HTLV 1&2, syphilis serologies
* Targetted
** Toxoplasmosis serology
** Stronyloides serology
** Malaria
** Endemic fungi in high-risk patients
*** Histoplasmosis only rarely reactivates post-transplant
** Tuberculosis, thought TST may be negative depending on their immunosuppression and IGRA is unstudied

== Specific Diseases ==

=== CMV ===

* Donor and recipient are both screened with serology
* Preventing CMV infection prevents end-organ damage
* Approaches
** Prophylaxis: in SOT for 90 days, unless D-/R- (lowest risk)
*** Avoided in HSCT, because would like to avoid bone marrow suppression from valgan/etc.
** Pre-emptive: done in HSCT
*** PCR is positive 1+ week before end-organ damage, so screening and treatment is useful
*** CMV reactivation extremely rare in first 30 days
*** PCR weekly starting at day 21; if above threshold, treat
**** Threshold is 1451 copies/mL
*** Screen until day 100, or longer if persistently immunocompromised as in GVHD

{|
! Transplantation
! Donor
! Recipient
! Risk category
! Approach
|-
| SOT
| +
| –
| highest risk
| prophylaxis
|-
| SOT
| +
| +
|
| prophylaxis
|-
| SOT
| –
| +
|
| prophylaxis
|-
| SOT
| –
| –
| lowest risk
| no treatment
|-
| allo-HSCT
| +/–
| +
| high risk
| pre-emptive
|-
|
|
|
|
|
|-
| Use of AMT
|
|
| higher risk
|
|}

==== Treatment ====

* Start treatment, repeat the viral load at 2 weeks
* Monitor for failure with a 1-log decrease at 2 weeks

=== EBV ===

* 90% of adults are IgG positive
* High risk populations for developing PTLD
** Highest risk are children who acquire primary EBV after transplantation
** Others: mismatched BMT, T-cell depleted BMT, ATG, splenectomy
** Monitor these patients weekly for 3 months post-transplant
* Treatment
** No antivirals that are helpful
** Decrease immunosuppression
** Rituximab is a treatment option

=== HSV/VZV ===

* Can cause morbidity
* Usually reacivates pre-engraftment
* All HSV-positive patients get acyclovir until day 30 or discharge
* All VZV-positive get prophylaxis for one year post-alloHSCT
** Acyclovir may prevent VZV reactivation
** Acyclovir 800 mg bid or valacyclovir 500 mg bid
** Extend duration if T-cell suppression or ongoing GVHD
* In SOT, depends on centre and specific organ, but likely prophylaxed with acyclovir at least until off prednisone

=== Hepatitis B ===

* Risk factors for reactivation
** Alemtuzumab, bortezomib, fludarabine/rituximab
** High-dose glucocorticoids
* Screen for HBsAg, HBsAb, and HBcAb, but ignore the HBsAb
** If positive, do HBV-DNA
** If sAg negative but cAb positive, prophylax with lamivudine until 6 months after stopping immunosuppression
** If sAg positive, needs treatment with two drugs
* If donor is positive, recipient should be given HBIg immediately and at 1 months, then reimmunized as well as the routine prophylaxis

=== Hepatitis C ===

* If serology positive, get HCV-RNA
* If HCV-RNA negative, not at risk for reactivation
* ''May'' be able to donate HCV-positive donor organs, though still early developments

=== HTLV-I/II ===

* Testing is for both, does not distinguish
* HTLV-I endemic in SW Japan and Caribbean, and causes clinical disease
* HTLV-II associated with IVDU in US/Europe, but does not appear to cause clinical disease
* If donor is positive, may have increased risk of progression to T-cell lymphoma
** Send testing to public health for HTLV-I, and if positive, precludes donation

=== Other Routine ===

* VDRL, ideally treat before transplantation
* Can do TBST for latent TB in the recipient, depending on the clinical context
** May benefit from LTBI treatment with isoniazid
* WNV NAT/PCR in donor only, and precludes HSCT

=== Other Optional ===

==== Toxoplasmosis ====

* Consider it in undocooked meat, especially game animals, or lots of cats
* Concern is for reactivation in alloHSCT

==== HPV ====

* Talk to the women about it
* Up to 40% of positive women can develop high-grade genital tract lesions, usually years after HSCT
* Ensure they get Pap smears routinely, and likely more frequently than normal-risk populations

=== Travel-specific Screening ===

==== Trypansoma cruzi ====

* Screen high-risk populations with Trypanosoma cruzi antibody
* Lived in endemic countries (Mexico, Central America, South America) x6+ months
* Either donor or recipient's mother was born in an endemic area
* Maternal history of unexplained cardiac disease
* High-risk living conditions in an endemic country even if less than 6 months
** Reduviid bug exposure
** Mud wall dwellings
** Unmilled logs or sicks
** Thatched roof

==== Strongyloides ====

* Present in southern US and eastern Europe
* Low threshold for screening and treating

==== Malaria ====

* Can be transmited via graft in alloHSCT
* Diagnostic tests of the donor may be negative but still transmit infection, so don't bother
* Ideally defer if donor traveled within 1 to 3 years
* If donor has infection, treat them first

==== Endemic fungi ====

* Coccidioides in recipient does have a higher risk of reactivation
** Maybe fluconazole prophylaxis
* No information on Paracoccidoides
* Histoplasmosis in recipient does not tend to reactivate
* Many recipients get prophylaxis for other fungi anyway

== Contraindications ==

* HIV infection
* HTLV-1 infection
* ACUTE CMV or EBV infection
* Acute hepatitis A infection (ie, Hepatitis A IgM+)
* Acute toxoplasmosis
* Active TB (ie, until it is well controlled)
* An acute tickborne infection, such as Rocky Mountain spotted fever, babesiosis, anaplasmosis, ehrlichiosis, Q fever, or Colorado tick fever
* Active or past history of Chagas disease
* Acute or recent West Nile Virus infection
* Chronic, active hepatitis B or C is relative contraindication

== Vaccination ==

=== Pre-transplantation ===

* Can give inactivated, non-live vaccines
** Give them their flu shot
* Will need to be repeated post-engraftment

=== Post-transplantation ===

* Need to be reviewed as