Pre-transplant screening: Difference between revisions
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*Screen for latent infections that may reactivate, and for risk for future infections |
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= Pre-tranplant screening = |
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=Approach= |
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* Screen for latent infections that may reactivate, and for risk for future infections |
|||
== |
==History== |
||
*Look for primary infections, based on epidemiology |
|||
=== History === |
|||
**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== |
|||
* 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 |
|||
*Signs of active infections |
|||
=== Physical Exam === |
|||
==Investigations== |
|||
* Signs of active infections |
|||
*Chest and abdomeinal CT for staging and signs of active infection |
|||
=== Investigations === |
|||
*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= |
|||
* 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 |
|||
==CMV== |
|||
== Specific Diseases == |
|||
*Donor and recipient are both screened with serology |
|||
=== CMV === |
|||
*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 |
|||
{| class="wikitable" |
|||
* Donor and recipient are both screened with serology |
|||
!Transplantation |
|||
* Preventing CMV infection prevents end-organ damage |
|||
!Donor |
|||
* Approaches |
|||
!Recipient |
|||
** Prophylaxis: in SOT for 90 days, unless D-/R- (lowest risk) |
|||
!Risk category |
|||
*** Avoided in HSCT, because would like to avoid bone marrow suppression from valgan/etc. |
|||
!Approach |
|||
** 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 |
| rowspan="4" |SOT |
||
| + |
| + |
||
| |
|– |
||
| |
|highest risk |
||
| |
|prophylaxis |
||
|- |
|- |
||
| SOT |
|||
| + |
| + |
||
| + |
| + |
||
|moderate risk |
|||
| |
|||
| |
|prophylaxis |
||
|- |
|- |
||
|– |
|||
| SOT |
|||
| – |
|||
| + |
| + |
||
|moderate risk |
|||
| |
|||
| |
|prophylaxis |
||
|- |
|- |
||
|– |
|||
| SOT |
|||
| |
|– |
||
|lowest risk |
|||
| – |
|||
|no treatment |
|||
| 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== |
|||
* Start treatment, repeat the viral load at 2 weeks |
|||
* Monitor for failure with a 1-log decrease at 2 weeks |
|||
*90% of adults are IgG positive |
|||
=== EBV === |
|||
*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== |
|||
* 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 |
|||
*Can cause morbidity |
|||
=== HSV/VZV === |
|||
*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== |
|||
* 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 |
|||
*Risk factors for reactivation |
|||
=== Hepatitis B === |
|||
**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== |
|||
* 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 |
|||
*If serology positive, get HCV-RNA |
|||
=== Hepatitis C === |
|||
*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== |
|||
* 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 |
|||
*Testing is for both, does not distinguish |
|||
=== HTLV-I/II === |
|||
*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== |
|||
* 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 |
|||
*VDRL, ideally treat before transplantation |
|||
=== Other Routine === |
|||
*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== |
|||
* 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 |
|||
==Toxoplasmosis== |
|||
=== Other Optional === |
|||
*Consider it in undocooked meat, especially game animals, or lots of cats |
|||
==== Toxoplasmosis ==== |
|||
*Concern is for reactivation in alloHSCT |
|||
==HPV== |
|||
* Consider it in undocooked meat, especially game animals, or lots of cats |
|||
* Concern is for reactivation in alloHSCT |
|||
*Talk to the women about it |
|||
==== HPV ==== |
|||
*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== |
|||
* 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 |
|||
==Trypansoma cruzi== |
|||
=== Travel-specific Screening === |
|||
*Screen high-risk populations with Trypanosoma cruzi antibody |
|||
==== Trypansoma cruzi ==== |
|||
*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== |
|||
* 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 |
|||
*Present in southern US and eastern Europe |
|||
==== Strongyloides ==== |
|||
*Low threshold for screening and treating |
|||
==Malaria== |
|||
* Present in southern US and eastern Europe |
|||
* Low threshold for screening and treating |
|||
*Can be transmited via graft in alloHSCT |
|||
==== Malaria ==== |
|||
*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== |
|||
* 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 |
|||
*Coccidioides in recipient does have a higher risk of reactivation |
|||
==== Endemic fungi ==== |
|||
**Maybe fluconazole prophylaxis |
|||
*No information on Paracoccidoides |
|||
*Histoplasmosis in recipient does not tend to reactivate |
|||
*Many recipients get prophylaxis for other fungi anyway |
|||
=Contraindications= |
|||
* 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 |
|||
*HIV infection |
|||
== Contraindications == |
|||
*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= |
|||
* 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 |
|||
==Pre-transplantation== |
|||
== Vaccination == |
|||
*Can give inactivated, non-live vaccines |
|||
=== Pre-transplantation === |
|||
**Give them their flu shot |
|||
*Will need to be repeated post-engraftment |
|||
==Post-transplantation== |
|||
* Can give inactivated, non-live vaccines |
|||
** Give them their flu shot |
|||
* Will need to be repeated post-engraftment |
|||
*Need to be reviewed as |
|||
=== Post-transplantation === |
|||
[[Category:Transplant patients]] |
|||
* Need to be reviewed as |
Latest revision as of 21:13, 19 September 2020
- 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
- HIV serology & p24 antigen, followed by NAT if positive
- 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
- Prophylaxis: in SOT for 90 days, unless D-/R- (lowest risk)
Transplantation | Donor | Recipient | Risk category | Approach |
---|---|---|---|---|
SOT | + | – | highest risk | prophylaxis |
+ | + | moderate risk | prophylaxis | |
– | + | moderate risk | prophylaxis | |
– | – | lowest risk | no treatment | |
allo-HSCT | +/– | + | high risk | pre-emptive |
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