PGY2 Solid Organ Transplant Pharmacy Residency

Utility of Cytomegalovirus-Specific T-Cell Immunity Panel to Predict Cytomegalovirus infections in Lung Transplant Recipients

Richard W. Lincoln, PharmD; Brett J. Pierce, PharmD, BCPS; Christine Pham, PharmD; Simon Yau, MD; Ahmad Goodarzi, MD; Jihad G. Youssef, MD; Howard Huang, MD

PURPOSE Lung transplant recipients (LTR’s) remain at the highest risk of CMV infection and disease in the solid organ transplant population. The use of cytomegalovirus T-cell immunity panels (CMV-TCIP) have been evaluated for use in the solid organ transplant population but given the limited data of CMV-TCIP in LTRs, we sought to describe our center’s experience with CMV TCIP in LTR.

METHODS

We reviewed all CMV TCIP results from LTRs drawn between 1/2019 – 6/2021. LTRs were excluded if they received a multi-organ transplant or re-transplantation. TCIP results were excluded if there was an assay control error or if no CMV PCR was checked after assay collection. Our primary outcome was the rate of CMV infection any point after TCIP collection. Secondary endpoints included CD4% and CD8%, characteristics of LTR’s who developed CMV infection, assessment of serial CMV TCIP monitoring, and characteristics of LTRs who did not show immunity.

RESULTS

A total of 191 CMV TCIPs from 156 LTRs were evaluated. Median time from transplant to CMV-TCIP was 687 (3891508) days. One hundred and twenty assays (62.8%) demonstrated immunity (both CD4% and CD8% >0.2%), with median CMV CD4% = 0.63% and CD8% = 1.42%. Twenty LTRs experienced a CMV infection after a TCIP was checked, 17/20 developed CMV after CMV TCIP was positive for immunity. CMV infection developed a median 121 of days after TCIP and 30% were off prophylaxis. Median CMV CD4% and CD8% in those who developed infection post-positive TCIP were 2.01% and 1.46%, respectively. ROC-AUC curve for CD4 and CD8 were 0.5663 and 0.5624 respectively. Twenty-nine patients had two or more CMV-TCIP drawn. Median time between repeat CMV-TCIP was 168 (122-298) days. The median change in CD4% and CD8% was -0.01 and 0.01 respectively.

CONCLUSION

These results suggest that T-cell specific CMV immunity monitoring in lung transplantation may not be an absolute indicator of CMV immunity. There were marginal changes in TCIP with repeat testing. Prospective trials are needed to assess the utility of serial TCIP monitoring.

PGY2 SOLID ORGAN TRANSPLANT RESIDENCY

Richard “Woody” Lincoln, PharmD

Woody earned his PharmD from the University of Cincinnati College of Pharmacy in 2020. He completed his PGY1 residency at The University of Cincinnati Medical Center. Following completion of his PGY2 residency, Woody has accepted a position as an Advanced Heart Failure and Heart Transplant Pharmacist at Banner University Medical Center – Phoenix. Primary project preceptor: Brett J. Pierce, PharmD, BCOP

Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference and 2022 American Transplant Congress in Boston, MA. This poster received an ATC Poster of Distinction Ribbon.

Plasmapheresis and Rituximab for Prevention of Focal Segmental Glomerulosclerosis Recurrence Post-Kidney Transplantation

Allison N. Yun, PharmD; Alex Rogers, PharmD, BCPS; Jill C. Krisl, PharmD, BCTXP; Anna Kagan, MD; Horacio E. Adrogue, MD; Abdul J. Khan, MD; Pascale Khairallah, MD; Stephanie G. Yi, MD; Mark J. Hobeika, MD; Robert R. McMillan, MD; Hemangshu Podder, MD; Ahmed O. Gaber, MD; Richard J. Knight, MD

PURPOSE Primary focal segmental glomerulosclerosis (FSGS) recurs after kidney transplantation (KT) in 30-50% of recipients with a median time of 1.5 months post-KT. Recurrence is associated with early graft loss in 60% of cases. The aim of this study is to assess the efficacy of pre-emptive therapeutic plasma exchange (TPE) and rituximab for the prevention of FSGS recurrence post-KT.

METHODS

This single-center, retrospective study included patients receiving KT for primary FSGS between May 2016 and August 2021. Living-donor KT recipients received three sessions of TPE prior to scheduled transplant. Recipients of both living and deceased donor KT received 3 postoperative sessions of TPE followed by one dose of 375 mg/m2 rituximab with or without intravenous immune globulin (IVIG) 0.5 g/kg. Recipients underwent protocol biopsy at one month to screen for FSGS recurrence. The primary endpoint was a composite for disease recurrence including proteinuria (≥1 g/day) or/and biopsy-proven FSGS within one month.

RESULTS

54 patients received KT for FSGS during the study period using the TPE/rituximab protocol. 5 patients (9%) experienced FSGS recurrence within one month of transplant. A total of 10 (23%) of 44 patients with followup were found to have disease recurrence within a year, with median (IQR) time to recurrence of 37 days (27-66). White race and history of hypertension were independent risk factors for recurrence, whereas African American race and diabetes were associated with a reduced risk of recurrence. 31 patients (57%) also received IVIG prior to discharge due to concerns for hypogammaglobulinemia. There were 18 documented infections in 13 patients (24%) within 3 months of transplant. Patients who received IVIG had significantly fewer cases of infection (3 cases: 1 viral and 2 COVID-19) compared to patients who did not receive IVIG (15 cases: 4 bacterial, 9 viral, 1 fungal, and 1 COVID-19), p<0.001. At one year, 9 patients (19%) had biopsy-proven rejection (5 acute cellular rejection, 1 antibody-mediated rejection, and 3 mixed rejection). There were no instances of graft loss or mortality observed at one year.

CONCLUSION

The utilization of plasma exchange and rituximab may prevent early disease recurrence of FSGS without significant rates of infection, graft loss, or mortality.

PGY2 SOLID ORGAN TRANSPLANT RESIDENCY

Allison Nara Yun, PharmD

Allison earned her PharmD from Northeastern University in Boston, Massachusetts in 2020. She completed her PGY1 Acute Care residency at Massachusetts General Hospital. After her completion of her PGY2 Solid Organ Transplant residency, Allison will stay on at Houston Methodist Hospital as an Abdominal Transplant Clinical Specialist. Primary project preceptor: Alex Rogers, PharmD, BCPS

Presented at 2021 Virtual Vizient Pharmacy Network, 2022 Midwest Pharmacy Residents Conference and 2022 American Transplant Congress.