Chapter 126. Infections in Transplant Recipients (Part 15) pps

Infections in Transplant Recipients Part 15 Virus-Associated Malignancies In addition to malignancy associated with gammaherpesvirus infection EBV, KSHV and simple warts HPV, other tu

Chapter 126 Infections in Transplant Recipients

(Part 15)

Virus-Associated Malignancies

In addition to malignancy associated with gammaherpesvirus infection (EBV, KSHV) and simple warts (HPV), other tumors that are virus-associated or suspected of being virus-associated are more likely to develop in transplant recipients, particularly those who require long-term immunosuppression, than in the general population The interval to tumor development is usually >1 year Transplant recipients develop nonmelanoma skin or lip cancers that, in contrast to

de novo skin cancers, have a high ratio of squamous cells to basal cells HPV may play a major role in these lesions Cervical and vulvar carcinomas, quite clearly associated with HPV, develop with increased frequency in female transplant

recipients Among renal transplant recipients, rates of melanoma are modestly increased and rates of cancers of the kidney and bladder are increased

Vaccination of Transplant Recipients

In addition to receiving antibiotic prophylaxis, transplant recipients should

be vaccinated against likely pathogens (Table 126-6) In the case of HSCT recipients, optimal responses cannot be achieved until after immune reconstitution, despite previous immunization of both donor and recipient Recipients of allogeneic HSCTs must be reimmunized if they are to be protected against pathogens The situation is less clear-cut in the case of autologous transplantation

T and B cells in the peripheral blood may reconstitute the immune response if they are transferred in adequate numbers However, cancer patients (particularly those with Hodgkin's disease, in whom vaccination has been extensively studied) who are undergoing chemotherapy do not respond normally to immunization, and titers

of antibodies to infectious agents fall more rapidly than in healthy individuals Therefore, even immunosuppressed patients who have not had HSCTs may need booster vaccine injections If memory cells are specifically eliminated as part of a stem cell "cleanup" procedure, it will be necessary to reimmunize the recipient with a new primary series Optimal times for immunizations of different transplant populations are being evaluated Yearly immunization of household and other contacts (including health care personnel) against influenza benefits the patient by preventing local spread

Table 126-6 Vaccination for Hematopoietic Stem Cell Transplant (HSCT) or Solid Organ Transplant (SOT) Recipients

Streptococcus

meningitidis

Immunize after transplantation (optimal timing not established)

Use Prevnar

Preimmunize donor (graft)b

recommendations

Immunize before transplantation and every

5 years for Pneumovax (others not established)

recommendations

Seasonal influenza Vaccinate in the

fall

Vaccinate close

Vaccinate in the fall

Vaccinate close

contacts contacts

inactivated vaccine

Administer inactivated vaccine

Measles/mumps/rubella Immunize 24

transplantation if patient does not have graft-versus-host disease

Immunize before transplantation with attenuated vaccine

Tetanus, diphtheria Reimmunize after

transplantation with primary series

recommendations

Immunize before transplantation; give boosters at 10 years or as required; primary series not required

Hepatitis B and A Reimmunize after

transplantation

Immunize before transplantation as appropriate

recommendations

Human papillomavirus Recommendations

pending

Recommendations pending

a

Immunizations should be given before transplantation whenever possible

b

Studies indicate that it is possible to "immunize the graft" before transplantation