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For organ transplant recipients, skin diseases and risk factors differ by race – Medical Xpress

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For organ transplant recipients, skin diseases and risk factors differ by race

Incidence of malignant/premalignant lesions, infections and inflammatory processes in white, black, Asian and Hispanic organ transplant recipients. Credit: Drexel University
It’s been long recognized that the immunosuppressant drugs patients are prescribed after an organ transplant come with a fair share of dangerous side effects—including squamous cell carcinoma and other types of skin disease.

But despite advances to improve skin cancer prevention for these patients, little is known about how skin conditions affect African-American, Asian and Hispanic . That’s a problem, considering that more than half of the 120,000 Americans on the waiting list for organs are nonwhite, according to the U.S. Department of Health and Human Services.

Now, new research from Drexel University College of Medicine shows that nonwhite recipients require unique, specialized dermatological care following their procedure. It is one of the first studies to analyze the risk factors, incidence, locations and types of skin disease in this population.

The researchers found that the majority of skin cancers in black occurred in sun-protected areas, like the groin-genital area, and most of those lesions tested positive for high-risk human papillomavirus (HPV). Further, nonwhite organ transplant recipients were less likely than their white counterparts to have regular skin evaluations by a dermatologist and to know the signs of skin cancer. The results were published this week in JAMA Dermatology.

These findings suggest that dermatologists need to evaluate, counsel and treat organ transplant recipients differently based on their race, according to principal investigator Christina Lee Chung, MD, associate professor of dermatology in the College of Medicine.

“Practitioners need to know there is not a one-size-fits-all model for their patients,” said Chung, who is the director of the Drexel Dermatology Center for Transplant Patients.

The study builds on a previous report from Drexel Dermatology, which identified 19 skin cancer lesions in 6 percent of 259 nonwhite patients. The authors concluded that all organ transplant recipients, regardless of race, should receive routine, total-body screenings for skin cancer.

In their most recent study, the researchers compared medical records of 412 organ transplant recipients—including 154 white patients and 258 nonwhite (black, Asian or Hispanic)—who were referred to the Drexel Dermatology Center for Transplant Patients between 2011 and 2016. As one of the only models of its kind in the country, the center provides post-transplant dermatological care to every patient who is transplanted by and/or followed by the Drexel University and Hahnemann University Hospital Transplant Programs. That means that every patient, regardless of race is screened annually for skin cancer. This provided a rich dataset for the research team to analyze.

Two hundred eighty-nine transplant recipients exhibited malignant, infectious or inflammatory conditions during their evaluation. However, their primary acute diagnoses differed greatly by race. In 82 white patients, skin cancer was the most common acute problem requiring attention at first visit. Black and Hispanic patients, by contrast, were most often diagnosed with inflammatory or infectious processes, such as fungal infections, warts, eczema, psoriasis and rashes.

Overall, in situ was the most common type of skin cancer diagnosed in each racial or ethnic group. But the location of the cancerous lesions again depended on the race of the patient. Most lesions in white and Asian patients occurred in sun-exposed areas of the body, like the scalp, neck, chest and back. For black patients, the lesions were primarily found in the groin.

Moreover, six of the nine lesions found on black patients tested positive for high-risk HPV strains, suggesting a strong association between the virus and skin cancer for African-Americans. Chung says it is still unclear why African-American transplant patients would have higher rates of HPV-related skin cancer. But the findings from this study show that dermatologists need to closely examine the groin, genital and perianal areas in this population.

Additionally, although early detection of cancer is vital, nonwhite transplant recipients would also benefit from addressing fungal and HPV infections, which can be persistent and magnify over time, she said.

“A lot of times doctors are so worried about preventing skin cancer, that they are not thinking about other problems that can greatly affect a person’s quality of life,” Chung said. “But if patients of color who are at risk for these conditions are evaluated early, then they can get a jumpstart on treatment before the issues become chronic and frustrating.”

The researchers also provided questionnaires to 66 organ transplant recipients to find out more about the patients’ awareness of . Seventy-seven percent of white patients were aware their skin cancer risk was increased, compared to 68 percent of nonwhites. Only 11 percent of nonwhite patients reported having regular dermatologic examinations, compared to 36 percent of whites. Finally, 45 percent of white patients, but only 25 percent of nonwhite, reported knowing the signs of skin cancer.

The study authors note that the high rates of nonwhite individuals knowing their risk of skin cancer is likely thanks to the strong emphasis that the Drexel University and Hahnemann Hospital Transplant Programs place on the importance of dermatology as part of comprehensive post-transplant care.

The researchers’ total findings underscore the importance of skin cancer screening guidelines for , with counseling and treatment contingent on skin type and race.

“Right now, we don’t have any consensus screening guidelines pertaining to post-transplant development,” Chung said. “For the future, screening protocols, patient educational materials, and risk assessment tools must be developed that specifically address the non-white population.”

Explore further: African-American organ transplant recipients at risk for skin cancer

More information: JAMA Dermatology. DOI: 10.1001/jamadermatol.2017.0045

Common cold virus can cause deadly pneumonia in transplant patients, study shows – News-Medical.net

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The common cold is a major source of annoyance for most of us, but new research has found that the most prevalent respiratory infection can be far worse than a stuffy nose for one sector of the population — bone marrow transplant patients.

These vulnerable patients, whose immune defenses have taken a dramatic double hit from both their original disease and the treatments required to repopulate their immune system with donor cells, are especially susceptible to a wide range of infections that typically don’t cause major problems in healthy people. But rhinovirus, the most common respiratory virus, has traditionally been overlooked in this population, said Fred Hutchinson Cancer Research Center infectious disease specialist Dr. Michael Boeckh.

“This is such a prevalent virus … about 25 percent of stem cell transplant patients get infected [with rhinovirus] during the first year,” said Boeckh, who heads Fred Hutch’s Infectious Disease Sciences Program. “The virus was always considered kind of a common cold, a mild virus. People shrugged their shoulders, what should we do about it, it comes and goes.”

Now, a new study led by infectious disease researcher Dr. Sachiko Seo, formerly of Fred Hutch and now a physician at the National Cancer Research Center East in Chiba, Japan, and Boeckh and published last month in the journal Haematologica has found that like more “serious” viruses, rhinovirus can cause pneumonia — and when it does, it can be deadly to those recovering from transplantation.

The results not only point to the importance of strong infection prevention measures for transplant patients and better care for those with rhinovirus-related pneumonia but lend a rationale for drug companies and researchers to prioritize developing effective antiviral drugs for this most common of common cold-causing viruses, Boeckh said.

“Just to treat people like you and me who are irritated by the sniffles, that’s not good enough for the market,” he said. “For a company or anybody to step forward and say, ‘I’m going to make this a priority,’ you have to show that there’s a real disease.”

This virus ‘can’t be disregarded’

Their study was not the first to show that transplant patients get rhinovirus but the first to definitively link the virus to pneumonia in these patients. That new discovery is thanks to modern virus detection methods — rhinovirus was difficult to pinpoint using older technologies, Boeckh said. Over the past decade, with the advent of better viral detection, he and other clinicians started to see evidence of rhinovirus in the lungs in transplant patients with pneumonia. But they didn’t know if the virus was causing the complication or if it was just along for the ride.

In their recent study, the researchers took a retrospective look at 697 patients who’d received transplants at Seattle Cancer Care Alliance, Fred Hutch’s clinical care partner, between 1993 and 2015 and who had also tested positive for rhinovirus. They compared the 128 patients with rhinovirus in the lower respiratory tract to those infected with viruses already known to cause pneumonia — and sometimes death — in transplant patients, namely, influenza; parainfluenza virus, or PIV; and respiratory syncytial virus, or RSV.

In contrast to what researchers believed in the past, their study showed that rhinovirus is linked to pneumonia and death even without any other co-existing infections, strongly suggesting that the so-called mild virus can be dangerous all on its own.

Boeckh and his colleagues found that rhinovirus infection led to pneumonia less often than the other viruses. About 15 percent of patients with an upper respiratory tract infection — the type of infection we typically think of as a “common cold” — went on to develop pneumonia, or an infection of the lower respiratory tract. Progression from cold-like symptoms to pneumonia for patients infected with RSV, for example, happened about twice as often.

But once patients developed pneumonia, rhinovirus turned out to be just as deadly as the other viruses, the researchers found. About 40 percent of patients in their study who developed pneumonia from any viral infection died.

Even though rhinovirus is less likely on a case-by-case basis to lead to pneumonia, it’s actually the most common cause of pneumonia caused by respiratory viruses in transplant patients, Boeckh said. That’s because the virus is so common and because it’s present year-round, unlike the other, more seasonal viruses.

Overall, their results point to the need for better preventions and treatments for the virus, Boeckh said.

“This is an important pathogen,” he said. “It can’t be disregarded as a common cold virus.”

How to prevent complications — now and in the future

In fact, the scientists believe the pathogen is so important they’ve started an entire research program around it. Dr. Alpana Waghmare, one of the study authors who is a pediatric infectious disease specialist at Seattle Children’s and a Fred Hutch affiliate researcher, is launching a research project to better understand how and why rhinovirus is so dangerous to transplant patients.

For now, she’s concentrating on understanding which patients are most likely to develop pneumonia from the virus. In a different study Waghmare presented at the recent annual meeting of the American Society for Blood and Marrow Transplantation in Orlando, Florida, the researchers teased out a few risk factors that can drive the development of lower respiratory tract infections — namely, high levels of steroid use (commonly given to transplant patients for other complications such as graft-vs.-host disease) and a low white blood cell count.

Her team’s next step will be to understand whether certain patients are at higher risk for getting infected with rhinovirus in the first place and to ask if there are other risk factors for pneumonia and other poor outcomes from the infection.

Even though there’s no effective drug for rhinovirus on the market yet, understanding who is at highest risk of complications from the virus is still important, Waghmare said. The research field needs to provide evidence of how rhinovirus is harmful to spur such a drug’s development as well as to understand which patients would benefit most once such a treatment is available so clinicians can know who should be monitored or treated more aggressively, she said.

“So many of our patients get rhinovirus, but most of the infections are mild and we want to know who would likely benefit from any potential therapies,” Waghmare said. “You need to know how to stratify people to get the most bang for your buck in terms of whom you treat.”

For now though, in the absence of an effective drug, there are a few steps transplant patients and their caregivers can take, Waghmare said.

Patients who are within the first year of receiving a transplant should always check with their doctor as soon as they develop any cold-like symptoms. “Don’t wait things out,” she said.

As a general infection control practice, any family members and friends with cold or flu symptoms should limit contact with post-transplant patients as much as possible. Waghmare acknowledges that’s difficult in practice though, as for instance when the patient’s caregiver comes down with a cold.

For cancer care facilities, it’s important to keep employees with any cold symptoms out of the clinic, Boeckh said. He points out that the SCCA has a very aggressive infection control program and they all make infection prevention in this vulnerable population a top priority.

Disabled patients who need organ transplants may face bias, report says – Fox News

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Patients with mental disabilities are regularly turned down for life-saving procedures despite federal law prohibiting such bias, a Washington Post report published March 4 reveals. At the center of the potential ethical dilemma is Paul Corby, a 27-year-old who needs a life-prolonging heart transplant but has been rejected from programs due to “psychiatric issues, autism, the complexity of the process…and the unknown and unpredictable effect of steroids on behavior.”

“I couldn’t even believe this would happen, that this would be the reason in this day and age,” Karen Corby, Paul Corby’s mother, told The Post.

Corby suffers from a form of cardiomyopathy that killed his father at age 27. There is neither a cure nor a surgical fix, but he was rejected from the University of Pennsylvania transplant program in 2011 despite a letter of recommendation for the procedure from his psychiatrist. His mother told The Post that in addition to autism, Corby was diagnosed with a mood disorder and impulse-control disorder as a teen but has since made significant progress, which was also noted in his therapist’s letter. He takes 19 medications and requires some adult supervision for occasional outbursts, but manages his pills on his own and can communicate well.

“When individuals are referred for transplant evaluation here, all aspects of their medical status are reviewed,” Susan Phillips, Penn Medicine’s senior vice president for public affairs, told The Post. “This may include the potential impact of other existing health problems on the success of the surgery itself, and the potential interaction between a patient’s existing drug therapies and the drugs that would be necessary to stop transplant rejection. Given the criticality of post-surgery care following any solid organ transplant, the patient’s support system is also taken into account … the ultimate decision about whether transplant surgery is appropriate is, of course, made on an individual basis.”

While a patient with Corby’s disabilities may be rejected at one transplant center, it’s possible that he would be approved at another, the report found. The staff members who comprise transplant programs at 815 U.S. centers are able to weigh neurocognitive disabilities as heavily or lightly as they decide. According to the report, some of the centers, which were not identified, explicitly rule out all patients with certain disabilities.

More on this…

“As a society, we want individual transplant centers to maintain discretion about putting people on their list or not,” Scott Halpern, an ethicist at the University of Pennsylvania medical center, told The Post. “We don’t want government playing doctor at the bedside. Having said that, the current system lacks the accountability that we might wish it to have. There are virtually no checks and balances on the decisions that transplant centers make.”

There currently are no guidelines against discrimination based on disabilities for organ transplants, but in October members of Congress called on the Department of Health and Human Services’ civil rights office to produce them. An HHS spokesperson told The Post that the agency is working “to clarify the obligations of covered entities participating in the transplant process and to provide equal access to their programs to individuals with disabilities.”

Four states, including Pennsylvania which named its legislation after Corby, have passed laws in an attempt to bar discrimination in transplant decisions, according to The Post. 

New antiviral drug cuts cytomegalovirus infection, improves survival in patients undergoing donor stem cell transplant – Science Daily

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In a significant advance in improving the safety of donor stem cell transplants, a major clinical trial led by researchers at Dana-Farber Cancer Institute and Brigham and Women’s Hospital (BWH) has shown that a novel agent can protect against the most common viral infection that patients face after transplantation.

The results represent a breakthrough in a decade-long effort to identify an effective drug for the prevention of CMV infection in transplant patients that doesn’t produce side effects that negate the benefit of the drug itself, the study authors said.

The findings, from an international phase 3 clinical trial of the drug letermovir for preventing cytomegalovirus (CMV) infection in transplant patients, will be presented at the 2017 Bone Marrow Transplant Tandem Meetings of the American Society for Blood and Marrow Transplantation (ASBMT) and the Center for International Blood and Marrow Transplant Research (CIBMTR) in Orlando, Florida, February 22, 2017.

The study, which involved 565 adult patients at 67 research centers in 20 countries, compared letermovir to placebo in preventing an active CMV infection following transplant with donor stem cells. The patients, who were undergoing transplant as treatment for blood-related cancers or other disorders, all carried a CMV infection from earlier in life that had been wrestled into dormancy by their immune system. Twenty-four weeks after completing up to 14 weeks of treatment, 61 percent of the patients receiving a placebo had developed a CMV infection serious enough to require treatment or had discontinued the trial. By contrast, only 38 percent of those treated with letermovir developed that level of CMV infection or did not complete the trial.

Unlike other drugs able to forestall active CMV infection in stem cell transplant patients, letermovir did so without producing unacceptable toxicities. Most of the side effects associated with letermovir were tolerable, including mild cases of nausea or vomiting, and some swelling, investigators found. Letermovir also conferred a survival benefit: at the 24-week mark, 15 percent of the placebo patients had died, compared to 10 percent of those receiving letermovir.

“For the first time, we seem to have a drug that is a true safe and effective preventive for CMV infection in stem cell transplant patients,” said the study’s lead author, Francisco Marty, MD, an infectious disease specialist at Dana-Farber and BWH. “Letermovir will allow many patients to avoid infection, usually with no or mild side effects, and seems to provide a survival benefit in the first six months post-transplant.”

Transplantation of donor hematopoietic stem cells — which give rise to all types of blood cells, including white blood cells of the immune system — is used to treat blood-related cancers such as leukemia, lymphoma, and myeloma, as well as several types of non-cancerous blood disorders. Patients typically receive chemotherapy to wipe out or reduce the bone marrow, where blood cells are formed, followed by an infusion of donor stem cells to rebuild their blood supply and reconstitute their immune system.

While refinements in transplant techniques have sharply improved the safety of the procedure, the reactivation of CMV infection following a transplant has been a longstanding problem.

Infection with CMV, a type of herpes virus, is one of the most common viral infections in the world. In the United States, it’s estimated that over 50 percent of people are infected before adulthood. In other parts of the world, infection rates can be significantly higher. The effects of CMV infection can range from no symptoms to a flu-like fever or mononucleosis (“mono”) syndrome. Once the immune system has brought the infection under control, the virus persists unobtrusively in the body.

The jolt of a stem cell transplant — the rapid erasure or diminishment of the immune system produced by pre-transplant chemotherapy, as well as measures to prevent graft-versus-host disease — can give CMV a chance to reawaken and run amok before the newly reconstituted immune system takes hold. In the early years of bone marrow transplant therapy, 60 to 70 percent of transplant recipients developed CMV infection, Marty recounts. Of those, 20 to 30 percent contracted CMV pneumonia, and of those, 80 percent died of the disease.

In previous clinical trials, several drugs aimed at preventing CMV infection in stem cell transplant patients either were not effective or produced intolerable side effects. In the absence of safe preventive drugs, physicians worked out a “surveillance” approach in which they provide treatment only when patients develop CMV infection, and only for a short period of time. This strategy has largely been a success: patients now have just a 2 or 3 percent chance of getting CMV disease affecting the lungs or other organs. Still, the often harsh side effects of current drugs were reason to continue the search for a useful preventive agent.

Letermovir works by a different mechanism from previously tested agents, which block an enzyme known as DNA polymerase, which viruses use to duplicate their DNA. (Human cells use the same process to replicate their own DNA.) By contrast, letermovir blocks a process by which CMV is “packaged” inside infected cells — a wrapping that allows it to go on and infect other cells. The fact that this process does not occur in human cells may explain in part why letermovir usually gives rise to only mild side effects, researchers say.

In the trial, patients received letermovir or a placebo beginning an average of nine days after transplant. “The goal was to suppress the virus before it has a chance to become active,” Marty remarked. “The results of this trial offer encouragement that letermovir can offer a new strategy for donor stem cell transplant patients in preventing the emergence of CMV infection following transplant.”

Building Cy’s Place, Rochester’s First Pediatric Transplant House – KAALtv.com

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“Your heart breaks and then it breaks and you wonder how many times it can continue to break,” Randy Erickson said. 

After many trips to Mayo Clinic, the Ericksons lost Silas to cancer in December of 2007. Sunday, they raised money for a place to help families, just like theirs by promoting ‘Cy’s Place’.

“If they need to talk about it, we’ll be there and we know what it’s like,” Erickson said.

It will be a place for people thrown into an uncertain and stressful time while their child is waiting to receive an organ transplant.

“If we could help at least take this part of that, they have a place to stay and it’s cheap just $10, if we could do that for them, it would take a lot of burden off of them,” Erickson said.  

Some of the Erickson’s church friends stepped in to help after Randy Erickson gave a presentation in a Sunday school class. 

“It was in my mind for maybe two or three weeks, we’ve just [have to] do it,” family friend Boyd Brue said.

Brue also said nine acres of land has already been claimed, the family is just waiting for the funds.

“’Cy’s Place’ actually exists right now in their basement,” Brue said.

The Ericksons have been housing people who are going through the same experience they did years ago.

“And so after Silas died, we thought it’d be fun for us to someday move back to Rochester and give back to people,” Erickson said.  

So the Erickson family and their friends are trying to show as much support as they can to those who need it.

“It’s been a lot of work but hopefully it’ll pay off,” Brue said.  

Toddler survives 2nd second organ transplant – FOX 7 Austin

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Miles Wagner, 2, got a new kidney thanks to his mother’s emotional plea on Facebook and a selfless donor. 

Miles is a survivor. He already made it through a successful liver transplant last year.  But at 8 weeks old, he was diagnosed with a rare kidney disease that affects one person in a million. 

“A lot of gratitude to the donors that have given our little boy a new chance,”  said Ashley Wagner, Miles’ mother.

The kidney, and Miles’ future along with it, came from Liz Wolodkiewicz, his father’s high school classmate, after she saw the Facebook post from Miles’ mother asking for help. 

The transplant couldn’t have come soon enough, as Miles’ father, Ryan, was diagnosed with stage four colon cancer when Ashley was pregnant. 

“The amount of time I have because of cancer is definitely reduced. My main goal is that I wanted to see him healthy,” said Ryan Wagner.

Doctors say there is little hope Ryan will live longer than five years, but it’s more time. Time to hear the joy of Miles free from pain. 

Although the story is bittersweet, Ryan gets what every parent wants before they die. Knowing their child is going to be ok. Watch the video to see how Miles is doing now.

How Aries Merritt recovered from a kidney transplant to reach the Olympic trials

PHOTOGRAPHY BY BILL FRAKES

REPORTING BY JIM CAPLE

07/10/16

Aries Merritt won the gold medal in the 110 hurdles at the 2012 Olympics. He set the world record in the event a month later. As impressive as that is, what he has been able to overcome over the past three years is even more amazing.

Merritt’s kidneys began failing in 2013 to the point that they were functioning at only 10 percent. Last September, he underwent a kidney transplant. Despite that, he is still competing, still hurdling and is still among the best in the world.

You may have your attention fixed on Michael Phelps, Simone Biles and Usain Bolt at the upcoming Olympics, but Merritt is someone you had better keep in your mind, because his story is incredible and inspiring.

When Merritt received the news that his kidneys were functioning at just 10 percent due to a genetic disorder, he feared that he never would run again. Well, briefly. Because this is a man who was not about to give in — to anything.

 

Read more at Source: How Aries Merritt recovered from a kidney transplant to reach the Olympic trials

Morbidity from CMV Infection in Transplant Patients

Panelists: Harry Erba, MD, PhD, University of Alabama at Birmingham; Roy Chemaly, MD, MPH, MD Anderson Cancer Center; Mark Levis, MD, PhD, Sidney Kimmel Comprehensive Cancer Center talk about CMV and how it used to effect transplant patients and the therapies they can use now to help.

Published Online: Wednesday, Jan 25, 2017

Source: Morbidity from CMV Infection in Transplant Patients

Kidney chains now an option for children waiting for transplant in Seattle | KOMO

SEATTLE — Belinda Hudson and her son Nigel Dalton were first in the hospital together 19 years ago. That was for his birth. This time, it’s his rebirth.

Nigel was born with irreversible kidney damage and recently started dialysis.

“He was becoming increasingly fatigued, having a poor appetite and there was just changes in him physically,” Belinda described.

She wanted to donate a kidney to her son, but she wasn’t compatible.

“I was pretty devastated,” she said. “I thought, ‘I’m the mom. What do you mean? I don’t understand.'”

Instead of going onto the waiting list – which can take years – the family joined a kidney chain where a living donor gives a kidney to a stranger and then gets a kidney for a loved one. Belinda’s donated kidney went to a patient at UCLA.

Their chain lasted three weeks and involved 28 surgeries across the country, with 14 donors and 14 recipients. It was a first for Seattle Children’s.

“It’s been an amazing breakthrough that’s been more rapidly adopted in adult transplantation. We were excited to be able to offer it and enroll our patients in that program,” said Dr. Patrick Healey, the transplant division chief at Children’s.

Nigel’s kidney came from a young man in California.

“I won’t have to do dialysis anymore,” Nigel said. “And hopefully i’m going to live a life I’ve already been living.”

And it starts on his 19th birthday, thanks to the gift of life and love.

“You’re never getting another gift from me again,” Belinda laughed. “This is it. This is your lifetime gift.”

“I’ll take it,” Nigel said.

Source: Kidney chains now an option for children waiting for transplant in Seattle | KOMO

More Lives Saved: New Milestone Reached in 2016

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There was a new milestone reached in 2016: more than 33,600 organ transplants were performed in the U.S. This number sets a new record number of U.S. transplants for the fourth year in a row. The 2016 milestone represents an 8.5 percent increase in total number of organ transplants, and an almost 20 percent increase … Continue reading More Lives Saved: New Milestone Reached in 2016 »

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