The annual standard dose influenza vaccine has suboptimal immunogenicity in solid organ transplant recipients (SOTR). Influenza vaccine containing higher doses of antigens may lead to greater immunogenicity in this population. We conducted a randomized, double blind trial comparing the safety and immunogenicity of the 2016-17 high dose (HD; FluzoneHD,Sanofi) versus standard dose (SD; Fluviral,GSK) influenza vaccine in adult SOTR. Preimmunization and 4-week postimmunization sera underwent strain-specific hemagglutination inhibition assay. We enrolled 172 patients who received study vaccine and 161 (84 HD; 77 SD) were eligible for analysis. Seroconversion to at least 1 of 3 vaccine antigens was present in 78.6% vs. 55.8% in HD vs. SD vaccine respectively (p<0.001). Seroconversion to A/ H1N1, A/H3N2 and B strains were 40.5% vs. 20.5%, 57.1% vs. 32.5%, and 58.3% vs. 41.6% in HD vs. SD vaccine (p=0.006, 0.002, 0.028 respectively). Post-immunization geometric mean titers of A/H1N1, A/H3N2, and B strains were significantly higher in HD group (p=0.007, 0.002, 0.033). Independent factors associated with seroconversion to at least one vaccine strain were the use of HD vaccine (OR 3.23, 95% CI 1.56-6.67) and use of mycophenolate doses less than 2g daily (OR 2.76, 95% CI 1.12-6.76). High-dose vaccine demonstrated significantly better immunogenicity than SD vaccine in adult transplant recipients and may be the preferred influenza vaccine for this population.

Seasonal influenza infection may cause significant morbidity and mortality in transplant recipients. The purpose of this study was to assess the epidemiology of symptomatic influenza infection posttransplant and determine risk factors for severe disease. Twenty centers in the United States, Canada, and Spain prospectively enrolled solid organ transplant (SOT) or hematopoietic stem cell transplant (HSCT) recipients with microbiologically confirmed influenza over 5 consecutive years (2010–2015). Demographics, microbiology data, and outcomes were collected. Serial nasopharyngeal swabs were collected at diagnosis and upto 28 days, and quantitative polymerase chain reaction for influenza A was performed. We enrolled 616 patients with confirmed influenza (477 SOT; 139 HSCT). Pneumonia at presentation was in 134 of 606 (22.1%) patients. Antiviral therapy was given to 94.1% for a median of 5 days (range, 1–42 days); 66.5% patients were hospitalized and 11.0% required intensive care unit (ICU) care. The receipt of vaccine in the same influenza season was associated with a decrease in disease severity as determined by the presence of pneumonia (odds ratio [OR], 0.34 [95% confidence interval {CI}, .21–.55], P < .001) and ICU admission (OR, 0.49 [95% CI, .26–.90], P = .023). Similarly, early antiviral treatment (within 48 hours) was associated with improved outcomes. In patients with influenza A, pneumonia, ICU admission, and not being immunized were also associated with higher viral loads at presentation (P = .018, P = .008, and P = .024, respectively). Annual influenza vaccination and early antiviral therapy are associated with a significant reduction in influenza-associated morbidity, and should be emphasized as strategies to improve outcomes of transplant recipients.

Symptomatic cytomegalovirus (CMV) disease has been the standard endpoint for clinical trials in organ transplant recipients. Viral load may be a more relevant endpoint due to low frequency of disease. We performed a meta-analysis and systematic review of the literature. We found several lines of evidence to support the validity of viral load as an appropriate surrogate end-point, including the following: (1) viral loads in CMV disease are significantly greater than in asymptomatic viremia (odds ratio, 9.3 95% confidence interval, 4.6–19.3); (2) kinetics of viral replication are strongly associated with progression to disease; (3) pooled incidence of CMV viremia and disease is significantly lower during prophylaxis compared with the full patient follow-up period (viremia incidence: 3.2% vs 34.3%; P < .001) (disease incidence: 1.1% vs 13.0%; P < .001); (4) treatment of viremia prevented disease; and (5) viral load decline correlated with symptom resolution. Based on the analysis, we conclude that CMV load is an appropriate surrogate endpoint for CMV trials in organ transplant recipients.

Although initial therapy for cytomegalovirus (CMV) is usually successful, a significant subset of patients may have recurrent viremia. However, the epidemiology and risk factors for recurrence have not been fully defined, as well as the utility of prolonged antivirals after initial clearance. Solid organ transplant patients with first episode of CMV disease or asymptomatic viremia (≥1000 IU/mL) requiring treatment were identified by chart review. Clinical and virologic data were collected. The primary outcome was recurrence of CMV viremia or disease within 6 months of treatment discontinuation. The first episode of CMV viremia requiring antiviral therapy was assessed in 282 patients (147 CMV disease and 135 asymptomatic viremia). Cytomegalovirus occurred at 5.6 (0.63-27.7) months posttransplant. Recurrent CMV occurred in 30.5% patients at a median of 51 (0-160) days after discontinuation of therapy. Factors predictive of recurrence were treatment phase viral kinetics (P = 0.005), lung transplant (P = 0.002), CMV donor (D)+/recipient (R)- serostatus(P = 0.04) and recent acute rejection(P = 0.02). Prolonged antiviral therapy was given to 226 (80.1%) of 282 patients. Recurrence occurred in 73 (32.3%) of 226 patients that received prolonged antivirals versus 13 (23.2%) of 56 in those with no prolonged antivirals (P = 0.19). Recurrent CMV occurs in a significant percentage of patients after treatment of the first episode of CMV viremia/disease. CMV D+/R- serostatus, lung transplant, and treatment phase viral kinetics were significant predictors of recurrence. Continuation of prolonged antivirals beyond initial clearance was not associated with a reduced risk of recurrence.

Solid organ transplant recipients (SOTRs) are predisposed to infection due to the need for lifelong immunosuppression, although tools to measure the overall degree of immunosuppression are limited. In this study, we used a novel global cell-mediated immunity (CMI) assay to quantify the degree of immunosuppression and predict subsequent infections. Consecutive SOTRs were enrolled and provided whole blood to conduct the global CMI assay (QuantiFERON Monitor) at 1, 3, and 6 months posttransplant. The assay measures plasma interferon gamma (IFN-γ) levels after stimulation of whole blood with antigens that stimulate both innate and adaptive immunity. Bacterial, viral, and fungal infections were prospectively recorded. We enrolled 137 patients who provided CMI measurements on at least 1 study timepoint. Median age was 58 years; transplant types were kidney (32.1%), liver (30.7%), and lung (36.5%). At least 1 episode of infection occurred in 32 of 137 (23.4%) patients between 1 and 3 months, 34 of 135 (25.1%) between 3 and 6 months, and 39 of 132 (29.5%) between 6 and 12 months. IFN-γ levels were significantly lower in those with at least 1 episode of infection vs no infection at month 1 (P = .04), month 3 (P = .05), and month 6 (P = .006). Patients who developed opportunistic infections (OIs) also showed a significantly lower CMI than those without OI at months 3 and 6. Using a cutoff value of ≤10 IU/mL of IFN-γ, there was a 2- to 3-fold greater likelihood of subsequent infection in those with lower CMI. We show that a novel global immunity assay is able to quantify the level of immunosuppression and predict the risk of subsequent infection episodes in organ transplant recipients.