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Previous Article | Next Article 
Journal of Clinical Microbiology, February 2001, p. 506-508, Vol. 39, No. 2
Institute of
Microbiology,1 Institute of
Dermatology,2 and Transplant
Unit,3 Università Cattolica del Sacro
Cuore, 00168 Rome, Italy
Received Recieved 4 October 2000/Returned for modification 26 October
2000/Accepted 6 December 2000
This study investigates the prevalence of human herpesvirus 8 (HHV-8) infection in kidney transplant patients, evaluating the risk of
HHV-8 transmission via transplantation and the association between pre-
and posttransplantation HHV-8 infection and the subsequent development
of Kaposi's sarcoma (KS). Immunofluorescence and an enzyme immunoassay
were used to determine HHV-8 seroprevalence in 175 patients awaiting
kidney transplantation and 215 controls who were attending our clinic
for other reasons. All patients in the study came from central or
southern Italy. Seroprevalence was similar in both groups (14.8 versus
14.9%), with no significant difference between the rates for male and
female patients. Of the 175 patients, 100 were tested for anti-HHV-8
antibodies at various times during follow-up. During follow-up,
seroprevalence increased from 12% on the date of transplantation to
26%. This increase was paralleled by an age-related increase in
seroprevalence in the control group. During follow-up from 3 months to
10 years after transplantation, KS was diagnosed in seven patients
(4.0%). Six of these patients were positive for HHV-8 prior to
transplantation. Overall, 23.0% of patients who were HHV-8 positive
before transplantation developed KS, whereas only 0.7% of seronegative
patients developed the disease (relative risk, 34.4; 95% confidence
interval, 4.31 to 274.0). This finding suggests that the key risk
factor for KS is infection prior to transplantation and that antibody
detection in patients awaiting transplantation could be useful in
identifying patients at high risk for KS. In patients from geographic
areas with a high prevalence of HHV-8, serological tests on donors may be less important.
Human herpesvirus 8 (HHV-8; also
known as Kaposi's sarcoma-associated herpesvirus) has been associated
with all forms of Kaposi's sarcoma (KS), including
transplantation-associated KS. Although its role in pathogenesis has
yet to be defined, HHV-8 has been identified as an important cofactor
in the development of KS. HHV-8 has been detected in virtually all KS
patients. Viral DNA and serum antibodies to HHV-8 appear to have
predictive value for the onset of KS, especially in patients with
compromised immune systems (2, 5, 7, 20).
HHV-8 is not, however, restricted to KS patients. Seroprevalence in the
general population varies. Higher-than-average seroprevalence has been
reported in geographic areas such as central and southern Italy, where
classical KS is also more frequent than in other parts of the world. A
strict association between HHV-8 and KS has been demonstrated in
transplant recipients. HHV-8 seroprevalence and iatrogenic KS also
appear to be correlated (6, 9, 11, 15). It is still
unclear whether posttransplantation KS is due to the reactivation of
HHV-8 as a result of immunosuppressive treatment or to primary HHV-8
infection transmitted via organ transplantation (16, 18,
19).
The aim of this study was to compare HHV-8 seroprevalence in a group of
patients awaiting kidney transplants and in a control group. All
patients in the study came from central or southern Italy. Transplant
recipients were studied during follow-up in order to evaluate the risk
of HHV-8 transmission via kidney transplantation and the correlation
between HHV-8 infection and the subsequent development of KS.
Patients and specimens.
Serum samples were collected from
175 out of 212 patients who underwent transplantation in the Transplant
Unit of the Università Cattolica del Sacro Cuore Rome, Rome,
Italy. Data collection took place over a 9-year period from 1989 to
1997. Patients whose sera prior to transplantation were not available
and patients lost at follow-up were excluded from the study. In this
period the waiting list for our Transplantation Unit included over 600 patients. The low percentage of transplants is a consequence of a
scarcity of donors in central and southern Italy. The mean age of
transplant patients (TP) was 39.9 years (range, 16 to 52), with a
male/female ratio of 1.6:1.
0095-1137/01/$04.00+0 DOI: 10.1128/JCM.39.2.506-508.2001
Copyright © 2001, American Society for Microbiology. All rights reserved.
Kaposi's Sarcoma Associated with Previous Human Herpesvirus 8 Infection in Kidney Transplant Recipients
ABSTRACT
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
INTRODUCTION
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
MATERIALS AND METHODS
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
HHV-8 antibody detection. Serum was tested using an immunofluorescence assay based on the HHV-8-infected cell line BC-3 (American Type Culture Collection, Manassas, Va.). Serum was stimulated with the phorbol ester 12-O-tetradecanoylphorbol-13-acetate (TPA; Sigma, St. Louis, Mo.) to induce the lytic cycle, as described elsewhere (6). Cells were spotted onto welled slides, fixed in cold acetone for 10 min, and incubated with 20 µl of human serum that was diluted 1:2, starting from 1:80, until no reactivity was observed. Slides were then washed, incubated with a prestandardized dilution of Kallestad fluorescein-conjugated goat F(ab')2 fragment anti-human immunoglobulin G (Sanofi Diagnostics Pasteur, Chaska, Minn.), washed again, air dried, and examined under a fluorescence microscope. Samples showing specific reactivity at a 1:80 dilution were considered positive for HHV-8 antibodies. Positive results for reactive samples were confirmed by immunoenzymatic assay (HHV-8 IgG antibody; Advanced Biotechnologies, Columbia, Md.) as recommended by the supplier.
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RESULTS |
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Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
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All serum samples from TP and controls were tested for HHV-8
antibodies (Table 1). No significant
difference was detected between pretransplant seroprevalence in TP
(14.8%) and seroprevalence in controls (14.9%). In neither group was
there any significant difference in rates for males and females. In the
control group, seroprevalence tended to increase with age, with a rate
of 10.8% in patients between 18 and 49 years old (121 of 215) and
20.3% in patients over 50 (94 of 215). Antibody titers (ranging from 1:80 to 1:2,560) were similar for both groups of patients. The staining
patterns observed were specific for reactivity with lytic viral
antigens. Samples tested with only secondary antibody showed no
reactivity.
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Follow-up testing of 100 out of the initial 175 TP, in the period from 3 months to 10 years after transplantation, showed an increase in seroprevalence from 12 to 26%. During this period, 14 (16%) of the 88 patients who had tested negative for HHV-8 on the day of transplantation seroconverted; the remaining 74 patients continued to test negative.
In our group of TP we observed seven cases of iatrogenic KS, with a
prevalence of 4.0% (7 of 175). Six out of seven KS patients were
seropositive before transplantation and developed KS over a period of
time ranging from 3 months to 3 years after the operation. Only one
patient was seronegative before transplantation and developed KS 2.5 years after the transplant (Table 2). The
relative risk of developing KS was 34.4 (95% confidence interval
[CI], 4.31 to 274.0) for HHV-8-positive transplant patients.
Analyzing results from pretransplant HHV-8-seropositive patients, it
was found that 6 out of 26 (23.0%) developed KS while only 1 out of
149 seronegative patients (0.7%) developed the disease. Of the 14 seronegative patients who seroconverted following transplantation, 1 patient (7.1%) developed KS.
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No statistical association was found between HHV-8 seropositivity and blood transfusions or years of dialysis.
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DISCUSSION |
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Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
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Prevalence rates and transmission mechanisms for HHV-8 are still under study. There is, however, widespread agreement that rates of HHV-8 prevalence are relatively higher in Mediterranean and African areas and lower in Western countries (6, 9, 11, 15).
In this study, the overall rate of HHV-8 seroprevalence in patients awaiting transplant was 14.8%. This rate was statistically indistinguishable from the rate (14.9%) observed in controls. The observed rate of seropositivity in pretransplant patients was higher than rates reported in other European countries (8, 19) and can be explained by the higher-than-average HHV-8 seroprevalence in the general population of central and southern Italy (5, 14, 22, 23). The data suggest that HHV-8 seroprevalence is unaffected by pretransplant therapeutic regimens. This conclusion is supported by other studies showing a low rate of parenteral transmission of HHV-8 (8, 12, 13). The lack of any statistically significant association between HHV-8 seropositivity and blood transfusion or years of dialysis suggests that HHV-8 transmission may involve other routes (4, 5, 6, 10, 15, 22).
In this study, 7 (4.0%) out of 175 patients developed iatrogenic KS after kidney transplantation. This relatively high rate could be explained by the fact that our patients came from central and southern Italy, which have a higher-than-average rate of HHV-8 infection and where classical KS is endemic (1, 6, 23). This hypothesis is supported by previous reports of a strong correlation between KS and HHV-8 infection (5, 7, 17).
Six out of seven KS patients were seropositive before transplantation, and only one was seronegative. Of the seropositive patients, 23.0% developed KS, as opposed to 0.7% of patients who tested negative for HHV-8 (relative risk, 34.4; 95% CI, 4.31 to 274.0). This result shows a significantly increased risk of KS in patients who are seropositive prior to transplantation.
The observed 12 to 26% increase in rates of seropositivity following transplantation is paralleled by the age-related increase in prevalence observed in the control group and by previous reports pointing in the same direction (14, 15). This suggests that seroconversion due to transplantation may be relatively rare. Of the 14 patients who seroconverted, only 2 seroconversions were observed within 6 months of transplantation; in such instances it is impossible to exclude donor transmission. Neither of these patients developed KS during 3 years of follow-up.
The only case of KS among the 14 seroconverted patients was observed 30 months after transplantation; unfortunately, it was not possible to determine the exact time at which seroconversion had occurred. Of the seven patients who developed KS, this patient was the only one who presented a complete remission of the disease (cutaneous and gastric KS) after withdrawal of treatment with cyclosporine and methylprednisolone. This suggests an important role for immunosuppression.
In this study we did not have access to donor data. We therefore cannot exclude the possibility that in some cases seropositive organ recipients were reinfected with HHV-8 from donors. The data nonetheless suggest that pretransplant HHV-8 seropositivity is a more important risk factor for KS than infection via transplantation.
We suggest that in geographic areas where HHV-8 infection is frequent and many patients are seropositive before transplantation, immunosuppressive treatment may induce the reactivation of latent infections, playing an important role in the development of iatrogenic KS in association with virus- or host-associated factors (16). This of course does not exclude the possibility that, in populations with a low prevalence of HHV-8, primary HHV-8 infection acquired through or after transplantation may play a role in iatrogenic KS, with immunosuppressive therapy acting as the most important cofactor.
In conclusion, our study suggests that antibody detection in transplant recipients could be useful to detect patients with high risk for KS and that, at least in areas where HHV-8 infection is common, this may be more important than HHV-8 antibody detection in donors.
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ACKNOWLEDGMENTS |
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This work was partly supported by grant no. 7021309 from the Ministero dell'Università e della Ricerca Scientifica e Tecnologica (MURST), Italy.
Thanks are due to Richard Walker for assistance with editing and to Patrizia Andaloro and Creola Rocchetti for their expert technical assistance.
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FOOTNOTES |
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* Corresponding author. Mailing address: Istituto di Microbiologia, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy. Phone: 39-06-30154964. Fax: 39-06-3051152. E-mail: p_universi{at}libero.it.
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