BACKGROUND:The optimal treatment for respiratory syncytial virus (RSV) infection in adult immunocompromised patients is unknown. We assessed the management of RSV and other non-influenza respiratory viruses in Midwestern transplant centers.METHODS:A survey assessing strategies for RSV and other non-influenza respiratory viral infections was sent to 13 centers.RESULTS:Multiplex polymerase chain reaction assay was used for diagnosis in 11/12 centers. Eight of 12 centers used inhaled ribavirin (RBV) in some patient populations. Barriers included cost, safety, lack of evidence, and inconvenience. Six of 12 used intravenous immunoglobulin (IVIG), mostly in combination with RBV. Inhaled RBV was used more than oral, and in the post-stem cell transplant population, patients with lower respiratory tract infection (LRTI), graft-versus-host disease, and more recent transplantation were treated at higher rates. Ten centers had experience with lung transplant patients; all used either oral or inhaled RBV for LRTI, 6/10 treated upper respiratory tract infection (URTI). No center treated non-lung solid organ transplant (SOT) recipients with URTI; 7/11 would use oral or inhaled RBV in the same group with LRTI. Patients with hematologic malignancy without hematopoietic stem cell transplantation were treated with RBV at a similar frequency to non-lung SOT recipients. Three of 12 centers, in severe cases, treated parainfluenza and metapneumovirus, and 1/12 treated coronavirus.CONCLUSIONS:Treatment of RSV in immunocompromised patients varied greatly. While most centers treat LRTI, treatment of URTI was variable. No consensus was found regarding the use of oral versus inhaled RBV, or the use of IVIG. The presence of such heterogeneity demonstrates the need for further studies defining optimal treatment of RSV in immunocompromised hosts.

Background: Renal transplant recipients have been reported to develop de novo DSA to donor HLA-DQ only. The ability to bind complement is thought to be associated with DSA which contribute to antibody-mediated rejection. The objectives of this study were to assess whether de novo DSA to DQ alone could bind complement and be associated with changes in renal allograft histology in a cohort of pediatric renal transplant recipients. Methods: This retrospective cohort study was conducted at a single pediatric renal transplant center and included all first, kidney alone, transplants since 2007. DSA testing was performed every 3 months using FlowPRA ® Single Antigen and LABScreen® Single Antigen using a threshold of of 1000 MFI. Biopsies were performed at 3, 6, 12 and 24 months and for cause. Retrospective testing for the ability of DSA to bind the complement component C1q (C1qScreen™) was performed for samples which were positive for DSA and associated with a biopsy. All biopsies were re-reviewed retrospectively by a pathologist using the Banff classification of renal allograft pathology. This study analyzed the level of C4d deposition and the level of interstitial fibrosis and tubular atrophy (IFTA). Results: A total of 132 subjects had both DSA and renal allograft biopsy evaluation. Donor specific anti-HLA antibody was detected in 52 (39%) subjects; 19 of these had antibody to donor HLA-DQ only (14% of total cohort, 37% of those with DSA). DSA which bound C1q (DSA-C1q) developed in 44 subjects (85%). The onset of DSA-C1q to DQ only was observed later than DSA-C1q to class I HLA or to HLA-DR (mean 59.3 m vs 29.4 m, p=0.009). In addition, DSA to DQ only was less likely to develop into DSA-C1q compared to DSA to class I HLA or HLA-DR (p=0.05). Subjects with DSA to DQ only had lower C4d and IFTA scores than those with DSA to Class I HLA or HLA-DR (p=0.001). However, 10 of the DSA-C1q to DQ only patients did have biopsies positive for C4d and 9 of the patients with DSA to DQ only developed moderate to severe IFTA. Conclusions: Although biopsies positive for C4d and IFTA are more likely to be associated with DSA to multiple HLA, DSA to DQ alone are associated with later development of both C4d and IFTA.