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Table 3 Impact of the disease: mortality and morbidity

From: Varicella infections in patients with end stage renal disease: a systematic review

Reference Patient’s presentation Results Elaborations on results Main conclusions Study quality
Complication Length of stay (LOS) Mortality
Ong CY, et al. (2018) [15] -66 patients developed varicella in the 12-year review of all ESRD patients.
-Age range: 19–89 years old (median:53)
-37 male patients.
-Timing of infection: 6 to 19 years post diagnosis of ESRD.
+ + + -24 patients developed at least one complication.
Encephalitis, meningitis, pneumonia/pneumonitis.
-LOS: median 10 days
-9 died (13.6%)
-ESRD patients had significant morbidity and mortality associated with varicella infection.
-Screen for seronegative patients and consider vaccinate them.
Level 3
Errasti P, et al. (1999) [19] -31 y.o. Woman, 5 years post-transplant, admitted for acute epigastric pain with 3 days vesicular rash. + NA + -Multiorgan failure:
-Fulminant hepatitis (post-mortem showed massive hepatic necrosis).
-Died in 2 days.
-Chickenpox often follows severe and often fatal course in adults with renal transplantation.
-Vaccine appears to prevent clinical varicella following subsequent exposure.
Level 3
-29 y.o. Man, 17 years post-transplant, admitted for confluent-haemorrhagic rash. + NA + -Encephalitis (post-mortem showed cerebral oedema).
-Disseminated intravascular coagulation (DIC) with multiple bleeding sites.
-Multiorgan failure.
-Secondary Staphylococcus bacteraemia.
-Patient died.
−59 y.o. Man, 2 years post-transplant, had few vesicular rash. Exposed to his son who had varicella 4 weeks ago. NA -No complication
-69 y.o. Woman, 8 months post-transplant, admitted for vesicular rash and fever. NA -No complication
Ishikawa N, et al. (2000) [20] -29 y.o. Man, 11 months post-renal transplantation. With papular and vesicular rash and abdominal pain. + NA -DIC and gastrointestinal bleeding. -Varicella vaccination should be administered before transplantation if patients had no past varicella infection based on history and antibody titre Level 3
-36 y.o. Woman with a vesicular rash on face. Had renal transplant 3 years ago. + NA -DIC
Fehr T, et al. (2002) [5] -51 y.o. man, 11 years post-transplantation, had abdominal pain, nausea, vomiting, and generalised pustulosis. + NA -Pneumonitis and hypoxic respiratory failure.
-Failure of graft 6 months later.
-Overall mortality of 34%. Mortality after 1990 with acyclovir and reduction of immunosuppressants were 22%.
−82% of patients summarised had substantial mortality.
-Vaccination is effective and has no severe side effects.
-Routine VZV serology test for every ESRD patients before renal transplant.
-Vaccination in those with negative or very low VZV antibody titres.
Level 3
-34 y.o. Man, 1.5 years post-transplant, had acute epigastric pain, nausea, vomiting, and vesicular rash. + NA -DIC, hepatitis.
-51 y.o. Man, 6 months post-transplant, admitted for progressive dyspnoea. + + -Pneumonitis with respiratory failure.
-LOS: 26 days.
-23 y.o. Man, 6 months post-transplant, presented with vesicles whole body. + + -Hepatitis
-LOS: 10 days
Lauzurica R, et al. (2003) [21] -30 y.o. Man presented with vesicular-pustular rash, fever and abdominal pain, 3.5 years post-transplant. + NA + -Pneumonitis with respiratory failure
-Mild transaminitis.
-Died 4 days upon admission due to multiorgan failure: (hepatitis, myocarditis, DIC)
-Detecting VZV seronegative patients before the renal transplant is relevant because vaccination may minimise the risks of future infection. Level 3
Sinha S, et al. (2003) [46] -22 y.o. Woman, 42 months post-transplant, presented with abdominal pain 1 week after the development of chickenpox. + NA -Pancreatitis. -Acute pancreatitis as a consequent of viral infection is well known Level 3
-36 y.o. Man, 10 days post-transplant, developed pancreatitis 2 weeks after pancreatitis. + NA -Mild acute pancreatitis
Robertson S, et al. (2005) [22] -30 y.o. Man with a generalised maculopapular rash + NA + -Fulminant varicella with multiorgan involvement (acute renal failure, acute liver failure)
- Died within 60 h of admission
-Although regarded mild infection in children, chickenpox can cause fatality in adults and in the immunocompromised.
-Screen potential renal transplant recipients for VZV susceptibility and offer vaccination to the seronegative patients.
-Test for immunity for varicella as soon as progressive renal failure is diagnosed.
Level 3
Rodríguez-Moreno A, et al. (2006) [13] -Eight patients (1%) developed varicella (7 men, 1 women).
-Age range: 32–64.
-Median time from transplantation to infection was 32mths.
+ + + Complications:
- 2 pneumonitis, 1 hepatitis, 1 thrombotic microangiopathy, 1 multiorgan failure
- LOS: 11 days (median 3 to 21).
- One (12.5%) death due to multiorgan failure
-Varicella infection in adult allograft recipients is unusual but highly morbid
-Vaccination of seronegative pre-transplant candidates should be attempted
Level 3
Shahbazian H, et al. (2007) [47] -37 y.o. Man, a year post-transplant, admitted for severe abdominal pain. + + -Acute kidney injury
-LOS: 10 days
-All renal transplant recipients should be screened for VZV immunity before transplant irrespective of previous VZV infection.
- Seronegative patients should receive live VZV vaccine several months prior to transplant.
Level 3
-44 y.o. Man, 9 years post-transplantation, admitted for low back pain of 2 days duration. 2 days later he developed fever and papulovesicular rash 2 days later + -LOS: 15 days
-34yo man, 8 years post-transplantation, admitted for acute abdominal pain with intractable nausea vomiting. Papulovesicular rash appeared on the face and trunk 48 h later before became generalised. + -LOS: 13 days
Crowther N, et al. (2008) [31] -43 y.o. Man, 16 years post-renal transplant. Acute renal failure detected at routine clinic review. He had scattered skin lesion after his children had chickenpox 2 weeks ago. + NA -Diagnosis: late acute mediated rejection post-transplant precipitated by recurrent varicella infection. Level 3
Kandasamy R et al. (2009) [48] -58 y.o. Man with fever and progressive rash + NA -Darrier disease related to disseminated varicella Level 3
Sato A, et al. (2009) [27] -36 y.o. Woman presented with an irritable cough + + -Varicella pneumonia
-LOS: 1 month and 10 days
-One should keep the possibility of VZV reinfection in mind, in Immunocompromised patients with past history of varicella. Level 3
Assi M, et al. (2011) [29] -68 y.o. man with kidney transplant 10 years ago, presented with 5-days fever, confusion and altered sensorium + NA Varicella encephalitis, followed by Guillain-Barre syndrome (GBS). Level 3
Mustapic Z, et al. (2011) [49] -Two renal allograft patients developed varicella. Details unavailable. NA NA NA -Not available -VZV infection is a rare but potentially serious complication in renal transplant recipients.
-Active immunisation for VZV-seronegative patients before transplantation should be performed.
Level 3
Chiang E, et al. (2012) [50] -42 y.o. Woman, unknown years post kidney transplant, had right eye redness, tearing, and blurred vision for 1 month. + NA -Acute retinal necrosis Level 3
Kaul A, et al. (2012) [9] -23 patients developed varicella in the 10-year review of post renal transplant.
-Age range: 21–54 years old (median:39)
-17 male patients.
-Timing of infection: < 15 days post-transplant to > 5 years post-transplant.
+ NA + -5 had graft dysfunction.
- 7 had infections (6 bacterial, 1 fungal).
- 3 had sepsis
- 5 had gastritis
- 2 had encephalitis
- 2 had pancreatitis
- 2 had orchitis
- 2 died (8.6%)
-Primary varicella/chickenpox is a potentially fatal infection in adult renal transplant recipients.
-Varicella vaccination in the high-risk groups, especially during the pre-ESRD stage, may reduce the number of varicella infection.
Level 3
Inokuchi R, et al. (2013) [23] -A 69 y.o. Woman (20 years ESRD on dialysis, then 1 month post renal transplantation) presented with generalised rash one day. + NA + -Varicella pneumonia with respiratory failure.
-Demised at Day 28 illness (despite change of antiviral to foscarnet on day10, mechanical ventilation on day3)
-Patients with VZV pneumonia with deep and vast ulcerations on bronchoscopy had fatal outcomes. Level 3
Low LL, et al. (2014) [30] -58 y.o. Man on haemodialysis, presented with fever and cough. Subsequently developed a papulovesicular rash on the 4th day of admission. + NA -Varicella pneumonia
-Varicella encephalitis
-Renal Physicians and Family Physicians in the Asia-Pacific region should study the epidemiological data in each country.
-Consensus guidelines needed and how the varicella vaccination program can be targeted for those at risk.
-Live attenuated varicella vaccine is has been proven to be safe when administered to adult ESRD patients regardless of RRT mode.
Level 3
Nabi S, et al. (2014) [26] -73 y.o. Woman with kidney transplantation and recent CMV infection, presented with altered mental status. + NA -Varicella encephalitis -Disseminated VZV with encephalitis is rare, but a life-threatening condition Level 3
Sampathkumar K, et al. (2015) [24] -34 y.o. Man had kidney transplant 10 months ago, came with fever ×  2 weeks and bitemporal headache. + NA -VZV induced central nervous system angiopathy Level 3
Depledge D, et al. (2016) [25] -55y.o. Man post renal transplant day23 presented with abdominal pain, macular rash and abnormal liver function test. + NA -VZV pneumonitis, hepatitis -Risk of airborne transmission of VZV is evident, especially when viral load is high.
- Immunocompromised patients are vulnerable to serious infection.
- Need for pre-transplant vaccination.
Level 3
-61y.o. Man post renal transplant day25 presented with 4 days fever, vesicular rash and abnormal liver function. + NA + -VZV hepatitis.
- Died on day 6 admission (3 days in ICU)
Chhabra P, et al. (2017) [51] -33y.o. Man, 3 years post-transplant, had severe epigastric pain for 7 days. + NA -Varicella pancreatitis and hepatitis Level 3
Momani H, et al. (2017) [52] -One patient developed varicella
-Details unavailable
+ NA -Varicella pneumonitis Level 3
  1. NA Not available