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• W2891859287 abstract "This editorial comments on Larsen et al’s (page 156) important population-based study showing that renal transplant recipients have a higher incidence of HPV-associated anogenital warts compared to the general population, and makes a case for more diligent screening and vaccination in transplant patients. This editorial comments on Larsen et al’s (page 156) important population-based study showing that renal transplant recipients have a higher incidence of HPV-associated anogenital warts compared to the general population, and makes a case for more diligent screening and vaccination in transplant patients. Human papillomavirus (HPV) infection is the most common sexually transmitted infection worldwide and the cause of anogenital warts. More than 80% of sexually active adults are infected at some point. Although most acquired HPV infection is transient because of a successful CD4+ T cell-dominated Th1 response, in some individuals HPV can persist, become latent, and cause disease. One important at-risk population is immunosuppressed patients. HIV-infected and transplant recipients have a disproportionate burden of anogenital warts for two reasons. First, attenuated cell-mediated immunity increases the probability that HPV infection becomes persistent. If latent pretransplant, HPV may also reactivate, resulting in disease. Second, increased survival in HIV-infected and transplant patient populations over the past decades has increased the likelihood that HPV disease such as anogenital warts will occur. Despite this biological plausibility and our clinical observations, definite evidence has been lacking. Few investigators have gone beyond single-center studies to conclusively show an increased risk in transplant patients compared to the general population — until now. In this issue of American Journal of Transplantation, Larsen et al present a well-executed historical prospective cohort study of 166 178 participants.1Larsen H, Thomsen L, Haederstal M, Dehlendorff C, Soerensen S, Kjaer S. Risk of genital warts in renal transplant recipients - a registry-based, prospective cohort study [published online ahead of print 2018]. Am J Transplant. https://doi.org/10.1111/ajt.15056.Google Scholar This population-based study draws on data from the comprehensive and well-characterized Danish Nephrology and national Danish registries. The investigators demonstrate that renal transplant recipients have a higher adjusted hazard of incident anogenital warts compared to an age- and sex-matched population of nontransplant recipients in the general Danish population (HR 3.3, 95% CI, 2.8-3.9). Given the observation that the risk may be heightened in patients with functioning kidneys, compared to those who had graft failure and were receiving dialysis posttransplant, it emphasizes how important immunosuppression is in increasing incident genital wart risk. Transplant patients may bring anogenital warts to the attention of health care providers because they can be large, numerous, treatment refractory, psychologically upsetting, and result in lower quality of life. However, the oncogenic consequences of persistent infection with high-risk HPV types are often overlooked in busy transplant clinics. Although anogenital warts are of low malignant potential, HPV famously causes cervical and anal cancer and the corresponding precancerous lesions of cervical intraepithelial neoplasia (CIN) and anal intraepithelial neoplasia (AIN). HPV can also cause a proportion of vulvar, vaginal, penile, and head and neck cancers. Transplant patients are at substantial risk of HPV-associated malignancies compared to the general population. In one cohort study that linked data from the US Scientific Registry of Transplant Recipients with 13 state and regional cancer registries,2Engels EA Pfeiffer RM Fraumeni Jr, JF et al.Spectrum of cancer risk among US solid organ transplant recipients.JAMA. 2011; 306: 1891-1901Crossref PubMed Scopus (972) Google Scholar investigators found higher standardized incidence ratios (SIR) in HPV cancers compared to the general population for the oropharynx, anus, vulva, and penis (SIRs 6.9, 9.6, 6.5, 2.2). In a cohort of 1695 kidney transplant patients in a single center in South Korea,3Hwang JK Moon IS Kim JI Malignancies after kidney transplantation: a 40-year single-center experience in Korea.Transpl Int. 2011; 24: 716-721Crossref PubMed Scopus (0) Google Scholar the incidence of cervical cancer was substantially higher than in the general population (SIR 10.2). Given the striking data of elevated risk of HPV-associated disease in transplant patients, we need to be laser focused on prevention as a community. But easier said than done. In a study looking at uptake of cervical cancer screening in kidney transplant recipients in one area in the United Kingdom over 10 years, only 10% of eligible women were screened with the appropriate number of tests, and 32% never had a cervical Pap test.4Courtney AE Leonard N O’Neill CJ McNamee PT Maxwell AP The uptake of cervical cancer screening by renal transplant recipients.Nephrol Dial Transplant. 2009; 24: 647-652Crossref Scopus (40) Google Scholar Very few transplant centers have instituted anal cancer screening as it requires appropriate infrastructure and training although the first step is straightforward: anal Pap testing can be easily performed and even self-collected by patients. In addition, cervical colposcopists and others can be efficiently trained to perform high-resolution anoscopy, and pathologists used to reading cervical cytology can also interpret abnormal anal cytology.5Chin-Hong PV Human papillomavirus in kidney transplant recipients.Semin Nephrol. 2016; 36: 397-404Abstract Full Text Full Text PDF Google Scholar Another powerful addition to the HPV prevention toolkit is HPV prophylactic vaccination. The current 9-valent vaccine (Gardasil 9, Merck, Whitehouse Station, NJ) includes HPV-types that account for 90% of anal and cervical cancer and 90% of genital warts. In addition, a substantial proportion of head and neck, vulvar, vaginal, and penile cancers is averted. There are some safety and efficacy data in the transplant population, but eligible patients should ideally receive vaccine pretransplant. Yet so many questions remain. We need more research in transplant populations to address key gaps in knowledge: natural history studies to describe the precise epidemiology of HPV disease, which will inform the periodicity of screening; treatment studies to determine how transplant recipients respond to treatment of disease in the context of immunosuppression; and more prophylactic and therapeutic vaccine studies. Sure, we need the political will to fund research, but ultimately the motivation for action must come from within. Are we willing to rise to the challenge of routinely thinking of HPV — warts, and all — in our transplant patients? The author of this manuscript has no conflicts of interest to disclose as described by the American Journal of Transplantation." @default.
• W2891859287 created "2018-09-27" @default.
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• W2891859287 date "2019-01-01" @default.
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• W2891859287 title "Time to take on HPV in transplant clinic — Warts and all" @default.
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