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Silva F, Martins A, Ferraz P, Lopes D, Bastos J, Joana Araújo JA, Trigo F, Pinto R, Silva-Pinto A. [Management of Cytomegalovirus Infection in Allogeneic Hematopoietic Stem Cell Transplant Recipients]. ACTA MEDICA PORT 2024. [PMID: 39008637 DOI: 10.20344/amp.21441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/04/2024] [Indexed: 07/17/2024]
Abstract
Cytomegalovirus (CMV) is a type of double-stranded deoxyribonucleic acid virus belonging to the herpesviridae family. Following a primary infection, the virus becomes latent in various types of white blood cells. Cytomegalovirus infection can remain latent or become active, especially in immunocompromised individuals, such as those undergoing hematopoietic stem cell transplantation (HSCT), where CMV reactivation can occur. In this context, CMV infection is common and associated with high rates of morbidity and mortality. Pneumonia is one of the most serious complications, with mortality rates exceeding 50%. Additionally, even in the absence of organ-specific disease, CMV infection is related to increased mortality unrelated to hematologic neoplasm recurrence. Given the frequency and severity of this infection in HSCT patients, it is crucial to implement effective strategies for monitoring, prevention, and treatment. This guideline was developed to identify patient groups that benefit from a systematic approach to CMV infection and to define the most appropriate strategy for each group. Monitoring CMV viral load in peripheral blood is crucial, especially in patients at moderate to high risk of active infection. Primary prophylaxis with letermovir (an antiviral drug) is recommended to reduce the incidence of active infection, especially in high-risk patients. Secondary prophylaxis with valganciclovir (antiviral drug) is recommended after an episode of active infection, while preemptive and disease treatment is based on monitoring viral load and clinical response. The aim of this guideline is to improve the approach to CMV infection in HSCT patients, ensuring an effective and safe preventive and therapeutic approach.
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Affiliation(s)
- Fernando Silva
- Serviço de Doenças Infeciosas. Unidade Local de Saúde São João. Porto. Portugal
| | - António Martins
- Serviço de Doenças Infeciosas. Unidade Local de Saúde São João. Porto. Portugal
| | - Paula Ferraz
- Serviço de Farmacologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | - Diogo Lopes
- Serviço de Farmacologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | - Juliana Bastos
- Serviço de Hematologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | | | - Fernanda Trigo
- Serviço de Hematologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | - Ricardo Pinto
- Serviço de Hematologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | - André Silva-Pinto
- Serviço de Doenças Infeciosas. Unidade Local de Saúde São João. Porto; Departamento de Medicina. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
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Cui J, Zhou Y, Zhao K, Li X, Zhang H, Zhang X, Sun Y, Long B. Application of CMV-IVIg as prophylaxis against cytomegalovirus reactivation in allogeneic hematopoietic stem cell transplantation patients. Clin Transplant 2024; 38:e15300. [PMID: 38555576 DOI: 10.1111/ctr.15300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/21/2024] [Accepted: 03/14/2024] [Indexed: 04/02/2024]
Abstract
Cytomegalovirus (CMV) reactivation remains one of the major and life-threatening complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Yet, there is still a lack of safe and effective ways to prevent CMV reactivation in allo-HSCT patients. Here, we retrospectively analyzed a cohort of patients who underwent HSCT at our transplant center between 2018 and 2022 to evaluate the efficacy of prophylactic CMV-specific intravenous immunoglobulin (CMV-IVIg) against CMV reactivation. After Propensity Score Matching, the CMV reactivation rate was significantly decreased in the CMV-IVIg group (HR, 2.952; 95% CI,1.492-5.841; P = .002) compared with the control group. Additionally, the time duration of CMV reactivation (P = .001) and bacterial infection rate (P = .013) were significantly lower in the CMV-IVIg group. Moreover, prophylactic CMV-IVIg was more effective in CMV seropositive patients who received ATG as part of GVHD prevention (HR, 8.225; 95% CI,1.809-37.39; P = .006). In conclusion, CMV-IVIg is considered an effective and safe way to prevent CMV reactivation in HSCT recipients, which may be related to the acceleration of immune reconstitution in the early stage after transplantation.
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Affiliation(s)
- Jiaqi Cui
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuhang Zhou
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Gastroenterology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Kui Zhao
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xudong Li
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hanyue Zhang
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiangzhong Zhang
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanling Sun
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bing Long
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Kang KW, Jeon MJ, Yu ES, Kim DS, Lee BH, Lee SR, Choi CW, Park Y, Kim BS, Sung HJ. Cytomegalovirus reactivation under pre-emptive therapy following allogeneic hematopoietic stem cell transplant: Pattern, survival, and risk factors in the Republic of Korea. PLoS One 2023; 18:e0291268. [PMID: 37703263 PMCID: PMC10499250 DOI: 10.1371/journal.pone.0291268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Pre-emptive therapy for cytomegalovirus (CMV) reactivation has been used in allogeneic hematopoietic stem cell transplantation (allo-HSCT). It is unclear if this strategy has poorer clinical outcomes in CMV-endemic areas and if more aggressive prophylaxis is required. METHODS We retrospectively analyzed the patterns and survival after CMV reactivation in patients undergoing pre-emptive therapy following allo-HSCT and assessed high-risk patients who could benefit from aggressive CMV prophylaxis in endemic areas. RESULTS Of the 292 patients who underwent allo-HSCT, 70.5% (donor+ or recipient+) were CMV seropositive. CMV reactivation occurred in 139 patients (47.6%), with a median of 31.5 days from day 0 of allo-HSCT. The overall survival of patients with CMV reactivation who received pre-emptive therapy did not differ from those without reactivation. Of the 139 patients with CMV reactivation, 78 (56.1%) underwent ≥2 rounds of pre-emptive therapy. In multivariate analysis, the risk of CMV reactivation was higher in patients with multiple myeloma, with CMV seropositivity of the recipient and donor, administered with a higher dose of anti-thymocyte globulin (ATG), and with acute graft-versus-host disease (aGVHD) ≥ grade 2. CONCLUSION Although half of the patients with allo-HSCT were administered with pre-emptive therapy for CMV, CMV reactivation did not affect their survival, indicating the advantages of pre-emptive therapy, even in CMV-endemic areas. The cost-effectiveness of more aggressive CMV prophylaxis should be re-evaluated in patients at a high risk for CMV reactivation.
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Affiliation(s)
- Ka-Won Kang
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Ji Jeon
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Eun Sang Yu
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Dae Sik Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung-Hyun Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Se Ryeon Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Chul Won Choi
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yong Park
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Soo Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hwa Jung Sung
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
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Varkey J, Jonsson V, Hessman E, De Lange T, Hedenström P, Oltean M. Diagnostic yield for video capsule endoscopy in gastrointestinal graft- versus -host disease: a systematic review and metaanalysis. Scand J Gastroenterol 2023; 58:945-952. [PMID: 36740843 DOI: 10.1080/00365521.2023.2175621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND The gastrointestinal tract is the second most involved organ for graft-versus-host disease where involvement of the small intestine is present in 50% of the cases. Therefore, the use of a non-invasive investigation i.e., video capsule endoscopy (VCE) seems ideal in the diagnostic work-up, but this has never been systematically evaluated before. OBJECTIVE The aim of this systematic review was to determine the efficacy and safety of VCE, in comparison with conventional endoscopy in patients who received hematopoietic stem cell transplantation. METHOD Databases searched were PubMed, Scopus, EMBASE, and Cochrane CENTRAL. All databases were searched from their inception date until June 17, 2022. The search identified 792 publications, of which 8 studies were included in our analysis comprising of 232 unique patients. Efficacy was calculated in comparison with the golden standard i.e., histology. Risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. RESULTS The pooled sensitivity was higher for VCE at 0.77 (95% CI: 0.60-0.89) compared to conventional endoscopy 0.62 (95% CI: 0.47-0.75) but the difference was not statistically significant (p = 0.155, Q = 2.02). Similarly, the pooled specificity was higher for VCE at 0.68 (95% CI: 0.46-0.84) than for conventional endoscopy at 0.58 (95% CI: 0.40-0.74) but not statistically significant (p = 0.457, Q = 0.55). Moreover, concern for adverse events such as intestinal obstruction or perforation was not justified since none of the capsules were retained in the small bowel and no perforations occurred in relation to VCE. A limitation to the study is the retrospective approach seen in 50% of the studies. CONCLUSION The role of video capsule endoscopy in diagnosing or dismissing graft-versus-host disease is not yet established and requires further studies. However, the modality appears safe in this cohort.
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Affiliation(s)
- Jonas Varkey
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Sahlgrenska Intestinal Failure and Transplant Centre, Gothenburg, Sweden
- Division of Gastroenterology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Viktor Jonsson
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Hessman
- Biomedical Library, Gothenburg University Library, University of Gothenburg, Gothenburg, Sweden
| | - Thomas De Lange
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Medical Department, Sahlgrenska University Hospital-Möndal, Gothenburg, Sweden
| | - Per Hedenström
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Division of Gastroenterology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mihai Oltean
- Department of Surgery, Institute for Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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Effectiveness of Prophylactic Human Cytomegalovirus Hyperimmunoglobulin in Preventing Cytomegalovirus Infection following Transplantation: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12030361. [PMID: 35330112 PMCID: PMC8955988 DOI: 10.3390/life12030361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022] Open
Abstract
Cytomegalovirus (CMV) is a common infection occurring in patients undergoing solid organ transplantation (SOT) or hematopoietic stem cell transplantation (HSCT). CMV-specific hyperimmunoglobulin (CMVIG) has been used for the past four decades and is typically administered either prophylactically or pre-emptively. The present meta-analysis evaluated CMV infection rates in SOT patients who received prophylactic CMVIG. PubMed and the Cochrane Library were searched for studies published up to October 2021. The primary endpoint was CMV infection rate. Thirty-two SOT studies were identified (n = 1521 CMVIG-treated and n = 1196 controls). Prophylactic CMVIG treatment was often associated with a lower risk of CMV infection in transplant recipients. The average CMV infection rate was 35.8% (95% confidence interval [CI]: 33.4−38.2%) in patients treated prophylactically with CMVIG and 41.4% (95% CI: 38.6−44.2%) in the control group not receiving CMVIG (p = 0.003). Similar results were observed in analyses limited to publications evaluating currently available CMVIG products (Cytotect CP and Cytogam; p < 0.001). In combination with the established safety profile for CMVIG, these results suggest that prophylactic CMVIG treatment in patients undergoing solid organ transplantation may be beneficial, particularly in those at high risk of CMV infection or disease.
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