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van Vugt LK, Hesselink DA, de Winter BCM. Challenges for the improvement of valganciclovir prophylaxis in solid organ transplantation and the possible role of therapeutic drug monitoring in adults. Br J Clin Pharmacol 2024. [PMID: 38889884 DOI: 10.1111/bcp.16138] [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: 03/08/2024] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 06/20/2024] Open
Abstract
Cytomegalovirus (CMV) infection frequently occurs after solid organ transplantation and is associated with an increased morbidity and mortality. Fortunately, the development of valganciclovir prophylaxis has lowered the incidence of CMV infection and its complications in immunosuppressed solid organ transplant recipients. However, breakthrough infections during valganciclovir prophylaxis and late CMV infection after cessation of valganciclovir prophylaxis still occur with the current prophylactic strategy. Additionally, valganciclovir resistance has emerged among CMV strains, which complicates the treatment of CMV infections. Furthermore, the use of valganciclovir is associated with myelotoxicity, which can lead to the premature withdrawal of prophylaxis. It is important to address these current issues in order to improve the standard care after solid organ transplantation. This paper will therefore discuss the clinical practice of valganciclovir prophylaxis, elaborate on its issues and suggest how to improve the current prophylactic strategy with a possible role for therapeutic drug monitoring.
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Affiliation(s)
- Lukas K van Vugt
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
| | - Brenda C M de Winter
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
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Rocha FA, Silveira CRF, Dos Santos AF, Stefanini ACB, Hamerschlak N, Marti LC. Development of a highly cytotoxic, clinical-grade virus-specific T cell product for adoptive T cell therapy. Cell Immunol 2024; 395-396:104795. [PMID: 38101075 DOI: 10.1016/j.cellimm.2023.104795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/17/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023]
Abstract
At present, recipients of allogeneic hematopoietic stem-cells are still suffering from recurrent infections after transplantation. Infusion of virus-specific T cells (VST) post-transplant reportedly fights several viruses without increasing the risk of de novo graft-versus-host disease. This study targeted cytomegalovirus (CMV) for the development of an innovative approach for generating a very specific VST product following Good Manufacturing Practices (GMP) guidelines. We used a sterile disposable compartment named the Leukoreduction System Chamber (LRS-chamber) from the apheresis platelet donation kit as the starting material, which has demonstrated high levels of T cells. Using a combination of IL-2 and IL-7 we could improve expansion of CMV-specific T cells. Moreover, by developing and establishing a new product protocol, we were able to stimulate VST proliferation and favors T cell effector memory profile. The expanded VST were enriched in a closed automated system, creating a highly pure anti-CMV product, which was pre-clinically tested for specificity in vitro and for persistence, biodistribution, and toxicity in vivo using NOD scid mice. Our results demonstrated very specific VST, able to secrete high amounts of interferon only in the presence of cells infected by the human CMV strain (AD169), and innocuous to cells partially HLA compatible without viral infection.
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Affiliation(s)
- Fernanda Agostini Rocha
- Hospital Israelita Albert Einstein, Department of Experimental Research, Rua Comendador Elias Jafet, 755 Zip code: 05653 000, São Paulo, SP, Brazil
| | - Caio Raony Farina Silveira
- Hospital Israelita Albert Einstein, Department of Experimental Research, Rua Comendador Elias Jafet, 755 Zip code: 05653 000, São Paulo, SP, Brazil
| | - Ancély Ferreira Dos Santos
- Hospital Israelita Albert Einstein, Department of Experimental Research, Rua Comendador Elias Jafet, 755 Zip code: 05653 000, São Paulo, SP, Brazil
| | - Ana Carolina Buzzo Stefanini
- Hospital Israelita Albert Einstein, Department of Experimental Research, Rua Comendador Elias Jafet, 755 Zip code: 05653 000, São Paulo, SP, Brazil
| | - Nelson Hamerschlak
- Hospital Israelita Albert Einstein, Department of Bone Marrow Transplant, Avenida Albert Einstein, 627 Zip code: 05652 000, São Paulo, SP, Brazil
| | - Luciana Cavalheiro Marti
- Hospital Israelita Albert Einstein, Department of Experimental Research, Rua Comendador Elias Jafet, 755 Zip code: 05653 000, São Paulo, SP, Brazil.
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3
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Demirhan S, Munoz FM, Valencia Deray KG, Bocchini CE, Danziger-Isakov L, Blum S, Sharma TS, Sherman G, Boguniewicz J, Bacon S, Ardura MI, Maron GM, Ferrolino J, Foca M, Herold BC. Body surface area compared to body weight dosing of valganciclovir is associated with increased toxicity in pediatric solid organ transplantation recipients. Am J Transplant 2023; 23:1961-1971. [PMID: 37499799 DOI: 10.1016/j.ajt.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
Optimal dosing of valganciclovir (VGCV) for cytomegalovirus (CMV) prevention in pediatric solid organ transplantation recipients (SOTR) is controversial. Dosing calculated based on body surface area (BSA) and creatinine clearance is recommended but simplified body weight (BW) dosing is often prescribed. We conducted a retrospective 6-center study to compare safety and efficacy of these strategies in the first-year posttransplant There were 100 (24.2%) pediatric SOTR treated with BSA and 312 (75.7%) with BW dosing. CMV DNAemia was documented in 31.0% vs 23.4% (P = .1) at any time during the first year and breakthrough DNAemia in 16% vs 12.2% (P = .3) of pediatric SOTR receiving BSA vs BW dosing, respectively. However, neutropenia (50% vs 29.3%, P <.001), lymphopenia (51% vs 15.0%, P <.001), and acute kidney injury causing treatment modification (8.0% vs 1.8%, P <.001) were documented more frequently during prophylaxis in pediatric SOTR receiving BSA vs BW dosing. The adjusted odds ratio of VGCV-attributed toxicities comparing BSA and BW dosing was 2.3 (95% confidence interval [CI], 1.4-3.7] for neutropenia, 7.0 (95% CI, 3.9-12.4) for lymphopenia, and 4.6 (95% CI, 2.2-9.3) for premature discontinuation or dose reduction of VGCV, respectively. Results demonstrate that BW dosing is associated with significantly less toxicity without any increase in CMV DNAemia.
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Affiliation(s)
- Salih Demirhan
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Flor M Munoz
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kristen G Valencia Deray
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Claire E Bocchini
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Samantha Blum
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tanvi S Sharma
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gilad Sherman
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juri Boguniewicz
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samantha Bacon
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Monica I Ardura
- Department of Pediatrics, Division of Infectious Diseases & Host Defense, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Marc Foca
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Betsy C Herold
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA.
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Descourouez JL, Smith JA, Saddler CM, Mandelbrot DA, Odorico JS, Jorgenson MR. Real-World Experience With CMV inSIGHT T Cell Immunity Testing in High-Risk Kidney and Pancreas Transplant Recipients. Ann Pharmacother 2023:10600280231207899. [PMID: 37897238 DOI: 10.1177/10600280231207899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV)-specific cell-mediated immunity is important for control of CMV after transplant. Assays exist to measure this, but their place in therapy is unclear, particularly in CMV high-risk recipients, without pretransplant exposure. OBJECTIVE The objective of this study was to evaluate predictive potential of a positive assay to determine freedom from DNAemia and describe subsequent 3-month CMV outcomes. METHODS Adult CMV high-risk kidney and/or pancreas transplant recipients were included if a CMV inSIGHT T Cell Immunity Panel (TCIP, Eurofins Viracor) was ordered and resulted between 1 August, 2019 and 30 July, 2022. RESULTS Seventy-six patients were included in our study; 49 tested during prophylaxis and 27 during treatment. Most TCIP assays obtained in the prophylaxis cohort were negative (n = 46, 93.9%). Rate of post-TCIP CMV infection was 10.2%. In those tested during treatment, 33.3% were positive and rate of post-TCIP CMV recurrence was 22.2%. The positive predictive value of the assay to successfully predict immunity was 66.7% during both prophylaxis and treatment. There were 4 cases of TCIP predictive failure with progressive CMV replication. At time of replication, 2 patients had concomitant clinical confounders thought to influence immune control of viral replication. All patients had intensification of immunosuppression prior to recurrent replication, but after TCIP was collected. CONCLUSION AND RELEVANCE The data obtained from the TCIP are not static, immune control of CMV in latency can change and must be evaluated in clinical context. Timing of TCIP after transplant is significant, and patient-specific factors remain important to assess the likelihood of CMV in each unique patient-specific scenario. A CMV stewardship program can aid in application and interpretation of results.
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Affiliation(s)
- Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jeannina A Smith
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christopher M Saddler
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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Chen GL, Shpall EJ. Another tool against cytomegalovirus after allogeneic hematopoietic cell transplantation. J Clin Invest 2023; 133:e170282. [PMID: 37183817 PMCID: PMC10178833 DOI: 10.1172/jci170282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Cytomegalovirus (CMV) viremia from reactivation of latent infection is a common complication after allogeneic hematopoietic cell transplantation (HCT). Untreated, CMV viremia can progress to affect other organs, resulting in organ dysfunction with high morbidity and mortality. In this issue of the JCI, Prockop and authors demonstrate that third-party donor T cells sensitized ex vivo to CMV pp65-derived overlapping pentadecapeptides are safe and effective for the treatment of CMV reactivation or CMV disease refractory to first-line pharmacotherapies occurring after HCT. They also provide insight into the biological differences between responders and nonresponders. This work confirms the utility of third-party CMV pp65 VSTs and suggests strategies for further improving the efficacy of this cell-therapy approach.
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CMV antiviral stewardship: navigating obstacles to facilitate target attainment. Curr Opin Organ Transplant 2023; 28:8-14. [PMID: 36579682 DOI: 10.1097/mot.0000000000001032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Despite the availability of potent antivirals, consensus guidelines and decades of research, cytomegalovirus (CMV) continues to be associated with negative outcomes after solid organ transplant. This has been attributed to postprophylaxis CMV infection and a lack of development of CMV-specific cell mediated immunity (CMI). A shift from a focus on antiviral prevention to a focus on CMI target attainment is needed to improve CMV outcomes after transplantation. RECENT FINDINGS There are many obstacles to CMI target attainment. Antiviral stewardship programs (AVS) have been employed to improve patient outcomes through appropriate antiviral use, reduction of unnecessary exposure and resistance mitigation. By focusing on the patient's unique substrate of conglomerate risk factors and addressing these factors specifically with evidenced based methodology, the AVS can address these obstacles, increasing rates of CMI and subsequently reducing risk of future CMV infection and negative outcomes. SUMMARY With its multidisciplinary composition utilizing decades of experience from antimicrobial stewardship principles and practices, the AVS is uniquely poised to facilitate the shift from a focus on prevention to CMI target attainment and be the supporting pillar for the frontline transplant clinician caring for transplant patients with CMV.
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Hellemans R, Bertels A, Wijtvliet V, Wouters K, Massart A, Bergs K, Matheeussen V, Abramowicz D. Is Polyomavirus-Associated Nephropathy More Common in Kidney Transplant Recipients Exposed to Valganciclovir? A Retrospective Single Center Analysis. Transplant Proc 2023; 55:123-128. [PMID: 36609024 DOI: 10.1016/j.transproceed.2022.10.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/18/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND BK polyomavirus-associated nephropathy (PVAN) is a frequent complication in the early phase after kidney transplantation. The most important risk factor for PVAN is the intensity of immunosuppression. A recent study suggests that exposure to valganciclovir (VGC) could also be a risk factor. METHODS We performed a retrospective, single-center study to investigate the effect of valganciclovir exposure on the risk for PVAN during the first 100 days post transplant. Cytomegalovirus (CMV) seronegative recipients of a CMV seropositive donor kidney received VGC prophylaxis, whereas CMV seropositive recipients were managed by a pre-emptive CMV strategy. Cox regression analysis was used to identify risk factors for PVAN development with VGC treatment and strength of immunosuppressive therapy as time-dependent variables. RESULTS A total of 211 adults who received a kidney transplant between 2014 and 2019 were included. Eighteen (9%) developed PVAN. Multivariate regression analysis showed that women have a lower risk of developing PVAN (hazard ratio [HR] 0.08 (confidence interval [CI] 0.01-0.58), P = .013), whereas age was associated with an increased risk for PVAN (HR 1.04 for every additional year [CI 1.00-1.08], P = .029). There was a trend toward a lower risk of PVAN for patients on reduced immunosuppressive therapy (HR 0.44 [CI 0.15-1.24], P = .12). VGC use was not associated with the risk for PVAN (HR 0.99 [CI 0.35-2.78], P = .98). CONCLUSIONS In our study, VGC exposure was not associated with the risk for PVAN. Our study is the first to reassess in depth the hypothesis that VGC treatment increases the risk of PVAN. The unique strength of this study is the correction for the degree of immunosuppression and the statistical use of time-dependent covariates. This methodological approach can provide a foundation for further studies needed to confirm our findings.
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Affiliation(s)
- Rachel Hellemans
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Wilrijk, Belgium.
| | - Andrea Bertels
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium
| | - Veerle Wijtvliet
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Wilrijk, Belgium
| | - Kristien Wouters
- Clinical Trial Center, Antwerp University Hospital, Edegem, Belgium
| | - Annick Massart
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Wilrijk, Belgium
| | - Kristof Bergs
- Department of Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Veerle Matheeussen
- Department of Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Edegem, Belgium; Clinical Trial Center, Antwerp University Hospital, Edegem, Belgium
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Cowan MJ, Yu J, Facchino J, Fraser-Browne C, Sanford U, Kawahara M, Dara J, Long-Boyle J, Oh J, Chan W, Chag S, Broderick L, Chellapandian D, Decaluwe H, Golski C, Hu D, Kuo CY, Miller HK, Petrovic A, Currier R, Hilton JF, Punwani D, Dvorak CC, Malech HL, McIvor RS, Puck JM. Lentiviral Gene Therapy for Artemis-Deficient SCID. N Engl J Med 2022; 387:2344-2355. [PMID: 36546626 PMCID: PMC9884487 DOI: 10.1056/nejmoa2206575] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The DNA-repair enzyme Artemis is essential for rearrangement of T- and B-cell receptors. Mutations in DCLRE1C, which encodes Artemis, cause Artemis-deficient severe combined immunodeficiency (ART-SCID), which is poorly responsive to allogeneic hematopoietic-cell transplantation. METHODS We carried out a phase 1-2 clinical study of the transfusion of autologous CD34+ cells, transfected with a lentiviral vector containing DCLRE1C, in 10 infants with newly diagnosed ART-SCID. We followed them for a median of 31.2 months. RESULTS Marrow harvest, busulfan conditioning, and lentiviral-transduced CD34+ cell infusion produced the expected grade 3 or 4 adverse events. All the procedures met prespecified criteria for feasibility at 42 days after infusion. Gene-marked T cells were detected at 6 to 16 weeks after infusion in all the patients. Five of 6 patients who were followed for at least 24 months had T-cell immune reconstitution at a median of 12 months. The diversity of T-cell receptor β chains normalized by 6 to 12 months. Four patients who were followed for at least 24 months had sufficient B-cell numbers, IgM concentration, or IgM isohemagglutinin titers to permit discontinuation of IgG infusions. Three of these 4 patients had normal immunization responses, and the fourth has started immunizations. Vector insertion sites showed no evidence of clonal expansion. One patient who presented with cytomegalovirus infection received a second infusion of gene-corrected cells to achieve T-cell immunity sufficient for viral clearance. Autoimmune hemolytic anemia developed in 4 patients 4 to 11 months after infusion; this condition resolved after reconstitution of T-cell immunity. All 10 patients were healthy at the time of this report. CONCLUSIONS Infusion of lentiviral gene-corrected autologous CD34+ cells, preceded by pharmacologically targeted low-exposure busulfan, in infants with newly diagnosed ART-SCID resulted in genetically corrected and functional T and B cells. (Funded by the California Institute for Regenerative Medicine and the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT03538899.).
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Affiliation(s)
- Morton J Cowan
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Jason Yu
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Janelle Facchino
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Carol Fraser-Browne
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Ukina Sanford
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Misako Kawahara
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Jasmeen Dara
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Janel Long-Boyle
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Jess Oh
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Wendy Chan
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Shivali Chag
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Lori Broderick
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Deepak Chellapandian
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Hélène Decaluwe
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Catherine Golski
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Diana Hu
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Caroline Y Kuo
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Holly K Miller
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Aleksandra Petrovic
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Robert Currier
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Joan F Hilton
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Divya Punwani
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Christopher C Dvorak
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Harry L Malech
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - R Scott McIvor
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
| | - Jennifer M Puck
- From the Departments of Pediatrics (M.J.C., J.Y., J.F., C.F.-B., U.S., M.K., J.D., J.L.-B., W.C., S.C., R.C., C.C.D., J.M.P.) and Epidemiology and Biostatistics (J.F.H.), the Smith Cardiovascular Research Institute (M.J.C., J.M.P.), and the School of Pharmacy (J.L.-B.), University of California, San Francisco (UCSF), and UCSF Benioff Children's Hospital (M.J.C., J.F., J.D., J.L.-B., J.O., C.C.D., J.M.P.), San Francisco, the Department of Pediatrics, University of California, San Diego, and Rady Children's Hospital, San Diego (L.B.), and the Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles (C.Y.K.) - all in California; the Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.C.); the Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal (H.D.); Tuba City Regional Health Care, Tuba City (C.G., D.H.), and Phoenix Children's Hospital, Phoenix (H.K.M.) - both in Arizona; the Department of Pediatrics, University of Washington Seattle Children's Hospital, Seattle (A.P.); Clinical Development, Roche Diagnostics Solutions, Singapore (D.P.); the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD (H.L.M.); and the Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis (R.S.M.)
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9
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Baradaran H, Hashem Zadeh A, Dashti-Khavidaki S, Laki B. Management of drug-induced neutropenia, thrombocytopenia, and anaemia after solid organ transplantation: A comprehensive review. J Clin Pharm Ther 2022; 47:1895-1912. [PMID: 36250775 DOI: 10.1111/jcpt.13775] [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: 08/02/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 12/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Advances in the development of more effective immunosuppressive drugs have increased graft survival and drug induced adverse effects. Haematological complications including neutropenia, thrombocytopenia, and anaemia are common side effects that affect the grafts' and patients' outcomes. Several studies have stated the important role of various medications in haematological complications after transplantation. They have reported the incidence and different mechanisms of drug induced cytopenia, as well as an overview of possible treatment modalities. However, there is no comprehensive protocol for the management of these complications following transplantation. This narrative review was performed to develop a comprehensive practical approach for management of drug induced haematological complications following solid organ transplantation. METHOD PubMed, Embase, Cochrane library, Web of Science, and Google scholar databases were searched without time limitations until March, 2021. In addition, some valid drug information data bases (Uptodate and Micromedex) were searched for detailed information until October, 2021. RESULTS AND DISCUSSION Several immunosuppressive and antimicrobial medications may induce neutropenia, thrombocytopenia or anaemia following transplantation. Most of these agents cause dose-related cytopenia, which resolves with dose reduction or drug withdrawal. However, any change in medications may result in negative consequences such as severe infections, bleeding, cardiovascular complications, acute allograft rejection, and graft or patient loss. Thus, cautious evaluation of the patient's condition and the pharmacological properties of the culprit medication are required. WHAT IS NEW AND CONCLUSION Three algorithms are presented to guide healthcare providers in the stepwise management of drug-induced neutropenia, thrombocytopenia, and anaemia after solid organ transplantation.
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Affiliation(s)
- Hananeh Baradaran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Simin Dashti-Khavidaki
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahareh Laki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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10
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Humoral/Cellular Immune Discordance in Stem Cell Donors: Impact on Cytomegalovirus-Specific Immune Reconstitution after Related Hematopoietic Transplantation. Transplant Cell Ther 2022; 28:703.e1-703.e8. [DOI: 10.1016/j.jtct.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/27/2022] [Accepted: 07/01/2022] [Indexed: 11/22/2022]
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11
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Camacho-Bydume C, Mauguen A, Rodriguez-Sanchez MI, Klein E, Kernan NA, Prockop S, Boelens JJ, Papanicolaou GA, Cancio M. Time to initiation of pre-emptive therapy for cytomegalovirus impacts overall survival in pediatric hematopoietic stem cell transplant recipients. Cytotherapy 2022; 24:428-436. [PMID: 35042670 PMCID: PMC10019069 DOI: 10.1016/j.jcyt.2021.10.002] [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: 08/25/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AIMS Cytomegalovirus (CMV) reactivation is a significant complication following allogeneic hematopoietic stem cell transplant (HSCT) and affects upwards of 40% of pediatric HSCT patients. Pre-emptive therapy remains the only effective treatment strategy available for pediatric patients following CMV reactivation. Little is known about how the timing of induction treatment following CMV reactivation impacts outcomes in pediatric patients, especially following ex vivo T-cell-depleted (TCD) HSCT. METHODS The authors evaluated how the timing of induction treatment after CMV reactivation impacts overall survival (OS) and CMV disease in pediatric patients undergoing TCD HSCT at a single institution. The authors retrospectively analyzed patients treated on the pediatric service who received an initial ex vivo TCD HSCT at Memorial Sloan Kettering Cancer Center (MSKCC) from January 2010 to June 2018. CMV reactivation was defined as ≥1 CMV polymerase chain reaction >500 copies/mL in whole blood or >137 IU/mL in plasma within the first 180 days after allogeneic HSCT. To analyze the impact of the timing of induction treatment, the authors' primary study outcome was OS and secondary outcome was CMV disease. RESULTS A total of 169 patients who underwent an initial allogeneic TCD HSCT on the pediatric service at MSKCC from January 2010 to June 2018 were included in the analysis. Thirty-seven (22%) patients reactivated CMV during the first 180 days following HSCT. Of those patients who reactivated CMV, CMV donor/recipient (D/R) serostatus was as follows: D+/R+ n = 28 (76%) and D-/R+ n = 9 (24%). There was no CMV reactivation observed among recipients who were CMV-seronegative irrespective of donor serostatus. In those patients who reactivated CMV, the median time from HSCT to CMV reactivation was 24 days (interquartile range, 20-31). Eleven patients ultimately developed CMV disease in addition to CMV viremia, whereas the remaining patients had only CMV viremia. The cumulative incidence of CMV reactivation at 60 days was 45.2% (95% confidence interval [CI], 32.8-57.5) in the D+/R+ subgroup and 31% (95% CI, 14.2-47.9) in the D-/R+ subgroup. For those patients who reactivated CMV, 30 (81%) received induction treatment with ganciclovir or foscarnet. To analyze the impact of the timing of induction treatment on clinical outcomes, the authors restricted the analysis to those patients who reactivated CMV and received induction treatment (n = 30). The timing of induction treatment was significantly associated with OS, with optimal timing of initiation within a week of CMV reactivation (P = 0.02). There was no significant impact on the timing of induction treatment and risk of CMV disease (P = 0.30). CONCLUSIONS In ex vivo TCD HSCT in pediatric patients, early initiation of induction treatment after CMV reactivation is associated with improved OS.
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Affiliation(s)
- Christine Camacho-Bydume
- General Oncology Service, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - M Irene Rodriguez-Sanchez
- Pediatric Translational Medicine Program, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth Klein
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nancy A Kernan
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Susan Prockop
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Maria Cancio
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
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12
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Jorgenson MR, Kleiboeker H, Garg N, Parajuli S, Mandelbrot DA, Odorico JS, Saddler CM, Smith JA. Letermovir conversion after valganciclovir treatment in cytomegalovirus high-risk abdominal solid organ transplant recipients may promote development of cytomegalovirus-specific cell mediated immunity. Transpl Infect Dis 2021; 24:e13766. [PMID: 34799964 DOI: 10.1111/tid.13766] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the association of conversion from valganciclovir to letermovir on cytomegalovirus-specific cellular immunity. METHODS Adult patients were included if they received a kidney or liver transplant between 8/1/2018-12/31/20, developed symptomatic, high-level CMV viremia and were converted to letermovir 480 mg daily as monotherapy after treatment with ganciclovir-derivatives for a minimum of 4 weeks and had subsequent CMV cell-mediated immunity (CMI) testing via ICS assay by flow cytometry (Viracor Eurofins T Cell Immunity Panel). RESULTS Seven patients met inclusion criteria; 87.5% were male and recipients of a kidney transplant. All patients were CMV high risk (D+/R-). Mean time from transplant to CMV disease was 200 ± 91 days. Peak viral load (VL) during CMV treatment was 540,341 ± 391,211 IU/mL. Patients received a mean of 30 ± 24 weeks (range: 4-78 weeks) of therapy with ganciclovir-derivatives at induction doses prior to letermovir introduction. The median absolute lymphocyte count (ALC) at letermovir initiation was 400/μL (IQR 575) and the median VL was 51.6 (range: ND-490) IU/mL. Most patients (n = 5/7, 71.4%) experienced an increase in VL 1 and/or 2 weeks after conversion to letermovir. All patients had positive CMI per ICS assay after conversion. Patients received a mean of 10.3 ± 6.9 weeks of letermovir prior to having a positive result. Median ALC at positivity was 900/μL. Immunosuppression was not further reduced from initiation of letermovir to demonstration of CMV CMI. No patient had progressive replication or breakthrough disease while maintained on letermovir and three patients (42.9%) underwent antiviral withdrawal without recurrence at the last follow-up. CONCLUSION In this case series of abdominal transplant recipients with severe or persistent CMV infection, patients developed CMV-specific CMI after conversion to letermovir monotherapy. These data suggest that using letermovir in place of valganciclovir for secondary prophylaxis may address the lack of efficacy previously seen with this approach, as well as the issues that plague antiviral withdrawal with systematic monitoring. Future prospective studies are needed to evaluate this effect in a more controlled research environment with serial CMI testing to elucidate the optimal duration of letermovir when used in this way.
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Affiliation(s)
- Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Hanna Kleiboeker
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | - Neetika Garg
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jon S Odorico
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Christopher M Saddler
- Department of Medicine, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jeannina A Smith
- Department of Medicine, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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13
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Zamora D, Duke ER, Xie H, Edmison BC, Akoto B, Kiener R, Stevens-Ayers T, Wagner R, Mielcarek M, Leisenring WM, Jerome KR, Schiffer JT, Finak G, De Rosa SC, Boeckh M. Cytomegalovirus-specific T-cell reconstitution following letermovir prophylaxis after hematopoietic cell transplantation. Blood 2021; 138:34-43. [PMID: 33657225 PMCID: PMC8493975 DOI: 10.1182/blood.2020009396] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/17/2021] [Indexed: 12/17/2022] Open
Abstract
Decreased cytomegalovirus (CMV)-specific immunity after hematopoietic cell transplantation (HCT) is associated with late CMV reactivation and increased mortality. Whether letermovir prophylaxis-associated reduction in viral exposure influences CMV-specific immune reconstitution is unknown. In a prospective cohort of allogeneic HCT recipients who received letermovir, we compared polyfunctional CMV-specific T-cell responses to those of controls who received PCR-guided preemptive therapy before the introduction of letermovir. Thirteen-color flow cytometry was used to assess T-cell responses at 3 months after HCT following stimulation with CMV immediate early-1 (IE-1) antigen and phosphoprotein 65 (pp65) antigens. Polyfunctionality was characterized by combinatorial polyfunctionality analysis of antigen-specific T-cell subsets. Use of letermovir and reduction of viral exposure were assessed for their association with CMV-specific T-cell immunity. Polyfunctional T-cell responses to IE-1 and pp65 were decreased in letermovir recipients and remained diminished after adjustment for donor CMV serostatus, absolute lymphocyte count, and steroid use. Among letermovir recipients, greater peak CMV DNAemia and increased viral shedding were associated with stronger CD8+ responses to pp65, whereas the CMV shedding rate was associated with greater CD4+ responses to IE-1. In summary, our study provided initial evidence that letermovir may delay CMV-specific cellular reconstitution, possibly related to decreased CMV antigen exposure. Evaluating T-cell polyfunctionality may identify patients at risk for late CMV infection after HCT.
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Affiliation(s)
- Danniel Zamora
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
| | - Elizabeth R Duke
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Bradley C Edmison
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Brenda Akoto
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Richard Kiener
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - Terry Stevens-Ayers
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ralf Wagner
- Institute of Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany; and
| | - Marco Mielcarek
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Medical Oncology, Department of Medicine, and
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Joshua T Schiffer
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Greg Finak
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Stephen C De Rosa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Michael Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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14
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Oreschak K, Saba LM, Rafaels N, Ambardekar AV, Deininger KM, PageII R, Lindenfeld J, Aquilante CL. Variants in mycophenolate and CMV antiviral drug pharmacokinetic and pharmacodynamic genes and leukopenia in heart transplant recipients. J Heart Lung Transplant 2021; 40:917-925. [PMID: 34253456 DOI: 10.1016/j.healun.2021.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The objective was to assess the relationship between single nucleotide polymorphisms in mycophenolate and cytomegalovirus antiviral drug pharmacokinetic and pharmacodynamic genes and drug-induced leukopenia in adult heart transplant recipients. METHODS This retrospective analysis included n = 148 patients receiving mycophenolate and a cytomegalovirus antiviral drug. In total, 81 single nucleotide polymorphisms in 21 pharmacokinetic and 23 pharmacodynamic genes were selected for investigation. The primary and secondary outcomes were mycophenolate and/or cytomegalovirus antiviral drug-induced leukopenia, defined as a white blood cell count <3.0 × 109/L, in the first six and 12 months post-heart transplant, respectively. RESULTS Mycophenolate and/or cytomegalovirus antiviral drug-induced leukopenia occurred in 20.3% of patients. HNF1A rs1169288 A>C (p.I27L) was associated with drug-induced leukopenia (unadjusted p = 0.002; false discovery rate <20%) in the first six months post-transplant. After adjusting for covariates, HNF1A rs1169288 variant C allele carriers had significantly higher odds of leukopenia compared to A/A homozygotes (odds ratio 6.19; 95% CI 1.97-19.43; p = 0.002). Single nucleotide polymorphisms in HNF1A, SLC13A1, and MBOAT1 were suggestively associated (p < 0.05) with the secondary outcome but were not significant after adjusting for multiple comparisons. CONCLUSION Our data suggest genetic variation may play a role in the development of leukopenia in patients receiving mycophenolate and cytomegalovirus antiviral drugs after heart transplantation. Following replication, pharmacogenetic markers, such as HNF1A rs1169288, could help identify patients at higher risk of drug-induced leukopenia, allowing for more personalized immunosuppressant therapy and cytomegalovirus prophylaxis following heart transplantation.
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Affiliation(s)
- Kris Oreschak
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Laura M Saba
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Nicholas Rafaels
- Division of Biomedical Informatics and Personalized Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amrut V Ambardekar
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kimberly M Deininger
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - RobertL PageII
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA.
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15
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Adoptive therapy with CMV-specific cytotoxic T lymphocytes depends on baseline CD4+ immunity to mediate durable responses. Blood Adv 2021; 5:496-503. [PMID: 33496746 DOI: 10.1182/bloodadvances.2020002735] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/03/2020] [Indexed: 11/20/2022] Open
Abstract
Adoptive cell therapy using cytomegalovirus (CMV)-specific cytotoxic T lymphocytes (CMV-CTLs) has demonstrated efficacy posttransplant. Despite the predicted limited engraftment of CMV-CTLs derived from third-party donors, partially matched third-party donor-derived CMV-CTLs have demonstrated similar response rates to those derived from primary hematopoietic cell transplantation donors. Little is known about the mechanisms through which adoptive cellular therapies mediate durable responses. We performed a retrospective analysis of patients receiving CMV-CTLs for treatment of CMV viremia and/or disease after allogeneic transplant between September of 2009 and January of 2018. We evaluated whether response to adoptively transferred CMV-CTLs correlated with immune reconstitution (IR), using validated CD4+ IR milestones of 50 × 106/L and 200 × 106/L. In this analysis, a cohort of 104 patients received CMV-CTLs derived from a primary transplant donor (n = 25), a third-party donor (n = 76), or both (n = 3). Response to therapy did not increase the likelihood of achieving CD4+ IR milestones at 1 (P = .53 and P > .99) or 2 months (P = .12 and P = .33). The origin of CMV-CTLs did not impact subsequent CD4+ IR. CMV-CTLs appeared to interact with host immunity in mediating responses. Recipients with a baseline CD4 >50 × 106/L had higher response to therapy (P = .02), improved overall survival (P < .001), and protection from CMV-related death (P = .002). Baseline endogenous immunity appears to improve CMV-related and overall survival in this cohort and can be an important marker at the initiation of therapy.
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16
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Perera MR, Wills MR, Sinclair JH. HCMV Antivirals and Strategies to Target the Latent Reservoir. Viruses 2021; 13:817. [PMID: 34062863 PMCID: PMC8147263 DOI: 10.3390/v13050817] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/11/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a ubiquitous human herpesvirus. In healthy people, primary infection is generally asymptomatic, and the virus can go on to establish lifelong latency in cells of the myeloid lineage. However, HCMV often causes severe disease in the immunosuppressed: transplant recipients and people living with AIDS, and also in the immunonaive foetus. At present, there are several antiviral drugs licensed to control HCMV disease. However, these are all faced with problems of poor bioavailability, toxicity and rapidly emerging viral resistance. Furthermore, none of them are capable of fully clearing the virus from the host, as they do not target latent infection. Consequently, reactivation from latency is a significant source of disease, and there remains an unmet need for treatments that also target latent infection. This review briefly summarises the most common HCMV antivirals used in clinic at present and discusses current research into targeting the latent HCMV reservoir.
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Affiliation(s)
| | | | - John H. Sinclair
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK; (M.R.P.); (M.R.W.)
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17
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Rodríguez-Goncer I, Ruiz-Ruigómez M, López-Medrano F, Corbella L, Polanco N, González Monte E, San Juan R, Ruiz-Merlo T, Parra P, Folgueira L, Andrés A, Aguado JM, Fernández-Ruiz M. CMV infection, valganciclovir exposure, and the risk of BK viremia and associated nephropathy after kidney transplantation: Is there a link? Transpl Infect Dis 2021; 23:e13597. [PMID: 33751753 DOI: 10.1111/tid.13597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 02/21/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Immunomodulatory effects attributable to cytomegalovirus (CMV) would predispose to BK polyomavirus (BKPyV) infection after kidney transplantation (KT), although available evidence is conflicting. It has been suggested that (val)ganciclovir therapy may increase the risk of BKPyV viremia and BKPyV-associated nephropathy (BKPyVAN) as a result of drug-induced T-cell impairment. METHODS We investigated whether CMV replication and/or (val)ganciclovir exposure (either as prophylaxis or treatment) were associated with the development of BKPyV viremia or BKPyVAN in a prospective cohort of 399 KT recipients. CMV infection (any level or high-level viremia and area under the curve of DNAemia) and (val)ganciclovir exposure (any duration of therapy and cumulative days of treatment) during the first post-transplant year were explored through separate landmark survival analyses. RESULTS Cumulative incidence of BKPyV viremia and BKPyVAN after a median follow-up of 551 days was 23.1% and 2.5%, respectively. One-year rates of CMV infection and (val)ganciclovir therapy were 47.4% and 54.1%, respectively. No differences were observed in BKPyV viremia- or BKPyVAN-free survival according to previous CMV infection or (val)ganciclovir exposure in any of the landmark analyses. Adjusted Cox models confirmed this lack of association. CONCLUSION Our findings do not confirm the existence of a relevant impact of CMV infection or (val)ganciclovir therapy on the risk of post-transplant BKPyV events.
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Affiliation(s)
- Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - María Ruiz-Ruigómez
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Laura Corbella
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Esther González Monte
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Patricia Parra
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Lola Folgueira
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain.,Department of Microbiology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
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18
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Solano C, Vázquez L, Giménez E, de la Cámara R, Albert E, Rovira M, Espigado I, Calvo CM, López-Jiménez J, Suárez-Lledó M, Chinea A, Esquirol A, Pérez A, Bermúdez A, Saldaña R, Heras I, González-Huerta AJ, Torrado T, Bautista G, Batlle M, Jiménez S, Vallejo C, Barba P, Cuesta MÁ, Piñana JL, Navarro D. Cytomegalovirus DNAemia and risk of mortality in allogeneic hematopoietic stem cell transplantation: Analysis from the Spanish Hematopoietic Transplantation and Cell Therapy Group. Am J Transplant 2021; 21:258-271. [PMID: 32812351 DOI: 10.1111/ajt.16147] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/07/2020] [Accepted: 06/11/2020] [Indexed: 01/25/2023]
Abstract
The net impact of cytomegalovirus (CMV) DNAemia on overall mortality (OM) and nonrelapse mortality (NRM) following allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains a matter of debate. This was a retrospective, multicenter, noninterventional study finally including 749 patients. CMV DNA monitoring was conducted by real-time polymerase chain reaction (PCR) assays. Clinical outcomes of interest were OM and NRM through day 365 after allo-HSCT. The cumulative incidence of CMV DNAemia in this cohort was 52.6%. A total of 306 out of 382 patients with CMV DNAemia received preemptive antiviral therapy (PET). PET use for CMV DNAemia, but not the occurrence of CMV DNAemia, taken as a qualitative variable, was associated with increased OM and NRM in univariate but not in adjusted models. A subcohort analysis including patients monitored by the COBAS Ampliprep/COBAS Taqman CMV Test showed that OM and NRM were comparable in patients in whom either low or high plasma CMV DNA threshold (<500 vs ≥500 IU/mL) was used for PET initiation. In conclusion, CMV DNAemia was not associated with increased OM and NRM in allo-HSCT recipients. The potential impact of PET use on mortality was not proven but merits further research.
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Affiliation(s)
- Carlos Solano
- Hematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Lourdes Vázquez
- Hematology Department, Complejo Asistencial Universitario de Salamanca-IBSAL, Salamanca, Spain
| | - Estela Giménez
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | | | - Eliseo Albert
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Montserrat Rovira
- Hematology Department, Hospital Clinic Institute of Hematology & Oncology, Barcelona, Spain
| | | | - Carmen M Calvo
- Hematology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | | | - María Suárez-Lledó
- Hematology Department, Hospital Clinic Institute of Hematology & Oncology, Barcelona, Spain
| | - Anabella Chinea
- Hematology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Albert Esquirol
- Hematology Department, Hospital Sant Creu i Sant Pau, Barcelona, Spain
| | - Ariadna Pérez
- Hematology Department, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Aránzazu Bermúdez
- Department of Hematology, Hospital Marques de Valdecilla, Santander, Spain
| | - Raquel Saldaña
- Hematology Department, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain
| | - Inmaculada Heras
- Hematology Department, Hospital Universitario Morales Meseguer y Centro Regional de Hemodonación, IMIB, Universidad de Murcia, Murcia, Spain
| | - Ana J González-Huerta
- Hematology-Stem cell Transplantation Unit, Hospital Universitario Central de Asturias, Oviedo IISPA. IUOPA, Oviedo, Spain
| | - Tamara Torrado
- Hematology Department, Complejo Hospitalario Universitario, Vigo, Spain
| | - Guiomar Bautista
- Hematology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Montserrat Batlle
- Hematology Department, Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Santiago Jiménez
- Hematology Department, Hospital Universitario Doctor Negrín de Gran Canaria, Las Palmas, Spain
| | - Carlos Vallejo
- Hematology Department Hospital Universitario Donostia-Aránzazu, San Sebastián, Spain
| | - Pere Barba
- Hematology Department Hospital, Universitario Vall de Hebrón, Barcelona, Spain
| | - María Á Cuesta
- Hematology Department, Hospital Regional Universitario, Málaga, Spain
| | - José L Piñana
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain.,Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
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19
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Hellemans R, Abramowicz D. Cytomegalovirus after kidney transplantation in 2020: moving towards personalized prevention. Nephrol Dial Transplant 2020; 37:810-816. [PMID: 33280028 DOI: 10.1093/ndt/gfaa249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Indexed: 12/24/2022] Open
Abstract
Cytomegalovirus (CMV)-related complications after kidney transplantation remain a substantial challenge. Rather than applying one preventive strategy to all at-risk patients, we can now adapt our strategy at the individual patient level. Antiviral prophylaxis or a strict pre-emptive strategy may be optimal for patients at the highest risk for CMV, while patients at lower risk may benefit particularly from pre-emptive monitoring and the administration of therapy only if needed. CMV-specific T-cell assays may be useful for further refining the pre-transplant determination of CMV risk, and for guiding decisions about antiviral therapy need or duration. An immunosuppressive regimen including a mammalian target of rapamycin inhibitor reduces CMV risk and may thus be an attractive option in some patients. New antiviral agents may further expand our therapeutic arsenal in the near future, and the prospects of CMV vaccination and adoptive T-cell therapy appear to be on the horizon.
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Affiliation(s)
- Rachel Hellemans
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium.,Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Belgium
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium.,Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Belgium
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20
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Freeland J, Zhang L, Wang ST, Ruiz M, Wang Y. Bent DNA Bows as Sensing Amplifiers for Detecting DNA-Interacting Salts and Molecules. SENSORS (BASEL, SWITZERLAND) 2020; 20:E3112. [PMID: 32486417 PMCID: PMC7309149 DOI: 10.3390/s20113112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/23/2020] [Accepted: 05/29/2020] [Indexed: 01/20/2023]
Abstract
Due to the central role of DNA, its interactions with inorganic salts and small organic molecules are important. For example, such interactions play important roles in various fundamental cellular processes in living systems and are involved in many DNA-damage related diseases. Strategies to improve the sensitivity of existing techniques for studying DNA interactions with other molecules would be appreciated in situations where the interactions are too weak. Here we report our development and demonstration of bent DNA bows for amplifying, sensing, and detecting the interactions of 14 inorganic salts and small organic molecules with DNA. With the bent DNA bows, these interactions were easily visualized and quantified in gel electrophoresis, which were difficult to measure without bending. In addition, the strength of the interactions of DNA with the various salts/molecules were quantified using the modified Hill equation. This work highlights the amplification effects of the bending elastic energy stored in the DNA bows and the potential use of the DNA bows for quantitatively measuring DNA interactions with small molecules as simple economic methods; it may also pave the way for exploiting the bent DNA bows for other applications such as screening DNA-interacting molecules and drugs.
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Affiliation(s)
- Jack Freeland
- Department of Physics, University of Arkansas, Fayetteville, AR 72701, USA; (J.F.); (M.R.)
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, AR 72701, USA
| | - Lihua Zhang
- Center for Functional Nanomaterials, Brookhaven National Laboratory, Upton, NY 11973, USA; (L.Z.); (S.-T.W.)
| | - Shih-Ting Wang
- Center for Functional Nanomaterials, Brookhaven National Laboratory, Upton, NY 11973, USA; (L.Z.); (S.-T.W.)
| | - Mason Ruiz
- Department of Physics, University of Arkansas, Fayetteville, AR 72701, USA; (J.F.); (M.R.)
- Department of Biology, University of Arkansas, Fayetteville, AR 72701, USA
| | - Yong Wang
- Department of Physics, University of Arkansas, Fayetteville, AR 72701, USA; (J.F.); (M.R.)
- Cell and Molecular Biology Program, University of Arkansas, Fayetteville, AR 72701, USA
- Microelectronics-Photonics Program, University of Arkansas, Fayetteville, AR 72701, USA
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21
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Kim D, Kobayashi T, Voisin B, Jo JH, Sakamoto K, Jin SP, Kelly M, Pasieka HB, Naff JL, Meyerle JH, Ikpeama ID, Fahle GA, Davis FP, Rosenzweig SD, Alejo JC, Pittaluga S, Kong HH, Freeman AF, Nagao K. Targeted therapy guided by single-cell transcriptomic analysis in drug-induced hypersensitivity syndrome: a case report. Nat Med 2020; 26:236-243. [PMID: 31959990 PMCID: PMC7105105 DOI: 10.1038/s41591-019-0733-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 12/06/2019] [Indexed: 12/17/2022]
Abstract
Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DiHS/DRESS) is a potentially fatal multiorgan inflammatory disease associated with herpesvirus reactivation and subsequent onset of autoimmune diseases1-4. Pathophysiology remains elusive and therapeutic options are limited. Cases refractory to corticosteroid therapy pose a clinical challenge1,5 and approximately 30% of patients with DiHS/DRESS develop complications, including infections and inflammatory and autoimmune diseases1,2,5. Progress in single-cell RNA sequencing (scRNA-seq) provides an opportunity to dissect human disease pathophysiology at unprecedented resolutions6, particularly in diseases lacking animal models, such as DiHS/DRESS. We performed scRNA-seq on skin and blood from a patient with refractory DiHS/DRESS, identifying the JAK-STAT signaling pathway as a potential target. We further showed that central memory CD4+ T cells were enriched with DNA from human herpesvirus 6b. Intervention via tofacitinib enabled disease control and tapering of other immunosuppressive agents. Tofacitinib, as well as antiviral agents, suppressed culprit-induced T cell proliferation in vitro, further supporting the roles of the JAK-STAT pathway and herpesviruses in mediating the adverse drug reaction. Thus, scRNA-seq analyses guided successful therapeutic intervention in the patient with refractory DiHS/DRESS. scRNA-seq may improve our understanding of complicated human disease pathophysiology and provide an alternative approach in personalized medicine.
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Affiliation(s)
- Doyoung Kim
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tetsuro Kobayashi
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
| | - Benjamin Voisin
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
| | - Jay-Hyun Jo
- Cutaneous Microbiome and Inflammation Section, Dermatology Branch, NIAMS, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Keiko Sakamoto
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
| | - Seon-Pil Jin
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA
| | - Michael Kelly
- Cancer Research Technology Program, Single-Cell Analysis Facility, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Helena B Pasieka
- Department of Dermatology, MedStar Washington Hospital Center & Georgetown University Hospital, Washington, DC, USA
| | - Jessica L Naff
- Department of Dermatology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jon H Meyerle
- Department of Dermatology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ijeoma D Ikpeama
- Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD, USA
| | - Gary A Fahle
- Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD, USA
| | - Fred P Davis
- Molecular Immunology and Inflammation Branch, NIAMS, NIH, Bethesda, MD, USA
| | - Sergio D Rosenzweig
- Immunology Service, Department of Laboratory Medicine, Clinical Center, NIH, Bethesda, MD, USA
| | - Julie C Alejo
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Stefania Pittaluga
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Heidi H Kong
- Cutaneous Microbiome and Inflammation Section, Dermatology Branch, NIAMS, National Institutes of Health (NIH), Bethesda, MD, USA
| | - Alexandra F Freeman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, MD, USA
| | - Keisuke Nagao
- Cutaneous Leukocyte Biology Section, Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH, Bethesda, MD, USA.
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22
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Jehn U, Schütte-Nütgen K, Bautz J, Suwelack B, Reuter S. Valganciclovir is not a risk factor of BK polyomavirus viremia. Am J Transplant 2019; 19:3436-3437. [PMID: 31556235 DOI: 10.1111/ajt.15610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Ulrich Jehn
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, Muenster, Germany
| | - Katharina Schütte-Nütgen
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, Muenster, Germany
| | - Joachim Bautz
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, Muenster, Germany
| | - Barbara Suwelack
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, Muenster, Germany
| | - Stefan Reuter
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Muenster, Muenster, Germany
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23
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Krishna BA, Wills MR, Sinclair JH. Advances in the treatment of cytomegalovirus. Br Med Bull 2019; 131:5-17. [PMID: 31580403 PMCID: PMC6821982 DOI: 10.1093/bmb/ldz031] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/02/2019] [Accepted: 08/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Human cytomegalovirus (HCMV) is a threat to immunologically weak patients. HCMV cannot yet be eliminated with a vaccine, despite recent advances. SOURCES OF DATA Sources of data are recently published research papers and reviews about HCMV treatments. AREAS OF AGREEMENT Current antivirals target the UL54 DNA polymerase and are limited by nephrotoxicity and viral resistance. Promisingly, letermovir targets the HCMV terminase complex and has been recently approved by the FDA and EMA. AREAS OF CONTROVERSY Should we screen newborns for HCMV, and use antivirals to treat sensorineural hearing loss after congenital HCMV infection? GROWING POINTS Growing points are developing drugs against latently infected cells. In addition to small molecule inhibitors, a chemokine-based fusion toxin protein, F49A-FTP, has shown promise in killing both lytically and latently infected cells. AREAS TIMELY FOR DEVELOPING RESEARCH We need to understand what immune responses are required to control HCMV, and how best to raise these immune responses with a vaccine.
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Affiliation(s)
- B A Krishna
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M R Wills
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - J H Sinclair
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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24
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Reischig T, Kacer M, Hes O, Machova J, Nemcova J, Lysak D, Jindra P, Pivovarcikova K, Kormunda S, Bouda M. Cytomegalovirus prevention strategies and the risk of BK polyomavirus viremia and nephropathy. Am J Transplant 2019; 19:2457-2467. [PMID: 31220412 DOI: 10.1111/ajt.15507] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 01/25/2023]
Abstract
Polyomavirus BK (BKV) is the cause of polyomavirus-associated nephropathy resulting in premature graft loss. There are limited data regarding the role of cytomegalovirus (CMV) infection and its prevention in developing BKV viremia and PVAN. In a prospective study, we analyzed 207 consecutive renal transplant recipients previously enrolled in 2 randomized trials evaluating different CMV prevention regimens with routine screening for BKV and CMV. Of these, 59 received valganciclovir and 100 valacyclovir prophylaxis; 48 patients were managed by preemptive therapy. At 3 years, the incidence of BKV viremia and PVAN was 28% and 5%, respectively. CMV DNAemia developed in 55% and CMV disease in 6%. Both BKV viremia (42% vs 23% vs 21%, P = .006) and PVAN (12% vs 2% vs 2%, P = .011) were increased in patients treated with valganciclovir prophylaxis compared to valacyclovir and preemptive therapy. Using multivariate Cox proportional hazard regression, valganciclovir prophylaxis was independent predictor of BKV viremia (hazard ratio [HR] = 2.38, P = .002) and PVAN (HR = 4.73, P = .026). In contrast, the risk of subsequent BKV viremia was lower in patients with antecedent CMV DNAemia (HR = 0.50, P = .018). These data suggest valganciclovir prophylaxis may be associated with increased risk of BKV viremia and PVAN. CMV DNAemia did not represent a risk for BKV.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Martin Kacer
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Ondrej Hes
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Pathology, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic
| | - Jana Machova
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Jana Nemcova
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Daniel Lysak
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Haematology and Oncology, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic
| | - Pavel Jindra
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Haematology and Oncology, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic
| | - Kristyna Pivovarcikova
- Department of Pathology, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic
| | - Stanislav Kormunda
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Division of Information Technologies and Statistics, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Mirko Bouda
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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25
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Giménez E, Torres I, Albert E, Piñana JL, Hernández-Boluda JC, Solano C, Navarro D. Cytomegalovirus (CMV) infection and risk of mortality in allogeneic hematopoietic stem cell transplantation (Allo-HSCT): A systematic review, meta-analysis, and meta-regression analysis. Am J Transplant 2019; 19:2479-2494. [PMID: 31247126 DOI: 10.1111/ajt.15515] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/22/2019] [Accepted: 06/17/2019] [Indexed: 01/25/2023]
Abstract
Controversy surrounds the potential association between cytomegalovirus (CMV) infection and increased risk of mortality after allogeneic hematopoietic stem cell transplantation (Allo-HSCT). A systematic literature search was conducted using the PubMed, EMBASE, and Web of Science databases, assessing the association between CMV infection, as documented by the pp65 antigenemia assay or by polymerase chain reaction (PCR) using blood specimens, and overall mortality (OM) and nonrelapse mortality (NRM) in the allo-HSCT setting. Pooled effects were estimated using the generic inverse variance random effects model. Heterogeneity was evaluated by Cochrane's Q test and I2 statistics. The source of heterogeneity was investigated by meta-regression and subgroup analyses. Twenty-six of 1367 studies fulfilled eligibility criteria. CMV infection identified by PCR monitoring was significantly associated with an increased risk of OM and NRM (hazard ratio 1.47, 95% confidence interval [1.20-1.81], P ≤ .001; hazard ratio 1.68, 95% confidence interval [1.14-2.49], P = .05, respectively). In this setting, the use of preemptive antiviral therapy (PET) resulted in a twofold increased risk of OM and NRM. The estimated effect sizes were associated with allo-HSCT modalities. Although our analyses point to an association between CMV infection and an increased risk of OM and NRM in allo-HSCT recipients, the high heterogeneity across studies prevented drawing of robust conclusions on this matter.
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Affiliation(s)
- Estela Giménez
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Ignacio Torres
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - Eliseo Albert
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | - José-Luis Piñana
- Hematology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain
| | | | - Carlos Solano
- Hematology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain.,Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
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26
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Talaya A, Giménez E, Piñana JL, Albert E, Hernández‐Boluda JC, Pérez A, Torres I, Solano C, Navarro D. Spontaneously‐resolving episodes of cytomegalovirus DNAemia in allogeneic hematopoietic stem cell transplant recipients: Virological features and clinical outcomes. J Med Virol 2019; 91:1128-1135. [DOI: 10.1002/jmv.25426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/06/2019] [Accepted: 02/06/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Alberto Talaya
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research InstituteValencia Spain
| | - Estela Giménez
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research InstituteValencia Spain
| | - José Luis Piñana
- Hematology Service, Hospital Clínico Universitario, INCLIVA Research InstituteValencia Spain
| | - Eliseo Albert
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research InstituteValencia Spain
| | | | - Ariadna Pérez
- Hematology Service, Hospital Clínico Universitario, INCLIVA Research InstituteValencia Spain
| | - Ignacio Torres
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research InstituteValencia Spain
| | - Carlos Solano
- Hematology Service, Hospital Clínico Universitario, INCLIVA Research InstituteValencia Spain
- Department of MedicineSchool of Medicine, University of ValenciaValencia Spain
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research InstituteValencia Spain
- Department of MicrobiologySchool of Medicine, University of ValenciaValencia Spain
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27
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Reischig T, Kacer M, Hruba P, Hermanova H, Hes O, Lysak D, Kormunda S, Bouda M. Less renal allograft fibrosis with valganciclovir prophylaxis for cytomegalovirus compared to high-dose valacyclovir: a parallel group, open-label, randomized controlled trial. BMC Infect Dis 2018; 18:573. [PMID: 30442095 PMCID: PMC6238264 DOI: 10.1186/s12879-018-3493-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 11/01/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) prophylaxis may prevent CMV indirect effects in renal transplant recipients. This study aimed to compare the efficacy of valganciclovir and valacyclovir prophylaxis for CMV after renal transplantation with the focus on chronic histologic damage within the graft. METHODS From November 2007 through April 2012, adult renal transplant recipients were randomized, in an open-label, single-center study, at a 1:1 ratio to 3-month prophylaxis with valganciclovir (n = 60) or valacyclovir (n = 59). The primary endpoint was moderate-to-severe interstitial fibrosis and tubular atrophy assessed by protocol biopsy at 3 years evaluated by a single pathologist blinded to the study group. The analysis was conducted in an intention-to-treat population. RESULTS Among the 101 patients who had a protocol biopsy specimen available, the risk of moderate-to-severe interstitial fibrosis and tubular atrophy was significantly lower in those treated with valganciclovir (22% versus 34%; adjusted odds ratio, 0.31; 95% confidence interval, 0.11-0.90; P = 0.032 by multivariate logistic regression). The incidence of CMV disease (9% versus 2%; P = 0.115) and CMV DNAemia (36% versus 42%; P = 0.361) were not different at 3 years. CONCLUSIONS Valganciclovir prophylaxis, as compared with valacyclovir, was associated with a reduced risk of moderate-to-severe interstitial fibrosis and tubular atrophy in patients after renal transplantation. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ( ACTRN12610000016033 ). Registered on September 26, 2007.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic. .,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.
| | - Martin Kacer
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic
| | - Petra Hruba
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Transplant Laboratory, Institute for Clinical and Experimental Medicine, 14021, Prague, Czech Republic
| | - Hana Hermanova
- Department of Hemato-oncology, Teaching Hospital, 30460, Pilsen, Czech Republic
| | - Ondrej Hes
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Department of Pathology, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic
| | - Daniel Lysak
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Department of Hemato-oncology, Teaching Hospital, 30460, Pilsen, Czech Republic
| | - Stanislav Kormunda
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic.,Division of Information Technologies and Statistics, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic
| | - Mirko Bouda
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, 30460, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, 32300, Pilsen, Czech Republic
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28
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Sun K, Xu H, Hilfinger JL, Lee KD, Provoda CJ, Sabit H, Amidon GL. Improved Protease-Targeting and Biopharmaceutical Properties of Novel Prodrugs of Ganciclovir. Mol Pharm 2018; 15:410-419. [PMID: 29251944 DOI: 10.1021/acs.molpharmaceut.7b00792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The prodrug strategy has been frequently employed as a chemical approach for overcoming the disadvantages of existing parent drugs. In this report, we synthesized four monoester prodrugs of ganciclovir, an anticytomegalovirus drug, and demonstrated their potential advantages in protease-targeted activation and biopharmaceutical profiles over the parent compound. We demonstrated that these four prodrugs of ganciclovir, i.e., N-benzyloxycarbonyl-(L)-alanine-ganciclovir (CbzAlaGCV), N-benzyloxycarbonyl-(α,l)-aminobutyric acid-ganciclovir (CbzAbuGCV), N-acetyl-(l)-phenylalanine-(l)-alanine-ganciclovir (AcPheAlaGCV), and N-acetyl-(l)-phenylalanine-(α,l)-aminobutyric acid-ganciclovir (AcPheAbuGCV), are hydrolytically activated by the protease of human cytomegalovirus (hCMV), a serine protease that possesses intrinsic esterase activities. CbzAlaGCV and AcPheAlaGCV were found to be activated at a higher rate by the hCMV protease than CbzAbuGCV and AcPheAbuGCV. These ganciclovir prodrugs could potentially be targeted to selective activation by the hCMV protease which is only present at the viral infection sites, thereby achieving higher efficacy and lower systemic toxicity. The tissue stability, cellular uptake, and trans-epithelial transport of these ganciclovir prodrugs were also characterized. The N-acetylated dipeptide prodrugs of ganciclovir were found to be generally more stable than Cbz-amino acid prodrugs in various tissue matrices. Among the four prodrug candidates, AcPheAbuGCV was the most stable in human cell homogenates, plasma, and pooled liver microsomes. AcPheAbuGCV also possessed a superior cellular uptake profile and permeability across epithelial cell monolayers. Since the targeting and selective activation of a prodrug is determined by not only its rate of hydrolysis catalyzed by the hCMV protease target but also its biopharmaceutical properties, i.e., oral absorption and systemic availability, AcPheAbuGCV is considered the best overall candidate among the four ganciclovir prodrugs for further research and development for treatment of hCMV infection.
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Affiliation(s)
- Kefeng Sun
- Shire Pharmaceuticals Human Genetic Therapies, Inc. , 300 Shire Way, Lexington, Massachusetts 02421-2101, United States
| | - Hao Xu
- Pharmaceutical Sciences, University of Michigan , 428 Church Street, Ann Arbor, Michigan 48109-1065, United States
| | - John L Hilfinger
- TSRL, Inc. , 540 Avis Drive, Suite A, Ann Arbor, Michigan 48108, United States
| | - Kyung-Dall Lee
- Pharmaceutical Sciences, University of Michigan , 428 Church Street, Ann Arbor, Michigan 48109-1065, United States
| | - Chester J Provoda
- American Society for Clinical Investigation , 2015 Manchester Road, Ann Arbor, Michigan 48104, United States
| | - Hairat Sabit
- U.S. Food and Drug Administration , 10903 New Hampshire Ave, Silver Spring, Maryland 20903, United States
| | - Gordon L Amidon
- Pharmaceutical Sciences, University of Michigan , 428 Church Street, Ann Arbor, Michigan 48109-1065, United States
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Impact of cytomegalovirus reactivation on relapse and survival in patients with acute leukemia who received allogeneic hematopoietic stem cell transplantation in first remission. Oncotarget 2017; 7:17230-41. [PMID: 26883100 PMCID: PMC4941383 DOI: 10.18632/oncotarget.7347] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 01/29/2016] [Indexed: 01/01/2023] Open
Abstract
Cytomegalovirus (CMV)-reactivation is associated with graft-vs-leukemia (GVL) effect by stimulating natural-killer or T-cells, which showed leukemia relapse prevention after hematopoietic stem cell transplantation (HSCT). We enrolled patients with acute myeloid leukemia (n = 197) and acute lymphoid leukemia (n = 192) who underwent allogeneic-HSCT in first remission. We measured RQ-PCR weekly to detect CMV-reactivation and preemptively used ganciclovir (GCV) when the titer increased twice consecutively, but GCV was sometimes delayed in patients without significant graft-vs-host disease (GVHD) by reducing immunosuppressive agents. In the entire group, CMV-reactivation showed poor overall survival (OS). To evaluate subsequent effects of CMV-reactivation, we excluded early relapse and deaths within 100 days, during which most of the CMV-reactivation occurred. Untreated CMV-reactivated group (n = 173) showed superior OS (83.8% vs. 61.7% vs. 74.0%, p < 0.001) with lower relapse rate (10.1% vs 22.1% vs. 25.5%, p = 0.004) compared to GCV-treated CMV-reactivated group (n = 122) and CMV-undetected group (n = 42). After excluding chronic GVHD, untreated CMV-reactivated group still showed lower relapse rate (9.4% vs. 24.1% vs. 30.2%, p = 0.006). Multivariate analysis showed adverse-risk karyotype and patients in other than untreated CMV-reactivated group were independent factors for relapse prediction. Our data showed possible GVL effect of CMV-reactivation and minimizing antiviral therapy may benefit for relapse prevention in acute leukemia.
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30
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Wohlfarth P, Leiner M, Schoergenhofer C, Hopfinger G, Goerzer I, Puchhammer-Stoeckl E, Rabitsch W. Torquetenovirus Dynamics and Immune Marker Properties in Patients Following Allogeneic Hematopoietic Stem Cell Transplantation: A Prospective Longitudinal Study. Biol Blood Marrow Transplant 2017; 24:194-199. [PMID: 29032273 DOI: 10.1016/j.bbmt.2017.09.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/28/2017] [Indexed: 12/26/2022]
Abstract
Torquetenovirus (TTV) has been proposed as a marker of immune function in patients receiving immunosuppression after solid organ transplantation. This study aimed to define TTV plasma dynamics and investigate clinical associations in patients following allogeneic hematopoietic stem cell transplantation (HSCT). This was a single-center prospective longitudinal study involving 50 consecutive patients treated with HSCT between March 2015 and April 2016. TTV plasma DNA levels were measured with quantitative PCR at 12 consecutive time points during the first year after HSCT. Forty of the 50 patients (80%) had detectable TTV viremia before HSCT (median level, 5.37 log10 copies/mL; interquartile range [IQR], 3.51-6.44 log10 copies/mL). All patients subsequently developed TTV viremia during the follow-up period. Plasma viral loads evolved dynamically over time, with a peak of 8.32 log10 copies/mL (IQR, 7.33-9.35 log10 copies/mL) occurring at 79 days (IQR, 50-117 days) following HSCT and a stable plateau toward the end of the follow-up period. The type of malignancy, the use of antithymocyte globulin during conditioning, and the occurrence of acute graft-versus-host disease requiring systemic therapy had temporary effects on TTV dynamics. TTV levels showed a significant correlation with absolute lymphocyte counts following engraftment (rs = -.27; P < .01) and with cytomegalovirus (CMV; rs=.39; P < .01) and Epstein-Barr virus (EBV; rs=.45; P = .02) viral loads during phases of viremia. Immune-related clinical events were not predicted by TTV levels. TTV viremia occurred universally and was sustained throughout the first year after HSCT. Several variables and events before and after HSCT were correlated with TTV levels and hint toward immune marker properties of TTV, but their complex interactions might perturb the capability of TTV to predict immune-related complications in this population.
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Affiliation(s)
- Philipp Wohlfarth
- Division of Blood and Marrow Transplantation, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
| | - Michael Leiner
- Division of Blood and Marrow Transplantation, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Georg Hopfinger
- Division of Blood and Marrow Transplantation, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Irene Goerzer
- Department of Virology, Medical University of Vienna, Vienna, Austria
| | | | - Werner Rabitsch
- Division of Blood and Marrow Transplantation, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Smith CJ, Quinn M, Snyder CM. CMV-Specific CD8 T Cell Differentiation and Localization: Implications for Adoptive Therapies. Front Immunol 2016; 7:352. [PMID: 27695453 PMCID: PMC5023669 DOI: 10.3389/fimmu.2016.00352] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/31/2016] [Indexed: 01/09/2023] Open
Abstract
Human cytomegalovirus (HCMV) is a ubiquitous virus that causes chronic infection and, thus, is one of the most common infectious complications of immune suppression. Adoptive transfer of HCMV-specific T cells has emerged as an effective method to reduce the risk for HCMV infection and/or reactivation by restoring immunity in transplant recipients. However, the CMV-specific CD8+ T cell response is comprised of a heterogenous mixture of subsets with distinct functions and localization, and it is not clear if current adoptive immunotherapy protocols can reconstitute the full spectrum of CD8+ T cell immunity. The aim of this review is to briefly summarize the role of these T cell subsets in CMV immunity and to describe how current adoptive immunotherapy practices might affect their reconstitution in patients. The bulk of the CMV-specific CD8+ T cell population is made up of terminally differentiated effector T cells with immediate effector function and a short life span. Self-renewing memory T cells within the CMV-specific population retain the capacity to expand and differentiate upon challenge and are important for the long-term persistence of the CD8+ T cell response. Finally, mucosal organs, which are frequent sites of CMV reactivation, are primarily inhabited by tissue-resident memory T cells, which do not recirculate. Future work on adoptive transfer strategies may need to focus on striking a balance between the formation of these subsets to ensure the development of long lasting and protective immune responses that can access the organs affected by CMV disease.
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Affiliation(s)
- Corinne J Smith
- Department of Microbiology and Immunology, Thomas Jefferson University , Philadelphia, PA , USA
| | - Michael Quinn
- Department of Microbiology and Immunology, Thomas Jefferson University , Philadelphia, PA , USA
| | - Christopher M Snyder
- Department of Microbiology and Immunology, Thomas Jefferson University , Philadelphia, PA , USA
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32
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Zhang S, Mu Z, He C, Zhou M, Liu D, Zhao XF, Goldman D, Xu H. Antiviral Drug Ganciclovir Is a Potent Inhibitor of the Proliferation of Müller Glia-Derived Progenitors During Zebrafish Retinal Regeneration. Invest Ophthalmol Vis Sci 2016; 57:1991-2000. [PMID: 27096757 PMCID: PMC4849886 DOI: 10.1167/iovs.15-18669] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose The purpose of this study was to investigate the effect of the antiviral drug ganciclovir (GCV) on Müller glia dedifferentiation and proliferation and the underlying cellular and molecular mechanisms in adult zebrafish. Methods A Tg(1016tuba1a:GFP) transgenic line was generated to identify injury-induced dedifferentiation of Müller glia. Mechanical retinal damage was induced by a needle-poke injury on the back of the eyes in adult zebrafish. Phosphate-buffered saline or GCV was injected into the vitreous of the eye at the time of injury or through the cornea. The GCV clearance rate from the eye was determined by a reversed-phase HPLC method. Green fluorescent protein (GFP) and bromodeoxyuridine (BrdU) immunofluorescence were used to determine the effect of GCV on retinal regeneration. Cell apoptosis was evaluated by TUNEL staining. Microglia were labeled by vitreous injection of isolectin IB4 conjugates. Quantitative (q)PCR and Western blot analysis were used to determine gene expression in the retina. Results Ganciclovir treatment significantly reduced the number of BrdU+ Müller glia–derived progenitor cells (MGPCs) at 4 days post injury. Further analysis showed that GCV had no impact on Müller glia dedifferentiation and the initial formation of MGPCs. Our data indicate that GCV irreversibly inhibited MGPC proliferation likely through a p53-p21cip1–dependent pathway. Interestingly, unlike control cells, GCV-treated Müller glia cells were “locked” in a prolonged dedifferentiated state. Conclusions Our study uncovered a novel inhibitory effect of GCV on MGPC proliferation and suggests its potential use as a tool to uncover molecular mechanisms underlying retinal regeneration in zebrafish.
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Affiliation(s)
- Shuqiang Zhang
- Jiangsu Key Lab of Neuroregeneration Co-innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
| | - Zhaoxia Mu
- Eye Institute, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Chunjiao He
- Jiangsu Key Lab of Neuroregeneration Co-innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
| | - Minmin Zhou
- College of Biological Science, Nantong University, Nantong, Jiangsu Province, China
| | - Dong Liu
- Jiangsu Key Lab of Neuroregeneration Co-innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
| | - Xiao-Feng Zhao
- Department of Cell and Developmental Biology, University of Michigan, Ann Arbor, Michigan, United States
| | - Daniel Goldman
- Molecular and Behavioral Neuroscience Institute and Department of Biological Chemistry, University of Michigan, Ann Arbor, Michigan, United States
| | - Hui Xu
- Jiangsu Key Lab of Neuroregeneration Co-innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
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33
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CMV in Hematopoietic Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2016; 8:e2016031. [PMID: 27413524 PMCID: PMC4928522 DOI: 10.4084/mjhid.2016.031] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 06/06/2016] [Indexed: 12/12/2022] Open
Abstract
Due to its negative impact on the outcome of stem cell transplant (SCT) and solid organ transplant patients (SOT) CMV has been called “the troll of transplantation”. One of the greatest advances in the management of SCT has been the introduction of the preemptive strategy. Since its introduction, the incidence of the viremia, as expected, remains unchanged but there has been a marked decline in the incidence of early CMV disease. However, in spite of the advances in prevention of CMV disease, CMV is still today an important cause of morbidity and mortality. Late CMV disease is still occurring in a significant proportion of patients and the so-called indirect effects of CMV are causing significant morbidity and mortality. Fortunately there have been several advances in the development of new antivirals, adoptive immunotherapy and DNA-CMV vaccines that might transform the management of CMV in the near future.
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Human Cytomegalovirus Infection Enhances NK Cell Activity In Vitro. Transplant Direct 2016; 2:e89. [PMID: 27830183 PMCID: PMC5087575 DOI: 10.1097/txd.0000000000000605] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/11/2016] [Indexed: 12/20/2022] Open
Abstract
Supplemental digital content is available in the text. Background Occurring frequently after solid organ and hematopoietic stem cell transplantation, cytomegalovirus (CMV) replication remains a relevant cause of mortality and morbidity in affected patients. Despite these adverse effects, an increased alloreactivity of natural killer (NK) cells after CMV infection has been assumed, but the underlying physiopathological mechanisms have remained elusive. Methods We used serial analyses of NK cells before and after CMV infection in kidney transplant recipients as an in vivo model for CMV primary infection to explore the imprint of CMV infection using every patient as their own control: We analyzed NK cell phenotype and function in 47 CMV seronegative recipients of CMV seropositive kidney grafts, who developed CMV primary infection posttransplant. Seronegative recipients of seronegative kidney grafts served as controls. Results We observed a significant increase of NKG2C expressing NK cells after CMV infection (mean increase, 17.5%; 95% confidence interval [95% CI], 10.2-24.9, P < 0.001), whereas cluster of differentiation (CD)57 expressing cells decreased (mean decrease, 14.1%; 95% CI, 8.0-20.2; P < 0.001). Analysis of killer immunoglobulin-like receptor (KIR) expression showed an increase of cells expressing KIR2DL1 as their only inhibitory KIR in patients carrying the cognate ligand HLA-C2 (mean increase, 10.0%; 95% CI, 1.7-18.3; P = 0.018). In C2-negative individuals, KIR2DL1 expression decreased (mean decrease, 3.9%; 95% CI, 1.6-6.2; P = 0.001). As for activating KIR, there was no conclusive change pattern. Most importantly, we observed a significantly higher NK cell degranulation and IFNγ production in response to different target cells (target K562, CD107a: mean increase, 9.9%; 95% CI, 4.8-15.0; P < 0.001; IFNγ: mean increase, 6.6%; 95% CI, 1.6-11.1; P < 0.001; target MRC-5, CD107a: mean increase, 6.9%; 95% CI, 0.7-13.1; P = 0.03; IFNγ: mean increase, 4.8%; 95% CI, 1.7-7.8; P = 0.002). Conclusions We report evidence for an increased function of NK cells induced by CMV infection. This increased in vitro functionality was seen in NKG2C-positive and NKG2C-negative subsets, arguing for an NKG2C independent mechanism of action.
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Pelák O, Stuchlý J, Król L, Hubáček P, Keslová P, Sedláček P, Formánková R, Starý J, Hrušák O, Kalina T. Appearance of cytomegalovirus-specific T-cells predicts fast resolution of viremia post hematopoietic stem cell transplantation. CYTOMETRY PART B-CLINICAL CYTOMETRY 2016; 92:380-388. [PMID: 26647177 DOI: 10.1002/cyto.b.21348] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 11/11/2015] [Accepted: 12/01/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) specific T-cells are known to provide long-term control of CMV reactivation, which is a frequent complication of hematopoietic stem cell transplantation. We have studied 58 pediatric patients after hematopoietic stem cell transplantation who suffered from CMV reactivation to reveal which functional T cell subset is best correlating with successful reactivation resolution and which protects from reactivation episode. METHODS Detection of 30 combinatorial subsets of four types of response to ex vivo CMV stimulation (IFNγ secretion, IL-2 secretion, CD40L upregulation and degranulation) that were detectable on either CD8+ or CD4+ T cells through flow cytometry intracellular cytokine staining was used. RESULTS We found that the presence of CD8+ dual positive (IFNγ+ and IL-2+) cells is the most accurate functional parameter that can predict fast resolution of CMV reactivation. Next, we show that the presence of CD8+ dual positive (IFNγ+ and IL-2+) and CD8+ IFNγ+ cells provides a protective effect (a hazard risk of 0.28 (confidence interval 0.18 - 0.43) and 0.45 (CI 0.27 - 0.75), respectively) and the presence of corticotherapy increases the risk of reactivation (HR 2.47 (CI 1.82-3.36)). Thus, a patient without corticotherapy and with both of the critical T cell subsets present has a cumulative 19.6 times lower risk of developing CMV reactivation than a patient on corticotherapy and without CD8+ dual positive (IFNγ+ and IL-2+) or CD8+ IFNγ+ cells. CONCLUSIONS We have established parameters of CMV specific functional response ex vivo that can be used in assisting clinical management of patients with CMV reactivation. © 2015 International Clinical Cytometry Society.
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Affiliation(s)
- Ondřej Pelák
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic.,CLIP-Childhood Leukemia Investigation Prague, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
| | - Jan Stuchlý
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic.,CLIP-Childhood Leukemia Investigation Prague, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
| | - Ladislav Król
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic.,CLIP-Childhood Leukemia Investigation Prague, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
| | - Petr Hubáček
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
| | - Petra Keslová
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
| | - Petr Sedláček
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
| | - Renata Formánková
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
| | - Jan Starý
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
| | - Ondřej Hrušák
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic.,CLIP-Childhood Leukemia Investigation Prague, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
| | - Tomáš Kalina
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic.,CLIP-Childhood Leukemia Investigation Prague, 2nd Faculty of Medicine, Charles University Prague and University Hospital Motol, V Uvalu 84, Prague, 150 06, Czech Republic
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36
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Stachel D, Stevens-Ayers T, Boeckh M. In vitro studies of the impact of maribavir on CMV-specific cellular immune responses. J Clin Virol 2015; 75:53-9. [PMID: 26780109 DOI: 10.1016/j.jcv.2015.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/23/2015] [Accepted: 12/29/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ganciclovir has demonstrated immunosuppressive effects in vitro which may lead to delayed cytomegalovirus (CMV)-specific immune reconstitution when the drug is given prophylactically. Maribavir is a new and more potent anti-CMV drug that is under evaluation for therapeutic use in transplant recipients. OBJECTIVES The objective of this study was to evaluate the potential effect of maribavir on CMV-specific T cell function in comparison to ganciclovir. STUDY DESIGN In ten immunocompetent CMV seropositive donors, maribavir and ganciclovir were compared over a broad range of concentrations (0.2-500μM) regarding their effects on lymphoproliferation, CMV-specific CD4+ and CD8+ cytokine expression, T cell multifunctionality, degranulation and apoptosis. RESULTS Maribavir inhibited lymphocyte proliferation at concentrations of 50μM and above, however, cytokine expression, cellular degranulation and multifunctionality of CD4+ and CD8+ T cells in response to CMV lysate and pp65 peptide mix were not impaired except at the highest concentration of 500μM. Ganciclovir inhibited lymphoproliferative responses starting at 10μM. As with maribavir, other cellular responses following stimulation with CMV lysate and pp65 peptide mix were only impaired at the highest concentration of 500μM of ganciclovir. Neither maribavir nor ganciclovir showed induction of lymphocyte apoptosis. CONCLUSIONS Maribavir exhibits a low potential to suppress CMV-specific T cell function. This finding supports the use of higher doses in the prophylactic setting than originally proposed.
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Affiliation(s)
- Daniel Stachel
- From the Vaccine and Infectious Disease and Clinical Research Divisions, Fred Hutchinson Cancer Research Center, and the Department of Medicine, University of Washington, Seattle, WA, United States
| | - Terry Stevens-Ayers
- From the Vaccine and Infectious Disease and Clinical Research Divisions, Fred Hutchinson Cancer Research Center, and the Department of Medicine, University of Washington, Seattle, WA, United States
| | - Michael Boeckh
- From the Vaccine and Infectious Disease and Clinical Research Divisions, Fred Hutchinson Cancer Research Center, and the Department of Medicine, University of Washington, Seattle, WA, United States.
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Hashimoto H, Kitano S, Yamagata S, Miyagi Maeshima A, Ueda R, Ito A, Tada K, Fuji S, Yamashita T, Tomura D, Nukaya I, Mineno J, Fukuda T, Mori S, Takaue Y, Heike Y. Donor lymphocytes expressing the herpes simplex virus thymidine kinase suicide gene: detailed immunological function following add-back after haplo-identical transplantation. Cytotherapy 2015; 17:1820-30. [PMID: 26452983 DOI: 10.1016/j.jcyt.2015.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 08/07/2015] [Accepted: 08/13/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND AIMS Haplo-identical hematopoietic stem cell transplantation (HSCT) with add-back of donor lymphocytes expressing the herpes simplex virus thymidine kinase suicide gene (TK cells) is one of the most widely applied promising new gene therapy approaches. However, the immunological status of added-back TK cells after HSCT has yet to be well characterized. METHODS We investigated TK cells through the use of flow cytometry, T-cell receptor (TCR) Vβ repertoire spectratyping and linear amplification-mediated polymerase chain reaction followed by insertion site analysis in a patient enrolled in our clinical trial. RESULTS A comparison of onset with remission of acute graft-versus-host disease confirmed that TK cells were predominantly eliminated and that proliferative CD8(+) non-TK cells were also depleted in response to ganciclovir administration. The TCR Vβ-chain repertoire of both TK cells and non-TK cells markedly changed after administration of ganciclovir, and, whereas the TCR repertoire of non-TK cells returned to a normal spectratype long after transplantation, that of TK cells remained skewed. With the long-term prophylactic administration of acyclovir, TK cells oligoclonally expanded and the frequency of spliced variants of TK cells increased. Known cancer-associated genes were not evident near the oligoclonally expanded herpes simplex virus (HSV)-TK insertion sites. CONCLUSIONS We demonstrate obvious differences in immunological status between TK cells and non-TK cells. In addition, we speculate that long-term prophylactic administration of acyclovir increases the risk of oligoclonal expansion of spliced forms of TK cells.
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Affiliation(s)
- Hisayoshi Hashimoto
- Division of Molecular and Cellular Medicine, National Cancer Center Research Institute, Tokyo, Japan
| | - Shigehisa Kitano
- Department of Experimental Therapeutics, National Cancer Center Hospital, Tokyo, Japan; Division of Cancer Immunotherapy, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Tokyo, Japan
| | - Shizuka Yamagata
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Akiko Miyagi Maeshima
- Division of Pathology and Clinical Laboratories, National Cancer Center Hospital, Tokyo, Japan
| | - Ryosuke Ueda
- Division of Molecular and Cellular Medicine, National Cancer Center Research Institute, Tokyo, Japan
| | - Ayumu Ito
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Kohei Tada
- Division of Cancer Immunotherapy, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Tokyo, Japan; Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Shigeo Fuji
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Takuya Yamashita
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Daisuke Tomura
- Center for Cell and Gene Therapy, Takara Bio Inc, Tokyo, Japan
| | - Ikuei Nukaya
- Center for Cell and Gene Therapy, Takara Bio Inc, Tokyo, Japan
| | - Junichi Mineno
- Center for Cell and Gene Therapy, Takara Bio Inc, Tokyo, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Shinichiro Mori
- Department of Hematology and Oncology, St Luke's International University and Hospital, Tokyo, Japan
| | - Yoichi Takaue
- Research Planning and Management Department, St Luke's International University and Hospital, Tokyo, Japan
| | - Yuji Heike
- Immunotherapy and Cell Therapy Service, St Luke's International University and Hospital Tokyo, Japan; Laboratory for Joint Research and Development, St Luke's International University and Hospital, Tokyo, Japan.
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Xu LP, Zhang CL, Mo XD, Zhang XH, Chen H, Han W, Chen YH, Wang Y, Yan CH, Wang JZ, Wang FR, Zhao T, Liu YR, Liu KY, Huang XJ. Epstein-Barr Virus-Related Post-Transplantation Lymphoproliferative Disorder after Unmanipulated Human Leukocyte Antigen Haploidentical Hematopoietic Stem Cell Transplantation: Incidence, Risk Factors, Treatment, and Clinical Outcomes. Biol Blood Marrow Transplant 2015; 21:2185-2191. [PMID: 26253005 DOI: 10.1016/j.bbmt.2015.07.035] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/30/2015] [Indexed: 10/23/2022]
Abstract
We examined the incidence, risk factors, treatments, and clinical outcomes of post-transplantation lymphoproliferative disorder (PTLD) after unmanipulated haploidentical (haplo) hematopoietic stem cell transplantation (HSCT) in 1184 patients between 2006 and 2012. Age-, transplantation time-, and transplantation duration-matched controls were randomly selected from the same cohort. Forty-five patients experienced PTLD. The median time from HSCT to PTLD occurrence was 61 (range, 33 to 360) days and the 1-year cumulative incidence of total PTLD after haplo-HSCT was 3.0%. In multivariate analysis, a lower absolute count of CD8(+) T lymphocytes at day 30, a lower absolute count of immunoglobulin M at day 30, and cytomegalovirus DNAemia after HSCT were significantly associated with higher risk of PTLD. The 2-year probability of overall survival (OS) after HSCT was 42.8%, which was comparable between the probable PTLD and the proven PTLD patients. Patients who received rituximab-based therapy had significantly better 2-year OS (48.2% versus 13.2%, P = .02). Thus, we were able to identify individuals at a high risk of developing PTLD after unmanipulated haplo-HSCT. Rituximab-based therapy can help to improve the outcomes of PTLD patients.
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Affiliation(s)
- Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Chun-Li Zhang
- Department of Hematology, Beijing Hospital, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Ting Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yan-Rong Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Peking-Tsinghua Center for Life Sciences, Beijing, China.
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Beloki L, Ciaurriz M, Mansilla C, Zabalza A, Perez-Valderrama E, Samuel ER, Lowdell MW, Ramirez N, Olavarria E. Assessment of the effector function of CMV-specific CTLs isolated using MHC-multimers from granulocyte-colony stimulating factor mobilized peripheral blood. J Transl Med 2015; 13:165. [PMID: 25990023 PMCID: PMC4458005 DOI: 10.1186/s12967-015-0515-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 05/04/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adoptive transfer of CMV-specific T cells has shown promising results in preventing pathological effects caused by opportunistic CMV infection in immunocompromised patients following allogeneic hematopoietic stem cell transplantation. The majority of studies have used steady-state leukapheresis for CMV-reactive product manufacture, a collection obtained prior to or months after G-CSF mobilization, but the procurement of this additional sample is often not available in the unrelated donor setting. If the cellular product for adoptive immunotherapy could be generated from the same G-CSF mobilized collection, the problems associated with the additional harvest could be overcome. Despite the tolerogenic effects associated with G-CSF mobilization, recent studies described that CMV-primed T cells generated from mobilized donors remain functional. METHODS MHC-multimers are potent tools that allow the rapid production of antigen-specific CTLs. Therefore, in the present study we have assessed the feasibility and efficacy of CMV-specific CTL manufacture from G-CSF mobilized apheresis using MHC-multimers. RESULTS CMV-specific CTLs can be efficiently isolated from G-CSF mobilized samples with Streptamers and are able to express activation markers and produce cytokines in response to antigenic stimulation. However, this anti-viral functionality is moderately reduced when compared to non-mobilized products. CONCLUSIONS The translation of Streptamer technology for the isolation of anti-viral CTLs from G-CSF mobilized PBMCs into clinical practice would widen the number of patients that could benefit from this therapeutic strategy, although our results need to be taken into consideration before the infusion of antigen-specific T cells obtained from G-CSF mobilized samples.
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Affiliation(s)
- Lorea Beloki
- Oncohematology Research Group, Navarrabiomed - Miguel Servet Foundation, IDISNA (Navarra's Health Research Institute), Irunlarrea 3, 31008, Pamplona, Spain.
| | - Miriam Ciaurriz
- Oncohematology Research Group, Navarrabiomed - Miguel Servet Foundation, IDISNA (Navarra's Health Research Institute), Irunlarrea 3, 31008, Pamplona, Spain.
| | - Cristina Mansilla
- Oncohematology Research Group, Navarrabiomed - Miguel Servet Foundation, IDISNA (Navarra's Health Research Institute), Irunlarrea 3, 31008, Pamplona, Spain.
| | - Amaya Zabalza
- Oncohematology Research Group, Navarrabiomed - Miguel Servet Foundation, IDISNA (Navarra's Health Research Institute), Irunlarrea 3, 31008, Pamplona, Spain.
| | - Estela Perez-Valderrama
- Oncohematology Research Group, Navarrabiomed - Miguel Servet Foundation, IDISNA (Navarra's Health Research Institute), Irunlarrea 3, 31008, Pamplona, Spain.
| | - Edward R Samuel
- Department of Haematology, University College London Medical School, University College London, London, UK.
| | - Mark W Lowdell
- Department of Haematology, University College London Medical School, University College London, London, UK.
| | - Natalia Ramirez
- Oncohematology Research Group, Navarrabiomed - Miguel Servet Foundation, IDISNA (Navarra's Health Research Institute), Irunlarrea 3, 31008, Pamplona, Spain.
| | - Eduardo Olavarria
- Oncohematology Research Group, Navarrabiomed - Miguel Servet Foundation, IDISNA (Navarra's Health Research Institute), Irunlarrea 3, 31008, Pamplona, Spain. .,Department of Haematology, Complejo Hospitalario de Navarra, Navarra Health Service, IDISNA (Navarra's Health Research Institute), Pamplona, Spain.
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Reischig T, Kacer M, Jindra P, Hes O, Lysak D, Bouda M. Randomized trial of valganciclovir versus valacyclovir prophylaxis for prevention of cytomegalovirus in renal transplantation. Clin J Am Soc Nephrol 2014; 10:294-304. [PMID: 25424991 DOI: 10.2215/cjn.07020714] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Both valganciclovir and high-dose valacyclovir are recommended for cytomegalovirus prophylaxis after renal transplantation. A head-to-head comparison of both regimens is lacking. The objective of the study was to compare valacyclovir prophylaxis with valganciclovir, which constituted the control group. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS In a randomized, open-label, single-center trial, recipients of renal transplants (recipient or donor cytomegalovirus-seropositive) were randomly allocated (1:1) to 3-month prophylaxis with valacyclovir (2 g four times daily) or valganciclovir (900 mg daily). Enrollment occurred from November of 2007 to April of 2012. The primary end points were cytomegalovirus DNAemia and biopsy-proven acute rejection at 12 months. Analysis was by intention to treat. RESULTS In total, 119 patients were assigned to valacyclovir (n=59) or valganciclovir prophylaxis (n=60). Cytomegalovirus DNAemia developed in 24 (43%) of 59 patients in the valacyclovir group and 18 (31%) of 60 patients in the valganciclovir group (adjusted hazard ratio, 1.35; 95% confidence interval, 0.71 to 2.54; P=0.36). The incidence of cytomegalovirus disease was 2% with valacyclovir and 5% with valganciclovir prophylaxis (adjusted hazard ratio, 0.21; 95% confidence interval, 0.01 to 5.90; P=0.36). Significantly more patients with valacyclovir prophylaxis developed biopsy-proven acute rejection (18 of 59 [31%] versus 10 of 60 [17%]; adjusted hazard ratio, 2.49; 95% confidence interval, 1.09 to 5.65; P=0.03). The incidence of polyomavirus viremia was higher in the valganciclovir group (18% versus 36%; adjusted hazard ratio, 0.43; 95% confidence interval, 0.19 to 0.96; P=0.04). CONCLUSIONS Valganciclovir shows no superior efficacy in cytomegalovirus DNAemia prevention compared with valacyclovir prophylaxis. However, the risk of biopsy-proven acute rejection is higher with valacyclovir.
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Affiliation(s)
- Tomas Reischig
- Departments of Internal Medicine I, Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Martin Kacer
- Departments of Internal Medicine I, Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Pavel Jindra
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic Hemato-oncology, and
| | - Ondrej Hes
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic Pathology, Charles University Medical School and Teaching Hospital, Pilsen, Czech Republic; and
| | - Daniel Lysak
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic Hemato-oncology, and
| | - Mirko Bouda
- Departments of Internal Medicine I, Biomedical Centre, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
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Beloki L, Ramírez N, Olavarría E, Samuel ER, Lowdell MW. Manufacturing of highly functional and specific T cells for adoptive immunotherapy against virus from granulocyte colony-stimulating factor–mobilized donors. Cytotherapy 2014; 16:1390-408. [DOI: 10.1016/j.jcyt.2014.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/08/2014] [Accepted: 05/08/2014] [Indexed: 10/25/2022]
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Reischig T, Kacer M. The efficacy and cost-effectiveness of valacyclovir in cytomegalovirus prevention in solid organ transplantation. Expert Rev Pharmacoecon Outcomes Res 2014; 14:771-9. [PMID: 25252996 DOI: 10.1586/14737167.2014.965157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Prevention of cytomegalovirus infection using antiviral prophylaxis or the pre-emptive therapy approach is an integral part of management of patients after solid organ transplantation. Regarding renal transplantation, valacyclovir is currently the only antiviral agent recommended for prophylaxis as an alternative to valganciclovir. This review article discusses studies documenting the efficacy and safety of valacyclovir prophylaxis as well as those comparing valacyclovir with other prophylactic regimens or with pre-emptive therapy. Also addressed are the economic aspects supporting the cost-effectiveness of valacyclovir prophylaxis and demonstrating lower costs compared with other cytomegalovirus preventive strategies.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Alej Svobody 80, 304 60 Pilsen, Czech Republic
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Jain NA, Lu K, Ito S, Muranski P, Hourigan CS, Haggerty J, Chokshi PD, Ramos C, Cho E, Cook L, Childs R, Battiwalla M, Barrett AJ. The clinical and financial burden of pre-emptive management of cytomegalovirus disease after allogeneic stem cell transplantation-implications for preventative treatment approaches. Cytotherapy 2014; 16:927-33. [PMID: 24831837 DOI: 10.1016/j.jcyt.2014.02.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 02/24/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AIMS Although cytomegalovirus (CMV) infection after allogeneic stem cell transplantation (SCT) is rarely fatal, the management of CMV by pre-emptive medication for viral reactivation has toxicity and carries a financial burden. New strategies to prevent CMV reactivation with vaccines and antiviral T cells may represent an advance over pre-emptive strategies but have yet to be justified in terms of transplantation outcome and cost. METHODS We compared outcomes and post-transplantation treatment cost in 44 patients who never required pre-emptive CMV treatment with 90 treated patients undergoing SCT at our institute between 2006 and 2012. Eighty-one subjects received CD34+ selected myeloablative SCT, 12 umbilical cord blood transplants, and 41 T-replete non-myeloablative SCT. One hundred nineteen patients (89%) were at risk for CMV because either the donor or recipient was seropositive. Of these, 90 patients (75.6%) reactivated CMV at a median of 30 (range 8-105) days after transplantation and received antivirals. RESULTS There was no difference in standard transplantation risk factors between the two groups. In multivariate modeling, CMV reactivation >250 copies/mL (odds ratio = 3, P < 0.048), total duration of inpatient IV antiviral therapy (odds ratio = 1.04, P < 0.001), type of transplantation (T-deplete vs. T-replete; odds ratio = 4.65, P < 0.017) were found to be significantly associated with increased non-relapse mortality. The treated group incurred an additional cost of antiviral medication and longer hospitalization within the first 6 months after SCT of $58,000 to $74,000 per patient. CONCLUSIONS Our findings suggest that to prevent CMV reactivation, treatment should be given within 1 week of SCT. Preventative treatment may improve outcome and have significant cost savings.
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Affiliation(s)
- Natasha A Jain
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kit Lu
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sawa Ito
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Pawel Muranski
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Christopher S Hourigan
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Janice Haggerty
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Puja D Chokshi
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Catalina Ramos
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Elena Cho
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa Cook
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Richard Childs
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Minoo Battiwalla
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
| | - A John Barrett
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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In Vitro Treatment with Ganciclovir Restores the Functionality of Exhausted T Cells from Cancer Patients. INT J GERONTOL 2013. [DOI: 10.1016/j.ijge.2012.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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45
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Borchers S, Weissinger E, Pabst B, Ganzenmueller T, Dammann E, Luther S, Diedrich H, Ganser A, Stadler M. Expansion of recipient-derived antiviral T cells may influence donor chimerism after allogeneic stem cell transplantation. Transpl Infect Dis 2013; 15:627-33. [DOI: 10.1111/tid.12101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 11/13/2012] [Accepted: 12/23/2012] [Indexed: 11/29/2022]
Affiliation(s)
- S. Borchers
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation; Hannover Medical School (MHH); Hannover Germany
| | - E.M. Weissinger
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation; Hannover Medical School (MHH); Hannover Germany
| | - B. Pabst
- Department of Human Genetics; Hannover Medical School; Hannover Germany
| | - T. Ganzenmueller
- Department of Virology; Hannover Medical School; Hannover Germany
| | - E. Dammann
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation; Hannover Medical School (MHH); Hannover Germany
| | - S. Luther
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation; Hannover Medical School (MHH); Hannover Germany
| | - H. Diedrich
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation; Hannover Medical School (MHH); Hannover Germany
| | - A. Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation; Hannover Medical School (MHH); Hannover Germany
| | - M. Stadler
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation; Hannover Medical School (MHH); Hannover Germany
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Ito S, Pophali P, CO W, Koklanaris EK, Superata J, Fahle GA, Childs R, Battiwalla M, Barrett AJ. CMV reactivation is associated with a lower incidence of relapse after allo-SCT for CML. Bone Marrow Transplant 2013; 48:1313-6. [PMID: 23562969 DOI: 10.1038/bmt.2013.49] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 03/01/2013] [Accepted: 03/05/2013] [Indexed: 11/09/2022]
Abstract
Preemptive therapy at CMV reactivation has diminished post-transplant CMV mortality. Furthermore, recent studies suggest a favorable 'virus-versus-leukemia' effect from reactivating CMV, reducing relapse of AML after SCT. We studied the relationship of CMV reactivation with leukemic relapse in 110 patients with CML receiving HLA-identical sibling SCT between 1993 and 2008. Of these, 79 (72%) were in chronic phase, 5 in second chronic phase, 17 in accelerated phase and 9 in blast phase. A total of 97 patients (88%) received a myeloablative conditioning regimen, 97 received 4-log ex vivo T cell-depleted grafts and 13 received T-replete grafts. CMV reactivation before day 100 was observed in 72 patients (65.5%). At a median follow-up of 6.2 years, CMV reactivation < day 100 as a time-dependent covariate was an independent factor associated with decreased relapse. We conclude that CMV reactivation may contribute to a beneficial GVL effect in CML transplant recipients.
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Affiliation(s)
- S Ito
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Borchers S, Bremm M, Lehrnbecher T, Dammann E, Pabst B, Wölk B, Esser R, Yildiz M, Eder M, Stadler M, Bader P, Martin H, Jarisch A, Schneider G, Klingebiel T, Ganser A, Weissinger EM, Koehl U. Sequential anti-cytomegalovirus response monitoring may allow prediction of cytomegalovirus reactivation after allogeneic stem cell transplantation. PLoS One 2012; 7:e50248. [PMID: 23272059 PMCID: PMC3521740 DOI: 10.1371/journal.pone.0050248] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 10/19/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Reconstitution of cytomegalovirus-specific CD3(+)CD8(+) T cells (CMV-CTLs) after allogeneic hematopoietic stem cell transplantation (HSCT) is necessary to bring cytomegalovirus (CMV) reactivation under control. However, the parameters determining protective CMV-CTL reconstitution remain unclear to date. DESIGN AND METHODS In a prospective tri-center study, CMV-CTL reconstitution was analyzed in the peripheral blood from 278 patients during the year following HSCT using 7 commercially available tetrameric HLA-CMV epitope complexes. All patients included could be monitored with at least CMV-specific tetramer. RESULTS CMV-CTL reconstitution was detected in 198 patients (71%) after allogeneic HSCT. Most importantly, reconstitution with 1 CMV-CTL per µl blood between day +50 and day +75 post-HSCT discriminated between patients with and without CMV reactivation in the R+/D+ patient group, independent of the CMV-epitope recognized. In addition, CMV-CTLs expanded more daramtaically in patients experiencing only one CMV-reactivation than those without or those with multiple CMV reactivations. Monitoring using at least 2 tetramers was possible in 63% (n = 176) of the patients. The combinations of particular HLA molecules influenced the numbers of CMV-CTLs detected. The highest CMV-CTL count obtained for an individual tetramer also changed over time in 11% of these patients (n = 19) resulting in higher levels of HLA-B*0801 (IE-1) recognizing CMV-CTLs in 14 patients. CONCLUSIONS Our results indicate that 1 CMV-CTL per µl blood between day +50 to +75 marks the beginning of an immune response against CMV in the R+/D+ group. Detection of CMV-CTL expansion thereafter indicates successful resolution of the CMV reactivation. Thus, sequential monitoring of CMV-CTL reconstitution can be used to predict patients at risk for recurrent CMV reactivation.
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Affiliation(s)
- Sylvia Borchers
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Melanie Bremm
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Elke Dammann
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Brigitte Pabst
- Institute of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Benno Wölk
- Institute of Virology, Hannover Medical School, Hannover, Germany
| | - Ruth Esser
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Meral Yildiz
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
- Internal Medicine II, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Stadler
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Peter Bader
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Hans Martin
- Internal Medicine II, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andrea Jarisch
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Gisbert Schneider
- Institute of Pharmaceutical Science and Biostatistics, ETH Zürich, Switzerland
| | - Thomas Klingebiel
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Eva M. Weissinger
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Ulrike Koehl
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
- Institute of Cellular Therapeutics, IFB-Tx, Hannover Medical School, Hannover, Germany
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48
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Reischig T. Advances in cytomegalovirus-preventive strategies in solid organ transplantation: defending pre-emptive therapy. Expert Rev Anti Infect Ther 2012; 10:51-61. [PMID: 22149614 DOI: 10.1586/eri.11.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Prevention of cytomegalovirus (CMV) infection is an important part of clinical care provided to patients after solid organ transplantation. While the optimal preventive strategy has not been defined, most centers rely on universal prophylaxis or pre-emptive therapy. This article comments on recent studies designed to identify strategies that effectively reduce the incidence of late-onset CMV disease as the main problem associated with prophylaxis, and on recent data regarding the development of CMV-specific immunity depending on the CMV-preventive regimen used. Despite an apparent trend to prefer prophylaxis in clinical practice, this approach does not seem to be based on robust evidence.
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Affiliation(s)
- Tomáš Reischig
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Alej Svobody 80, 304 60 Pilsen, Czech Republic.
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49
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Adoptive immunotherapy with CMV-specific cytotoxic T lymphocytes for stem cell transplant patients with refractory CMV infections. J Immunother 2012; 35:293-8. [PMID: 22421947 DOI: 10.1097/cji.0b013e31824300a2] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Adoptive immunotherapy with cytomegalovirus (CMV)-specific cytotoxic T lymphocytes (CTL) is an effective strategy for preventing and treating viral reactivation after allogeneic stem cell transplantation (SCT). We have shown previously that CMV CTL can be generated in 1 to 2 weeks by stimulating donor lymphocytes with peptide mixes derived from full-length pp65 and IE1. We conducted a multi-institutional study of CMV-specific CTL for patients with persistent or anti-viral-resistant CMV infections after allogeneic SCT, to determine the safety, feasibility, and immunologic effects of this approach. We were successful in stimulating CTL from 10/10 donors with pooled CMV overlapping peptide mixes. Five of the 7 subjects who met infusion criteria had new onset CMV-specific CTL activity detected within 4 to 6 weeks after infusion. Of the 2 subjects who did not have immunologic responses after infusion, 1 received CTL with a low viability after thawing, and the other patient received cyclosporine A and systemic corticosteroids at the time of the infusion, achieving only a low, transient increase (10%) in pp65-specific activity. There was no graft-versus-host disease attributable to these infusions. These findings indicate that the infusion of CTL stimulated over 1 to 2 weeks with overlapping CMV peptides can result in virus-specific immune reconstitution in SCT recipients, without exacerbations of graft-versus-host disease.
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50
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Voisard R, Münder U, von Müller L, Baur R, Hombach V. Direct inhibitory effects of Ganciclovir on ICAM-1 expression and proliferation in human coronary vascular cells (SI/MPL-ratio: >1). Med Sci Monit 2011; 17:PI1-6. [PMID: 21169918 PMCID: PMC3524678 DOI: 10.12659/msm.881310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Treatment of the human cytomegalovirus (HCMV) infection with ganciclovir has beneficial indirect effects on the complex interactions of HCMV with restenosis, atherosclerosis, and transplant vascular sclerosis. The current study reports on direct effects of ganciclovir on expression of ICAM-1 and cell proliferation, key events of coronary atherosclerosis/restenosis. A potential clinical relevance of the data will be evaluated with the help of SI/MPL-ratio’s. Material/Methods Definition of the SI/MPL-ratio: relation between significant inhibitory effects in vitro/ex vivo and the maximal plasma level after systemic administration in vivo (ganciclovir: 9 μg/ml). Part I of the study investigated in cytoflow studies the effect of ganciclovir (0.05–5000 μg/mL) on TNF-a induced expression of intercellular adhesion molecule 1 (ICAM-1) in endothelial cells derived from umbilical veins (HUVEC), human coronary endothelial cells (HCAEC), and human coronary smooth muscle cells (HCMSMC). Part II of the study analysed the effect of ganciclovir (0.05–5000 μg/mL) on cell proliferation (HUVEC, HCAEC, and HCMSMC). In part III cytotoxic effects of ganciclovir (0.05–5000 μg/mL) were studied (HUVEC, HCAEC, and HCMSMC). Results Ganciclovir caused slight but significant inhibitory effects on expression of ICAM-1 in HUVEC, HCAEC, and HCMSMC. In all three cell types studied strong dose depending significant antiproliferative effects of ganciclovir were detected. Partially, the antiproliferative effects of ganciclovir were caused by cytotoxic effects. Conclusions SI/MPL-ratio’s >1 in HCAEC and HCMSMC indicate that the inhibitory effects of gancliclovir on ICAM-1-expression and cell proliferation may only be expected in vivo following local high dose administration e.g. in drug eluting stents (DES).
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Affiliation(s)
- Rainer Voisard
- Department of Internal Medicine II-Cardiology, University of Ulm, Ulm, Germany.
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